加齢と嚥下障害：戦略と介入

以前にも紹介しましたが、加齢と嚥下障害：インパクト、戦略、介入に関するレビュー論文を紹介します。

Ney DM, Weiss JM, Kind AJ, Robbins J. Senescent swallowing: impact, strategies, and interventions. Nutr Clin Pract. 2009 Jun-Jul;24(3):395-413.

下記のHPで全文見ることができます。

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2832792/pdf/nihms178630.pdf

以前、同じ論文を紹介したブログは下記です。

サルコペニアと嚥下障害の論文

サルコペニアによる嚥下障害に関して、比較的詳しくコメントされているレビュー論文です。今回は別のパート（Dysphagia, Nutrition and Hydration）を引用紹介します。以下、引用です。

Dysphagia, Nutrition and Hydration
Dysphagia has a profound effect on nutritional status often resulting in malnutrition and dehydration and may compromise nutrient status as a result of diminished capacity to eat or drink, anorexia or fear of eating. When dysphagia occurs in the elderly population in tandem with sarcopenia, or loss of skeletal muscle mass and strength (46), the risk for malnutrition　especially protein-energy malnutrition is increased (47). Consequences of the dysphagia　malnutrition relationship include: weight loss, dehydration, muscle breakdown, fatigue, aspiration pneumonia, and a general decline in functional status. Moreover, a recent study identified swallowing problems and sarcopenia as predictive of nosocomial infections in hospitalized elderly patients (48). Increased morbidity and mortality are documented outcomes　of undiagnosed or untreated dysphagia that have progressed to protein-energy malnutrition (49,50).

一部訳しますと、高齢者でサルコペニアとともに嚥下障害が生じると、低栄養のリスクが高くなります。嚥下障害と低栄養の結果、体重減少、脱水、筋肉分解、疲労、誤嚥性肺炎、身体機能低下がおこります。さらに、嚥下障害とサルコペニアは、高齢者の院内感染の予測因子です。未診断・未治療の嚥下障害では、合併症の罹患率や死亡率が高くなります。

サルコペニアによる嚥下障害という書き方はされていませんが、全身の筋肉にサルコペニアが生じれば、程度の差はあっても嚥下に関わる筋肉にもサルコペニアは生じます。サルコペニアによる嚥下障害の結果、誤嚥性肺炎となり、さらにサルコペニアによる嚥下障害が悪化するという悪循環も生じえます。

エビデンスはまだ少ないですが、サルコペニアによる嚥下障害と誤嚥性肺炎の悪循環というコンセプトをきちんとした形にしたいと考えています。時期尚早ではありますが、臨床現場には広義のサルコペニアによる嚥下障害患者が少なからずいますので、理解の枠組みから作りたいと思います。

そのためには、サルコペニアによる嚥下障害の診断基準が必要です。例えば、誤嚥を認める高齢者で、嚥下障害の明らかな器質的、心理的な原因がなく、麻痺がない場合、除外診断として広義のサルコペニアによる嚥下障害と推測するのはいかがでしょうか。麻痺とサルコペニアを合併することもありますが…。

Abstract
The risk for disordered oropharyngeal swallowing (dysphagia) increases with age. Loss of swallowing function can have devastating health implications, including dehydration, malnutrition, pneumonia, and reduced quality of life. Age-related changes increase risk for dysphagia. First, natural, healthy aging takes its toll on head and neck anatomy and physiologic and neural mechanisms underpinning swallowing function. This progression of change contributes to alterations in the swallowing in healthy older adults and is termed presbyphagia, naturally diminishing functional reserve. Second, disease prevalence increases with age, and dysphagia is a comorbidity of many age-related diseases and/or their treatments. Sensory changes, medication, sarcopenia, and age-related diseases are discussed herein. Recent findings that health complications are associated with dysphagia are presented. Nutrient requirements, fluid intake, and nutrition assessment for older adults are reviewed relative to dysphagia. Dysphagia screening and the pros and cons of tube feeding as a solution are discussed. Optimal intervention strategies for elders with dysphagia ranging from compensatory interventions to more rigorous exercise approaches are presented. Compelling evidence of improved functional swallowing and eating outcomes resulting from active rehabilitation focusing on increasing strength of head and neck musculature is provided. In summary, although oropharyngeal dysphagia may be life threatening, so are some of the traditional alternatives, particularly for frail, elderly patients. Although the state of the evidence calls for more research, this review indicates that the behavioral, dietary, and environmental modifications emerging in this past decade are compassionate, promising, and, in many cases, preferred alternatives to the always present option of tube feeding.