Title: Oropharyngeal dysphagia in an elderly post-operative hip fracture population
Authors: Love, Cornwell, Whitehouse
Journal: Age and Ageing
Year of Publication: 2013
Design Type: prospective cohort study
Purpose: “The aim of this study was to investigate the presence of OD following hip fracture surgery in the older population. Additionally, pre-admission, intra-operative and post-operative factors that may be associated with OD post-surgery were determined.”
Population: post-operative hip fracture surgery admitted patients
Inclusion criteria: >65 years old; admitted for hip fracture surgery (regardless of other medical co-morbidities)
Exclusion criteria: <65 years old; did not provide consent; discharged or deceased prior to swallowing assessment
You don’t even have to know the whole song to be able to understand that these two areas are nowhere near each other, let alone physically connected. Heck, you really don’t even have to know the song at all to know that! (although it is quite catchy😋)
So, why are we talking about it??
a) Because I for one have had umpteen evals for this population over my career (so naturally, I’m curious🤨)
b) Because I am sure other SLPs (you!) have also seen or had questions about this population🧐
c) Because sometimes a shorter article can be good for the SLP-soul😅
d) Because usually while it’s the thought that counts, this article can also serve as a great example of why improving our research reading skills can be important (keep reading and you’ll see why😉)
I can recall multiple times (specifically at long-term care facilities) where I’ve been “told” (emphasized to elicit a formal, authoritarian tone from superiors) that I need to provide descriptions and correct codes if I am evaluating a resident’s swallow whose admitting diagnosis is “hip fracture” as a Speech-Language Pathologist. Not gonna lie, my initial thought was pretty much always,
“Why would I need to see someone for swallowing who’s literally just having hip surgery??”
Cognition? Sure, I could see that given possible surgery complications or issues with anesthesia.
But swallowing? We never talked about that in Anatomy!!?!
I was actually introduced to this article while completing another amazing continuing education course centered around the aging adult with all the myriad of issues and sticky complications that get stacked upon each other like boxes in a moving truck, so after hearing that we might finally get an invite to the exclusive PT/OT party, I was in!🥳
No matter where you are in your SLP career, we all have some basic knowledge for the prevalence of dysphagia in neurological conditions, strokes, head/neck cancers, and various surgeries related to cardiothoracic and oral, ear/nose/throat. The authors know-that-we-know that cognition and psychological impairments can impact swallowing as well. Throw in pharmacology, aging, and gastrointestinal issues, and you might be able to cover all the general bases to call it a day.🤯
“I’ve never had any problem swallowing before, I’m only here for my hip“
“I’ve been swallowing my whole life fine, I just had hip surgery so that’s what I need fixing“
How many times have SLPs heard this after getting the order for a bedside swallow exam for someone post-hip surgery, only to be fighting over time between OT/PT?
Should we or shouldn’t we🤔? Can we or can’t we?🤨
These kinds of questions are ones we’re still plagued with almost a decade after the article, so I appreciate the authors trying to trek into unchartered territory early on to see if there’s anything that SLPs on Dysphagia Island can do to reduce increased hospital stay, healthcare costs, risk of aspiration pneumonia, dehydration, and/or malnutrition.
Before voyaging onward, a quick note: since the study’s home base is in Australia, some minor distinctions are likely to be present; however, I’m pretty sure here in The States we’re still, unfortunately, aging at a good enough rate to qualify for this rising population as well😉. Even so, it was no less surprising to read that prior to the article, no other research had looked into the relationship between oropharyngeal dysphagia post-hip-fracture surgery or what may be related to this anecdotal, clinical observation prior to this publication.
The Who? The Where?
To ensure they were getting the population they needed, patients from a specialized orthogeriatric unit from a metro hospital were selected over a 9-month period. And since “younger” people aren’t exactly getting admitted for hip surgeries, patients younger than 65 years old were excluded from the study to look more closely at age-related factors. At the end of the day, a mix of 181 participants similar to what you’d actually see in a hospital might not be too shabby.
What’s kind of neat in a geeky-research-loving-science-kind-of-way is the decision to do prospective versus retrospective design for this study. The authors could have just relied on loads of earlier data from medical records for those with swallowing issues post-hip fracture surgery and dug into those details.🤔
But knowing all the issues and limitations that can come with looking back in time and being unable to control for certain things, they decided to frame their study to be able to choose who, what, when, and how they looked at it all.
After selecting the who, each subject underwent a case history, “structured interview” of patient/family/residential staff to determine information relating to any previously diagnosed or described dysphagia (e.g. previous oral intake, diet modifications, and concerns eating/drinking, etc.) along with a clinical swallowing exam (CSE) that consisted of an oral mechanism exam, a perceptual voice evaluation (unsure if formal/informal?), and of course your oral food trials (Australia-style). This was all completed within 72 hours after surgery.
If you think that timeframe makes sense, I’m with ya because I don’t have enough fingers/toes to count how many times I’ve had an eval post-surgery when the patient is definitely not appropriate/awake! And if you’re thinking to yourself, “But, why didn’t they do all this before the surgery to have something to compare to?” I 100% agree with you too👍!! Turns out, because most of the patients were required to be nil-per-os (NPO/nothing by mouth) prior to surgery, the authors claim this just wasn’t feasible along with the assumptions that pain and medications could alter their pre-performance anyway.🙄
While I may have lost a tiny bit of sleep over not knowing specifically why the following variables were looked at, I’ll have to live with knowing previous research used these variables, so that’s what the authors went with.🤷♀️
“Clinical factors known on admission such as age, living environment, previous medical and surgical history; intra-operative and post-operative factors were obtained from medical records. These specific variables were identified for inclusion based on previous literature and clinical experience.” p.2
We’ve heard it close-to-if-not more than a MILLION times.🙉
We’ve discussed it.🙊
We’ve had “heated discussions/debates” about it.🙈
To avoid running the risk of causing a tirade into my living room, I’m just gonna whisper-type the thing-that-shall-not-be-named:
🤫(clinical signs of aspiration)🤫
Yes, these were essentially used to (loose quotes) “diagnose” dysphagia. Wom-womm-wommm.☹️😞😔 No, these are NOT enough to a) diagnose dysphagia nor b) “diagnose” anything to do with aspiration/penetration (or really pharyngeal impairments). And yes, I could write a LOT more about how these clinical signs are merely to help us look further into the physiology (aka MBSS/FEES), but for now, I’ll keep those thoughts (mostly) to myself.😊 (For a brief overview of all things clinical-bedside related, check out the review on last year’s controversial article!)
If you’re still sitting there going crazy wondering about the instrumental evaluations they used to further identify and assess the oropharyngeal dysphagia they were interested in: another dud😩. The authors offer the rationale that due to post-operative limitations and/or post-op delirium (ok, I guess that actually does sound more real-world😒) VFSS were not optional, and FEES was not available. While we’re all trying not to jump and yell with our hands in the air over how crazy it is to not be able to perform these *required* assessments for oropharyngeal dysphagia (see ASHA’S latest update in their Adult Dysphagia Practice Portal if ya don’t believe me😉), I can still try to appreciate how the authors try to show they may not be totally living in the past by at least grouping clinical signs into “reduced swallowing efficacy” and “reduced swallowing safety” observed during CSE versus simply saying “X, Y, Z are wrong/impaired.”🤷♀️🤦♀️
“Definitions of clinical signs of reduced swallowing efficacy (e.g. reduced lip seal, oral residue and multiple swallows per bolus) and reduced swallowing safety (e.g. coughing or choking after swallowing) were consistent with those used by Serra-Prat et al.” p.2
I know, I know. We’ll have time to vent about it all later…
(p.s. can somebody please send them some FEES equipment stat!!😁)
Before doing all the fancy math-magic, here’s what they already knew, a la ‘descriptive statistics’:
In general, prior to hip surgery, their sample population was mainly female, community-living adults. While the article does note that some participants lived in “residential aged care facilities,” (RACF), but fewer details were given for what level(s) (skilled nursing? independent retirement? assisted?), so I for one was left wondering exactly what “living-in-the-community” meant?🤷♀️
“Prior to admission, 92.8% (n=168) of patients were reported to have no clinical signs of OD and were managing a normal diet (including a full and soft textures according to national standards) with 175 patients (96.7%) tolerating thin fluids. All the patients admitted on thickened fluids were from an RACF, while 11 of 13 on modified diets came from an RACF.” p.2
The skeptical SLP in me couldn’t help but wonder if those patients on baseline thickened liquids/modified diets actually needed those modifications in the first place🙄. . .
To figure out what may have impacted any changes from the above raw data, the authors’ used their statistical analysis to essentially see if any variables could be identified that could explain the outcome/dependent variable (aka oropharyngeal dysphagia), and then analyzed each time after adding another variable to see if the outcome could be explained.
Some changes they saw:
“OD was present in 61 (34%) of 181 patients within 72 hours post-hip fracture surgery. Fifteen patients had documented OD prior to admission, and for eight of these patients, their post-operative diet and fluids were at a lower level.”
“three patients (1.6%) were placed nil by mouth, while 16% of patients (n=28) required modification of fluids, and 19.3% (n=35) required a texture-modified diet (minced and moist or smooth pureed).” p.2
So many questions, not enough answers guys!!!😩
Apparently, those who were on any kind of modified diet before, now were clinically worse!?😬 And if you’re asking questions to yourself like, “Why were they on a modified diet?” then you are not alone here!
It’s hard for me to draw any true correlation because I just couldn’t shake off the fact that not only were these “impairments” identified from mere clinical signs and symptoms versus true imaging, but also the fact that all these modifications to a diet were apparently made at the bedside, again, without proper visualization of the structures (or possibly without consent from the participants?😳). . .
Some other questions I couldn’t help erase from my mind (and maybe yours too?):
“Were these changes short-lived and did they ever return to their previous diet?”
“Did any of the patients have a history of falls or re-occurring injuries that might be related to malnutrition/dysphagia?”
“How long post-surgery was their hospital admission?”
“What would they find if their study was longer than 9 months?” (see Extras at the bottom for this⬇️😉)
And yet even more questions still lingered in my head even months after I re-read this article:
“Did they require any follow-up at the next level of care?”
“Would they get the same results if they used more standardized or patient-related outcome measures (e.g. EAT-10, SWAL-QOL, FOIS, etc.) to determine real functional changes?”
And so yet again I felt like “Limitation Lucy,” filled with all these questions that simply left me feeling:
And here is where the learning opportunity can kick in: Sometimes, articles aren’t great quality😕. How can you determine this? Well first, by reading the actual article versus a quick ‘one-and-done’ glance. Sometimes that’s all we have for the moment (totally been there!), but going back and really asking ourselves questions while reading🤔, and asking what questions are not answered (or even asked to begin with!), can help us weed out things that are and are not worth out precious SLP time!
BELIEVE ME when I say I cannot wait until another study replicating this comes out with the use of some type of instrumental evaluation and other reliable measures!🤩
But until then, it seems you work with what ya got in #realworld, right?
Outside of these, the limitations of the article should also be considered so we don’t use this study as an “end-all-be-all:”
“Sensitivity of the model was 52%, whereas specificity was 89% with a positive predictive value of 66.7% and a negative predictive value of 81.3%.” p.3
In other words, not that great👎, because we can’t be certain patients actually have the outcome of oropharyngeal dysphagia post-hip surgery (shocker🤐), but might be somewhat more sure they do not have swallowing issues.🤷♀️
If you’re anything like me (an inquisitive mind🤓), you might be sitting there asking why did these observations happen, and basically, what does the article say to look out for?
“The strongest factor was the presence of pre-existing neurological co-morbidities, followed by post-operative delirium and the presence of pre-existing respiratory co-morbidities.” p.3
Now, let’s discuss WHY.
We really already have the answers to this because we know:
- Loads of neurological and respiratory issues can have an impact on swallowing, even BEFORE surgery (likely exacerbating any baseline impairments)
- Delirium can majorly impact and inhibit one’s alertness and sensory responses to control these incredibly complex and time-regulated mechanisms such as swallowing
We also know enough about the other explanatory variables:
- The aging process changes the sensorimotor relationship for swallowing, which can impact safety and efficiency
- living as a “community-dwelling” resident in a facility can sometimes mean relying on others for feeding, oral hygiene, and other ADLs needed to maintain optimal health
Sing it with me:
🎵”Put it all together and what d’ya get?“🎵
Think about it: if my car bumper is duck-taped on, my gas tank is almost empty, or I’m driving on a doughnut tire, you can bet one of those alone might affect me getting from point A to B safely and quickly. But if all of those are going on? I’d be better off just calling the experts at AAA to come check it out.
“The development of OD is multifactorial and could be considered part of a geriatric syndrome. Therefore, older and more frail patients such as those among the elderly hip fracture population should be screened routinely for OD post-operatively.”
“Factors that could be related to OD (presence of neurological and respiratory co-morbidities, post-operative delirium, living in a RACF, increasing age), which could be used as criteria when screening, were also identified.” p.3
While some of those last claims might be quite a jump, consider these 2 scenarios:
1) Mr. Patient, 70 years old, runs quarterly marathons, only takes vitamins and rarely ever needing medical service, lives at home with wife, woke up after hip surgery fully oriented
2) Mrs. Resident, 89 years old, lives in skilled nursing facility where she receives daily breathing treatments for occasional COPD exacerbations, was confused for about 3 days after hip surgery, and had a small stroke years ago
Does one of these seem more likely to be at risk even though both had the same surgery? Ask yourself why that might be, and you’re starting to get the hang of critical thinking😉🤓. Thinking even deeper for what we know about all the risk factors for dysphagia (along with risk factors for developing aspiration pneumonia thanks to Langmore), should we really be all that surprised that this population might have some post-surgical changes to their overall swallow system? Because while it’s not the hip surgery per se that might cause some changes, it more than likely is all the other things that occur because of that surgery (e.g. anesthesia, deconditioning, poor appetite, etc.), along with any other previous issues!🤯
So, do we brush off an order because of a lack of connection between hips and swallowing? Or do we dive deeper and think critically about what we may already know through clinical expertise of foundational knowledge and patient goals?
It could be interesting for more hospitals to take data on this population, or to compare a younger population completing a hip surgery so we could really be able to say, “Are the hips really somehow connected to the swallow?”
How can you use this article?!?
Have you experienced similar changes reported in this article?
Were you blind-sighted by the thought between hips and swallowing??
What are your thoughts on screening for this population???
- “Anecdotal clinical experience suggests that older patients recovering from hip fracture surgery are a population that frequently present with OD post-operatively. It is unknown whether OD in this population is a pre-existing condition or a complication of hip fracture surgery.”
- “The reliance on CSE as the method to identify the presence of OD is not the gold standard for dysphagia diagnosis. However, VFSS or FEES which are considered the ‘gold standards’ in swallowing assessment were not feasible due to patient characteristics or availability (FEES).
- “The development of OD is multifactorial and could be considered part of a geriatric syndrome. Therefore, older and more frail patients such as those among the elderly hip fracture population should be screened routinely for OD post-operatively.”
Reference used: [FREE ACCESS]
Referenced *AMAZING* CEU from which this info burst into my already bombarded brain😅:
- Medbridge–Angela Mansolillo’s Continuing Education Courses
- *FYI* There was a more recent study that basically replicated this one, but WITHOUT instrumental swallow evaluations again, and in a rural population over a longer timeframe (’twas a good try, but still missed the mark in a lot of ways😕)
- In case you’re curious about the cost of what dysphagia in this population might be, check out last month’s review→”What’s the cost of a swallow??? “ that actually looks at this same population!🤑