geriatrics

Article
The Prevalence of Oropharyngeal Dysphagia in Acute
Geriatric Patients
Dorte Melgaard 1, *, Maria Rodrigo-Domingo 2 and Marianne M. Mørch 3
1 Center for Clinical Research, North Denmark Regional Hospital, Bispensgade 37,
DK-9800 Hjørring, Denmark
2 Unit of Epidemiology and Biostatistics, Aalborg University Hospital, DK-9000 Aalborg, Denmark;
mariarodrigo@rn.dk
3 Department of Geriatric, North Denmark Hospital, DK-9800 Hjørring, Denmark; m.moerch@rn.dk
* Correspondence: dmk@rn.dk; Tel.: +45-9764-1048




Received: 11 February 2018; Accepted: 22 March 2018; Published: 26 March 2018


Abstract: Oropharyngeal dysphagia (OD) is underdiagnosed and undertreated in many geriatric

centers. The aim of this study is to explore the prevalence of OD in acute geriatric patients.
The outcome was mortality during hospitalization, mortality, and rehospitalization within 0–30
and 31–180 days of discharge. A total of 313 consecutive acute geriatric patients (44.1% male, mean
age 83.1 years (SD 7.8)) hospitalized from 1 March to 31 August 2016 in the North Denmark Regional
Hospital were included in this study. The volume-viscosity swallow test and the Minimal Eating
Observation Form-II were conducted for each patient in order to screen for OD. A total of 50% patients
presented with OD. In the group of patients with OD, significantly more lived in nursing homes;
had a lower weight, DEMMI score, and handgrip strength; and smaller circumference of arms and
legs compared with non-dysphagia patients. Patients with OD presented an increased length of stay
in hospital of one day (p = 0.70). Intra-hospital mortality was 5.8% vs. 0.7%, (p < 0.001) compared
with patients with no symptoms of OD. OD is prevalent in acute geriatric patients, and the mortality
is 34% within six months of hospitalization. Screening for OD should be given more attention and
included in geriatric guidelines.

Keywords: swallowing disorders; elderly; prevalence; mortality; rehospitalization

1. Introduction
It is essential for humans to eat and drink, and dysphagia describes difficulties in meeting these
basic needs. There are several definitions of dysphagia, with one being “difficulties moving food from
the mouth to the stomach” [1]. The International Classification of Functioning, Disability, and Health
(ICF) classifies swallowing as “functions of clearing the food and drink through the oral cavity, pharynx
and oesophagus into the stomach at an appropriate rate and speed” [2].
Oropharyngeal dysphagia (OD) is highly prevalent in elderly patients in different settings.
The prevalence is 30–40% in independently living elderly people [3], and it is reported to be 44–47.4%
in patients in acute geriatric units [4,5]. In patients with different forms of dementia, the prevalence
is as high as 84% [6,7]. OD may lead to following complications in elderly people: (1) malnutrition
and/or dehydration due to lack of efficacy, and (2) choking and aspiration with pneumonia due to lack
of safety [8]. Over time, the complications may lead to frailty, social withdrawal, and mortality [5,9–13].
Loss of muscle mass, impaired dental status, reduction of saliva production, and changes in the cervical
spine all affect the swallowing function [11]. Older adults are particularly vulnerable to OD due to
the fact that disease prevalence increases with age and given age-related changes of the aerodigestive
tract, which affects the ability to efficiently and safely swallow [14,15]. Elderly people with OD often

Geriatrics 2018, 3, 15; doi:10.3390/geriatrics3020015 www.mdpi.com/journal/geriatrics

Geriatrics 2018, 3, 15 2 of 9

experience delayed oropharyngeal swallow response and weak tongue propulsion. This combined
with risk factors such as aging, confusion, and medication can lead to impaired safety in swallowing.
Weak tongue force related to sarcopenia and reduced bolus prolusion may lead to reduced swallowing
efficacy [16]. The European Geriatric Medicine Society and the European Society for Swallowing
Disorders have suggested dysphagia to be a geriatric syndrome in line with immobility, instability,
incontinence, intellectual impairment, sarcopenia, and frailty.
In Europe, geriatric patients are not systematically screened for OD, despite the fact that OD
is highly prevalent in elderly patients with multifactorial diseases associated with comorbidity and
poor outcomes.
The primary aim of this study was to assess the prevalence of OD in Danish patients hospitalized
in a geriatric department. The secondary aim was to document rehospitalization and mortality within
30 and 31–180 days of discharge and to document the prevalence of oropharyngeal dysphagia by
reason for hospitalization.

2. Materials and Methods

2.1. Subjects
A cross-sectional observational study with longitudinal follow-up was applied in the period from
1 March to 31 August 2016. Patients hospitalized in the Department of Geriatric Medicine at the North
Denmark Regional Hospital were consecutively screened for OD. Inclusion criteria were ≥60 years old,
hospitalized for minimum 24 h and able to cooperate in the test for OD. Of the 418 patients enrolled in
the study, 313 (75%) participated. The reasons for exclusion are illustrated in Figure 1.

Figure 1. Flowchart over included patients.

The North Denmark Regional Committee on Health Research Ethics (N-20160007) and the Danish
Data Protection Authority (2008-58-0028) approved the study.

2.2. Procedure and Measurements

Data were collected on body mass index (BMI), waist circumference (2 cm above the navel),
strength in the dominant hand, circumference of the lower leg (15 cm above the lower edge of the
patella), circumference of the upper arm (lateral epicondyle + 10 cm), Barthel 100, and DEMMI score.
Age, gender, admission date, discharge date, Charlson Comorbidity Index (CCI), and primary cause
of admission were recorded from the National Patient Register. Rehospitalization was defined as
hospitalization due to the disease they were discharged with in the Northern Region of Denmark.
Geriatrics 2018, 3, 15 3 of 9

2.3. Measurements
OD was screened by using the Volume-Viscosity Swallow Test (V-VST) and the Minimal Eating
Observation Form version II (MEOF-II). The V-VST assesses the ability to drink safe and effective.
The MEOF-II focus on the ability to eat a meal, including e.g., the sitting position, whether the patient is
able to manipulate the food at the plate and to transport the food to the mouth. The complexity of eating
and drinking is high and by choosing these two tests, the patient’s ability to eat and drink sufficiently is
uncovered clinically. Both tests were administered by trained and experienced occupational therapists.
The V-VST assesses different types of viscosity and volumes. The bolus volumes were 5, 10,
and 20 mL. The bolus viscosity was liquid viscosity (21.61 mPa.s), nectar viscosity (295.02 mPa.s)
was achieved by adding 1.2 g of the thickener Resource ThickenUp (Nestlé HealthCare Nutrition) to
100 mL water, and pudding viscosity (3682.21 mPa.s) was achieved by adding 6.0 g of the thickener
Resource ThickenUp to 100 mL water. Mineral water at a room temperature of 25 ◦ C was used.
Boluses of each volume and viscosity were offered to the patients with a syringe during the test to
ensure an accurate measurement of the volume. Before the V-VST, a pulse oximeter was placed on
the index finger, and baseline readings were measured before starting the test. During the screening,
the following clinical signs of disordered swallowing function were observed: impaired labial seal,
oral or pharyngeal residue, and multiple swallows per bolus. According to V-VST, the following
clinical signs of impaired safety of swallowing were also observed: changes of voice quality, cough,
or decrease in oxygen saturation ≥3% to detect silent aspiration [17]. One or more signs of impaired
safety or efficacy indicated OD [18].
The MEOF-II is a measurement tool for assessing elderly patients with OD performance in
eating [19]. It consists of nine items in three criteria: (1) Ingestion that includes “manipulation of
food on the plate”, “transport of food to the mouth”, and “sitting position”; (2) deglutition includes
“ability to chew”, “manipulation of food in the mouth”, and “swallowing”; and (3) energy includes
“alertness”, “appetite”, and “eating <3/4 of served food”. A higher score indicates a higher level
of dysfunction [20,21]. The patients were observed in a meal consisting of a range of viscosities:
e.g., breakfast with yoghurt, bread, apples, coffee, and juice. Patients with a dysfunction in ingestion
or deglutition were considered to have OD, but patients with a high score in energy were not because
these acute patients may express lower appetite for reasons other than OD.
The functional level was measured with the de Morton Mobility Index (DEMMI) and Barthel 100 [22,23]:
both measurements were developed to measure functionality in elderly people. Comorbidity was
measured using the Charlson Comorbidity Index (CCI) [24,25].

2.4. Statistical Analysis

Descriptive statistics of the demographic variables include the number and percentage of patients
for categorical variables, and median ([5th percentile; 95th percentile]) for continuous variables.
Differences between the two study groups were analyzed using Fisher’s exact test or the chi-squared
test, as appropriate depending on the number of observations, for categorical variables, and the
non-parametric equality of medians test for continuous variables.
Death status was classified as alive 180 days after discharge (level 1), dead between 31 and 180 days
of discharge (level 2), dead within 30 days of discharge (level 3), or in-hospital death (level 4). A trend
test was used to determine a possible increasing trend of death status in OD vs. non-OD patients.
The follow-up time for rehospitalization was 180 days (6 months) after discharge. The analyses does not
include the patients who died during the follow-up period without being rehospitalized. Differences
in time to rehospitalization between the OD and non-D groups were analyzed using survival analysis
(log-rank test). Throughout the analyses, 95% confidence intervals (CI) were reported, and results
with a p-value < 0.05 were considered statistically significant. We did not perform any imputation of
data. Statistical analyses were performed using Stata Version 14.2 (Stata Corporation, College Station,
TX, USA).
Geriatrics 2018, 3, 15 4 of 9

3. Results
In total, 313 patients were included in the project (44% male, mean age 83.1 years (SD 7.81)).
As illustrated in Table 1, 50% of the sample was diagnosed with OD (46% male, mean age 83.6 years
(SD 8.15)). Patients with OD had a significantly lower weight (p < 0.001), DEMMI score (p = 0.001), 30 s.
chair stand test (p = 0.001), smaller circumference of over arm (p = 0.001) and lower leg (p = 0.001) and
more were living in a nursing home (p = 0.004). Patients with OD were discharged after a median of
5 days (2; 14) compared with 4 days (1; 13) (p = 0.70) for patients not diagnosed with OD. The difference
is not statistically significant, but clinically relevant.

Table 1. Baseline demographics and clinical characteristics between patients with OD vs. patients
with no OD. The numbers in parenthesis after the variable name represent the number of patients in
each group with available information for that variable. Significant results present an asterisk after the
p-value.

Variable OD (N = 156) Not OD (N = 157) p-Value

Gender, male (156, 157) 72 (46.2%) 66 (42.0%) 0.50
Age, years (156, 157) 84 (69; 95) 83 (71; 94) 0.54
Residence, living in nursing home (156, 157) 28 (18.0%) 9 (5.7%) <0.01 *
Charlson Comorbidity Index (156, 157) 2 (0; 5) 2 (0; 7) 0.18
Barthel 100 (30, 20) 59.5 (0; 98) 72.5 (9; 95) 0.25
DEMMI (118, 128) 36 (0; 74) 44 (7; 85) <0.01 *
Weight, kg (81, 97) 62 (42.8; 91.2) 73.7 (47.5; 102.4) <0.01 *
BMI (80, 93) 23.6 (17.05; 32.9) 27.5 (20.0; 38.1) <0.01 *
Waist line, cm (84, 111) 96 (73; 125) 105 (82; 126) <0.01 *
Circumference—upper arm, cm (91, 119) 25.5 (19; 34) 28 (21; 36) 0.01 *
Circumference—lower leg, cm (88, 119) 32 (25; 39) 34 (26; 43) <0.01 *
Hand grip—dominant hand (88, 119) 18.1 (7; 44.6) 20.9 (8.6; 47.2) 0.047 *
Chair stand test (106, 117) 0 (0; 8) 0 (0; 11) <0.01 *
LOS in hospital, days (156, 153) 5 (2; 14) 4 (1; 13) 0.70
Rehabilitation plan, made (156, 157) 123 (79%) 107 (68%) 0.03 *

As illustrated in Table 2, the prevalence of OD is higher among patients hospitalized due to

dehydration, fall, or dyspnea. The association between cause of admission and OD is highly significant
(p-value = 0.009).

Table 2. Prevalence of oral dysphagia by reason for hospitalization.

Reason for Hospitalization OD Not OD

All 156 (49.8%) 157 (50.2%)
Pneumonia 11 (52.4%) 10 (47.6%)
Dyspnea 20 (57.1%) 15 (42.9%)
Dehydration 15 (75.0%) 5 (25.0%)
Fall 23 (65.7%) 12 (34.3%)
Reduction in food intake 5 (35.7%) 9 (64.3%)
Infections 31 (47.0%) 35 (53.0%)
Diverse 44 (47.3%) 49 (52.7%)
Pain 7 (24.1%) 22 (75.9%)

The data are presented as number and percentage of patients with OD or not OD for the total of
patients hospitalized for each reason.
The mortality in patients with OD is significantly higher than in patients with no OD (trend test
p = 0.001). Table 3 summarizes the death status and the OD status for all the patients.
Geriatrics 2018, 3, 15 5 of 9

Table 3. Mortality.

OD Not OD
Death Status p-Value
N = 156 N = 157
Survived the first 180 days after discharge 103 (66.0%) 128 (81.5%)
Died within 180 days of discharge 33 (21.1%) 23 (14.7%)
0.001
Died within 30 days of discharge 11 (7.1%) 5 (3.2%)
Died in hospital 9 (5.8%) 1 (0.6%)

The data are presented as number and percentage of patients in the OD and non-OD groups.
The p-value is from a trend test for association between group and death status.
The difference in readmission up to 180 days after discharge is not significantly different between
the OD and non-OD groups (p = 0.86). Because less than half of the patients had been readmitted
during the follow-up period we cannot report median times to readmission. The 25th percentile for
readmission is 30 days (CI 11–49) for the OD group and 36 days (CI 14–50) for the not OD group.

4. Discussion
The present study investigated the prevalence of OD in geriatric patients in order to identify
the factors associated with OD and the frequency of rehospitalization and mortality within 30 days
of discharge. OD was present in 50% of the patients; the LOS in acute geriatric patients with OD
was increased compared with patients with no OD. There was no significant difference between the
two groups of patients regarding readmission, but the mortality was significantly higher in patients
with OD, which affects the possibility of readmission. Dehydration, fall, and dyspnea as reasons for
hospitalization were strongly associated with OD in acute geriatric patients.

4.1. Prevalence
The prevalence of 50% documented in this study further supports the observed prevalence of OD
of 44% in an acute geriatric department [4]. Another study documents that the prevalence of OD in
patients with delirium and dementia are 59.4% and 73.8%, respectively [26]. In this study, we used
the V-VST, it is validated, reliable, and possible to use bedside and in the ward. It is rather fast to
use the V-VST and in a daily practice where focus of course is on quality in treatment but also length
of stay and time to perform the assessment are very important. The gold standard for assessing OD
is video fluoroscopy or fiberoptic endoscopic evaluation of swallowing, as both methods can detect
silent aspiration, which is not possible with the bedside test used in this present study [27]. For these
reasons, the prevalence of OD is assumed to be underestimated in the present study and other studies
where OD is assessed with bedside tests.

4.2. Risk Factors

OD is, in other studies, associated with age, functional capacity, frailty, and multi-morbidity [5,28].
In the present study, there was no significant difference between the groups of patients with and
without OD according to age and CCI. Unlike other studies, the Barthel 100 score was not significantly
lower—although lower in patients with dysphagia [26]. Patients with OD had a significantly lower
DEMMI score and more of them were living in nursing homes. Prevalence of OD is higher in
patients hospitalized due to dehydration (diminished total body water content [29]), fall, or dyspnea
(uncomfortable breathing sensations [30]). The subgroups are relative small and a larger sample size
will be relevant to describe the prevalence according to reason of hospitalization.
Frailty as a term is widely used as a multidimensional syndrome of loss of reserves, such as
physical ability, energy, health, and weight loss [31,32] and in relation to acute geriatric patients, it is
very relevant. More tools are available to measure frailty, but they are not used routinely in the clinic
and studies are showing the clinical value may be weak [33,34]. Nevertheless, it is relevant to compare
the prevalence in the present study with primarily frail elderly patients to the group of +65 years
Geriatrics 2018, 3, 15 6 of 9

able-bodied elderly people where the prevalence is approximately 10 to 30%, but true incidence and
prevalence are unknown [35].

4.3. Rehospitalization
This present study documents no significant difference between the two groups according to
rehospitalization. Some studies document a significantly higher frequency of rehospitalization in
patients with OD [26], the lower rehospitalization rate in the present study can be caused by the
follow-up in the municipalities. Over 75% of the patients with OD received a rehabilitation plan at
discharge and were contacted within an optimal five days after discharge by an OD team consisting of
a trained OD therapist (occupational therapist) and a dietitian. Nurses and care assistants in nursing
homes are trained in treating patients with OD. This focused intervention may have reduced the risk
of rehospitalization. The mortality rate is higher in the group of patients with OD, which of course
affects the possibility for readmission.

4.4. Mortality
This study confirms the high mortality in patients with OD [10,28]. The 180-days mortality
including mortality under hospitalization in this study is 33% and confirms the high mortality reported
in other studies. The abovementioned OD team in the municipalities appear to be able to prevent
rehospitalization but not mortality.

4.5. Strengths and Limitations

A strength in this study is that the screening was performed in 75% of all admitted patients and
that the patients were consecutively included.
A limitation of the study is that patients with severe dementia and delirium were not able to
participate and both groups are known to have a relatively high prevalence of OD [6,36]. This may lead
to an underestimated prevalence of OD in this study. Data regarding Barthel and BMI are not complete.
In observational studies including very frail patients, it may be impossible to collect all information.
Another limitation is that OD was assessed with an at-bedside test. In our clinical setting, it was
not possible to assess OD with fiberoptic endoscopic evaluation of swallowing. This would qualify
the assessment but more geriatric patients would not be able to cooperate with the assessment and it
was not available when this study was performed. We used V-VST, as studies have shown this has
a strong correlation with video fluoroscopy [37]. V-VST is considered a useful measurement despite
weaknesses concerning using oxygen saturation ≥3% to detect silent aspiration and visualizing
pharyngeal residue, and both silent aspiration and pharyngeal residue can only be visualized with an
instrumental assessment. V-VST has been recommended in other reviews [38,39], and is translated to
Danish, but is not validated in Denmark. MEOF-II is validated and recommended as a measurement
for performance of a meal [19]. It is not validated for detecting OD and there is no focus on viscosity
of the food, but the OTs performing MEOF-II used food with different viscosities such as bread with
toppings, apple, yoghurt, biscuits, and hot and cold fluids in different viscosities.
CCI has been developed and used to measure multimorbidity. In our hospital, it can build on
information from the medical records, and it is used in this study. A study from 2012 recommended
Cumulative Illness Rating Scale as the most accurate predictor of negative outcome in older people [40].

5. Conclusions
The prevalence of OD in acute geriatric patients is high (50%). OD in older people causes severe
complications with a significant impact on the patients’ health, functionality, and nutritional status.
Patients with OD are hospitalized for a longer period and their mortality is higher than in geriatric
patients with no OD.
Geriatrics 2018, 3, 15 7 of 9

The results of this study suggest a systematic screening of all acute geriatric patients to optimize
the treatment. Further investigation is needed to investigate whether systematic rehabilitation can
reduce the frequency of rehospitalization and mortality among acute geriatric patients.

Author Contributions: D.M. and M.M.M. conceived and designed the experiments; D.M. performed the
experiments; D.M. and M.R.-D. analyzed the data; D.M., M.R.-D., and M.M.M. wrote the paper.
Conflicts of Interest: The authors declare no conflict of interest.

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