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Dysphagia
Published in: Dysphagia 2/2022

Open Access 01-04-2022 | Dysphagia | Original Article

White Paper by the European Society for Swallowing Disorders: Screening and Non-instrumental Assessment for Dysphagia in Adults

Authors: Renée Speyer, Reinie Cordier, Daniele Farneti, Weslania Nascimento, Walmari Pilz, Eric Verin, Margaret Walshe, Virginie Woisard

Published in: Dysphagia | Issue 2/2022

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Abstract

This White Paper by the European Society for Swallowing Disorders (ESSD) reports on the current state of screening and non-instrumental assessment for dysphagia in adults. An overview is provided on the measures that are available, and how to select screening tools and assessments. Emphasis is placed on different types of screening, patient-reported measures, assessment of anatomy and physiology of the swallowing act, and clinical swallowing evaluation. Many screening and non-instrumental assessments are available for evaluating dysphagia in adults; however, their use may not be warranted due to poor diagnostic performance or lacking robust psychometric properties. This white paper provides recommendations on how to select best evidence-based screening tools and non-instrumental assessments for use in clinical practice targeting different constructs, target populations and respondents, based on criteria for diagnostic performance, psychometric properties (reliability, validity, and responsiveness), and feasibility. In addition, gaps in research that need to be addressed in future studies are discussed. The following recommendations are made: (1) discontinue the use of non-validated dysphagia screening tools and assessments; (2) implement screening using tools that have optimal diagnostic performance in selected populations that are at risk of dysphagia, such as stroke patients, frail older persons, patients with progressive neurological diseases, persons with cerebral palsy, and patients with head and neck cancer; (3) implement measures that demonstrate robust psychometric properties; and (4) provide quality training in dysphagia screening and assessment to all clinicians involved in the care and management of persons with dysphagia.
Footnotes
1
Methodologies and interpretation of Classic Test Theory (CTT) findings are easier to interpret than those of Item Response Theory (IRT); however, the CTT framework has some limitations. In IRT the unit of analysis and results are not restricted to the test population, whereas in CTT the evaluation of psychometric properties is specific to the test population. In addition, IRT evaluates the reliability of each individual item, while CTT assesses the performance of a measure as a whole [43]. IRT models estimate both item and person parameters within the same model, calculate person-free parameter estimation and item-free trait level estimation, and identify optimal scaling of individual differences based on the evaluation of differential item functioning [44].
 
2
The Delphi technique is a structured process which aims to develop group consensus on a defined topic through a series of survey rounds [107]. The same participants complete each round (although some individuals may discontinue participating). Rounds are held until consensus is reached (or it becomes apparent that consensus cannot be reached). Results from previous rounds are used to inform participants about changes that may facilitate consensus in subsequent rounds [108]. Using the Delphi technique enables large number of individuals across diverse locations and areas of expertise to be included anonymously, thus avoiding domination of the consensus process by one or a few experts [107].
 
Literature
1.
Shaker R. Oropharyngeal dysphagia. Gastroenterology & Hepatology. 2006;2(9):633–4.
2.
Roden DF, Altman KW. Causes of dysphagia among different age groups. Otolaryngol Clin North Am. 2013;46(6):965–87.PubMed
3.
Martino R, et al. Dysphagia after stroke. Stroke. 2005;36(12):2756–63.PubMed
4.
Vergis EN, et al. Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival. Arch Intern Med. 2001;161:2378–81.PubMed
5.
Jean A. Brain stem control of swallowing: neuronal network and cellular mechanisms. Physiol Rev. 2001;81(2):929–69.PubMed
6.
Kertscher B, et al. Prevalence of oropharyngeal dysphagia in the Netherlands: a telephone survey. Dysphagia. 2015;30(2):114–20.PubMed
7.
Takizawa C, et al. A systematic review of the rrevalence of oropharyngeal dysphagia in stroke, Parkinson’s disease, Alzheimer’s disease, head injury, and pneumonia. Dysphagia. 2016;31(3):434–41.PubMed
8.
Attrill S, et al. Impact of oropharyngeal dysphagia on healthcare cost and length of stay in hospital: a systematic review. BMC Health Serv Res. 2018;18(1):594.PubMedPubMedCentral
9.
Johnston, B.C, et al. Chapter 18: Patient-reported outcomes, in Cochrane handbook for systematic reviews of interventions, J.P.T. Higgins and J. Thomas, Editors. 2019, Cochrane.
10.
Prinsen CAC, et al. How to select outcome measurement instruments for outcomes included in a “Core Outcome Set” – a practical guideline. Trials. 2016;17(1):449.PubMedPubMedCentral
11.
Bours, G.J.J.W, et al. Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders systematic review. J Adv Nurs. 2009;65(3):477–93.
12.
Kertscher B, et al. Bedside screening to detect oropharyngeal dysphagia in patients with neurological disorders: an updated systematic review. Dysphagia. 2014;29(2):204–12.PubMed
13.
Martino R, et al. The Toronto Bedside Swallowing Screening Test (TOR-BSST). Stroke. 2009;40(2):555–61.PubMed
14.
15.
Clavé P, et al. Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration. Clin Nutr. 2008;27(6):806–15.PubMed
16.
Baijens LWJ, et al. FEES protocol derived estimates of sensitivity: aspiration in dysphagic patients. Dysphagia. 2014;29(5):583–90.PubMed
17.
Trapl M, et al. Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke. 2007;38:2948–52.PubMed
18.
Newman R, et al. Effect of bolus viscosity on the safety and efficacy of swallowing and the kinematics of the swallow response in patients with oropharyngeal dysphagia: white paper by the European Society for Swallowing Disorders (ESSD). Dysphagia. 2016;31(2):232–49.PubMedPubMedCentral
19.
Speyer R, et al. Prevalence of drooling, feeding and swallowing problems in cerebral palsy across the lifespan: systematic review and meta-analysis. Dev Med Child Neurol. 2019;61:1249–58.PubMed
20.
van der Maarel-Wierink CD, et al. Subjective dysphagia in older care home residents: a cross-sectional, multi-centre point prevalence measurement. Int J Nurs Stud. 2014;51:875–81.PubMed
21.
Summers D, et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke. 2009;40:2911–44.PubMed
22.
Speyer R. Oropharyngeal dysphagia: screening and assessment. Otolaryngol Clin North Am. 2013;46(6):989–1008.PubMed
23.
Donovan NJ, et al. Dysphagia Screening: State of the Art: Invitational Conference Proceeding From the State-of-the-Art Nursing Symposium, International Stroke Conference 2012. Stroke. 2012;44:e24–31.
24.
Mokkink, L.B., et al., COSMIN methodology for systematic reviews of Patient‐Reported Outcome Measures (PROMs)-User manual (version 1.0). 2018.
25.
Mokkink LB, et al. The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. J Clin Epidemiol. 2010;63(7):737–45.PubMed
26.
Bouter LM, Zielhuis G, Zeegers M, Diagnostic and prognostic research. Bohn. Houten: Stafleu van Loghum; 2018. p. 171–201.
27.
Chen P-C, et al. Systematic review and meta-analysis of the diagnostic accuracy of the water swallow test for screening aspiration in stroke patients. J Adv Nurs. 2016;72(11):2575–86.PubMed
28.
Zhou XH, Obuchowski NA, McClish DK, Statistical methods in diagnostic medicine. Hoboken. NJ: John Wiley & Sons Inc; 2011.
29.
Swan K, et al. Psychometric properties of visuoperceptual measures of videofluoroscopic and fibre-endoscopic evaluations of swallowing: a systematic review. Dysphagia. 2019;34(1):2–33.PubMed
30.
Scharitzer M, et al. Taking the history in patients with swallowing disorders: an international multidisciplinary survey. Abdominal Radiology. 2017;42(3):786–93.PubMed
31.
Cichero J. Respiration and swallowing. In: Cichero J, Murdoch B, editors. Dysphagia: foundation, theory and practice. Inc: John Wiley & Sons; 2006. p. 92–111.
32.
Ferrans CE, et al. Conceptual model of health-related quality of life. J Nurs Scholarsh. 2005;37(4):336–42.PubMed
33.
Porter I, et al. Framework and guidance for implementing patient-reported outcomes in clinical practice: evidence, challenges and opportunities. Journal of Comparative Effectiveness Research. 2016;5(5):507–19.PubMed
34.
Reuben DB, Tinetti ME. Goal-oriented patient care — an alternative health outcomes paradigm. N Engl J Med. 2012;366(9):777–9.PubMed
35.
van der Wees PJ, et al. Development of a framework with tools to support the selection and implementation of patient-reported outcome measures. Journal of Patient-Reported Outcomes. 2019;3(1):75–75.PubMedPubMedCentral
36.
Speyer R, et al. Psychometric properties of questionnaires on functional health status in oropharyngeal dysphagia: a systematic literature review. Biomed Res Int. 2014;2014:1–11.
37.
Timmerman AA, et al. Psychometric characteristics of health-related quality-of-life questionnaires in oropharyngeal dysphagia. Dysphagia. 2014;29(2):183–98.PubMed
38.
Cordier R, et al. Evaluating the psychometric properties of the Eating Assessment Tool (EAT-10) using Rasch analysis. Dysphagia. 2017;32(2):250–60.PubMed
39.
Cordier R, et al. Using Rasch analysis to evaluate the reliability and validity of the Swallowing Quality of Life Questionnaire: an item response theory approach. Dysphagia. 2018;33(4):441–56.PubMed
40.
Hansen T, Kjaersgaard A. Item analysis of the Eating Assessment Tool (EAT-10) by the Rasch model: a secondary analysis of cross-sectional survey data obtained among community-dwelling elders. Health Qual Life Outcomes. 2020;18(1):139.PubMedPubMedCentral
41.
Wilmskoetter J, et al. Construct validity of the Eating Assessment Tool (EAT-10). Disabil Rehabil. 2019;41(5):549–59.PubMed
42.
Kean J, et al. An introduction to item response theory and Rasch analysis: application using the Eating Assessment Tool (EAT-10). Brain Impairment. 2018;19(1):91–102.PubMed
43.
Linacre, J.M., Rasch-model computer programs: Program manual 3.92.0. 2016, Chicago: Mesa-Press.
44.
Reise S, Henson J. A discussion of modern versus traditional psychometrics as applied to personality assessment scales. J Pers Assess. 2003;81(2):93–103.PubMed
45.
Dwivedi RC, et al. Validation of the Sydney Swallow Questionnaire (SSQ) in a cohort of head and neck cancer patients. Oral Oncol. 2010;46(4):e10–4.PubMed
46.
McHorney CA, et al. The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III. Documentation of reliability and validity Dysphagia. 2002;17(2):97–114.PubMed
47.
Silbergleit AK, et al. The Dysphagia Handicap Index: development and validation. Dysphagia. 2012;27(1):46–52.PubMed
48.
Woisard, V., M.P. Andrieux, and M. Puech, Validation of a self-assessment questionnaire for swallowing disorders (Deglutition Handicap Index). Revue de Laryngologie - Otologie - Rhinologie, 2006. 127(5).
49.
Chen, A.Y., et al. The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer the M D Anderson Dysphagia Inventory. Arch Otolaryngol Head Neck Surg. 2001;127(7):870–6.
50.
51.
van der Maarel-Wierink CD, et al. Risk factors for aspiration pneumonia in frail older people: a systematic literature review. J Am Med Dir Assoc. 2011;12(5):344–54.PubMed
52.
van der Maarel-Wierink CD, et al. Meta-analysis of dysphagia and aspiration pneumonia in frail elders. J Dent Res. 2011;90(12):1398–404.PubMed
53.
van der Maarel-Wierink CD, et al. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology. 2013;30(1):3–9.PubMed
54.
Noguchi S, et al. Using oral health assessment to predict aspiration pneumonia in older adults. Gerodontology. 2018;35:110–6.PubMed
55.
Ortega O, Clavé P. Oral hygiene, aspiration, and aspiration pneumonia: from pathophysiology to therapeutic strategies. Current Physical Medicine and Rehabilitation Reports. 2013;1:292–5.
56.
Seedat, J. and C. Penn, Implementing oral care to reduce aspiration pneumonia amongst patients with dysphagia in a South African setting. South African Journal of Communication Disorders, 2016. 63(1).
57.
Mittal H, et al. Patient-reported outcome measures for adult dental patients: a systematic review. Journal of Evidence Based Dental Practice. 2019;19(1):53–70.PubMed
58.
Slade GD, Spencer AJ. Development and evaluation of the Oral Health Impact Profile. Community Dent Health. 1994;11(1):3–11.PubMed
59.
World Health Organization, Oral health surveys: basic methods. 2013, World Health Organization. p. 125.
60.
Cho SY, et al. Prevalence and risk factors for dysphagia: a USA community study. Neurogastroenterol Motil. 2015;27(2):212–9.PubMed
61.
Kendall KA. Airway closure delay: the predominant pathophysiology in reflux-associated dysphagia. Otolaryngology-Head and Neck Surgery. 2019;160(5):885–90.PubMed
62.
Bolier EA, et al. Systematic review: questionnaires for assessment of gastroesophageal reflux disease. Dis Esophagus. 2015;28(2):105–20.PubMed
63.
Jones R, Coyne K, Wiklund I. The Gastro-oesophageal reflux disease Impact Scale: a patient management tool for primary care. Aliment Pharmacol Ther. 2007;25(12):1451–9.PubMed
64.
Shaw MJ, et al. Initial validation of a diagnostic questionnaire for gastroesophageal reflux disease. Am J Gastroenterol. 2001;96(1):52–7.PubMed
65.
Vakil NB, et al. Systmatic review of patient-reported outcome instruments for gastroesophageal reflux disease symptoms. Eur J Gastroenterol Hepatol. 2013;25:2–14.PubMed
66.
Murry T, Carrau RL. Clinical manual of swallowing disorders. Singular Thomson Learning: San Diego; 2001.
67.
Miller, J.A., Sensory system: peripheral and central connections, in The neuroscientific principles of swallowing and dysphagia. 1999, Singular San Diego.
68.
Farneti, D. and E. Genovese, Correlations between bedside and instrumental endoscopic parameters in determining severity of dysphagia: an integrated clinical evaluation of safety and efficiency. Acta Otorhinolaryngologica Italica, [In press].
69.
German, R.Z. and J.B. Palmer, Anatomy and development of oral cavity and pharynx. GI Motility online, 2006.
70.
Morquette P, et al. Generation of the masticatory central pattern and its modulation by sensory feedback. Prog Neurobiol. 2012;96:340–55.PubMed
71.
Kahrilas JK, et al. Oropharyngeal accommodation to swallow volume. Gastroenterology. 1996;111:297–306.PubMed
72.
Tsumori N, et al. Morphologic characteristics of the superior pharyngeal constrictor muscle in relation to the function during swallowing. Dysphagia. 2007;22(2):122–9.PubMed
73.
Grillner S, et al. Mechanisms for selection of basic motor programs roles for the striatum and pallidum. Trends Neurosci. 2005;28(7):364–70.PubMed
74.
Walshe M, Ryan M, Regan J. Screening for dysphagia: perspectives and practices of speech and language therapists in the Republic of Ireland. Folia Phoniatr Logop. 2017;69(5–6):226–38.PubMed
75.
Farneti D, Turroni V, Genovese E. Aspiration: diagnostic contributions from bedside swallowing evaluation and endoscopy. Acta Otorhinolaryngol Ital. 2018;38:511–6.PubMedPubMedCentral
76.
Virvidaki IE, et al. Swallowing and aspiration risk: a critical review of non instrumental bedside screening tests. Journal of Clinical Neurology. 2018;14(3):265–74.PubMedPubMedCentral
77.
McCullough GH, et al. Utility of clinical/swallowing examination measures for detecting aspiration post-stroke. J Speech Lang Hear Res. 2005;48:1280–93.PubMed
78.
Crary MA, Mann GD, Groher ME. Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil. 2005;86(8):1516–20.PubMed
79.
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.PubMed
80.
Borson S, et al. The Mini-Cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15:1021–7.PubMed
81.
Mann G. The Mann Assessment of Swallowing Ability. New York: Singular/Thomson Learning; 2002.
82.
Carnaby GD, Crary MA. Development and validation of a cancer-specific swallowing assessment tool: MASA-C. Support Care Cancer. 2014;22(3):595–602.PubMed
83.
Chalmers JM, et al. The Oral Health Assessment Tool — Validity and reliability. Aust Dent J. 2005;50(3):191–9.PubMed
84.
Gillman A, Winkler R, Taylor NF. Implementing the free water protocol does not result in aspiration pneumonia in carefully selected patients with dysphagia: a systematic review. Dysphagia. 2017;32(3):345–61.PubMed
85.
Langmore SE. Why I like the free water protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2011;20(4):116–20.
86.
Palmer PM, et al. Effects of a sour bolus on the intramuscular electromyographic (EMG) activity of muscles in the submental region. Dysphagia. 2005;20(3):210–7.PubMed
87.
Sdravou K, Walshe M, Dagdilelis L. Effects of carbonated liquids on oropharyngeal swallowing measures in people with neurogenic dysphagia. Dysphagia. 2012;27(2):240–50.PubMed
88.
Cola PC, et al. Taste and temperature in swallowing transit time after stroke. Cerebrovascular Diseases Extra. 2012;2(1):45–51.PubMedPubMedCentral
89.
Teismann IK, et al. Tactile thermal oral stimulation increases the cortical representation of swallowing. BMC Neurosci. 2009;10(1):71–71.PubMedPubMedCentral
90.
Huckabee ML, et al. The Test of Masticating and Swallowing Solids (TOMASS): reliability, validity and international normative data. Int J Lang Commun Disord. 2018;53(1):144–56.PubMed
91.
Lambert HC, et al. McGill Ingestive Skills Assessment (MISA): development and first field test of an evaluation of functional ingestive skills of elderly persons. Dysphagia. 2003;18(2):101–13.PubMed
92.
Sheppard JJ, Hochman R, Baer C. The Dysphagia Disorder Survey: validation of an assessment for swallowing and feeding function in developmental disability. Res Dev Disabil. 2014;35(5):929–42.PubMed
93.
Hansen T, Lambert HC, Faber J. Validation of the Danish version of the McGill Ingestive Skills Assessment using classical test theory and the Rasch model. Disabil Rehabil. 2012;34(10):859–68.PubMed
94.
Speyer R, et al. Psychometric characteristics of non-instrumental swallowing and feeding assessments in pediatrics: a systematic review using COSMIN. Dysphagia. 2018;33(1):1–14.PubMed
95.
Britton D, et al. Utility of pulse oximetry to detect aspiration: an evidence-based systematic review. Dysphagia. 2018;33(3):282–92.PubMed
96.
Lagarde MLJ, Kamalski DMA, van den Engel-Hoek L. The reliability and validity of cervical auscultation in the diagnosis of dysphagia: a systematic review. Clin Rehabil. 2016;30(2):199–207.PubMed
97.
Bateman C, Leslie P, Drinnan MJ. Adult dysphagia assessment in the UK and Ireland: Are SLTs assessing the same factors? Dysphagia. 2007;22(3):174–86.PubMed
98.
Martino, R., G. Pron, and N. Diamant, Oropharyngeal dysphagia: surveying practice patterns of the speech language pathologist. Dysphagia, 2004. 19(3).
99.
Rumbach A, Coombes C, Doeltgen S. A survey of Australian dysphagia practice patterns. Dysphagia. 2018;33(2):216–26.PubMed
100.
Mokkink LB, et al. COSMIN risk of bias checklist for systematic reviews of patient-reported outcome measures. Qual Life Res. 2018;27(5):1171–9.PubMed
101.
Prinsen CAC, et al. COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual Life Res. 2018;27(5):1147–57.PubMedPubMedCentral
102.
Terwee CB, et al. COSMIN methodology for evaluating the content validity of patient-reported outcome measures: a Delphi study. Qual Life Res. 2018;27(5):1159–70.PubMedPubMedCentral
103.
Bergamaschi R, et al. The DYMUS questionnaire for the assessment of dysphagia in multiple sclerosis. J Neurol Sci. 2008;269(1–2):49–53.PubMed
104.
Koller M, et al. The process of reconciliation: evaluation of guidelines for translating quality-of-life questionnaires. Expert Rev Pharmacoecon Outcomes Res. 2012;12(2):189–97.PubMed
105.
Speyer R, et al. The effects of telehealth by allied health professionals and nursing in rural and remote areas: A systematic review and meta-analysis. J Rehabil Med. 2018;50(3):225–35.PubMed
106.
Burns CL, et al. Implementation of speech pathology telepractice services for clinical swallowing assessment: an evaluation of service outcomes, costs and consumer satisfaction. J Telemed Telecare. 2019;25(9):545–51.PubMed
107.
Boulkedid R, et al. Using and reporting the Delphi method for selecting healthcare quality indicators: A systematic review. PLoSONE. 2011;6:e20476.
108.
Tapio P, et al. The unholy marriage? Integrating qualitative and quantitative information in Delphi processes. Technol Forecast Soc Chang. 2011;78:1616–28.
109.
Massey, B.T., Physiology or oral cavity, pharynx and upper esophageal sphincter. GI Motility online, 2006.
110.
Damodaran O, et al. Cranial nerve assessment: a concise guide to clinical examination. Clin Anat. 2014;27:25–30.PubMed
111.
Gray, H, et al. Gray's Anatomy: The anatomical basis of clinical practice. 39th ed. 2005, Edinburgh: Elsevier Churchill Livingstone. p. 1627.
112.
Whiting PF, et al. QUADAS-2: A revised tool for the Quality Assessment of Diagnostic Accuracy Studies. Ann Intern Med. 2011;155(8):529–36.PubMed
Metadata
Title
White Paper by the European Society for Swallowing Disorders: Screening and Non-instrumental Assessment for Dysphagia in Adults
Authors
Renée Speyer
Reinie Cordier
Daniele Farneti
Weslania Nascimento
Walmari Pilz
Eric Verin
Margaret Walshe
Virginie Woisard
Publication date
01-04-2022
Publisher
Springer US
Published in
Dysphagia / Issue 2/2022
Print ISSN: 0179-051X
Electronic ISSN: 1432-0460
DOI
https://doi.org/10.1007/s00455-021-10283-7

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