Pneumonia is a common and serious disease in older adults, and the prevalence of dysphagia and aspiration in older adults with pneumonia is >50% (Cabre et al., 2010). In older adults with pneumonia, one half of those eventually diagnosed with dysphagia are initially at risk of aspiration pneumonia (Cabre et al., 2010). Older adults may develop swallowing dysfunction due to the limited reserve of swallowing and the prevalence of pneumonia may therefore increase (Wakabayashi, 2014). Older adults with pneumonia and swallowing dysfunction have worse outcomes, particularly regarding mortality and length of hospital stay (Cabré et al., 2014).
In an increasingly aging Japanese society, the treatment and prevention of pneumonia in older adult patients is important. Previous studies have suggested that early physical therapy (Momosaki et al., 2015b), switching from intravenous to oral antibiotic therapy, and clear discharge criteria reduce the length of hospital stay in pneumonia cases (Carratalá et al., 2012). However, hospitalized older adults with severe pneumonia are usually encouraged not to eat on admission and tend to be hospitalized for longer periods. Thus, the standards and practical methods for recommencement of oral intake for older adults with pneumonia have not yet been established.
Previous studies have provided evidence that dysphagia is associated with patients with pneumonia (Almirall et al., 2013; Cabré et al., 2014). An early intervention program for oral feeding, comprising intensive oral care and early behavioral intervention, has been reported to improve the proportion of patients with acute intracerebral hemorrhage who could tolerate oral feeding (Takahata, Tsutsumi, Baba, Nagata, & Yonekura, 2011). Daily oral care for tube-fed patients reduces the incidence of pneumonia (Maeda & Akagi, 2014).
Dysphagia rehabilitation mainly comprises oral health care, rehabilitative techniques, and food modification (Cabré et al., 2014; Wakabayashi, 2014), and has been shown to have a positive effect on oral intake in older adults with aspiration pneumonia (Momosaki et al., 2015a). Administration of antibiotic medications and combined therapy, such as dysphagia rehabilitation and nutrition management, are recommended in the pneumonia treatment guidelines (Kohno et al., 2013). Because the treatment of pneumonia and dysphagia can vary depending on the causes (e.g., overall condition, cognitive function, eating ability), a multidisciplinary comprehensive care (MDCC) team may be required. MDCC can increase the availability of support, staff motivation, and multidisciplinary interventions to assess and treat frail older adults. MDCC based on comprehensive geriatric assessment (CGA) has been shown to be beneficial for acutely sick, frail older adults (Ellis, Whitehead, O'Neill, Langhorne, & Robinson, 2011). However, which medical professionals should be a part of the MDCC team and their exact roles within that team have not yet been established. In addition, optimum timing and adequate models of such combined interventions have not yet been determined.
Because the associations between MDCC and swallowing function or length of hospital stay in older adult patients with pneumonia are unknown, the aim of the current study was to assess the importance and effectiveness of MDCC in hospitalized older adults with pneumonia. The correlation between MDCC and length of hospital stay, as well as between MDCC and oral intake at discharge, in older adult patients with pneumonia treated with and without MDCC was investigated.
The current retrospective cohort study was designed to assess the effectiveness of MDCC for patients who were consecutively admitted for the treatment of acute pneumonia during the following periods: April 2005 to March 2006 and April 2011 to March 2014.
All patients were 65 or older. Those admitted between 2011 and 2014 were treated with MDCC, whereas no comprehensive intervention was given to those admitted between April 2005 and March 2006 regardless of pneumonia severity. The severity of pneumonia was assessed using the Japanese version of the CURB-65 severity score by A-DROP assessment (Miyashita, Matsushima, & Oka, 2006). The score was calculated based on age (males 70 and older, females 75 and older), dehydration (blood urea nitrogen ≥21 mg/dL or presence of dehydration), respiratory failure (percutaneous oxygen saturation ≤90% or arterial oxygen saturation ≤60 torr), confusion, and systolic blood pressure (≤90 mmHg). Exclusion criteria were: discharge from hospital within 4 days, hospital stay for ≥150 days, feeding in a way other than oral intake, death, mild pneumonia (A-DROP = 0), patients who had not been referred to the MDCC team by attending physicians, and patients who had missing data for the parameters investigated. The data of the hospitalized pneumonia cases between April 2005 and March 2006 were exhaustive.
The study was approved by the ethics committee at Tomei Atsugi Hospital. Due to the nature of the study, written informed consent was not obtained; however, a waiver of consent was obtained from the ethics committee.
Pneumonia was diagnosed by attending physicians using the following criteria (Kohno et al., 2013): (a) the presence of two or more of the following four findings (i.e., leukocytosis [white blood cell count >9,000 dL], fever [body temperature >37.5°C], purulent sputum, and a high plasma C-reactive protein level) and (b) the presence of a new abnormal shadow on chest radiography or computed tomography.
Recommencement of Oral Intake
The standards for bedside screening to detect dysphagia or oral intake recommencement should satisfy the following conditions: (a) the patient is alert without any stimuli or is easily aroused by voice; (b) body temperature is <37.5°C; (c) no deterioration of pneumonia symptoms; (d) stable respiratory condition and circulation dynamics; and (e) little or no respiratory tract secretions, even with the use of tracheal aspiration. Patients whose oral ingestion was not expected to meet nutritional requirements received tube feeding. The swallowing function of the MDCC group was evaluated on the basis of a modified water swallowing and food test by nurses specializing in dysphagia nursing. The non-MDCC group received no bedside screenings.
Multidisciplinary Comprehensive Care
MDCC promotes improved physical function, activities of daily living, early mobilization, and weight-bearing exercise. The therapeutic policies of MDCC are based on CGA, which was defined as a comprehensive diagnostic process to develop a coordinated and integrated treatment plan as well as long-term monitoring (Ellis et al., 2011). MDCC includes four major features: (a) identification and assessment of medical, physical, social, and cognitive problems; (b) planning for the initiation of care and rehabilitation during mealtimes and daytime; (c) implementation and management of said plan; and (d) early initiation of discharge planning and support.
In the current study, the MDCC team comprised specialized nurses, dental hygienists, occupational therapists, speech-language pathologists, physiotherapists, and registered dietitians. In addition, the team provided interdisciplinary care, including medical treatment authorized by attending physicians. Dental hygienists performed mechanical and functional oral care in cooperation with attending nurses, especially in severe cases of pneumonia. Physiotherapists were responsible for respiratory physiotherapy, postural and gait training (which provides encouragement to leave beds and ambulate during the day), and improvement of the activities of daily living. Registered dietitians conducted meetings every morning with the specialized nurses to adjust the food texture, nutrient content of patients' diets, and serving time.
Patients were referred to the MDCC team by attending physicians on the first or second day of admission. Regular care provided by the attending nurses included maintenance of oral hygiene, help with adequate sitting posture, adjusting the position of the neck, and encouraging patients to leave their beds and ambulate during the day. Specialized nurses in the MDCC team examined patients' overall condition, neurological findings, higher brain function, oral cavity, and pharynx. Once it was decided that a bedside dysphagia screening test could be performed safely, they assessed patients' swallowing function and oral intake level.
Weekly meetings among the MDCC team were conducted to share patients' medical information, including results of the daily assessments. Consequently, this allowed for early intervention.
According to the hospital's protocols, the patient began to eat or drink orally. If a patient showed poor alertness or severe cognitive dysfunction, the MDCC team promoted improvement of the environment during the meal, taking visual perceptual information into consideration. Muscular relaxation in desensitization therapy and combined basic physical and eating training were also provided in accordance with symptoms. Registered dietitians and specialized nurses attempted to gradually modify food and liquid textures with 1- to 3-day intervals based on continuous assessment by attending nurses. The eating training by specialized nurses also included careful feeding by hand and assistance for self-management skills for oral intake. In severe cases that could not be assessed with bedside swallowing screening or recommencement of oral intake, occupational therapists and physiotherapists performed breathing, basic physical, and postural training in antigravity positions. They also aided arousal by special sensory stimulation and changes in posture and visuospatial and body perception.
Discharge criteria of pneumonia were: a stable general condition, establishment of feeding strategies if oral intake was impossible, ability to swallow thin or thick liquid, and preparation of a suitable discharge destination.
The current study did not include patients treated between April 2006 and March 2011. During this period, the MDCC team had not yet been established and early regular assessment of swallowing ability and care was performed by a specialized nurse only, without the cooperation of other medical staff members.
After excluding patients with mild pneumonia with an A-DROP score of 0, participants were classified into three groups of severity based on their score (where 1 to 2 = moderate, 3 = severe, and 4 to 5 = very severe).
Physical function was evaluated by a physical dependency scale introduced by the Ministry of Health, Labor, and Welfare in Japan in 1992. This scale has been used extensively to assess the physical function of Japanese individuals 65 and older, and was included as a functional measure in previous studies (Kuroda, 2014; Wakabayashi & Sakuma, 2014). The scale is a four-grade, observer-rated scale and is scored as follows:
- Rank J: some disability, is almost independent in activities of daily living (ADLs) and able to go outside unassisted;
- Rank A: mostly independent in ADLs at home but cannot go outside without assistance;
- Rank B: requires some assistance in performing indoor activities and is mainly confined to bed, although is able to sit up in bed; and
- Rank C: in bed all day and requires assistance for toileting, eating, and changing clothes.
Disturbances in consciousness were evaluated using the Japan Coma Scale (Shigematsu, Nakano, & Watanabe, 2013), which is a four-grade categorized scale that focuses on responses against external irritation, where 0 = fully alert, 1 = not fully alert but awake without stimulation, 2 = able to be aroused with stimulation, and 3 = unable to be aroused.
The primary and secondary outcome measures were the level of oral intake at discharge and length of hospital stay in patients who achieved total oral intake without enteral nutrition, respectively. The level of oral intake was evaluated retrospectively with the Functional Oral Intake Scale (Crary, Mann, & Groher, 2005) and a score ≥4 was defined as recommencement of oral intake.
Sample Size Calculation
The association of early commencement of oral intake and physical function in 370 hospitalized older adults with pneumonia who were treated by MDCC in the authors' previous study was described (Koyama et al., 2015). To perform a comparison between the 370 patients receiving and not receiving MDCC, an adequate control group sample size was calculated using data from a previous nationwide study on pneumonia (Momosaki et al., 2015a). The discharge rates of patients with total oral intake without tube feeding and who did not receive dysphagia rehabilitation reported in the nationwide study (75.2%) were compared with those in the current authors' previous study (88.6%) (Koyama et al., 2015), using >80% power and an alpha error of 0.05. This power analysis showed that the current study needed ≥100 participants in the control group. The current authors therefore collected and analyzed data of 101 patients with pneumonia over a 1-year period (between April 2005 and March 2006) to serve as the control group.
Parametric and nonparametric data are presented as means, standard deviations, and interquartile ranges. Differences between the MDCC and non-MDCC groups were analyzed using Welch's t test or the Mann–Whitney U test, as appropriate. Categorical data were expressed as incidences (percentages), with differences analyzed using Fisher's exact test or chi-square test. Multiple regression analysis was performed by entering program (MDCC versus non-MDCC), age, gender, consciousness, pneumonia severity, premorbid physical function, and discharge setting (home versus not home) as independent variables in a proceeding stepwise selection, with length of hospital stay as the dependent variable. It became necessary to eliminate one variable (i.e., residence before hospitalization) due to high collinearity (coefficient of correlation = 0.72) between pre- and post-hospitalization residence. A Cox regression analysis was used to determine which variables were associated independently with oral intake at discharge and to calculate the hazard ratios adjusted for the same parameters of the multiple regression analysis; p values <0.05 were considered statistically significant. The analyses and sample size calculation were performed using SPSS 21.0 and PS version 3.1.2.
From an initial sample of 630 patients, a total of 471 met the inclusion criteria, of whom 101 did not receive MDCC and 370 received MDCC. Reasons for exclusion were: 126 patients died in the hospital, four were diagnosed as having very mild pneumonia by A-DROP assessment, 17 were discharged from the hospital within 4 days, three were in the hospital for >150 days, eight were fed by parenteral nutrition without oral intake, and one had missing data. In comparison to the non-MDCC group (45 women, 56 men; mean age = 81.1, SD = 8.6 years), the MDCC group (164 women, 206 men; mean age = 82.7, SD = 8.4 years) had more severe pneumonia at admission and a higher proportion of poor premorbid physical function, consciousness disturbance, and transfer to either another hospital or nursing home. Patient characteristics and comparisons between the MDCC and non-MDCC groups are shown in Table 1.
Patient Characteristics and Comparative Examination Between MDCC and Non-MDCC Groups at Hospital Admission
Univariate Correlation Analyses Between Both Programs
Primary outcomes did not differ between the MDCC and non-MDCC groups in a univariate analysis (Table 2). The proportion of patients who were on total oral intake and had no alternative nutrition at discharge was not significantly different between groups (328 [88.6%] patients in the MDCC group versus 90 [89.1%] patients in the non-MDCC group) by univariate analysis. The median hospital stay duration for the MDCC group was 16 days (range = 11 to 25 days) and 15 days (range = 10 to 27 days) for the non-MDCC group. However, patients in the MDCC group were less likely to be discharged home than those in the non-MDCC group.
Clinical Outcomes in the MDCC and Non-MDCC Groups
Multivariate Correlation Analysis Between Both Programs
A Cox proportional hazard regression analysis, adjusted for the same parameters of the multiple regression analysis, showed that the MDCC program (hazard ratio [HR] = 1.42, 95% confidence interval [CI] [1.09, 1.85], p = 0.05), premorbid physical function (HR = 1.25, 95% CI [1.13, 1.4], p < 0.001), pneumonia severity (HR = 1.25, 95% CI [1.08, 1.44], p < 0.01), and residence after discharge (HR = 1.49, 95% CI [1.21, 1.85], p < 0.001) were independent determinants for oral intake at discharge (Table 3).
Cox Proportional Hazard Regression Analysis
Subsequently performed multiple regression analyses revealed that MDCC (p = 0.02), pneumonia severity (p < 0.01), premorbid physical function (p = 0.03), and residence after discharge (p < 0.001) had significant associations with length of hospital stay (Table 4). The MDCC program, milder pneumonia, better premorbid physical function, and discharge to home were independently associated with shortening of hospital stay.
Multiple Regression Analysis of Length of Hospital Stay
Patients in the MDCC group improved total intake ability sooner than those in the non-MDCC group. Analysis was performed by adjusting for gender, age, pneumonia severity, discharge to home, consciousness, and physical function as covariates, and censoring of patients who could not achieve total oral intake at discharge. In this model, cumulative curves, constructed by the length of hospital stay and rates of oral intake at discharge, showed that the MDCC program improved the ability of oral intake and shortened hospital stay duration (Figure).
Cumulative curves constructed from the Cox regression analysis. Total intake ability improved in the multidisciplinary comprehensive care (MDCC) group. The analysis was performed by adjusting for gender, age, pneumonia severity, discharge to home, consciousness, and physical function as covariates, with censoring of patients who could not achieve total oral intake at discharge.
The current study revealed that a MDCC program based on CGA may promote early recommencement of oral intake before hospital discharge and shorten the length of hospital stay for older adults with pneumonia, even if they experience severe pneumonia and a higher proportion of poor premorbid physical function and consciousness disturbance on admission. In this program, specialized nurses play a leading role in comprehensive care with the cooperation of other team staff. In addition, specialized nurses share patient information and achieve a common understanding with attending nurses and physicians. Attending nurses encouraged patients to leave their beds during the day to strengthen respiratory muscles and maximize lung function. Because the attending and specialized nurses had the most interaction with patients, they could intervene quickly.
Patients with pneumonia tend to be prohibited from oral intake and are instructed to get maximum bed rest during pneumonia treatment. Consequently, muscle atrophy and deterioration of ADLs may develop, and swallowing function can be further reduced, especially in older patients during pneumonia treatment. Pneumonia may cause disease-related sarcopenia and result in reduction of muscle strength and muscle mass. Sarcopenia is a risk factor of further decline in swallowing function. The current authors previously described that early dysphagia rehabilitation after admission was important for the recommencement of oral intake in older adults with pneumonia, and was likely to shorten the length of hospital stay (Koyama et al., 2015).
Poor physical activity and physical function are associated with malnutrition and sarcopenia, and are likely to result in impaired swallowing ability. Poor premorbid physical function also impairs swallowing ability in patients with pneumonia and prolongs the length of hospitalization (Koyama et al., 2015). The prevalence of impaired physical function and swallowing in older adults is relatively high (Maeda & Akagi, 2016), which is an important current public health issue (Wakabayashi & Sakuma, 2014). Nutritional assessment is required to evaluate swallowing function because a systematic review of nursing home patients has shown that difficulty swallowing or chewing and poor oral intake are associated with malnutrition (Tamura, Bell, Masaki, & Amella, 2013).
The most important point is that the aim of the MDCC program is not only early commencement of oral intake for improving respiratory function and preventing the decline of eating ability during hospitalization (Koyama et al., 2015), but also risk management of aspiration during mealtimes with food and liquid modification, help with adequate sitting posture and position of the neck, careful hand feeding, and prevention of hospital-associated deconditioning. The current authors previously described the details and possible effects of the MDCC program on early oral intake in patients with pneumonia (Koyama et al., 2015). Adequate nutritional therapy and early rehabilitation are used to prevent malnutrition and physical inactivity, thus precluding the recurrence of pneumonia, development of complications, and deterioration of overall health (Tamura et al., 2013). Appropriate techniques for assistance with meals of adequate texture and fluid thickness levels are needed for risk management of aspiration during mealtimes (Koyama et al., 2015).
CGA recognizes the risk factors and deficits in older adult patients for poor outcome, such as malnutrition and physical dys-function, and enables timely and safe intervention (DiMaria-Ghalili, 2014). The MDCC program with CGA requires early and easy sharing of medical, functional, and social problems; communication among medical staff; and the provision of adequate information to the next hospital, institution, and institutional or family caregivers (Ellis et al., 2011).
MDCC programs should be recognized and implemented as standard procedures by medical staff to lead to the facilitation of discharge planning through the various aforementioned efforts. A systematic approach, including the MDCC program with CGA for patients with severe pneumonia, may play an important role to enable oral intake (Sura, Madhavan, Carnaby, & Crary, 2012) and discharge directly home (Carratalá et al., 2012), as well as to shorten the length of hospital stay (Maeda, Koga, & Akagi, 2015; Takahata et al., 2011).
There are several limitations to the current study. First, this was a retrospective study performed without randomization, and may not have included patients with more severe pneumonia, especially during the post-MDCC period. Therefore, effectiveness of the MDCC program on early hospital discharge and oral intake at discharge was not comprehensively investigated. Second, patients who either died or had a prolonged length of hospital stay (>150 days) were excluded. This exclusion was necessary, as the objective of the study was to investigate the impact of the MDCC program on oral intake at discharge. Third, consecutive data between 2005 and 2014 were not included; it is possible that several confounding factors could not be measured. In addition, during the 9-year period between 2005 and 2014, improvement of medical treatment (e.g., introduction of new antibiotic medications, evolution of rehabilitation protocol) may have promoted better outcomes and shortened the length of hospital stay in patients with pneumonia (Kohno et al., 2013). In addition to the reform of health policy in Japan, the facilitation of hospital discharge planning may have improved during the post-MDCC period. However, promotion of early oral intake resumption may facilitate early discharge. A prospective and randomized study is therefore needed to fully determine the effectiveness of the MDCC program on early oral intake and hospital discharge in older adult patients with severe pneumonia.
The MDCC program with CGA in older adult patients with pneumonia could shorten the length of hospital stay and lead to the re-commencement of oral intake before hospital discharge.
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Patient Characteristics and Comparative Examination Between MDCC and Non-MDCC Groups at Hospital Admission
|Variable||MDCC Group (n = 370)||Non-MDCC Group (n = 101)|
|Age (years) (mean, SD)||82.72 (8.43)||81.1 (8.57)|
|C-reactive protein (mg/dL, 95% CI)||7.33 [3.12, 12.54]||8.46 [2.62, 14.17]|
| Male||206 (55.7)||56 (55.4)|
| Female||164 (44.3)||45 (44.6)|
| C||164 (44.3)**||22 (21.8)**|
| B||116 (31.4)**||13 (12.9)**|
| A||74 (20)**||23 (22.8)**|
| J||16 (4.3)**||43 (42.6)**|
|Residence before hospitalization|
| Home||209 (56.5)**||79 (78.2)**|
| Nursing home or hospital||161 (43.5)**||22 (21.8)**|
| Moderate||148 (40)*||62 (61.4)*|
| Severe||134 (36.2)*||26 (25.7)*|
| Very severe||88 (23.8)*||13 (12.9)*|
|Level of consciousnessb|
| 0||79 (21.4)**||72 (71.3)**|
| 1||222 (60)**||21 (20.8)**|
| 2||53 (14.3)**||4 (4)**|
| 3||16 (4.3)**||4 (4)**|
Clinical Outcomes in the MDCC and Non-MDCC Groups
|Variable||MDCC Group (n = 370)||Non-MDCC Group (n = 101)|
|Length of hospital stay (days) (mean, range)||16 (11 to 25)||15 (10 to 27)|
|Nutritional intake route at discharge|
| Oral||328 (88.6)||90 (89.1)|
| Tube-fed||42 (11.4)||11 (10.9)|
|Residence after discharge|
| Home||188 (50.8)*||76 (75.2)*|
| Nursing home or hospital||182 (49.2)*||25 (24.8)*|
Cox Proportional Hazard Regression Analysis
|Variable||Hazard Ratio||95% CI|
|Gender (male)||0.92||[0.75, 1.13]|
|Pneumonia severityc||1.25**||[1.08, 1.44]|
|Premorbid physical functiond||1.25***||[1.13, 1.4]|
|Residence after discharge (non-home)||1.49***||[1.21, 1.85]|
Multiple Regression Analysis of Length of Hospital Stay
|Gender (male)||−0.06||[−1.25, 5.32]|
|Pneumonia severityc||−0.15**||[−5.87, −1.25]|
|Premorbid physical functiond||−0.11*||[−3.69, −0.16]|
|Residence after discharge (home)||−0.19***||[−10.17, −3.42]|