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ustralia
MULTICULTURALISM AND DYSPHAGIA
Progression of aspiration to pneumonia
Logically, it would seem that dysphagic patients who are very
sick are at higher risk of mortality than patients with swallow
ing impairment who are otherwise well; however, this
distinction is not clearly described in the literature (DeLegge,
2002). Despite an association between aspiration and the
development of pneumonia, it is not an inevitable sequence
(Cook & Kahrilas, 1999) even if subjects demonstrate aspiration
on modified barium swallow (Addington, Stephens, & Gil
liland, 1999; Teasell, McRae, Heitzner, Bhardwaj, & Finestone,
1999). It has been estimated that only 25% to 50% of all
aspirations progress to pneumonia (Cassiere, 1998). Most
mortality rates reported for aspiration pneumonia are in very
ill, hospitalised patients (DeLegge, 2002).
In a study of 304 acute stroke patients, 29 (9.5%) developed
aspiration pneumonia in the first year post stroke. Neither
penetration nor aspiration on videofluoroscopy correlated
with development of pneumonia (Johnson, McKenzie, &
Sievers, 1993). In a study using videofluoroscopy to examine
55 male patients within the 5 days post stroke, Daniels,
Brailey, Priestly, Herrington, Weisberg and Foundas (1998).
found aspiration occurred in 21 patients (38%) with 14 of
these aspirating silently. Notably only one patient developed
aspiration pneumonia during hospitalisation.
Low, Wyles, Wilkinson and Sainsbury (2001) found subjects
with documented aspiration who did not comply with
dysphagia recommendations were more likely to be admitted
to hospital with chest infections. However, they were not
statistically more likely to develop a chest infection or require
a course of antibiotics than those who always complied with
recommendations. The non-compliant subjects tended to be
younger, living at home and therefore presumably in better
general health (Low et al. 2001).
To date, there has been one randomised control trial in
vestigating the effect of access to free water by stroke patients
who were documented aspirators. The control group received
thickened fluids only, while the intervention group had all
liquids thickened, but were allowed free access to water in
addition to the thickened liquids. No patient in either group
developed pneumonia, dehydration or complications during
the study, or in a 30-day follow-up period (Garon, Eagle, &
Ormiston, 1997). However, participant numbers were small,
with only 10 subjects in each group, and the patients were at
least 3 weeks post stroke when enrolled in the study, so they
may have experienced some spontaneous recovery of swallow
function.
Aspiration pneumonia in paediatric
populations
An investigation into development of pneumonia in a paediatric
population with known dysphagia found that the impact of
aspiration on development of pneumonia is correlated with
the presence of other factors, such as gastroesophageal reflux,
asthma and Downs syndrome (Weir, McMahon, Barry, Ware,
Masters & Chang, 2007). However, a Cochrane database
investigation found there is currently insufficient evidence to
support or contradict use of free water in paediatric populations
(Weir, McMahon, & Chang, 2005).
Impact of aspiration of thickened liquids
A randomised control trial noted that patients who aspirated
very thick liquids were the most likely to go on to develop
pneumonia (DePippo, Holas, Reding, Mandel & Lesser, 1994).
A recent trial has also noted that participants who aspirated
honey thick fluids were at greater risk of developing
respiratory complications than those on thin fluids and on
nectar thick fluids (Robbins et al., 2008).
percutaneous endoscopic gastrostomy (PEG) tubes and 17.5%
of patients fed orally (Leibovitz, Plotnikov, Habot, Rosenberg,
& Segal, 2003).
A study of factors that predicted development of pneumonia
in a sample of 102,842 American nursing home residents
found 18 significant predictors. These included suctioning,
COPD, congestive heart failure (CHF), presence of a feeding
tube, bedfast, reduced alertness, weight loss, dysphagia,
number of medications/day, urinary tract infection (UTI) and
dependence for activities of daily living (ADLs). Compared to
an earlier study (Langmore et al. 1998), dependent for feeding,
presence of a feeding tube and number of medications were
significant predictor variables in both studies (Langmore,
Skarupski, Park, & Fries, 2002).
Dentures.
A study of 233 elderly in a long-term hospital ward
found 72% of patients who wore dentures had denture
stomatitis, while many of those with natural teeth were
affected by caries. They concluded high oral yeast counts and
prevalence of oral candidiasis were associated with poor oral
hygiene and neglect of denture care (Budtz-Jorgensen, Mojon,
Banon-Clement & Baehni, 1996).
Preston, Gosney, Noon, and Martin (1999) found a correlation
between presence of oral gram-negative bacteria and use of
dentures. Forty-three percent (n = 12) of subjects had intra-
oral gram-negative bacteria, and 43% had Candida albicans.
They found that 61% of subjects who wore dentures had
debris covering part of their denture (Preston et al., 1999).
Sumi, Sunakawa, Michiwaki, and Sakagami (2002) evaluated
the dentures of 50 dependant elderly patients who required
full assistance for denture care. They isolated aerobic bacteria
from all 50 patients, with potential respiratory pathogens
colonising dental plaque in 23 of 50 cases (Sumi, 2002).
Saliva and xerostomia.
Saliva plays an important role in homeo
stasis (“state of balance”) of the oral cavity. It contains many
components including immunoglobulins, lactoferrin, lacto
peroxidase, lysozyme and proteins. Saliva provides a fluid
environment for lubrication of the oral cavity to aid in speech,
swallowing and cleansing of the oral tissues. Salivary proteins
possess antibacterial properties and inhibit microbial
adherence (immunoglobulins) (Diaz-Arnold & Marek, 2002).
Saliva seems to undergo chemical changes with ageing, with
the amount of ptyalin decreasing and mucin increasing,
causing saliva to become thick and viscous (Astor, Hanft, &
Ciocon, 1999). It has been reported that saliva production
does not decrease with normal ageing (Vissink, Spijkervet, &
Van Nieuw Amerongen, 1996), rather xerostomia (a lack of
saliva in the mouth) is a side effect of many of the medications
taken by the elderly; more than 400 medications are associated
with oral dryness (Diaz-Arnold & Marke, 2002). Multiple
medications are commonly prescribed to many older patients,
with resulting xerostomia a common problem (Sreebny &
Valdini, 1987).
Other causes of xerostomia include mouth breathing,
radiation therapy, dehydration and autoimmune diseases
(e.g., Sjogren’s syndrome), and systemic illness (e.g., diabetes,
nephritis and thyroid dysfunction) (Astor et al., 1999).
Xerostomia can lead to dysgeusia, glossodynia, sialadenitis,
cracking and fissuring of the oral mucosa and halitosis, difficulties
with denture retention and problems with mastication and
swallowing (Astor et al., 1999). The presence of saliva appears
to be a defence against colonisation with bacteria (Smaldone,
2001). There was a greater than two-fold increase in adherence
of Klebsiella pneumoniae to buccal cells of patients with
xerostomia compared with normal subjects and colonisation
by gram-negative bacteria in patients receiving head and neck
radiation treatments increasing from 8% prior to treatment to
36% during treatment (Gibson & Barrett, 1992).