Purpose: The aim of this study was to develop an algorithm to assess the risk of developing aspiration pneumonia.
Subjects: Among those who were urgently admitted to the study hospital between April and August 2013 within 5 days after the onset of cerebral infarction or cerebral hemorrhage and who received conservative treatment without endotracheal intubation, we obtained consent for 160 patients to enter the study either directly from them or their families.
Methods: We performed this study with the approval of the study ethical review board of Aichi Prefectural University and the study hospital. We collected basic data on subjects as well as relevant data regarding aspiration pneumonia from the medical records. Physical examination, intraoral observation, bacterial count, and tongue fluid volume measurements were carried out every other day from the 2nd through 14th hospital day. All subjects were grouped into either a pneumonia group or a non-pneumonia group based on definite. Subsequently, based on the algorithm, we determined the aspiration pneumonia risk and calculated the sensitivity and specificity, defining the pneumonia group as the gold standard.
Results: One hundred and sixty subjects were classified into the pneumonia group (23 subjects; 16 developed aspiration pneumonia and 7 developed suspected aspiration pneumonia) and the non-pneumonia group (137 subjects). Fourteen subjects (87.5%) developed aspiration pneumonia by the 5th hospital day, for which we took particular note of the 2nd and 4th hospital days. Those determined as aspiration pneumonia-risk individuals by physical examination of the algorithm were 57 subjects on the 2nd hospital day and 60 subjects on the 4th hospital day. While the sensitivity and the specificity were 0.86 and 0.71 on the 2nd hospital day, they were 0.75 and 0.67 on the 4th hospital day, respectively. When there was tongue coating and secretion in the oral cavity on the 2nd hospital day, both the sensitivity and the specificity were 0.75. The inter-rater reliability on assessing each physical examination data was 82.0 to 95.3%, thus verifying reliability.
Conclusion: We developed an algorithm for assessing the risk of aspiration pneumonia, and showed that the algorithm appears to be valid. When subjects with aspiration risk were screened using the algorithm on the 2nd hospital day, sensitivity was 0.86 and specificity was 0.71. Furthermore, when tongue coating and secretion in the oral cavity were observed, both the sensitivity and specificity were 0.75.
Skeletal muscle mass decreasing and muscle weakness can cause long-term care needs for elderly people. The relationship between skeletal muscle status and muscles relevant to oral function has been little reported. Therefore, the aim of the present study was to survey skeletal muscle status, oral function, and the relationship between the two in community-dwelling elderly people.
Twenty-four community-dwelling elderly from two elderly associations in N city, T prefecture enrolled in the present survey (3 males, 21 females; mean age, 77.0±5.0 years). Skeletal muscle index (SMI) was used to assess skeletal muscle mass, grasping power to assess skeletal muscle strength. Oral function was evaluated in terms of jaw-opening force, diadochokinesis, the repetitive saliva swallowing test (RSST), and the modified water swallowing test (MWST). Correlations between parameters were analyzed using Spearman's correlation coefficient. Consequently stepwise regression analysis was performed with jaw-opening force as objective variable and SMI, grasping force, age and sex as explanatory variables.
The subjects were divided into two groups according to standards for grasping force: healthy and muscle weakness (male: ＜26 kgw; female: ＜18 kgw). Parameters were statistically compared between the two groups using the Mann-Whitney U test.
There were statistical relationships between SMI and jaw-opening force (r＝0.578, p＝0.003), grasping force and jaw-opening force (r＝0.640, p＝0.001), grasping force and the number of diadochokinetic movement of /ta/ (r＝0.447, p＝0.029). As a result of stepwise regression analysis, SMI was a factor that affects jaw-opening force.
In the muscle weakness group, jaw-opening force was less than the value in the healthy group ( p＝0.011). It is reasonable that an overall decrease in muscle mass would evoke decreases in muscle strength in both the extremities and the jaw-opening muscles.
We confirmed significant relationships between skeletal muscle mass, skeletal muscle strength, and oral function (i.e., jaw-opening force and tongue skilled movement) in Japanese community-dwelling elderly.
Introduction: We report a patient with a giant osteophyte, due to ankylosing spinal hyperostosis (ASH), causing severe dysphagia. This patient, who refused modified dysphagia diets and gastric fistula, regained oral intake ability with conservative therapies alone.
Patient: The patient, a 84-years-old man, underwent cervical laminoplasty (C3-6) via a posterior approach for cervical spondylotic myelopathy. After the operation, severe aspiration and pharyngeal stenosis developed. However, no other treatment than the use of modified dysphagia diets had been given before the patient was transferred to our hospital. Videofluoroscopic examination of swallowing (VF) on admission showed marked anterior protrusion of a beak-like osteophyte involving the C3-6 levels, poor laryngeal elevation, lack of epiglottic retroversion, and silent aspiration.
Course: VF was performed 3 times during hospitalization, confirming moderate improvement of the patient’s condition. However, we considered this patient to still be at extremely high risk of developing aspiration and thus repeatedly explained to him the urgent need for modified dysphagia diets. Nevertheless, the patient strongly insisted upon eating the foods of his choice; eventually, he was allowed to consume a normal diet and moderately thickened fluids on his own on condition that he maintained a sitting position with inclination of the trunk at an angle of 60°. Prior to discharge, we held a conference with the patient’s family doctor to share our concerns about the risk of aspiration at home. After discharge, home visits for rehabilitation by a speech-language pathologist from our hospital were continuously provided, once a week. At 6 months after discharge, decreased pharyngeal residue and further improvement of the swallowing reflex on VF were noted; the patient had very mild aspiration when eating in a sitting position with 60° tr unk inclination. No aspiration pneumonia developed during this 6-month period.
Discussion: We considered dysphagia to have worsened postoperatively due to inflammation associated with the cervical spine surgery that had affected the surrounding area. The patient received only conservative therapies such as swallowing rehabilitation and administration of anti-inflammatory analgesics, but showed greater-than-expected improvement in dysphagia, thereby regaining oral intake ability. For patients with dysphagia due to ASH, it appears to be worthwhile to consider whether conservative therapies are available option prior to immediate surgical treatment.