2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Volume 27, Number 12, December 2015

Oral microbiota in older dysphagic patients

80% of hospital readmissions for AP were attributable to OD, indicating the relevance of OD in terms of healthcare resource consumption. 9 Oropharyngeal dysphagia is a symptom of swallow- ing disorder recognized by the World Health Organiza- tion (WHO) with specific ICD codes (787.2, R13). 10 It is underdiagnosed despite its prevalence among the older population: 23% in independently living older people, 55% in hospitalized older patients, and 56% to 78% in institutionalized older people. 11 – 13 Impaired safety (penetrations and aspirations) in FOP is related to delayed laryngeal vestibule closure (LVC) and caused by impaired neural swallow response due to neuro- genic diseases and aging. 14 The pathophysiology of AP involves three key elements: OD with impaired safety of swallow and aspirations; frailty and impaired health and immuno- logical status, and poor oral health and hygiene with bacterial colonization (15 – 21). The oral cavity contains a complex microbial ecosystem of commensal and pathogenic bacteria dependent on oral health and hygiene. We found that older patients with OD had poor oral health with high prevalence of periodontitis and caries, 15 signifying high risk for AP in patients with impaired safety of swallow. 16 – 18 Interventions treating oral health and hygiene reduced the incidence of respiratory infections and pneumonia in older patients suggesting AP can be prevented with adequate identification and care. 19 – 21 Oral microbiota of dysphagic patients is not well described in the literature so we designed and devel- oped a proof of concept study to assess and compare the health status of the patients, the mechanisms of oropharyngeal dysfunction, the oral health and hygiene status, oral and nasal microbiota, and colonization by respiratory pathogens. The aim of the study was to better understand the pathophysiology of AP in differ- ent phenotypes of FOP with OD in order to develop therapeutic strategies against colonizing respiratory pathogens in the future.

comorbidities, poor functionality, polymedication, and prevalent videofluoroscopic signs of impaired safety of swallow (33.3 – 61.5%). However, patients with OD-APN also presented malnutrition, delayed laryngeal vestibule closure (409.23 115.6 ms; p < 0.05), and silent aspirations (15.6%). (ii) Oral health was poor in all groups, 90% presented peri- odontitis and 72%, caries. (iii) Total bacterial load was similar in all groups, but higher in the oropharynx ( > 10 8 CFU/mL) than in the nose ( < 10 6 CFU/mL) (p < 0.0001). Colonization by respiratory pathogens was very high: 93% in OD patients (p < 0.05 vs H); 93% in OD-PNP (p < 0.05 vs H); 88% in OD-APN (p = 0.07 vs H), and lower in controls (67%). Conclu- sions & Inferences Frail older patients with OD had impaired health status, poor oral health, high oral bacterial load, and prevalence of oral colonization by respiratory pathogens and VFS signs of impaired safety of swallow, and were therefore at risk for contracting AP. Keywords aspiration pneumonia, geriatrics, oral microbiota, respiratory pathogens, swallowing disor- ders. Aspiration pneumonia (AP) has been defined as pneu- monia contracted by a patient with oropharyngeal dysphagia (OD) who aspirates colonized oropharyngeal material. 1,2 Aspiration pneumonia occurs in older people with swallowing disorders. 1 A review on older patients hospitalized for pneumonia found a 93.5% increase in AP, whereas other types of pneumonia decreased, 3 and the proportion of admissions due to AP among all admissions due to pneumonia increased gradually with age. 4 Both results have been attributed to increased prevalence of OD among older people. We recently found OD was an independent risk factor for lower respiratory tract infections, 5 community-ac- quired pneumonia (CAP) in older patients, 6 and pneu- monia in frail older patients (FOP). 7 In addition, OD is an indicator of severity and mortality in older patients with CAP. One-year mortality for patients with pneu- monia and OD reached 40% and 55% for patients above 70 and 80 years, respectively. 6,7 In nursing home residents with OD, AP occurs in 43 – 50% during the first year, with a mortality of up to 45%. 8 Finally, in a prospective study we found that OD was a risk factor for readmission for pneumonia, bronchoaspirations, and AP in older patients from an acute geriatric unit and that nearly 5% of all hospital readmissions and INTRODUCTION

MATERIAL & METHODS

Study population

Study population included 61 older patients, 70 years of age or more admitted prospectively to the Gastrointestinal Physiology Unit of the Hospital de Mataro between April 2011 and January 2012. We recruited three phenotypes of FOP with OD and one control group of persons without OD: Group 1 (OD-PNP): 15 patients with dysphagia who had had prior pneumonia, recruited from the outpatient dysphagia clinic; Group 2 (OD): 15 patients with dysphagia, without pneumonia or history of previous pneumonia, recruited from the same place; Group 3 (OD-APN):

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