Occupational Therapy Rehabilitation for Frail Elders With Dysphagia

Study Overview
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Brief Summary
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The goal of this proof-of-concept study is to assess the potential of a newly developed intervention with combined skill- and strength-based principles for maximizing swallowing-related outcomes and prevent further weakening of the swallowing muscles in older people with dysphagia (difficulty swallowing). The main questions to be answered are: Does the intervention produce clinically significant improvement in ingestive skills during meals in older individuals with dysphagia? Does the intervention produce clinically significant improvements in tongue strength and orofacial function in older persons with dysphagia? Does the intervention produce clinically significant improvements in nutritional status and quality of life in older individuals with dysphagia? Is there an association between perceived autonomy support and intervention engagement when older individuals with dysphagia receive the intervention during hospitalization and continued in community-based rehabilitation after discharge? Participants will be asked to perform goal-directed and task-specific swallowing exercises in eating and drinking activities where the intensity variables include advancing steps of an altered bolus volume and consistency according to a 17-level task hierarchy, which are introduced according to predetermined progression rules, as well as increases in swallowing repetitions. The dosage is 2-3 individual, face-to-face therapy sessions per week for up to a maximum of eight weeks. A therapy session lasts up to 45 min. In between therapy sessions, participants integrate the achieved level from therapy into their daily meals as self-training.

Official Title
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No Food or Drink Does Any Good Until it is Swallowed: a Proof-of-concept Study on Occupational Therapy Rehabilitation for Frail Elders With Dysphagia

Conditions
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Dysphagia, Oropharyngeal, Deglutition Disorders

Intervention / Treatment
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* Behavioral: ACT-ING program ( Activity-based skill- and strength training to improve ingestion)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: A score of 5-18 on the Gugging Swallowing Screen. Speaks and understands Danish. Are able to cooperate in the intervention and give written informed consent; i.e. is oriented in time, place and own data, and able to perform four simple oral motor movements on request. Has given written informed consent. Exclusion Criteria: Esophageal dysphagia. Progressive neurologenic dysphagia. Psychiatric illness. Delirious. Infections that requires isolation. Need for palliative care.

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Combined skill- and strength-based swallowing exercise<br>The intervention is delivered as face-to-face therapy 2 times per week in 8 weeks | Behavioral: ACT-ING program ( Activity-based skill- and strength training to improve ingestion)<br>* The intervention is based on a client-centered Occupational therapy task-oriented approach, in which real objects are employed in a realistic context. The intervention uses the effortful swallowing in combination with advancing steps of liquid and food items as resistive forces to challenge the swallow in a safe environment during eating and drinking activities. Progression is realized based on pre-determined progression rules to ensure the right challenges in combination with safety (Hansen et al, 2023).<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The McGill Ingestive Skills Assessment-version 2 (MISA2). | Maasure of meal-time task performance. The total score range from 36-108, where higher score indicate higher performance | From enrollment to the end of treatment at 8 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Functional Oral Intake Scale (FOIS) | Functional Oral Intake with a score range of 1( no oral intake) to 7 (Total oral diet with no restrictions). | From enrollment to the end of treatment at 8 weeks | 
| Nordic Orofacial Test - screening (NOT-S) | Physical examination of orofacial function. The score range from 0 to 6, where higher score indicate impaired function. | From enrollment to the end of treatment at 8 weeks | 
| Mini Nutritional Assessment-Short Form | The total score range from 0 to 14, where a score <8 indicates malnutrition, 8-11 indicates risk of malnutrition, and >11 indicates no malnutrition. | From enrollment to the end of treatment at 8 weeks | 
| Iowa Oral Performance Instrument (IOPI) | Continuous measure of tongue strength in Kilopascals (KpA). | From enrollment to the end of treatment at 8 weeks | 
| Self-reported swallowing difficulties | 100 mm VAS scale (left side = no difficulties and right side = unable to swallow). | From enrollment to the end of treatment at 8 weeks | 
| Emotional wellbeing and global quality of life | Two single VAS items using a horizontal line from 0 (worst imaginable emotional well-being / worst imaginable quality of life) to 100 mm (perfect emotional wellbeing /perfect quality of life). | At end of treatment at 8 weeks | 
| Basic psychological needs in exercise scale (BPNES) | A self-report measure with a total score range of 12 to 60, where higher scores indicate higher levels of autonomy support. | At end of treatment at 8 weeks |