ESPEN Congress Madrid 2018

Transcription

1 ESPEN Congress Madrid 2018 Dysphagia In Hospital Setting Nutritional Consequences Of Dysphagia I. Bretón (ES)

2 Nutritional consequences of oropharyngeal dysphagia Irene Bretón. Nutrition Unit. H. Gregorio Marañón. Madrid, Spain

3 Disclosures for Irene Bretón In compliance with COI policy, ESPEN requires the following disclosures to the session audience: Shareholder Grant / Research Support Consultant Employee Paid Instructor Speaker bureau Other No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare Abbott, Fresenius Kabi, Nutricia, Nestlé, Vegenat No relevant conflicts of interest to declare

4 Learning objectives: Know the relationship between dysphagia and malnutrition Know the consequences of dysphagia on food security and safety Understand the challenges of oral feeding in dysphagic patients

5 Introduction Oropharyngeal dysphagia is highly prevalent in hospitalized patients. Frequently under-diagnosed Higher risk Neurological diseases Head&Neck diseases Elderly Others: post- orotracheal intubation, drug therapy

6 Dysphagia in neurological diseases: prevalence Stroke % Parkinson s disease 11-81% ALS % ( % in bulbar form and % in spinal form) Multiple sclerosis 35-51% Burgos R. Et al. Clin Nutr 2018; 37:

7 Dysphagia in H&N cancer patients 60 70% of patients with HNC treated with CRT Prevelence of penetration and aspiration post CRT: 24-70% at 10 years. 4 clinical presentations: Type 1: transient dysphagia Type 2: chronic or long-term CTR dysphagia Type 3: late onset, progressive dysphagia Type 4:chronic progressive dysphagia Kraaijenga SA, Oral Oncol 2015; 51: Nguyen NP. Anticancer Res 2007; 27: Goldsmith T. Curr Opin Otolaryngol Head Neck Surg. 2018;26:

8 Dysphagia and anterior cervical fussion Singh et al, 2013 Stamer et al, 2014 Joseph JR, 2016 NIH database NIH database UHC database n Dysphagia prevalence commentaries 159,590 2,5% more common with use rhbmp. in older patients and in those with more comorbidities. 1,649,871 2,9% Higher risk of morbidity, LOS and cost 49,300 6,4% Higher risk of mortality, LOS; readmission, and costs Fountas, 2007 Retrospective ,5% 90% < 7 d Bazaz, et, 2002 prospective % 1m; 12,5% 12m Phone questionnarie Lee et al,2009 prospective m; 13,6 24m questionnarie Rihn et al, 2011 prospective 58 71% 12w; 8% 12w. questionnarie

9 Dysphagia following endotracheal intubation Dysphagia frequency ranged from 3% to 62% The highest dysphagia frequencies occurred following prolonged intubation and included patients across all diagnostic subtypes. Skoretz SA,Chest. 2010;137: Brown CVR. J Crit Care 2011, 26:e9 e13. Leder SB, Dysphagia 1998, 13:

10 Dysphagia in elderly population Independently living Evaluation method Prevelence Author, year screening % Holland, 2011; Roy, 2007; Bloem, 1990; Kawachima 2004 clinical exploration 23% Serra-Prat, 2011 Hospitalized AGU various % Cabre, 2014; Lee 1999 Hospitalized CAP clinical exploration % Cabre, 2010 Almiral, 2013 instrumental 75% Almiral, 2013 Institucionalized screening 40% Nogueira 2013 water-swallow-tes 38% Lin 2002 screening+clinical 51% Kalf 2012 Dementia reported by caregivers 19-30% Langmore 2007, Ikeda 2002 instrumental 57-84% Sug 2009, Langmore 2007 Clave P. Nat Rev Gastroenterol Hepatol. 2015; 12: Baijens LWJ. Clin Interven Aging 2016;11:

11 Clinical consequences of dysphagia depend on patient s clinical condition and underlying disease

12 Dysphagia Decrease in the efficacy of swallowing Decrease in the safety of swallowing

13 Dysphagia Decrease in the efficacy of swallowing Decrease in the safety of swallowing Malnutrition Dehydration Aspiration pneumonia

14 Dysphagia increases the risk of malnutrition and related complications

15 Decrease intake Anorexia Confusion, cognitive impairment, Apraxia Depression Dependency Dysphagia Nausea&vomiting Nill-per-mouth Social problems Malabsorption Of any cause Increase requirements Energy Protein Micronutrient Malnutrition

16 J Rehabil Med understand the nature d of this relationship. Dysphagia may contribute to the development of malnutrition following stroke. For those able to eat orally, fear of eating and/or choking, unwillingness to eat and the decreased palatability of texture-modifie diets may lead directly to inadequate intake; however, other factors that often accompany dysphagia may also impact indirectly on an individual s desire or ability to eat. Depending on the location of stroke, fatigue, motor impairment, visuospatial perceptual, depression, and dysphagia, while also noting that right-arm motor deficits dependency in self-care were better predictors of undernu tion 3 weeks post-stroke than eating problems. While it been demonstrated previously that subjects with neuroge dysphagia have exhibited dysphagia-induced starvation evidenced by significant weight loss (32), the use of non-o feeding strategies, such as enteric feeding tubes, has beco more commonplace in recent years as a means for patients safe with oral intake to achieve their nutritional requireme Fig. 1. Pooled analysie the association betw dysphagia and malnutr following stroke. confidnce int erval. Foley NC. J Rehabil Med 2009; 41: 707 7

17 OR 95%CI p Malnutrition at admission 8, P<0,00001 Dysphagia p> Previous stroke P<0,00001 Diabetes Mellitus P< Tube feeding 5, P< Reduced level of conciuosness P< N. Chen et al. Clinical Nutrition. 2017; 1e9

18 Suominen M. Eur J CLin Nutr 59:478, 2005

19 Clinical consequences of malnutrition in patients with dysphagia Malnutrition is an independent risk factor for mortality Exacerbates atrophy, and dysfunction of extremity and respiratory muscles. Impairs muscle function and the recovery of swallowing ability Impairs immune function and increases the risk of pneumonia Increases the susceptibility of pressure sores Increases the risk of treatment toxicity Decreases the efficacy of the rehabilitation process Increases the risk of disability and dependence

20 Malnutrition can impair the recovery of swallowing capacity Acute stroke patients on enteral nutrition Long term tube-fed nursing home residents Nishioca S. Clin Nutr. 2017;36: Lee JSW, J Am Geriat Soc 52:1588, 2004

21 Malnutrition can impair the recovery of swallowing capacity dysphagia malnutrition Acute stroke patients on enteral nutrition Long term tube-fed nursing home residents Nishioca S. Clin Nutr. 2017;36: Lee JSW, J Am Geriat Soc 52:1588, 2004

22 Dysphagia can increase the risk of dehydration and related complications

23 Dysphagia and dehydration Dehydration is common in patients with dysphagia, but frequently under-diagnosed Prevalence is difficult to quantify because of lack of agreement for the standard clinical definition.

24 Dysphagia and dehydration Nausea/vomiting Diarrhoea poliuria Hyperthermia dyspnea Decrease fluid intake Decrease consciousness Cognitive impairment Dysphagia Functional dependency Self-imposed water restriction Nill-per-mouth/water restriction Dehydration Drug therapy Diuretics Sedatives Many others Vivanti AP, J Hum Nutr Diet. 2009;22(2): Whelan K. Clin Nutr. 2001;20(5): McGrail A, Rehabil Nurs. 2012;37(5): Crar MA. Dysphagia 2013; 28:69-76.

25 Confusion Dehydration: clinical consequences Altered functionality Renal failure Higher susceptibility to iatrogenia Alt. in oro-pharyngeal secretions Dysphagia Dyspnoea

26 Dehydration: clinical consequences Confusion Altered functionality Renal failure Higher susceptibility to iatrogenia Alt. in oro-pharyngeal secretions Dysphagia Dyspnoea dysphagia dehydration

27 Dysphagia increases the risk of aspiration pneumonia

28 Aspiration pneumonia No uniform definition Prevalence: 6-53% of all pneumonias Stroke NICUs %, MICUs 17 50%, stroke units %, mixed studies % and rehabilitation % ALS 14% H&N cancer 21% Hannawi Y. Cerebrovasc Dis 2013;35: Sorenson EJ. MN Amyotroph Lateral Scle 2007; 8:87-9 Kawai S. BMC Cancer. 2017; 17:59

29 Nationwide survey of geriatric medical and nursing center in Japan patients (median age: 86 years, women: 76%) Compared patients who had experienced an episode of aspiration pneumonia in the previous 3 months and those who had not. Manabe T. PLoS One 2015; 7:10 e

30 59 studies Nº studies Overall combined OR with p-value age ( ) p < male ( ) p = 0,001 NIHSS ( ) p < Dysphagia ( ) p < Nasogastric tube ( ) p < Diabetes ( ) p < Mec. ventilation ( ) p < Smoking ( ) p < COPD ( ) p = Atrial fibrilation ( ) p < Dysphagia screnning ( ) p = Hypertension ( ) p = Previous Stroke ( ) p = Wa stfelt et al. BMC Neurology; 2018:18:49

31 Dysphagia Aspiration Aspiration pneumonia

32 Dysphagia Malnutrition Aspiration Dehydration Muscle dysfunction Alteration immunity Oropharingeal colonization Aspiration pneumonia Age Antibiotics Hygiene Tobacco

33 Underlying diseases Dysphagia Malnutrition Aspiration Dehydration Muscle dysfunction Alteration immunity Oropharingeal colonization Aspiration pneumonia Age Antibiotics Hygiene Tobacco

34 Neurodegenerative disease Digestive consequences Metabolic consequences dysphagia Confusion Depression Lack of authonomy gastroparesia Hipermetabolism hyperglycemia aspiracion dehydration malnutrition Alt muscle function Alt oropharyngeal secretions Alt immunity Oropharingeal colonization Pneumonia Main cause of mortality Other factors: Age hygiene Antibiotics Alcohol-tobbaco use

35 Stroke-associated pneumonia Hannawi Y. Cerebrovasc Dis 2013;35:

36 Dysphagia Aspiration Aspiration pneumonia

37 Dysphagia increases the risk of mortality

38 Dysphagia and mortality One y. after stroke Five y. after stroke Post-intubation dysphagia stroke 28 d Ho CA, J. Stroke Cerebrovasc Dis. 2018;27: Hospitalized elderly 90 d Schefold JC. Crit Care Med 2017; 45: Carrion S. Clin Nutr, 2015; 34:

39 Dysphagia impairs Quality of Life

40 Dysphagia and quality of life Oropharingeal dysphagia can adversely affect quality of life, psychosocial function and mental well being in various patient populations. ALS Paris G. J Oral Rehabil. 2013; 40:199. Tabor L. Dysphagia. 2016; 3: Parkinson s disease Argolo N. Int J Lang Commun Disord 2015;50(5): Leow LP. Dysphagia 2010;25(3): Heijnen BJ. Dysphagia 2012;27(3): Ayres A. Int Arch Otorhinolaryngol 2016;20: Multiple sclerosis Klugman TM. F Phoniatrica et Logopaedica. 2002; 54(4):201. Head and neck cancer Lin BM. Laryngoscope. 2012; 122(7): Lee L-Y. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015; 119:

41 Dysphagia increases health-care costs

42 Dysphagia-related health costs in USA Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample ( ): 88 million Lenght of stay Dysphagia : 8.8 days (95% CI ) Non dysphagia: 5.0 days (95% CI ) (P < 0.001). Total in-patient costs A mean $6,243 higher among those with dysphagia ($19,244 vs. 13,001, P < 0.001). In-hospital mortality: 1.7 times more likely in patients with dysphagia Transfer to post-acute care facility: 33.2% more likely in patients with dysphagia Patel DA. Dis Esophagus. 2018;31(1):1-7.

43 Dysphagia increases health-care costs 11 studies (10 in USA, 1 in Taiwan ) Settings included surgical wards (n = 5), acute care (n = 3) inpatient rehabilitation (n = 1) Total of 1,850,406 individuals (46,013 dysphagia) Mean attributable cost of dysphagia across all eleven studies was USD$ 12,715. Increase of 40,36% in comparison to non-dysphagic patients. Attrill et al. BMC Health Services Research. 2018: 18:594

44 Dysphagia increases LOS 3,98 (3,41-4,54) days Attrill et al. BMC Health Services Research (2018; 18:594

45 Wu CP. Ann Am Thorac Soc Vol 14, , 2017

46 challenges of oral feeding in patients with dysphagia

47 Thickened fluids / Texture modified food Dysphagia efficacy safety

48 Level 1: pureed For moderate to severe dysphagia. The diet consists of pureed, homogeneous and cohesive foods. Foods should be pudding like. Any food that requires bolus formation, controlled manipulation or chewing should be excluded. Level 2: mechanically altered For mild to moderate oral and/or pharingeal dysphagia. This level consists of all foods from Level 1, plus foods that are moist, soft-textured and easily formed into a bolus. Pieces can be no larger from one-quarter inch. Some ability to chew is required. The ability to tolerate mixed tectures ar this level will be individualized. Level 3: Advanced For mild dysphagia. This level constis of most textures except very hard, sticky or crinchy foods. Foos should be still be moist and in bite-sice pieces. More chewing ability is required. National Dysphagia Diet Task Force (2002). American Dietetic Association

49 Need for standarization

50

51 Texture modified food and fluid can reduce the risk of aspiration 711 patients ages 50 to 95 years who aspirated on thin liquids on VFSS % aspiration on VFSS * * chin-down nectar honey Logemann JA. J Speech Lang Hear Res ; 51:

52 NIH-PA Author Manuscript NIH-PA Author Manuscript 47 hospitals and 79 subacute facilities. 515 patients >50 years dementia or Parkinson disease who aspirated thin liquids on VFS Randomized to: Chin-down posture Nectar texture Honey texture Robbins et al. Page 12 No differences in 3-month cumulative incidence of pneumonia Robbins JA. Ann Intern Med. 2008; 148(7): Figure 2. Cumulative incidence of pneumonia in the chin down posture and thickened liquid groups (P = 0.53, log-rank test).

53 challenges of oral feeding in patients with dysphagia Effect Adequate Compliance Monitoring Individualized on aspiration and residue intake of nutrients and fluid and quality of life approach!!

54 Burgos R. Et al. Clin Nutr 2018; 37:

55 Burgos R. Et al. Clin Nutr 2018; 37:

56 Burgos R. Et al. Clin Nutr 2018; 37:

57 Take home messages Dysphagia is a major risk factor for poor outcomes, including aspiration pneumonia, malnutrition, dehydration, reduced functional status, impaired quality of life and increased healthcare cost. Thickened fluid and texture modified food can be easier and safer to swallow for patients with dysphagia An individualized approach and monitoring is mandatory.

58 Thank you for your attention