Physical Mobility and Dysphagia Severity in the Elderly

Celine Raschilla celine.schirripa@oum.edu.ws

Abstract

Background: The purpose of the study performed was to determine if there was a positive correlation between physical mobility status and dysphagia outcomes within the elderly population (65 years and above) with oropharyngeal dysphagia. Previous research into this relationship exists primarily within the paediatric population and is more specifically with reference to paediatric neuromuscular conditions, however, the focus of our study was to identify whether similar findings will also apply to adult populations.

Methods: A retrospective review of client medical charts from an aged care facility within Western Australia was performed to gather data for this research. Participants were grouped based on mobility status as either; non-ambulant, semi-ambulant and ambulant. Corresponding evaluation of dysphagia was then determined and each participant was allocated a score from 0-5 (no dysphagia to severe dysphagia).

Results: A chi-square test for independence found that the frequency of dysphagia was significantly different with decreasing mobility status (X2 = 16.09, p= 0.0003, Cramer’s V=0.47). Further ANOVA analysis with an additional Turkey HSD test demonstrated a significant difference in mean dysphagia score (P<.05), specifically between the semi-ambulant and the non-ambulant group.

Conclusion: From these findings we were able to establish that with decreasing mobilising capacity, particularly in the jump from semi-ambulant (requiring minimal assistance) to complete assistance necessary such in the case of nonambulant, dysphagia presence and severity is more pronounced.

Background

Dysphagia; described generically as a difficulty with swallowing, can be further isolated and defined as oropharyngeal in aetiology and is associated with inability to safely and comfortably transition a food bolus from mouth to oesophagus [1]. Oropharyngeal dysphagia is well-known and established to affect older populations of individuals with much more significant epidemiology as compared to younger adults and children [1]. Australian and New Zealand statistics indicate that a significant proportion of older adults experience dysphagia, with estimates as high as a prevalence of 22% and an incidence of 40-50% for elderly adults who reside in residential or long-term care facilities [2]. Dysphagia has also been associated with consequent impact on quality of life of the individual as they may withdraw from enjoyable activities surrounding eating or drinking which can result in social isolation and low mood [3]. When factoring in the estimated incidence with the social and emotional impact of the condition the importance becomes highly evident for increasing our understanding of how to prevent dysphagia, its deterioration and subsequent outcomes.

Studies on the relationship between physical mobility and dysphagia have been explored in greater depth in the paediatric population, particularly within the medical context of Cerebral Palsy (CP) and much less so with adults. A study performed by Benfer et al. [4] investigated the prevalence of oropharyngeal dysphagia and its subtypes (oral phase, pharyngeal phase and saliva control) and the relationship between gross motor skills in preschool children with diagnosed Cerebral Palsy. They hypothesised that oropharyngeal dysphagia would be present in children across all levels of mobility status however with more severe physical mobility impairment there would likely be more severe oropharyngeal dysphagia. The study confirmed that oropharyngeal dysphagia was indeed present across all levels of gross motor severity [4] but that there was a significant increase in odds of having oropharyngeal dysphagia for children who were non-ambulant compared to those were ambulant. A further study performed by Kim et al. [5] explored the characteristics of dysphagia in children with Cerebral Palsy, related to gross motor function. They reported that in the more severely impaired mobility group characteristics such as reduced lip closure, inadequate bolus formation, residue in the oral cavity, delayed triggering of pharyngeal swallow, reduced larynx elevation, delayed pharyngeal transit time and aspiration were significantly more common. They reported that aspiration occurred in 50% of the children who had severe CP and corresponding gross motor disability compared to 14.3% with moderate and none with mild CP [5]. One study was found regarding the older adult population which utilised self-surveys in the context of Parkinson’s Disease, whereby the researchers found a significant association between declining gross motor function and dysphagia [6]. This was the only study however focusing this relationship within the older adult setting amongst the literature.

It is clear epidemiologically that dysphagia is highly prevalent in the elderly, however, the relationship between dysphagia and significant medical factors such as mobility is not well-established despite both sharing a function of the neuromuscular system. The singular, primary aim of this preliminary research was to establish whether a correlation between physical mobility and dysphagia was present, thus establishing the basis for future more in-depth research and guide clinical management and support positive health outcomes for this population. It was hypothesised in our study that elderly individuals with oropharyngeal dysphagia would likely experience worse dysphagia severity with poorer mobility status than those with better mobility status.

Methodology

The study was approved by the Institutional Review Board of Oceania University of Medicine which was inclusive of ethics approval. IRB reference number is 21-1010CR.

This preliminary study consisted of collecting data from chart review of eligible elderly participants within an aged care facility in Perth, Western Australia. Data was collected from within a sixmonth period that was inclusive of July 2022 to January 2023. Inclusion criteria of the study included; participants being over 65 years of age who reside in the aged care facility who of which had a dysphagia diagnosis of 6 months or greater to establish chronicity. Exclusion criteria included: Newly diagnosed dysphagia. Dysphagia aetiologies secondary to surgical intervention or an offending agent. Diagnoses of dysphagia clearly attributed to uniquely oropharyngeal pathology (e.g surgical structural interventions, oropharyngeal masses etc) and participants with dysphagia diagnoses clearly attributed to specific medications that cause oesophageal dysmotility (such as tetracyclines) were excluded from the study.

No materials were necessary to facilitate the study. Convenience sampling was utilised of all individual’s medical files residing at the facility unless they were deemed ineligible as per criteria to participate.

The participants were split into groups based on their mobility status which was: ambulatory (mobilising without assistance), semi-ambulatory (mobilising but required an assistant for transfers) and non-ambulatory (unable to mobilise without significant assistance). Within these groups, the participants were then provided a dysphagia severity rating ascertained from clinical assessment records ranging from: 0 (not present), 1 (mildly present), 2 (mild-to-moderate), 3 (moderate), 4 (moderate-to-severe) and 5 (severe). Severity was quantified based on the use of the IDDSI ([7]; see Appendices) classification which allocates various numerical degrees of diet texture and liquid modification (from levels 0 to 7) based on the physiological function of the oropharyngeal system. Within the IDDSI classification system, food textures fall into levels three to seven, with level 3 having the highest level of modification (liquidised consistency) to level 7 being unmodified or very minimally modified to be softer in consistency. These levels correspond to the participant having severe dysphagia through to essentially no presence of dysphagia, respectively. The IDDSI classification of liquids refers to levels zero to four, with level 0 being no modification (regular ‘thin’ fluids) through to level 4 which is extremely thick fluids, which are additionally allocated as per level of dysphagia severity ranging from no dysphagia to severe dysphagia. For the purposes of this study, participants were allocated their dysphagia score/severity based on their IDDSI modification prescription. Participants who were allocated levels 7 and 0 were labelled as no dysphagia. Participants allocated food level 6 or drink level 1/2 were considered to have mild dysphagia. Participants allocated food level 5 or drink level 3 were considered to have moderate dysphagia. Participants allocated food level 4 or drink level 4 were considered to have severe dysphagia. Participants were allocated as falling between the two most closely fitting severities when food and drink levels were not consistent (for example if a participant had been prescribed food level 6 (“mild”) and drink level 3 (“moderate”) they were then deemed as having a severity rating of 2 which was “mild-to-moderate”.

The data was analysed using a Chi square test of independence which was inclusive of dichotomous variable which in this study was the presence or absence of dysphagia. An ANOVA utilising mean dysphagia scores with post-hoc analysis was

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Results

There were 72 participants in the study, including 47 females (65%) and 25 males (35%), who ranged in age from 72 to 99 (M = 87.22, SD= 6.77). There were 41 ambulant participants, 10 semi-ambulant participants and 21 non-ambulant participants. Demographic data is further described in Table 1. Mobility status and corresponding dysphagia severities of participants expressed as percentages are delineated in Table 2. ANOVA analyses confirmed there was no statistical significance in ages between the groups.

The hypothesis of this project was to determine if a positive correlation between greater degrees of physical mobility and dysphagia existed within the elderly participants being studied. Statistical analyses of the gathered data were analysed using various modalities in order to establish whether there was significance present within the grouped data, which once determined was then further analysed in order to delineate where the significant relationship was found within the data. Post-hoc analyses were required to achieve this.

The initial analysis utilised the chi-square test for independence which found that the presence of dysphagia was significantly different with decreasing mobility status (2 = 16.09, p= 0.0003, Cramer’s V=0.47), thus allowing for refusal of the null hypothesis. Secondary analysis with one-way ANOVA using the mean dysphagia scores for each of the three mobility groups revealed that there were significant differences between groups with differing levels of mobility (F= 5.09, p=0.012). Post-hoc analysis demonstrated a significant relationship between the mean dysphagia score of the semi-ambulant group and the non-ambulant group (P<.05), visualised in Figure 1. From this data, we can establish that the decline in mobilising capacity from semi-impairment to complete impairment correlated with a significantly notable increase in dysphagia severity.

The results of this study positively shed light to the relationship that exists between impaired mobility and degree of oropharyngeal dysphagia severity, particularly with the step-decline from partial capacity to ambulate to inability to independently ambulate. Interestingly, a significant relationship was not found between the ambulant and semiambulant cohort or ambulant and non-ambulant cohort. This may highlight a possible distinctive clinical relevance with the final segmental loss of mobility, which in the greater picture may represent a clinical scenario of chronicity versus acute decline.

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