老嚥下と口咽頭嚥下障害に立ち向かう

[Confronting Presbyphagia and Oropharyngeal Dysphagia].

• Yueh-Juen Hwu

抄録

The ability to swallow efficiently and safely is essential to maintaining nutrition, hydration, health status, and quality of life. The process of swallowing requires coordination among a complex series of psychological, sensory, and motor behaviors that are both voluntary and involuntary (Balou, Herzberg, Kamelhar, & Molfenter, 2019). Presbyphagia refers to the changes associated with natural, healthy aging in the head and neck anatomy and in the physiologic and neural mechanisms that underpin the function of swallowing (Cichero, 2018). This progression of change contributes, in part, to a natural decline in the ability of the body to adapt to physiological stress. Chewing impairment and dysphagia are syndromes that are most-often associated with old age. The World Health Organization included oropharyngeal dysphagia in the International Statistical Classification of Diseases and Related Health Problems (ICD) under subordinate codes 787.2 ICD9 and R13.10 ICD10 (Centers for Disease Control and Prevention, 2015). The reported prevalence of oropharyngeal dysphagia among older adults has varied widely among studies, subjects, and locations (Ortega, Cabré, & Clavé, 2014). For example, the reported prevalence of chewing and swallowing disorders among community-healthy elders ranges between 11%~60% (Di Pede, Mantovani, Del Felice, & Masiero, 2016). Oropharyngeal dysphagia is an important factor that causes malnutrition and aspiration pneumonia in the elderly (Imaizumi et al., 2020). In view of the increasing prevalence of chewing and swallowing difficulties, PEACE has been adopted as the theoretical framework for this column "Perspectives on Chewing and Swallowing Care". The ultimate goal is to enable people to live long and enjoy a satisfactory quality of life (Enjoyment). To achieve this goal, people must have the ability to preserve in good condition the muscle groups and mechanisms related to swallowing (Preservation). However, preservation depends on three strategies: (1) Enhancing the knowledge and care skills related to chewing and swallowing difficulties, such as addressed in the four articles in this column: "Chewing screen and interventions for the elders", "The triangular relationship among swallowing disorder, aspiration pneumonia, and poor oral hygiene", "International classification systems of texture-modified foods", and "Innovative development of texture-softened foods for older adults living in residential care". (2) Holding a positive attitude (Attitude), especially regarding the potential for thoroughly implementing oral hygiene to break the vicious cycle of dysphagia-related aspiration pneumonia. Trust that people have the ability to maintain the strength of chewing and swallowing muscle groups and to resolve the comorbidities associated with sarcopenia and presbyphagia. (3) Practicing consistency in knowledge and action. Chewing and swallowing-related knowledge and care skills and positive attitudes may still be insufficient if knowledge and action are not united. When knowledge and action are united, the body may maintain to a good state of function and patients may enjoy peace through their life journey.

タイトル:

正視吞嚥老化與口咽吞嚥困難。

TITLE: 正視吞嚥老化與口咽吞嚥困難.

有效與安全的吞嚥能力，乃為維持人體營養、水合狀況、健康與生活品質的要素。吞嚥功能涉及複雜的自發與非自發性之心理、感覺、與運動行為的協調過程（Balou, Herzberg, Kamelhar, & Molfenter, 2019）。健康老化所引發的頭頸部解剖構造，與吞嚥功能的生理，神經機轉之變化，統稱為吞嚥老化（presbyphagia.

有效與安全的吞嚥能力，乃為維持人體營養、水合狀況、健康與生活品質的要素。吞嚥功能涉及複雜的自發與非自發性之心理、感覺、與運動行為的協調過程（Balou, Herzberg, Kamelhar, & Molfenter, 2019）。健康老化所引發的頭頸部解剖構造，與吞嚥功能的生理、神經機轉之變化，統稱為吞嚥老化（presbyphagia; Cichero, 2018）。吞嚥老化的進展，可能會降低人身體面對生理壓力的調適能力。 咀嚼與吞嚥障礙是老年症候群之一，世界衛生組織特別將口咽吞嚥困難（oropharyngeal dysphagia）標示於國際疾病與相關健康問題的統計分類（International Statistical Classification of Diseases and Related Health Problems, ICD）中，分屬代號為787.2 ICD9與R13.10 ICD10（Centers for Disease Control and Prevention, 2015）。不同研究，或調查對象、地點不同，老年人罹患口咽吞嚥困難的盛行率也不同（Ortega, Cabré, & Clavé, 2014），例如11%−60 %的社區健康長者有咀嚼、吞嚥障礙（Di Pede, Mantovani, Del Felice, & Masiero, 2016），而口咽吞嚥困難是造成老年人營養不良與吸入性肺炎的重要因素（Imaizumi et al., 2020）。 有鑑於咀嚼、吞嚥困難問題的日漸普及，本專欄「咀嚼與吞嚥照護的展望」，以PEACE來做為理論架構。終極目標是要讓人們活得長又活得有生活品質（Enjoyment）；欲達此目標，人們就必須具備保存與吞嚥有關肌群、機轉在良好狀態的能力（Preservation）；而此能力的保存則有賴三大策略：(1)增進有關咀嚼與吞嚥困難照護的知能（Enhancement），例如本專欄的四篇文章： 「銀髮族咀嚼初篩與照護良策」、「咀嚼吞嚥障礙、吸入性肺炎與口腔衛生不良的三角關係」、「國際質地調整食品分級介紹」、與「機構住民軟食餐點的創新研發」。(2)抱持正向的態度（Attitude），尤其是堅信口腔衛生的徹底執行，可以破除吞嚥困難導致吸入性肺炎的惡性循環；堅信人們有能力維持咀嚼吞嚥肌群的力量，而非無奈承受肌少症或吞嚥老化帶來的許多合併症。(3)知行合一（Consistency），不論所擁有的咀嚼、吞嚥困難知能有多豐厚，態度有多正向，少了知行合一，還是只能在原點踏步，因此惟有知行合一，才能讓我們保有身體在良好的功能狀態，繼而享受長壽帶來的千山萬水喜曠達。.