Eating is not just swallowing: Redefining the “swallowing” process in the elderly Samantha Shune, PhD, CCC-SLP University of Oregon Jerald B. Moon, PhD University of Iowa November 20, 2014 Disclosures Financial Disclosures Funding sources: NIH-NIA 1F31AG042255 Executive Council of Graduate and Professional Students at the University of Iowa Acknowledgements Molly Cook; Shawn Goodman, PhD; many, many students and faculty at Iowa Preview Introduction Why is swallowing/nutrition important? What other factors are involved? Current Study Future Steps Clinical implications Research directions 1 Why should we care? What role does swallowing/nutrition play in our everyday lives? What would it mean to not be able to swallow safely or effectively? Biopsychosocial ramifications Why is this particularly important in our aging population? e.g., Altman et al., 2010; Ashford et al., 2009; Martino et al., 2005; Mick et al., 1991; Ney et al., 2009; Robbins et al., 1992 http://swallowingdisorderfoundation.com/swallow-a-documentary/ Four Phases of Swallowing Buettner A et al. Chem. Senses 2001;26:1211-1219 Oxford University Press 2 Sensorimotor Integration Sensory input is a vital component of the swallowing process Peripheral and central recognition of food Trigger for the swallow response (initiation) Modulate the motor response Pressure, taste, touch, temperature Bolus volume, consistency, viscosity, density, flavor e.g., Steele & Miller, 2010; Steele & Van Lieshout, 2004 Recognized importance in nursing literature Optimizing sensory input Providing visual and auditory assistance Maximizing body language and gestures Minimizing external distractions mealtime improvements in nursing home residents Not all oropharyngeal! Implications of feeding assistance? e.g., Eaton et al., 1986; Lange-Alberts & Shott, 1994; VanOrt & Phillips, 1992 Terminology Feeding vs Swallowing vs Eating 3 Other Components of Eating Pre-Oral/Anticipatory Phase Mastication arguably begins when foods and/or liquids meant for consumption are recognized Audition Cognition Olfaction Proprioception Vision Upper limb/physical mobility e.g., Leopold & Kagel, 1997; Maeda et al., 2004; Steele & Miller, 2010 What is the intention or final goal of the action? e.g., grasping to eat versus grasping to place (Cattaneo et al., 2007) Various individual- and environmental-level factors may ultimately influence later swallowing 4 Other Components of Eating (in elderly) Decreased nutrition does not (necessarily) mean a problem with swallowing, but still important to consider! Many other factors involved Physical changes Taste changes Disease Transportation Loneliness/grief Limit food choices/forget or choose not to eat limit nutrition and potential for malnutrition e.g., Toner et al., 2011 Dysphagia vs. Presbyphagia Dysphagia – disordered oropharyngeal swallowing Presbyphagia – characteristic alterations in swallowing mechanism in otherwise healthy older adults Aged, but healthy swallow NOT DISORDERED Presbyphagia Primary Aging Young versus Elderly Swallow: (http://vimeo.com/60944584) 5 Presbyphagia Masticatory, lingual, pharyngeal/laryngeal muscles Decreased maximal force, strength Increased variability in movements Decreased hyolaryngeal reserve Temporal Changes Prolonged oropharyngeal phase Delay in moving from oral to pharyngeal phase Uncoupling of phases increased variability in timing/ initiation e.g., McComas, 1998; Monemi et al., 1998; Logemann, 1998; Logemann et al., 2000; Ney et al., 2009; Rastatter et al., 1987; Robbins et al., 1992; Steele & Van Lieshout, 2009) Sensory (dys)function Increased discrimination thresholds Taste, temperature, tactile sensation, olfaction changes Decreased pharyngeal sensitivity Delay in initiation Increased penetration Sensory (dys)function – other Salivation (xerostomia) Proprioception Slower and more variable (upper) limb movements e.g., Adamo et al., 2007; Aviv, 1997; Chavez & Ship, 2000; Ney et al., 2009; Robbins et al., 1999 Questions What are the anticipatory motor patterns that occur during swallowing and eating? What are the implications of absent anticipatory information/cues? On a typical system? On a taxed system? What age-related changes in the anticipatory stage and the overall eating process occur? 6 The Current Study Participants 24 Younger Adults Ages 18-30 (M = 24.4, SD = 3.5) 12 females, 12 males 24 Older Adults Ages 70-85 (M = 76.1, SD = 4.5) 12 females, 12 males Methods Task Procedures Feeding Task Conditions: Sensory Present Cues Absent Independent Dependent Typical SelfFeeding Typical AssistedFeeding Sensory Loss Self-Feeding Sensory Loss Assisted-Feeding Variables of interest Onset of hand/arm movement (i.e., onset of the eating process) Onset of lower lip/jaw lowering Junction between gross motor and fine motor hand movement (i.e., the approximate onset of the oral stage of swallowing) Point of maximal lower lip/jaw lowering (prior to onset of closing gesture or offset of lip/jaw lowering) 7 Predictions: Lip/jaw complex movement will be linked to hand/ arm movement under typical eating conditions. Given complete or partial cue removal, lip/jaw onset will be delayed. Delay (or increased delay) in onset under all conditions will be present in older adults. Results – Question 1 What are the anticipatory motor patterns that occur during swallowing and eating? Durations of movement Variability in attention to cues Durations of anticipatory movements in the typical selffeeding condition 8 What anticipatory stage “cues” influence the timing of oral movement? Onset of hand movement? Change in direction of hand movement? Older adults: Hand onset for lowering onset Hand change for lowering offset Younger adults: Hand change for lowering offset Results – Question 2 What are the implications of absent anticipatory information/cues? Durations and timing of movement Lip lowering onset to hand onset 9 Lip lowering offset to hand change Discussion Anticipatory stage of swallowing Oral posturing begins prior to the onset of oral sensation System readying for bolus acceptance/the swallow Influenced by age and available sensory cues (proprioception, vision) Older adults’ “compensatory advantage” Further lowering Slower movement Decreased efficiency in online modifications Must attend to lowering onset 10 Both proprioception and visual cues crucial Proprioception onset Vision offset Both necessary for timing the final phase of motor execution Increased variability given the loss of either or both Implications/Future Directions Deglutition begins prior the onset of oral sensation Impact of sensory loss Feeding strategy recommendations Decrease in system readiness? Exacerbated given increased task demands and/or an already taxed system? Optimizing proprioceptive and visual cues Decreasing distractions/increasing attention How do these strategies impact the entire process of deglutition? Swallowing assessment 11 Future Directions Mealtime success as a function of ??? Social enjoyment Communicative success Decreased adverse behaviors Nutritional intake Others? Interaction between “survival” and QOL Changing family dynamics Changes in self-identity Gender specific? Age specific? Culturally based? Age Conversation tion n Mealtime Gender G Feeding Swallowing Health Environment Social Soci ial Interaction Inter eraccti ction ctio Relationships 12 Interestingly, factors shown to enhance quality of life have also been shown to increase survival. Nutrition Swallow function Social engagement Communicative function e.g., Holt-Lunstad et al., 2010; Karvonen-Gutierrez et al., 2008; Mick et al., 1991; Ney et al., 2009; Shune et al., 2012 Our Objective How can we integrate the physiologic components of swallowing with a more holistic view of the shared meal in order to promote mealtime safety and socio-emotional connectedness for our rapidly growing population of older adults? Leading to enhanced survival AND quality of life Age Conversation Mealt ttii Mealtime Gender Feeding Fee F eedi Swallow Swallowing win wi Health Environment Social Soci iaall Interaction I te ter e actio era ctiio io Relationships Swallowing lowing 13 Questions and Thoughts? sshune@uoregon.edu References Adamo, D.E. et al., (2007). Age-related differences in upper limb proprioceptive acuity. Perceptual Motor Skills, 104, 1297-1309. Ashford, J. et al. (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part III--impact of dysphagia treatments on populations with neurological disorders. J Rehab Res Dev, 46(2), 195-204. Aviv, J. (1997). Effects of aging on sensitivity of the pharyngeal and supraglottic areas. Am J Med, 103(5A), 74S-76S. Chavez & Ship, 2000 Eaton, M. et al. (1986). The effect of touch on nutritional intake of chronic organic brain syndrome patients. J Gerontology, 41(5), 611-616. Humbert, I.A. et al. (2009) Neurophysiology of Swallowing: Effects of Age and Bolus Type. NeuroImage, 44, 982-991. Lange-Alberts, M.E. & Shott, S. (1994). Nutritional intake. use of touch and verbal cuing. J Gerontological Nursing, 20(2), 36-40. Leopold, N.A. & Kagel, M.C. (1997). Dysphagia--ingestion or deglutition?: A proposed paradigm. Dysphagia, 12, 202-206. Logemann, J.A. (1998). Evaluation and treatment of swallowing disorders. Austin, TX: PRO-ED. Logemann, J.A. et al. (2000). Temporal and biomechanical characteristics of oropharyngeal swallow in younger and older men. J Speech Lang Hear Res, 43(5), 1264-1274. Maeda, K. et al. (2004). Modulation of voluntary swallowing by visual inputs in humans. Dysphagia, 19, 1-6. Malandraki, G.A. et al. (2011). Reduced somatosensory activations in swallowing with age. Hum Brain Map, 32, 730-743. Malandraki, G.A. et al. (2010). Age-related differences in laterality of cortical activations in swallowing. Dysphagia, 25, 238-249. Martino et al., 2005 McComas,A.J. (1998). Oro-facial muscles: Internal structure, function and ageing. Gerodontology, 15(1), 3-14. Mick, R et al. (1991). Prognostic factors in advanced head and neck cancer patients undergoing multimodality therapy. Otolaryngol Head Neck Surg, 105, 62-73. Monemi, M. et al. (1998). Adverse changes in fibre type composition of the human masseter versus biceps brachii muscle during aging. J Neurol Sci, 154, 35-48. Ney, D. et al. (2009). Senescent swallowing: Impact, strategies, and interventions. Nutrit Clin Practice, 24(3), 395-413. Rastatter, M.P. et al.(1987). Speech-motor equivalence in aging subjects'. Perceptual Motor Skills, 64(2), 635-638. Robbins, J. et al. (1999). Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia, 14, 228-232. Robbins, J. et al. (1992). Oropharyngeal swallowing in normal adults of different ages. Gastroenterology, 103(3), 823-829. Steele, C., & Miller, A. (2010). Sensory input pathways and mechanisms in swallowing: A review. Dysphagia, 25(4), 323-333. Steele, C., & Van Lieshout, P. (2004). Influence of bolus consistency on lingual behaviors in sequential swallowing. Dysphagia, 19(3), 192-206. Steele, C., & Van Lieshout, P. (2009). Tongue movements during water swallowing in healthy young and older adults. J Speech Lang Hear Res, 52(5), 1255-1267. Teismann, I.K. et al. (2010). Neurobiol Aging, 31, 1044-1050. Toner, M.A. et al. (2011). Aging and Communication, 2nd ed. Austin, TX: Pro-Ed. VanOrt, S. & Phillips, L. (1992). Feeding nursing home residents with Alzheimer's disease. Ger Nurs, 13(5), 249-253. 14
