Original articleOropharyngeal dysphagia is a prevalent risk factor for malnutrition in a cohort of older patients admitted with an acute disease to a general hospital☆
Introduction
Oropharyngeal dysphagia (OD) is a frequent and severe condition among older people [1] and is specifically classified by the World Health Organization in the International Statistical Classification of Diseases and Related Health Problems (ICD), 787.2 in ICD-9 and R13.10 in ICD-10 [2]. Prevalence of OD varies among the different phenotypes of older patients, the highest being in older patients with neurological diseases: 13%–57% in patients with dementia [3], between 30% and 81% in patients with Parkinson's [4], [5] and 37%–78% in stroke patients [6]. We recently found that the prevalence of OD in independently-living older subjects (>70 yr) was 27.2% (95% CI 21.7–32.7%) [7], and other studies have found a prevalence of over 51% in older institutionalized patients, many of them tube fed due to severe swallowing dysfunction [8]. The prevalence of OD among older patients hospitalized for acute diseases in general hospitals is not known and studies using nonvalidated instruments have reported widely varying prevalence, from 17% to 71% [9], [10], [11], [12].
Malnutrition (MN) is a severe geriatric syndrome related to increased healthcare costs and impaired health outcomes as it increases hospital stay and risk of infections, impairs recovery and increases mortality [13]. MN is also underestimated and underdiagnosed among older hospitalized patients despite being classified in the ICD. A recent resolution of the Council of Europe claimed that undernutrition among hospital patients was highly prevalent and identified OD as a major contributor to MN. The overall prevalence of MN among older persons admitted to general hospitals for acute diseases is estimated to be 38.7% [14].
Despite its enormous impact on functional capacity, health and quality of life [15], OD is underestimated and underdiagnosed as a cause of major nutritional and respiratory complications in older patients admitted to hospitals, and the level of healthcare resources dedicated to dysphagic patients is very low. The relationship between OD and pneumonia is well recognized and gives rise to the term “aspiration pneumonia” for those patients with abnormal swallowing function and pneumonia [16]. In contrast, the association between OD and MN is less recognized, probably because the nutritional complication develops slowly and insidiously. We recently found that OD was a relevant risk factor for MN (OR 2.46 (1.10–5.46) in independently-living older persons [7]. In nursing-home residents, the relationship between OD and MN is also widely recognized [17] as well as in patients with stroke [18] and neurodegenerative diseases [19]. In contrast, the association between OD and MN in older patients admitted to an acute geriatric unit (AGU) has not been established and the integrated management of both conditions is rarely considered in standard hospital geriatric care.
The aim of our study was to assess the prevalence of OD and MN, their relationship and their correlation with clinical outcome in older patients hospitalized with an acute disease.
Section snippets
Study design and patient sample
We designed a prospective observational cohort study with 1-year follow up. Patients were 70 years and older, with acute diseases, and able to undergo a volume-viscosity swallow test (V-VST) for the study of OD. No other exclusion criteria were considered. Patients were consecutively admitted to the Acute Geriatric Unit (AGU) of Hospital de Mataró, Consorci Sanitari del Maresme, Spain from January 1, 2005 to December 31, 2009. This is a general hospital with an AGU of 12 beds and 300 discharges
Demographics, comorbidities, geriatric syndromes and functional capacity of the overall sample studied
We studied 1662 patients with a mean age of 85.1 ± 6.23 years, 61.7% of whom were women. These patients were hospitalized with an acute disease: a) 26.2% with diseases of the circulatory system – heart disease in 11.5% and stroke in 5.2%; b) 24% with diseases of the respiratory system, 6.7% of which were respiratory infections; c) 7.5% with diseases of the genitourinary system, 4.8% of which were urinary infection; d) 6.8% with digestive diseases, and less than 5% for each of the following
Discussion
This study shows the high prevalence of OD and MN among older patients admitted with an acute disease to the AGU; OD was more prevalent and an independent risk factor for malnutrition. Both OD and MN were associated with poor outcome in these frail older patients, regardless of their functional status and comorbidities. Based on these findings, future studies should clarify the effect of routine systematic screening and assessment for both OD and MN as part of standard geriatric evaluation and
Statement of authorship
SC, MC, PC: concept and writing of the manuscript; EP, MS: statistical analysis; RM, MR: recruitment and assessment of patient; LR: critical input and revision of the manuscript.
Funding sources
This work was supported by a grant from the Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, Spain, INT 10/228 and PI09/01012 and an award from Fundació Agrupació Mutua 2011.
Conflict of interest
The authors declare that they have no conflict of interest regarding this manuscript.
Acknowledgements
We would like to thank Mrs Jane Lewis for reviewing the English of the manuscript.
References (28)
- et al.
Evaluation and management of oropharyngeal dysphagia in different types of dementia: a systematic review
Arch Gerontol Geriatr
(2013) - et al.
Prognostic impact of disease-related malnutrition
Clin Nutr
(2008) - et al.
Malnutrition in stroke patients on the rehabilitation service and at follow-up: prevalence and predictors
Arch Phys Med Rehabil
(1995) - et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987) - et al.
Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration
Clin Nutr
(2008) - et al.
Depressive symptoms are associated with food insufficiency and nutritional deficiencies in poor community-dwelling elderly people
J Nutr Health Aging
(2011) - et al.
Pathophysiology of oropharyngeal dysphagia in the frail elderly
Neurogastroenterol Motil
(2010) International classification of diseases, ninth revision, clinical modification (ICD-9-CM)
(1993)- et al.
Referral criteria for speech and language therapy assessment of dysphagia caused by idiopathic Parkinson's disease
Acta Neurol Scand
(1998) - et al.
Dysphagia in Parkinson's disease
Eur Neurol
(1997)
Dysphagia after stroke: incidence, diagnosis, and pulmonary complications
Stroke
Prevalence of oropharyngeal dysphagia and impaired safety and efficacy of swallow in independently living older persons
J Am Geriatr Soc
Prevalence of impaired swallowing in institutionalized older people in Taiwan
J Am Geriatr Soc
Clinical and scintigraphic assessment of swallowing of older patients admitted to a tertiary care geriatric ward
Dysphagia
Cited by (0)
- ☆
Conference presentation: This study was presented in part at the 1st Meeting of the European Society for Swallowing Disorders (ESSD), in Leiden, Netherlands Sept 9–10, 2011; and at the Plenary Session of the 2012 European Society for Clinical Nutrition and Metabolism (ESPEN) Meeting Sept 8–11, 2012 in Barcelona, Spain.