Prevalence and management of dysphagia in nursing home residents in Europe and Israel: the SHELTER Project

Abstract

Background Dysphagia is a frequent condition in older nursing home residents (NHRs) which may cause malnutrition and death. Nevertheless, its prevalence is still underestimated and there is still debate about the appropriateness and efficacy of artificial nutrition (AN) in subjects with severe dysphagia. The aim is to assess the prevalence of dysphagia in European and Israeli NHRs, its association with mortality, and the relationship of different nutritional interventions, i.e. texture modified diets and AN—with weight loss and mortality. Methods A prospective observational study of 3451 European and Israeli NHRs older than 65 years, participating in the SHELTER study from 2009 to 2011, at baseline and after 12 months. All residents underwent a standardized comprehensive evaluation using the interRAI Long Term Care Facility (LTCF). Cognitive status was assessed using the Cognitive Performance Scale (CPS), functional status using Activities of Daily Living (ADL) Hierarchy scale. Trained staff assessed dysphagia at baseline by clinical observation. Data on weight loss were collected for all participants at baseline and after 12 months. Deaths were registered by NH staff. Results The prevalence of dysphagia was 30.3%. During the one-year follow-up, the mortality rate in subjects with dysphagia was significantly higher compared with that of non-dysphagic subjects (31.3% vs 17.0%,p = 0,001). The multivariate analysis showed that NHRs with dysphagia had 58.0% higher risk of death within 1 year compared with non-dysphagic subjects (OR 1.58, 95% CI, 1.31–1.91). The majority of NHRs with dysphagia were prescribed texture modified diets (90.6%), while AN was used in less than 10% of subjects. No statistically significant difference was found concerning weight loss and mortality after 12 months following the two different nutritional treatments. Conclusions Dysphagia is prevalent among NHRs and it is associated with increased mortality, independent of the nutritional intervention used. Noticeably, after 12 months of nutritional intervention, NHRs treated with AN had similar mortality and weight loss compared to those who were treated with texture modified diets, despite the clinical conditions of patients on AN were more compromised.

Screening of dysphagia in geriatrics

“…These results could be due to the aging related muscle weakness, neuromuscular incoordination, their limited strength and range of movement of several organs involved in the feeding and swallowing process that led to difficulty with feeding and might thereafter have a negative impact on their desire for food intake and subsequently lead to decrease in body weight. Weight loss was previously documented in Nursing home residents in a study by Dell'Aquila et al [ 34 ] in their dysphagic and non dysphagic groups with higher percentage in the dysphagic group. Among the aging-related diseases, two pathological conditions existed in elderly people including sarcopenia and dysphagia.…”

Malnutrition in aged care: interplay between dysphagia and diet

“…[12 ▪▪ ] reported that residents without dysphagia, compared with those with dysphagia, were significantly older and had a higher prevalence of comorbidities, including pressure ulcers, coronary heart disease, cerebrovascular disease, dementia and Parkinson's disease. In addition, residents with dysphagia were prone to weight loss and were more dependent on feeding assistance [12 ▪▪ ]. Future research is warranted to gain a deeper understanding of the underlying mechanisms and explore effective interventions in addressing diagnosis and management.…”

“…In a recent substantial sample of European and Israeli nursing home residents ( n = 3451), dysphagia was observed in 30% of residents, with 14% of those with dysphagia experiencing unintentional weight loss [12 ▪▪ ]. The prevalence of dysphagia in older adults was recently examined in a comprehensive systematic review by Doan et al [13], including 32 studies conducted between 2002 and 2021.…”

“…The key challenge in optimizing nutrition in aged care residents with dysphagia is designing food that is well tolerated, nutrient-dense, pleasurable and cost-effective. To promote safer and more manageable swallowing, texture-modified foods and thickened fluids are the most common nutrition approach for individuals with dysphagia [12 ▪▪ ]. Texture modification involves altering the thickness, viscosity or particle size of foods, while fluid thickening techniques are utilized to adjust the consistency of liquids [27].…”

“…The use of artificial nutrition in severe dysphagia is still controversial. Although artificial nutrition is commonly prescribed for patients with severe dementia or neurologic diseases who have minimal ability to eat orally, there is a risk of complications associated with tube feeding and limited evidence available regarding its effectiveness in improving clinical outcomes [12 ▪▪ ,37].…”