Dysphagia refers to the difficulty or discomfort experienced during the progression of the alimentary bolus from the oral cavity to the stomach (Rofes et al., 2011). In a systematic literature review, dysphagia proved to be a prominent risk factor for aspiration pneumonia in frail older adults (van der Maarel-Wierink, Vanobbergen, Bronkhorst, Schols, & de Baat, 2011). Aspiration pneumonia causes high hospitalization rates, morbidity, and often death in frail older adults (Welte, Torres, & Nathawani, 2012). Therefore, risk factors of aspiration pneumonia, such as dysphagia, should be eliminated in cases of frail older adults whenever possible.
A retrospective data analysis of the Dutch National Prevalence Survey of Care Problems (LPZ), which contained data on 8,119 care home residents 65 and older, showed that the prevalence rate of dysphagia in care home residents in the Netherlands was 9% (van der Maarel-Wierink et al., 2014). However, in the LPZ study, dysphagia was assessed subjectively by interviewing the residents on swallowing problems they experienced. A video fluoroscopic swallowing test is the most reliable method of investigating dysphagia (Logemann & Larsen, 2012). Because video fluoroscopy is rarely feasible with care home residents, a clinical examination by a speech-language therapist may be the optimum method for screening aspiration risk in care home residents. Actual prevalence or incidence figures of dysphagia in frail older adults in general, as well as in care homes, are scarce (Kayser-Jones & Pengilly, 1999; Langmore et al., 1998; Lin, Wu, Chen, Wang, & Chen, 2002).
After multivariate backward stepwise regression analysis, the retrospective data analysis of the LPZ revealed eight significant variables associated with dysphagia: (a) age (ß = −0.022); (b) Care Dependency Scale score (B = −0.985); (c) malnutrition (odds ratio [OR] = 1.58; 95% confidence interval [CI] [1.31, 1.90]); (d) comorbidity (OR = 1.07; 95% CI [1.01, 1.14]); and the disease clusters (e) dementia (OR = 0.55; 95% CI [0.45, 0.66]); (f) nervous system disorder (OR = 1.55; 95% CI [1.20, 1.99]); (g) cardiovascular disease (OR = 0.81; 95% CI [0.67, 0.99]); and (h) cerebrovascular disease/hemiparesis (OR = 1.74; 95% CI [1.45, 2.10]) (van der Maarel-Wierink et al., 2014).
In addition, the aforementioned systematic literature review assessing risk factors of aspiration pneumonia showed evidence that the use of antipsychotic drugs and proton pump inhibitors are significant risk factors, whereas the use of angiotensin-converting enzyme (ACE) inhibitors is a significant protective factor (van der Maarel-Wierink et al., 2011). It was suggested that dysphagia might explain the relation between the use of these medications and the onset of aspiration pneumonia; antipsychotic agents can cause poor swallowing function, and proton pump inhibitors influence gastric acidity but also reduce acidity of the upper aerodigestive tract, thus resulting in increased bacterial colonization and high bacterial load with aspiration due to dysphagia (Eom et al., 2011; Rudolph, Gardner, Gramigna, & McGlinchey, 2008). The preventive effect of ACE inhibitors is most likely caused by increased substance P concentration, resulting in an improved cough reflex (Takahashi et al., 2005).
Care homes in the Netherlands have separate wards for residents with primarily physical disability and residents with primarily cognitive dysfunction. The most frequent medical diagnoses registered in physically disabled residents are cerebrovascular diseases and other neurological diseases, status post-hip fracture surgery and other locomotor disabilities, and malignancies. More than 85% of cognitively impaired residents have dementia (Schols, Crebolder, & van Weel, 2004).
The first objective of the current study was to screen for the risk of aspiration in primarily physically disabled and primarily cognitively impaired care home residents in the Netherlands determined by speech-language therapists. The second objective was to assess potential associations of risk of aspiration with Parkinson’s disease, cerebrovascular disease, and dementia, as well as with the use of antipsychotic drugs, proton pump inhibitors, and ACE inhibitors.
Five experienced speech-language therapists, who were trained similarly, assessed an integral item of the routine nutrition assessment (i.e., a water swallowing test) in all care home residents 60 and older in the first week after admission to one of the six care homes of the care home organization Vivre (part of Envida, with 850 residents in total) in Maastricht, the Netherlands, during the period of May 2010 to March 2011. Given that the water swallowing test was an integral item of routine nutrition assessment at admission to the care home, approval by a medical ethics committee was not required. However, informed consent was received from all residents, as the resulting data of the assessments were used for study purposes.
The water swallowing test was conducted, unless a resident was suffering from severe dysphagia (known from hospital diagnosis). Ambulatory patients were seated in a chair; bed-bound patients were seated upright in bed. The 3-ounce water swallowing test, a widely used method of screening individuals who are at risk of oropharyngeal dysphagia and aspiration, was used. Although the test has a low specificity and a high false-positive rate, it is a valuable screening instrument (Suiter & Leder, 2008). Criteria for reference to further assessment of swallowing include the inability to complete the task, coughing, choking, or a wet-hoarse vocal quality exhibited either during the test or within 1 minute after test completion. In such cases, the speech-language therapists determined risk of aspiration existed.
The speech-language therapists also interviewed residents using questions based on the previously developed and validated self-report symptom inventory for assessing oral-pharyngeal dysphagia (Wallace, Middleton, & Cook, 2000). If a resident was unable to respond (e.g., in the case of dementia), the responsible ward nurse answered the question. The questions (translated from Dutch) were:
- Do you ever have a feeling of food getting stuck in your throat when you swallow?
- Do you ever lose saliva from your mouth?
- Do you ever lose drinks or food from your mouth?
- Do you ever cough or choke when swallowing solid foods or liquids?
- Can you eat warm/cold/spicy/ crumbly food?
- Can you drink thin liquids?
- Can you eat food that needs chewing/food that needs biting off?
The purpose of the interviews was to get more insight into subjective dysphagia, but the decision on risk of aspiration was based on the result of the water swallowing test.
Residents’ data were collected from the medical records. Data included: (a) age; (b) gender; (c) status of admission, whether the resident was primarily physically disabled or primarily cognitively impaired; (d) registered diagnoses (e.g., Parkinson’s disease, cerebrovascular disease, dementia); and (e) actual use of antipsychotic drugs, proton pump inhibitors, and ACE inhibitors.
Statistical analyses were performed using SPSS version 18.0, including descriptive frequency distributions for all variables. Differences between groups were tested using Student’s t test for age and Fisher’s Exact test for other variables. To explore the role of potential risk factors of aspiration and assess confounding factors, a prediction model was built using multivariate logistic regression analysis. A p value of 0.05 was considered statistically significant.
In total, 203 care home residents (117 women, 86 men) 60 and older were screened on the risk of aspiration by speech-language therapists. The mean age of residents was 82.8 (SD = 8.3 years).
The speech-language therapists found risk of aspiration in 43 (21.2%) residents. Table 1 shows the background data of the assessed care home residents. Approximately 57% (n = 115) of residents were primarily physically disabled and 43% (n = 88) were primarily cognitively impaired. The difference in prevalence of aspiration risk between physically disabled residents (26.1%) and cognitively impaired residents (14.8%) was not statistically significant (p = 0.058). Cognitively impaired residents used statistically significantly more antipsychotic drugs (p < 0.001) and fewer proton pump inhibitors than physically disabled residents (p = 0.029). No significant difference existed in the prevalence of the use of ACE inhibitors between physically disabled and cognitively impaired residents (p = 0.323).
Background Data of Assessed Care Home Residents
Table 2 shows the background data separately for residents with aspiration risk (n = 43) and residents without aspiration risk (n = 160). Residents with aspiration risk were significantly younger and showed a significantly higher prevalence of Parkinson’s disease compared with residents without aspiration risk (p = 0.02). In contrast, the prevalence of dementia (p = 0.025) and the use of antipsychotic drugs were significantly lower (p = 0.022) among residents with aspiration risk compared with residents without aspiration risk.
Background Data of Residents with and without Risk of Aspiration (N = 203)
Dementia, Parkinson’s disease, and the use of antipsychotic drugs were significant variables in the univariate analysis. Cerebrovascular disease showed a statistically significant relation with dementia (p = 0.02). These four variables, as well as the age variable, were included in the multivariate logistic regression analysis. Because the current study showed 43 cases with risk of aspiration, five variables is the maximum for inclusion in the multivariate logistic regression analysis (Harrell, Lee, Califf, Pryor, & Rosati, 1984). Using multivariate logistic regression analysis, the final prediction model for aspiration risk showed Parkinson’s disease as a significant positive factor (OR = 5.11; 95% CI [1.493, 17.519]). The use of antipsychotic drugs revealed a small but significant protective effect (Table 3).
Final Prediction Model for Risk of Aspiration Using Logistic Regression Analysis
In the current study, the overall prevalence of aspiration risk (21.2%), as assessed by speech-language therapists, proved to be more than twice the prevalence of subjective dysphagia found in care home residents in the LPZ study (van der Maarel-Wierink et al., 2014). Residents may not always recognize their swallowing problems, or they may consider these as a natural symptom of aging or an ordinary symptom of their diseases, thus resulting in underdiagnosis of dysphagia when assessed subjectively (Kalf, de Swaat, Bloem, & Munneke, 2012). Empirical data to support the current study findings of objective dysphagia are scarce. Nogueira and Reis (2013) found a prevalence of 38% of dysphagia signs in care home residents using the 3-ounce water swallowing test. Park et al. (2013) evaluated the presence of dysphagia with the Gugging Swallowing Screen (GUSS), a dysphagia test for acute stroke patients. Among 395 older adults, the prevalence of dysphagia was 52.7%.
In the current study, as well as in the LPZ study, gender was not a significant factor. In the final prediction model for risk of aspiration, age was not a significant factor. The group with aspiration risk in the current study, as well as the group with subjective dysphagia in the LPZ study, were statistically significantly younger than the group without aspiration risk or subjective dysphagia.
The only significant, positive predicting factor for aspiration risk in the current study was Parkinson’s disease. This result is in agreement with a recently published meta-analysis that showed a pooled relative risk of 3.2 for both subjective dysphagia (95% CI [2.32, 4.41]) and objective dysphagia (95% CI [2.08, 4.98]) in patients with Parkinson’s disease (Kalf et al., 2012). Subjective dysphagia for the disease cluster “nervous system disorders” in the LPZ study had an OR = 1.59 (95% CI [1.23, 2.05]) (van der Maarel-Wierink et al., 2014).
Cerebrovascular disease was not a significant factor in the final prediction model for aspiration risk in the current study. This finding contrasts previous findings reporting a relatively high frequency of dysphagia in the acute phase after a cerebrovascular accident (Mann, Hankey, & Cameron, 1999; Paciaroni et al., 2004) and with the results of the final prediction model for subjective dysphagia of the LPZ study, which showed the disease cluster CVA (i.e., cerebrovascular accident]/hemiparesis) to be a significant factor (van der Maarel-Wierink et al., 2014).
Based on literature results, dementia was expected to be a significant predicting factor for dysphagia (Wada et al., 2001). However, in the final prediction model of the current study, dementia was not a significant factor. It may be the case that the dementia of the care home residents had not yet progressed to the point where dysphagia was an obvious issue, as they were newly admitted. If monitored over a longer period of time, these residents might develop dysphagia as the dementia progresses.
The use of antipsychotic drugs was a minor but significant protecting factor in the final prediction model for aspiration risk. The prevalence of the use of antipsychotic medication was significantly lower in residents with aspiration risk compared with residents without aspiration risk. The authors have no explanation for this finding. The use of antipsychotic drugs was found to be a significant risk factor of aspiration pneumonia in frail older adults (van der Maarel-Wierink et al., 2011).
No significant difference existed in the use of proton pump inhibitors between residents with and without aspiration risk.
In the current study, risk of aspiration was assessed with a water swallowing test, which was conducted by experienced speech-language therapists. A video fluoroscopic swallowing test is the gold standard in the diagnosis of dysphagia (Logemann & Larsen, 2012). However, it is not customary to refer older adult care home residents to such major examinations. Nevertheless, the lack of video fluoroscopic swallowing tests must be mentioned as a limitation of this study. A second limitation was the fact that no inter- and intrareliability tests of the speech-language therapists’ assessments were performed. However, the speech-language therapists were experienced with the swallowing assessment, as the protocol had been accurately implemented 1 year before the start of this study.
More research with validated screening tools is warranted on the prevalence of aspiration risk and dysphagia in care home residents to confirm the results of the current study and to further assess the risk factors of dysphagia.
Health care providers in care homes should be aware of the high prevalence (i.e., 1 in 5) of aspiration risk. According to the literature, the findings of the LPZ, and the results of the current study, specific attention is needed for high care dependent patients and patients with malnutrition, nervous system disorders (e.g., Parkinson’s disease), cerebrovascular diseases, or dementia, as they may have a higher risk of dysphagia. Timely notification of symptoms of aspiration, such as coughing, choking, or a wet-hoarse voice during eating or drinking, and timely consultation with a speech-language therapist for diagnosis and therapy may decrease the prevalence of aspiration pneumonia. Strategies to decrease the risk of aspiration may be supervised feeding, dietary modifications, swallowing therapy (i.e., compensatory strategies or exercises to strengthen swallowing musculature), or pharmacological therapy. When these therapy strategies are unsuccessful, reference to a hospital for a video fluoroscopic swallowing test is recommended.
Within the limitations of the current study, it seems justified to conclude that risk of aspiration, as assessed by speech-language therapists, is a relevant care problem among care home residents in the Netherlands, particularly those residents with Parkinson’s disease. Therefore, screening for risk of aspiration, as incorporated into the routine nutrition assessment of every care home resident, is recommended.
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Background Data of Assessed Care Home Residents
|Characteristic||Total Group (N = 203) n (%)||Primarily Physically Disabled (n = 115) n (%)||Primarily Cognitively Impaired (n = 88) n (%)||p Valuea|
| Female||117 (58)||67 (58)||50 (57)||0.886|
|Age (years) (mean [SD])||82.8 (8.3)||81.6 (8.8)||84.4 (7.3)||0.015|
| Parkinson’s disease||15 (7.4)||12 (10.4)||3 (3.4)||0.064|
| Cerebrovascular disease||37 (18.2)||29 (25.2)||8 (9.1)||0.003|
| Dementia||98 (48.3)||13 (11.3)||85 (96.6)||<0.001|
| Antipsychotic drugs||57 (28.1)||20 (17.4)||37 (42)||<0.001|
| Proton pump inhibitors||124 (61.1)||78 (67.8)||46 (52.3)||0.029|
| ACE inhibitors||49 (24.1)||31 (27)||18 (20.5)||0.323|
|Risk of aspiration||43 (21.2)||30 (26.1)||13 (14.8)||0.058|
Background Data of Residents with and without Risk of Aspiration (N = 203)
|Characteristic||Residents With Risk of Aspiration (n = 43) n (%)||Residents Without Risk of Aspiration (n = 160) n (%)||p Valuea|
| Female||24 (56)||93 (58)||0.862|
|Age (years) (mean, [SD])||80.3 (8.8)||83.5 (8)||0.027|
| Parkinson’s disease||7 (16.3)||8 (5)||0.020|
| Cerebrovascular disease||11 (25.6)||26 (16.3)||0.183|
| Dementia||14 (32.6)||84 (52.5)||0.025|
| Antipsychotic drugs||6 (14)||51 (31.9)||0.022|
| Proton pump inhibitors||31 (72)||93 (58.1)||0.114|
| ACE inhibitors||14 (32.6)||35 (21.9)||0.162|
Final Prediction Model for Risk of Aspiration Using Logistic Regression Analysis
|Characteristic||p Value||OR||95% CI for OR|
|Age (years)||0.098||0.472||[0.194, 1.148]|
|Parkinson’s disease||0.009*||5.114||[1.493, 17.519]|
|Cerebrovascular disease||0.352||1.501||[0.639, 3.526]|
|Antipsychotic drugs used||0.033*||0.330||[0.119, 0.917]|