ANÁLISIS INTERNO DE LOS SISTEMAS DE PRODUCCIÓN DE COLÁCTEOS

Changes in the physiology of swallowing can be observed with increasing age as a result of strength losses due to decreased muscle mass and the elasticity of connective tissue (Sura, Madhavan, Carnaby, & Crary, 2012). Age-related changes in swallowing not only increase

the risk of choking and pneumonia but also the risk of malnutrition, seen in 25 – 75% of those suffering from dysphagia (Rofes et al., 2011). Dysphagia is a condition defined as the difficulty or inability to swallow either food or liquids (Forster, Samaras, Gold, & Samaras, 2011). As eating and drinking are typically social, anxiety and panic can occur while eating and can therefore also have harmful social consequences (Forster et al., 2011).

While well older adults are capable of compensating for the normal age-related reduction in swallowing ability due to sufficient functional reserves, changes such as poor neurological health, surgery and illness can cause a drop in functional reserves, consequently impairing oral feeding (Pendergast, Fisher, & Calkins, 1993). With reduction in ability to cope with ADLs potentially contributing to admission into ARRC facilities (Pendergast et al., 1993), negative changes in health status must be considered when considering risk for dysphagia and associated malnutrition.

The prevalence of dysphagia risk is fairly high in ARRC with a prevalence of 24% in participants across ARRC facilities in Japan (Sugiyama et al., 2014). Dysphagia of varying degrees was noted in 55% of the participants who were not eating optimally and lived in ARRC (Kayser-Jones & Pengilly, 1999). Similarly, a dysphagia screen on 395 older adults across two ARRC facilities in South Korea displayed a prevalence of 53% (Park et al., 2013). For these residents, there was a significant association between dementia, poor functional status requiring dependence, delayed feeding time and nutrition issues with dysphagia (Park et al., 2013). To ensure safety of swallow and maintenance of oral intake and hydration, a multi-disciplinary team approach is required (Marik & Kaplan, 2003). Many health care professionals such as a physician, speech and language therapist, clinical dietitian, physiotherapist and occupational therapist can assist with the management of dysphagia (Marik & Kaplan, 2003).

As malnutrition is recognised to further reduce functional capacity, malnutrition associated with dysphagia can hence increase frailty of older adults (Sura et al., 2012), with decreased energy and protein intake a major factor (Forster et al., 2011). Despite detection of dysphagia possible through the use of simple screening tools, under-diagnosis and inappropriate treatment of dysphagia can put these individuals at nutrition risk (Serra-Prat et al., 2012). Individuals with dysphagia may require texture-modified diets for safe oral intake, numerous strategies such as making food appear more attractive visually, dietitian consultation and encouragement of independent feeding are often utitilised to decrease nutrition risk and optimise nutrition in these individuals (Easterling & Robbins, 2008).

In ARRC environments, recognition of dysphagia risk is important for the appropriate care of residents, not only for nutritional adequacy and the prevention of fatal incidents such as aspiration pneumonia but also for quality of life through pleasurable eating experiences.

2.5.6.1 Eating Assessment Tool (EAT-10)

The EAT-10, a dysphagia tool, was developed in order to provide a rapid way of identifying severity of dysphagia and monitoring treatment effectiveness (Belafsky et al., 2008).

Dysphagia is a condition that commonly affects older adults with those affected also at a greater risk of aspiration (Australian and New Zealand Society for Geriatric Medicine, 2011). There are many consequences of dysphagia that are associated with increased morbidity and mortality. These can include: dehydration, choking, increased nutrition risk and malnutrition and aspiration pneumonia (Australian and New Zealand Society for Geriatric Medicine, 2011).

A multi-disciplinary team consisting of experts in dysphagia was asked to contribute 10 questions they felt to be valid to accurately screen for dysphagia (Belafsky et al., 2008). A list of 35 potential questions were voted on which lead to the development of the original dysphagia screen, the 20-item Eating Assessment Tool (EAT-20). The EAT-20 was administered to two groups of people, those with diagnoses of voice or swallow disorders and to normal controls. The 10 least reliable questions were taken out following tests for consistency and reliability to form the EAT-10 questionnaire. Normative data was then gained to set a cut-off score and validity was then analysed (Belafsky et al., 2008).

While the omission of visual analogue scales and formulas makes calculating the final score highly simple and rapid, a limitation of the tool is the lack of specific domains and sub- sections which means it is not possible to group the final result into more categories (Schindler et al., 2013). Also, this tool was validated in participants with a mean age of 62 ± 14 years for those with voice and swallowing disorders and 48 ± 16 years in the normal population. Further evaluation of the tool is necessary in an older age group for the normative data to ensure it is still valid in the older adult population (Belafsky et al., 2008) Validity and reliability of the tool was assessed using a large number of participants who had problems with their voice and swallowing (Belafsky et al., 2008). Determination of the at-risk cut-off point was suggested by the normative data (Belafsky et al., 2008). Significantly elevated EAT-10 scores were noted in those with a history of head and neck cancer or with oropharyngeal and oesophageal dysphagia when compared to individuals with voice

with no voice and swallowing disorders, EAT-10 scores were significantly higher in the group with voice and swallowing disorders (Belafsky et al., 2008).

The EAT-10 tool was tested for its sensitivity and specificity for oropharyngeal dysphagia (OD) and was found to be an effective screen, recommended for use in older adults at risk for OD and poor nutrition that would benefit from further testing (Rofes, Arreola, Mukherjee, & Clavé, 2014). Mean age of the participants was 74.4 ± 12.4 years and many were at a high risk of malnutrition in accordance with the MNA®-SF (Rofes et al., 2014). When the accuracy of the EAT-10 was compared against videofluoroscopy (VFS) for detection of OD, sensitivity and specificity was 0.89 and 0.82 respectively (Rofes et al., 2014). This was determined using a receiver operating characteristic (ROC) curve with a normative cut-off point of ≥3 points used (Rofes et al., 2014). Increased sensitivity of the EAT-10 was observed when the cut-off was reduced from 3 points to 2 points, with specificity unaffected (Rofes et al., 2014). As this led to a reduced number of false-negative results, further assessment is indicated with an EAT-10 score of ≥2 points (Rofes et al., 2014).