Title: The Prevalence and Prognosis of Sarcopenic Dysphagia in Patients Who Require Dysphagia Rehabilitation
Author: Wakabayashi, Takahashi, & Murakami
Journal: Journal of Frailty and Aging
Year of Publication: 2019
Study design: Prospective cohort
Purpose: “The purpose of this study was to assess the prevalence and prognosis of sarcopenic dysphagia in patients who require dysphagia rehabilitation”
Population: consecutive adult patients with dysphagia, receiving dysphagia treatment at an acute-tertiary hospital in Japan
Inclusion: > 65 years old; prescribed dysphagia rehabilitation by physiatrists; could provide informed consent
Exclusion: moderate or severe conscious disturbances and/or higher brain dysfunction; patients with missing values (handgrip strength, tongue pressure)
This article took me by surprise and I’m not gonna lie, was initially picked because of the shorter length (ya know, when you just grab an article to pass the time?😂). Not to mention how intriguing the topic of sarcopenia + dysphagia is. Really, anything that could have the potential to help me determine why someone might have dysphagia and what to do about it gets a 👍 in my book.
Besides the obvious “What is sarcopenia?” question, literally the very first thoughts I had (and you might have) before reading were:
“Is there a difference between sarcopenic dysphagia and presbyphagia?”
“”How are they different, how can you tell?”
After a quick search for just those thoughts, I was led to the author’s first publication that defines just that. While the article isn’t public access as of now (still working on obtaining a copy🤞), the abstract alone was still enlightening:
“Presbyphagia refers to age-related changes in the swallowing mechanism in the elderly associated with a frailty in swallowing. Presbyphagia is different from dysphagia. Sarcopenic dysphagia is difficulty swallowing due to sarcopenia of generalized skeletal muscles and swallowing muscles. Age-related loss of swallowing muscle mass becomes evident in the geniohyoid muscle and tongue.” Abstract, Presbyphagia and Sarcopenic Dysphagia: Association between Aging, Sarcopenia, and Deglutition Disorders
Apparently, one can have “whole-body” sarcopenia and sarcopenic dysphagia, which affects specifically the loss of muscle mass/function of skeletal and swallowing muscles, and have both along with dysphagia from a related disease (e.g. TBI, stroke, cancer, etc.). So picture someone who has whole-body sarcopenia (Cachexic° may be used as a related term), and also likely has sarcopenic dysphagia, now they are here for an acute diagnosis causing the dysphagia we are so much more (somewhat) familiar with. Obviously, these individuals of at least age 65 likely have other multiple factors at play, but talk about your 1-2 punch?!😬
Back to the current article that is trying to look at how common sarcopenic dysphagia is and what the prognosis would be….
What exactly did they use to find changes (if any)?
All individuals were grouped with the following measures:
- sarcopenia “types”
- one group= “probable sarcopenic dysphagia + possible sarcopenic dysphagia”
- one group= “no sarcopenic dysphagia“
- Barthel Index for activities of daily living
- Geriatric Nutritional Risk Index (GNRI) for nutritional status
- BMI/current body weight/ideal body weight /total energy intake
- “maximum tongue pressure-measuring instrument” for tongue pressure
- Food Intake Level Scale (FILS)
Basically, a lot of similar measurements we look at either clinically or what we read in the research (BTW the population setting is in Japan hence the comparisons😉). I was eventually able to discover that FILS appaers to be very similar to our version of the Functional Oral Intake Scale (FOIS),so might be something to remember for other international studies.
The authors did suggest some rationale why tongue pressure measurements were used in relation to swallow muscle strength: “Patients with sarcopenic dysphagia have lower tongue muscle mass and higher tongue muscle echo-intensity on ultrasound than patients without sarcopenic dysphagia,” and are more likely to have impairments at a lot of the levels you’d find for the ICF model. Unfortunately, the rationale behind using other measures didn’t seem as clear to me or explicitly explained, nor why other measures weren’t used instead? (Something to always be asking yourself😉).
It should also be noted that in order to define and diagnose “sarcopenic dysphagia,” the authors used a “reliable and validated 5-step diagnostic algorithm” which included the following:
- whole body sarcopenia (skeletal muscle strength)
- whole body sarcopenia (skeletal muscle mass)
- presence of dysphagia
- causes of dysphagia
- swallowing muscle strength
I can’t really get too much more into that algorithm because I’ll be honest that I haven’t heard or seen much about it, but it is interesting to think if this will or already is something being used elsewhere?🤔
After all the “stats magic” comparing the differences between:
- patients with and without sarcopenic dysphagia
- if there were any correlations in patients’ FILS, GNRI, age, Barthel Index, energy intake, and a C-reactive protein (sorry don’t have the slightest idea about that last one🤨)
- if discharge FILS could be independently associated with patients having sarcopenic dysphagia (after they filter out the “others” like age, sex, and the initial FILS)
What did they find?
The quick and dirty of it is the 2 groups (either some type of sarcopenic dysphagia or no sarcopenic dysphagia) had significantly differed in a lot of the original measures the investigators looked at (e.g. initial/discharge FILS, BMI, handgrip strength, calf circumference, serum albumin, along with those listed above). The sarcopenic group also had lower FILS at initial and discharge, meaning their functional oral intake was lower from the beginning to the end when compared to anyone that was not determined to have the swallow muscle wasting disorder.
Lastly, after looking back and piecing out (mathematically speaking) if age, gender, the initial FILS, and the presence of sarcopenic dysphagia could have contributed to the discharge FILS score, the authors found that all but age were independently associated.
“This is the first study examining the prevalence and prognosis of sarcopenic dysphagia in patients who require rehabilitation. The prevalence of sarcopenic dysphagia was 32%. Sarcopenic dysphagia was independently associated with poor swallowing function at discharge.” p. 3
I’m still mulling over that last statement in my head because personally, I would have liked a different terminology than “swallowing function, since my mind tends to think of physiological swallow function (meaning identified by instrumental assessment) when I see that term being used. So I’m curious if maybe an alternative like “swallowing function as it relates to diet/intake” since the measure that’s being used is really looking at oral intake as their ‘prognostic indicator.’ Any other thoughts on this conclusion?🤷♀️
I also couldn’t help but have additional questions when the authors introduced a broad idea of patients categorized as “generalized nonspecific dysphagia” as a main cause versus attributing a specific etiology (e.g. surgery, stroke, etc.) for possible sarcopenic dysphagia because “no obvious causes of dysphagia were observed.” Is this population really the ones to be on the lookout for sarcopenic dysphagia then?😬
“Sarcopenic dysphagia may be included in ‘something else’ and in dysphagia caused by advanced age. Therefore, it appears that sarcopenic dysphagia is a common cause of dysphagia. The possibility of sarcopenic dysphagia should be suspected in all older patients with dysphagia.” p. 4
Pretty bold statement!😯 Before jumping from A to Z, I think while the article could help us step into yet another new direction for thinking more about the who/when to see in our medical facilities and why, there’s still a few points to consider before using this all-or-nothing approach….
Hold up, wait just a minute!
We’ve got some limitations to consider before making large leaps and bounds and going around bugging every single geriatric patient…
The authors only looked at one location which happened to be an acute hospital with a length of stay of about 12 days, obviously limiting the generalizability of the conclusions, even if they did have over 100 participants!
Another hard detail to ignore was the fact that all patients were scheduled for their speech therapy session with doses anywhere from 2-5 times a week, and durations ranging between 20-40 minutes in length. I don’t know if I’m the only one, but my “therapy senses” started tingling because in the clinical world that big of a range could make a huge difference based on the nature of rehabilitation! Not to mention that we don’t even know what that speech therapy actually was?🤔
Patients who had an obvious cause of dysphagia were excluded from the study. However, patients with stroke, brain injury, neuromuscular disease, head and neck cancer, or connective tissue disease were still included if it was considered that their dysphagia was mainly attributed to age, activity, nutrition, invasion, or cachexia-related sarcopenia.
I was shaking my head here because I really would have liked to know more about just how they made this determination as far as “obvious dysphagia” goes when it comes to all those above factors, especially since as practicing clinicians it can be so dang hard sometimes to pinpoint exactly why this is happening 😓, so tips/tricks please!
The authors also agreed their exclusion of patients who had “consciousness disturbances” and “higher brain dysfunction” due to inability to provide informed consent also could have impacted the prevalence number claimed.🤨
I, for one, can say that I am looking forward to future studies where we can distinguish sarcopenic dysphagia from presbyphagia across multiple facility settings (skilled nursing, rehab hospitals, LTACH, etc.). At the very least, something we can takeaway from this is the ever-growing need for interdisciplinary intervention (who else semi-stalks the dieticians at their facility?).
How do you think increased collaboration could help with finding and receiving these individuals? I already know my other rehabilitative colleagues and medical staff know I could talk their ears off, but now I have a new reason to burst into the department office and strike up a conversation with some new material.😁
How can you use this article?!?
I am so curious to hear others’ perspectives and thoughts on this!😁
Should we have standard measures we look at to distinguish sarcopenic dysphagia?
Should we start having protocols or screenings for those that are over a certain age??
Are we really brushing off the “it’s just aging” issues related to presbyphagia and now, possibly sarcopenic dysphagia???
How does your facility categorize or even identify this population????
- “These data are important, because sarcopenic dysphagia can be treated with a combination of rehabilitation and aggressive nutrition care intervention, with an energy intake of approximately 35kcal/kg/day (ideal body weight) to improve muscle mass and function.”
- “rehabilitation, including resistance exercises of the swallowing and general muscles, and aggressive nutrition intervention to increase muscle mass and strength should be performed in patients with sarcopenic dysphagia.”
Wakabayashi, Hidetaka & Takahashi, R & Murakami, T. (2018). The Prevalence and Prognosis of Sarcopenic Dysphagia in Patients Who Require Dysphagia Rehabilitation. The journal of nutrition, health & aging. 23. 10.1007/s12603-018-1117-2.
🤩Some additional resources on the topic!🤩
- Sarcopenic Dysphagia. A Narrative Review
- Sarcopenia is an Independent Risk Factor for Dysphagia in Community‑Dwelling Older Adults
- Presbyphagia Versus Dysphagia: Identifying Age-Related Changes in Swallow Function