Abstract

Dysphagia is a prevalent age-related disorder among older populations that greatly affect one’s quality of life (QoL). One of the risk factors related to dysphagia is the deterioration in swallowing-related muscles, which leads to weakened coordination and strength in supporting swallowing. Despite its high occurrence in older adults, the deterioration rate and negative effects can be slowed down through training programs. Yet, many of those programs are implemented face-to-face in clinical settings. Hence, this study aims to develop a technology-assisted/online swallowing exercise program that can be used by participants at their living place. The training will be based on motor learning principles and past evidence on swallowing training for older adults. 20-30 participants will be recruited to complete a 6-weeks online training program on swallowing-related muscles.

Introduction and literature review

According to Crary & Groher (2003), any disruption in the swallowing process is defined as dysphagia. It can be caused by various reasons, including stroke, head and neck cancer treatment, chronic neurodegenerative disease, or age-related changes like reduction in salivary reserve (Baijens et. al, 2016; Maeda & Akagi, 2016). Dysphagia becomes more prevalent with increasing age, with over 20% of 50-60 years old adults suffering from it (Shune, Moon, & Goodman, 2016). Particularly in Hong Kong, 70% of the nursing home residents and 40% of the elderly at the daycare centers had swallowing problems (Pu et al., 2017; Pu, Chan & Yiu, 2015). The high percentage indicates that those living in nursing homes are more at risk of developing swallowing disorders. This may be explained by the insufficient professional swallowing management services provided, and the fewer opportunities for elderly to practice swallowing muscles through talking and eating (Chen et al., 2020).

Among numerous risk factors that may affect and deteriorate swallowing functions, muscles related to oro-motor (e.g. jaw muscles) significantly affect one’s chewing and swallowing ability (Park et al., 2013). In the studies conducted by Burkhead et al. (2007) and Park et al. (2015), training programs targeting retaining the strength of swallowing-related muscles such as tongue, lips and laryngeal muscles showed positive results in assisting dysphagia patients in improving their oromotor functions.

Yet, those programs were usually delivered face to face. In addition, the waiting time and expenses for a swallowing assessment and treatment with a speech therapist may be too long and unaffordable for some older adults in Hong Kong. Hence, establishing a sustainable online program might be able to increase patients' accessibility to clinical rehabilitation, possibly at a lower cost too. Telerehabilitation is also becoming a more popular alternative for face-to-face therapy in speech and language therapy recently and has proven to be effective for treating swallowing disorders too (Bascunana et al., 2021; Clawson et al., 2008; Robbins et al., 2007). Moreover, not only is online training beneficial as traveling time and cost are reduced, technology-assisted swallowing training may make training more fun, engaging and effective for older adults.

The current project aims to develop a sustainable technology-assisted/ online training program and investigate its effectiveness in improving older adults’ swallowing functions and preventing deterioration of dysphagia as a pilot testing. The exercises included will first be targeting mainly on improving muscle strengths of tongue because tongue plays an extensive role in oropharyngeal swallowing and is essential to normal swallowing function (Kim et al., 2017). Reference will be made according to existing evidence-based swallowing rehabilitations for dysphagia patients, such as Effortful swallowing training (Park et al., 2019) and Tongue-to-palate resistance training (Kim et al., 2017). It is expected that the exercises could improve oral function, including bolus formation and mastication (Kim et al., 2017). It is hoped to add some entertainments and themes into the online training program, such that the older adults will find it more intriguing when doing treatment compared with traditional delivery methods.

Methodology

The project will recruit 20-30 older adults with dysphagia from Hong Kong nursing homes or day-care centers. Inclusion criteria of participants include: (1) aged 60 or above, (2) diagnosed with dysphagia, (3) able to swallow voluntarily, (4) able to understand simple instructions for assessment and training tasks, (5) able to have basic knowledge with electronic device, (6) currently not on tube-feeding. Training will be administered once to twice per week using online delivery method. 

The water swallowing test (WST) will be used as a standardized method to evaluate the severity of dysphagia, as it is a quick and easily administered assessment (Zhang et al., 2014). A questionnaire will also be distributed to understand the satisfaction of participants towards their eating condition as additional information about participants' perceptions. These data will be gathered in 3-time points: (1) 1 week before the program, (2) 3^rd week of program (mid-block), (3) 1 week after the program.

Limitation

(1)  The sample size is small (N=20-30) and might not be representative of the general population.

(2)  The training time is short (6-weeks) and may limit the improvements of participants’ swallowing ability. Hence, the effectiveness of the online program might be underestimated

(3)  No control group is included, so it is hard to compare the effectiveness of online treatment with face-to-face treatment.

Timeline

Early March:

·       Draft questionnaire for assessing participants’ perception regarding their swallowing ability.

Mid-March – End of May:

·       Recruitment of participants

Early May – Mid-June:

·       Development of online swallowing training program

·       Gather pre-assessment results and questionnaires from participants

·       Briefing participants about the program (workshop may be conducted once to twice on teaching participants some basic skills on using the app/online program)

Mid-June – Mid-August:

·       Conducting the program

Mid-July:

·       Mid-block assessment and questionnaire of the participants’ ability and perception

Mid-August – End of August:

·       Measure the overall progress of participants

·       Post-treatment data collection

·       Prepare research report

References

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