Dysphagia

American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA) http://www.aappspa.org

American Dietetic Association (ADA) http://www.eatright.org

American Physical Therapy Association http://www.apta.org

American Speech-Language-Hearing Association http://www.asha.org

Atlanta Voice and Swallowing Center http://www.mindspring.com/~newvoice/

Otolaryngology for the Primary Care Practitioner [continuing education] http://cpmcnet.columbia.edu/dept/cme/cont0013.html

Dysphagia Research Society http://www.als.uiuc.edu/drs/

Evaluation and Interpretation of Acute Dysphagia Disorders and Dysphagia Rehabilitation/EMG

Biofeedback Assisted Treatment http://www.speechpaths.com/pms9.htm

Ivanhoe's Medical Breakthroughs-Electrical Swallowing #1057 http://www.ivanhoe.com/docs/backissues/electricalswallowing.html

NIH Speech Pathology http://www.cc.nih.gov/rm/sp

NYEEI: Otolaryngology: FAQs about Swallowing Disorders http://www.nyee.edu/otolaryn/dysphfaq.htm

Swallowing Disorders http://www.webpages.marshall.edu/~lynch4/swallow.html

Swallowing Disorders Program http://www.stjosephs.org/iv_k_6.htm

Aging

AgeInfo http://www.cpa.org.uk/ageinfo/html

GoldenAge.Net http://www.elo.mediasrv.swt.edu/goldenage/script.htm

National Aging Information Center http://www.aoa.dhhs.gov/naic/

Netherlands Institute of Gerontology: GeronLine http://www.nig.nl/

Statistical Information on the Aging - Online Data http://www.aoa.dhhs.gov/aoa/stats/statlink.html

Diseases

American Heart Association 1997 Statistical Supplement http://www.amhrt.org/1997/stats/Stroke.html

Ask NOAH About: Aging and Alzheimer's Disease http://www.noah.cuny.edu/aging/aging.html

The National Multiple Sclerosis Society http://www.nmss.org

National Stroke Association http://www.stroke.org

NINDS Stroke Information Guide http://www.ninds.nih.gov/healinfo/disorder/stroke/strokehp.htm

Section one of evidence model: Diagnostic tools

The first step in patient management is to diagnose the patient as having or not having dysphagia. The patient will likely have a history and physical first, which will identify any outward symptoms that may indicate a problem; alternatively, the physical exam may simply be part of the diagnosis of a disease or disorder with which dysphagia is commonly associated (e.g., stroke). Patients who meet some diagnostic criteria for having dysphagia (or suspected dysphagia) will continue on to a more dysphagia-specific examination (designated as D2 to D7 in the evidence model), which may include one or more of the following diagnostic tests (described in detail in the Introduction to this report):

• 3-ounce water test
• Formal BSE
• Informal BSE
• MBS
• FEESST
• FEES
• Other instrumented exam

Section two of evidence model: Symptoms detected by diagnostic tools

These diagnostic tests will have varying abilities to detect signs and symptoms of dysphagia. One of the main issues of this report is how well these diagnostic tests detect aspiration or risk for aspiration pneumonia. The two important symptoms (designated in the evidence model as S1 and S2) are therefore dysphagia and aspiration.

Section three of evidence model: Treatments

Depending on the symptoms detected, a patient with dysphagia or aspiration may undergo one or more treatments (designated as T1 to T4 in the evidence model). These include:

• Swallow therapy
• Modified diet
• Combined swallow therapy and modified diet
• Feeding tube

The treatment a patient receives depends on the type and severity of the problem detected.

Section four of evidence model: Short-term outcomes

There are many important outcomes reported in the field of medicine. Some of the most common and important ones are complications resulting from treatment and mortality. However, not every outcome of interest to society or patients is relevant to every intervention. It is therefore important to pick outcomes of interest based on relevance to the topic as determined by clinical experience (e.g., the observation of pneumonia in patients with dysphagia) or logical inference (e.g., that dysphagia may lead to malnutrition or dehydration).

It is possible, relatively soon after treatment has begun, to measure certain outcomes that indicate whether the treatment is working. These short-term outcomes are designated O1 to O6 in the evidence model and include:

• Swallow function
• Food intake
• Feeding method
• Weight change
• Aspiration
• Tube complications

Swallow function refers to the physiological changes in the process of swallowing that may occur after certain therapies, such as total swallow time and pharyngeal transit time. Food intake refers to the change in the amount of energy (e.g., kilocalories) ingested by the patient as a result of treatment. Weight change is an important outcome, as many elderly are malnourished, potentially as a result of a swallowing problem. Aspiration indicates whether the therapy of choice has successfully eliminated or reduced a previous aspiration problem. Tube complications, an outcome specific to the feeding tube, indicate that a problem has occurred with the tube, either intraoperatively or postoperatively (e.g., wound infection).

Section five of evidence model: Morbidities

One goal in the diagnosis and treatment of dysphagia is to prevent serious morbidities that can result from aspiration and an inability to ingest adequate amounts of food. The morbidities of interest in this report, designated M1 to M3, are:

• Pneumonia
• Malnutrition/dehydration
• Major tube complications

Pneumonia resulting from dysphagia and aspiration is usually specifically aspiration pneumonia, the result of material passing into the lungs and causing infection. Pneumonia is a major cause of morbidity and mortality in the elderly, and is therefore perhaps the most important consideration. Malnutrition and dehydration are a result of the inability to ingest adequate amounts of food or liquid and are included in this model through logical inference rather than clinical evidence (to be discussed in depth later in this report). Major tube complications can lead to serious systemic morbidity such as gastric fistula, septicemia, peritonitis, or gastric hemorrhage. Treatment effects on the incidence of these morbidities are important to examine.

Section six of evidence model: Long-term outcomes

The ultimate concern in the diagnosis and treatment of any disorder is how the patient is ultimately affected: Does the patient live or die, and if the patient lives, is it a good life? These concerns are addressed in the evidence model by boxes O6 to O9:

• QOL
• Mortality (other)
• Mortality resulting from morbidity
• Mortality resulting from treatment (feeding tube)

QOL specifically addresses a concern about the ability of the elderly person to maintain an active, rewarding life although suffering from dysphagia. The measurement of QOL is a developing field, in which the patient's physical, psychological, and social well-being are assessed. From the patient perspective, this is perhaps the most important outcome to consider because it incorporates all outcomes, including death. Mortality (other) refers to patients who die of their underlying disease rather than from complications related to or resulting from the dysphagia problem. Mortality resulting from morbidity refers to those patients who die directly as a result of the morbidities outlined above: either from malnutrition, pneumonia, or an acute aspiration event. Mortality resulting from treatment refers specifically to those tube-fed patients who experience serious complications with the feeding tube and die as a result; all other treatments covered in this report are noninvasive and therefore do not include any directly related mortality. In this report, the effect of treatment on these long-term outcomes is examined.

Viewing the evidence model as a clinical pathway, and not as six discrete sections, highlights the fact that no single section should be reviewed separately from any other section. Further, to separately measure the effects of diagnosis and treatment of swallowing disorders on patients is not possible (see the section titled The Relationship between Diagnosis and Treatment of Swallowing Problems).

Question 1: How does diagnosis of dysphagia affect subsequent course of treatment and outcomes? (Level 5)

This question is a Level 5 question because it calls for assembling evidence or for studies that directly address the efficacy of a swallowing disorder program. As such, this question calls for one to directly link diagnostic methodologies to treatment and then to patient outcomes. Specifically, this question asks: When a particular diagnostic technology is used to direct treatment, how often do patients come down with pneumonia, become malnourished, or require a feeding tube after failed treatment? How many of these patients die or experience decreased quality of life? The ultimate purpose of any diagnostic and treatment program is to avoid such patient outcomes, and thus the focus of this question is of relatively great importance.

The specific links in the evidence model that address this question and the question represented by each link are:

Link D2-D8 to M1: How does the use of each of these diagnostic tests affect the rate of pneumonia in patients with dysphagia?

Link D2-D8 to M2: How does the use of each of these diagnostic tests affect the rate of malnutrition or dehydration in patients with dysphagia?

Link D2-D8 to O7: How does the use of each of these diagnostic tests affect the quality of life of patients with dysphagia?

Link D2-D8 to O9: How does the use of each of these diagnostic tests affect the rate of death due to dysphagia-related morbidities (pneumonia, malnutrition/dehydration)?

Link D2-D8 to T1-T4 to O1-O10: How does the use of each diagnostic to guide treatment affect outcomes after specific treatments?

Link D2-D8 to T1-T4 to M1 to M3: How does the use of each diagnostic to guide treatment affect morbidities after specific treatments?

Link D2-D8 to T1-T4: How are the results of diagnostic tests used to guide treatment?

Question 2: What are the appropriate indications for having patients diagnosed using a full BSE, MBS, or FEES? (Level 2)

This question is a Level 2 question because in asking how to selectively choose patients to undergo more extensive testing for dysphagia and aspiration, the question is about the sensitivities and specificities of a particular noninstrumented exam, and does not consider the efficacy of any treatment(s) that may result from this test or how patient management might be changed by the test results. Of interest in this question is whether particular signs and symptoms are detected during preliminary clinical or noninstrumented examination (general physical exam, preliminary BSE, etc.) that identify patients who would be most or least likely to benefit from further testing (patients who in particular are at risk for morbidities or mortality resulting from dysphagia or aspiration).

The links addressed by this question are:

Link D1-D4 to M1: Do particular signs or symptoms detected during a history and physical or preliminary BSE predict pneumonia?

Link D1-D4 to S1: Do particular signs or symptoms detected during a history and physical or preliminary BSE predict aspiration?

Question 3: Is there any evidence that one diagnostic technology (full BSE, MBS, etc.) provides more useful information than any other diagnostic? (Level 2)

This question is a Level 2 question because it is restricted to the sensitivity and specificity of each diagnostic modality and compares them with one another in their ability to predict pneumonia or aspiration. This question only addresses the ability of these tests to identify the probability for these problems and does not consider the effect of these technologies on patient outcomes.

The links that represent these issues are:

Link D2-D8 to M1: How well do each of these diagnostic methods predict pneumonia?

Link D2-D7 to S1: How well do each of these diagnostic methods predict chronic aspiration?

Question 4: When is noninvasive swallow therapy appropriate? Does it work particularly well or particularly poorly in any particular patient population? What can the evidence tell us about this therapy? Is PEG useful, or is it a last resort? (Level 4)

This question is a Level 4 question because it addresses the efficacy of different therapies for the treatment of dysphagia and which patients, if any, receive the most benefit from the therapies. It does not, however, address the efficacy of any diagnostic test.

Of interest are both short-term outcomes, such as physiological changes immediately detectable during or after treatment, as well as long-term outcomes, such as rate of morbidity and mortality. The long-term outcomes are more important, and are therefore the primary focus of this question.

Several links in the evidence model are important in answering this question:

Supplemental analysis: What is the cost-effectiveness of dysphagia diagnosis and treatment programs? (Level 6)

This question addresses the cost-effectiveness of dysphagia programs. Ideally, this sort of analysis is performed from a societal perspective, but such analyses require data that are often difficult to obtain (e.g., costs to family members to drive a patient to a care facility). Even though some data relevant to the strict societal perspective of a Level 6 question have not yet been collected, we will, nevertheless, treat this question as if it were Level 6. It is the only question to take both costs and effectiveness into account, so it is clearly of a higher level than our other questions.