Abstract
Objectives:
To assess the impact of dysphagia on clinical and operational outcomes in hospitalized patients with dementia.
Design:
Retrospective cohort study.
Setting:
2012 Nationwide Inpatient Sample.
Participants:
All patients discharged with a diagnosis of dementia (N = 234,006) from US hospitals in 2012.
Measurements:
Univariate and multivariate regression models, adjusting for stroke and patient characteristics, to assess the impact of dysphagia on the prevalence of comorbidities, including pneumonia, sepsis, and malnutrition; complications, including mechanical ventilation and death; and operational outcomes, including length of stay (LOS) and total charges for patients with dementia.
Results:
Patients having dementia with dysphagia (DWD) had significantly higher odds of having percutaneous endoscopic gastrostomy placement during the admission (odds ratio [OR]: 13.68, 95% confidence interval [CI]: 12.53-14.95, P < .001), aspiration pneumonia (OR: 6.27, 95% CI: 5.87-6.72, P < .001), pneumonia (OR: 2.84, 95% CI: 2.67-3.02, P < .001), malnutrition (OR: 2.5, 95% CI: 2.27-2.75, P < .001), mechanical ventilation (OR: 1.69, 95% CI: 1.51-1.9, P < .001), sepsis (OR: 1.52, 95% CI: 1.39-1.67, P < .001), and anorexia (OR: 1.29, 95% CI: 1.01-1.65, P = .04). Mean LOS was 2.16 days longer (95% CI: 1.98-2.35, P < .001), mean charge per case was US$10,703 higher (95% CI: US$9396-US$12,010, P < .001), and the odds of being discharged to a skilled nursing, rehabilitation, or long-term facility was 1.59 times higher (95% CI: 1.49-1.69, P < .001) in the DWD cohort compared to patients having dementia without dysphagia.
Conclusion:
Dysphagia is a significant predictor of worse clinical and operational outcomes including a 38% longer LOS and a 30% increase in charge per case among hospitalized patients with dementia. Although these findings may not be surprising, this new evidence might bring heightened awareness for the need to more thoughtfully support patients with dementia and dysphagia who are hospitalized.
Keywords: dementia, dysphagia, resource utilization, NIS, cost
Introduction
Worldwide, the 2016 estimated 65-and-older population, (whom we refer to as senior) is 641 million. 1 The American senior population grew by 1.5 million in 1 year alone from 44.7 million in 2013 to 46.2 million in 2014. 2 Alongside, increased life expectancy is the increased incidence of dementia. The 2015 worldwide prevalence of dementia is estimated to be 47.5 million, and it is projected to increase to 75.6 million by 2030. 3 Per-person Medicare and Medicaid spending are almost 3 and 19 times higher, respectively, for seniors with dementia than for seniors without dementia. 4
Dysphagia also becomes more prevalent with increased age. 5 The prevalence of swallowing disorders in seniors ranges from 7% to 22% and dramatically increases to 40% to 50% in seniors who reside in long-term care facilities. 5 Although the mechanisms may differ, all types of dementia may be associated with dysphagia. 6 -8 Even in its early stages, Alzheimer’s dementia impairs the ability to focus on mastication and impacts the sensory aspects of swallowing, thus delaying oral transit time. 9 Similar to stroke, the leading cause of dysphagia in elderly patients, 10 -15 vascular dementia can affect the motor aspect of swallowing, resulting in difficulty in mastication and bolus formation. Individuals with vascular dementia are at higher risk of silent aspiration as compared to those with Alzheimer’s dementia. 6 Dysphagia is known to be associated with aspiration pneumonia, malnutrition, anorexia, dehydration, and depression among other comorbidities. 5,10 -16
Dysphagia may be overlooked as a canary in the dementia coal mine as a harbinger for increased hospital complications and mortality, longer hospital stays, and higher health-care costs. Furthermore, following discharge, patients with dysphagia may more likely be in need for rehabilitation facilities, skilled nursing facilities, and long-term care. Although prior studies have shown that dysphagia is associated with worse health outcomes in patients with stroke, 16,17 we sought to study the impact of dysphagia on hospital-based outcomes in patients with dementia at a national level using the 2012 Nationwide Inpatient Sample (NIS).
Methods
Study Design
We conducted a retrospective, cross-sectional population-based cohort study of patients who were discharged from acute care hospitals in the United States in 2012. Our study used the NIS to test our hypotheses that significant comorbidities (including aspiration pneumonia, death during hospitalization, mechanical ventilation), number of procedures performed during hospitalization, length of stay (LOS), and total hospital charges would all be increased in patients who have dementia with dysphagia (DWD) as compared to those who have dementia without dysphagia (DWOD).
Database Description
We extracted our study cohort from the 2012 Healthcare Cost and Utilization Project NIS database. Healthcare Cost and Utilization Project databases are derived from administrative data and contain encounter-level, clinical, and nonclinical information including all-listed diagnoses and procedures, discharge status, patient demographics, LOS, and total hospital charges for all patients, regardless of payer (eg, Medicare, Medicaid, private insurance, uninsured). The NIS is the largest publicly available all-payer inpatient database in the United States maintained by the Agency for Healthcare Research and Quality (AHRQ). With the 2012 redesign of the sampling system, the NIS includes 7,296,968, or approximately 20% of the roughly 37 million yearly hospital discharges from 9 census divisions across 48 states, thereby representing 95% of the US population. Veterans Affairs hospitals, Indian Health Service hospitals, other federal hospitals, short-term rehabilitation hospitals, and long-term care hospitals were excluded from the 2012 NIS database. 18 Up to 25 discharge diagnoses and 15 procedures were collected on each patient using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding system. We used the ICD-9-CM to identify our cohort population and code all diagnosis variables. We used the Procedure Clinical Classification Software (CCS) codes for all procedures of interest. (See Supplemental Appendix for specific codes used for individual diagnoses and procedures.) The institutional review board of Johns Hopkins University approved our study.
Patient Cohort
We included patients with all types and severities of dementia regardless of age, race, gender, payer, and household income because our interest was in exploring the overall impact of dysphagia in patients with dementia. The NIS does not contain unique patient identifiers, nor does it identify readmissions. As such, each discharge was treated as an independent event, even if it may have represented a repeat hospitalization by the same patient. Each hospitalization record contains patient demographic elements that were included as covariates in our analysis. Demographic elements included were age, gender, race, primary payer (Medicare, Medicaid, private insurance, self-pay, no charge, and other), and median national income quartile for the patient’s zip code.
Because the general Medicare enrollment age is 65 years, we categorized age into convenience categories of below 65 years and 65 years and above. Because it is known that dysphagia is an undercoded diagnosis on its own, 10,11,13 we queried the NIS database for all of the primary diagnoses associated with dysphagia and found stroke to be the most frequent primary diagnosis in hospitalizations that included dysphagia as one of their diagnoses. Acknowledging that stroke can independently affect all of our outcomes of interest, we repeated our outcome analyses adjusting for stroke.
Comorbidities and Outcomes
Clinical comorbidities of interest were aspiration pneumonia, pneumonia, sepsis, intensive care unit (ICU) stay, malnutrition, anorexia, gastrostomy (percutaneous endoscopic gastrostomy [PEG]) tube placement during admission, depression, and mortality (as defined as died during hospitalization). Because the NIS does not report ICU stays, we used the procedural CCS code 216 for “respiratory intubation and mechanical ventilation” as a surrogate marker for the patient having had an ICU stay. We included all pneumonia in addition to aspiration pneumonia due to imprecise determination of the etiology of pneumonia, and ambiguity in the ICD-9 coding definitions, including potential overlap between health care–acquired pneumonia, unspecified pneumonia, and aspiration pneumonia.
The operational outcomes of interest were LOS, total charges, number of procedures incurred during hospitalization, and discharge disposition to skilled nursing facility, intermediate care, rehabilitation facility, or other facilities.
Statistical Analysis
We used STATA 13 for all statistical analyses. The NIS is based on a complex sampling design that includes stratification, clustering, and weighting, facilitating analysis to produce nationally representative unbiased results, variance estimates, and P values. We used logistic regression analysis for unadjusted comparisons of within demographic elements between patients having DWD and patients having DWOD. To assess the impact of dysphagia, we constructed a univariate logistic model for each comorbidity of interest. We subsequently repeated each analysis using multivariate logistic models to adjust for stroke and demographic effect modifiers. For operational outcomes, we constructed unadjusted and adjusted (for stroke and demographics) linear regression models for the continuous variables (LOS, total charge, and number of procedures) and a logistic regression model for disposition to a facility. In addition, we constructed a multivariate model to isolate incremental changes in charges and LOS attributable to requiring mechanical ventilation, as well as discharge to nonhome settings in patients having DWD and patients having DWOD. All P values were 2-sided, with .05 as threshold for significance.
Results
The 2012 NIS database included 234,006 (3.2%) patients with dementia out of a total of 7,296,968 hospital discharges. Of all patients with dementia, 4558 (2.0%) patients had an associated diagnosis of dysphagia. Patients with dementia had 4.42 times higher odds of having a reported diagnosis of dysphagia than patients without dementia (95% confidence interval [CI]: 4.28-4.56, P < .001). The odds of having a reported diagnosis of dysphagia in senior patients with dementia was 15% less than that in patients with dementia who were younger than 65 years (odds ratio [OR]: 0.85, 95% CI: 0.74-0.97, P = .01; Table 1). Although females represented 62% of the patients with dementia, the odds of having a diagnosis of DWD were 32% lower in females than in males (OR: 0.68, 95% CI: 0.64-0.72, P < .001). The odds of having dysphagia in blacks, Hispanics, and Asians who had dementia were significantly higher than in whites with dementia (OR: 1.62, 95% CI: 1.49-1.75, P < .001; OR: 1.65, 95% CI: 1.48-1.83, P < .001; OR: 2.32, 95% CI: 1.99-2.71, P < .001, respectively). Medicare (91.6%) was the largest primary payer. Patients with dementia in the highest income quartile had 14% higher odds (OR: 1.14, 95% CI: 1.05-1.24, P < .001) of having a documented diagnosis of dysphagia than those in the lowest quartile.
Table 1.
Patient Demographics: Dementia With and Without Dysphagia.
| Demographic | Dementia, N (%) | Dementia Without Dysphagia, n (%) | Dementia With Dysphagia, n (%) | OR | 95% CI | P Value |
|---|---|---|---|---|---|---|
| Totala | 234,006 (100) | 229,448 (98.05) | 4558 (1.95) | |||
| Age 65 and olderb | 223,670 (95.58) | 219,347 (95.60) | 4323 (94.84) | 0.85 | (0.74-0.97) | .01 |
| Female sexc | 144,312 (61.67) | 141,917 (61.85) | 2395 (52.54) | 0.68 | (0.64-0.72) | <.001 |
| Raced | ||||||
| White | 170,367 (76.19) | 167,459 (72.98) | 2908 (63.80) | |||
| Black | 27,846 (12.45) | 27,086 (11.80) | 760 (16.67) | 1.62 | (1.49-1.75) | <.001 |
| Hispanic | 14,607 (6.53) | 14,201 (6.19) | 406 (8.91) | 1.65 | (1.48-1.83) | <.001 |
| Asian/Pacific Islander | 4517 (2.02) | 4342 (1.89) | 175 (3.84) | 2.32 | (1.99-2.71) | <.001 |
| Native American | 931 (0.42) | 920 (0.40) | 11 (0.24) | 0.69 | (0.38-1.25) | .219 |
| Other | 5351 (2.39) | 5234 (2.28) | 117 (2.57) | 1.29 | (1.07-1.55) | <.01 |
| Primary payere | ||||||
| Medicare | 214,088 (91.60) | 209,943 (91.50) | 4145 (90.94) | |||
| Medicaid | 5341 (2.29) | 5210 (2.27) | 131 (2.87) | 1.27 | (1.07-1.52) | <.01 |
| Private | 10,789 (4.62) | 10,573 (4.61) | 216 (4.74) | 1.03 | (0.90-1.19) | >.05 |
| Self-pay | 1137 (0.49) | 1116 (0.49) | 21 (0.46) | 0.95 | (0.62-1.47) | >.05 |
| No charge/other | 2353 (1.01) | 2312 (1.01) | 41 (0.90) | 1.13 | (0.16-8.17) | >.05 |
| Household income quartile, US$f | ||||||
| 1-38 999 | 68,103 (29.63) | 66,812 (29.12) | 1291 (28.32) | |||
| 39,000-47,999 | 55,431 (24.11) | 54,483 (23.75) | 948 (20.80) | 0.90 | (0.83-0.98) | .02 |
| 48,000-62,999 | 54,152 (23.56) | 53,050 (23.12) | 1102 (24.18) | 1.08 | (0.99-1.17) | >.05 |
| 63,000 and over | 52,184 (22.70) | 51,057 (22.25) | 1127 (24.73) | 1.14 | (1.05-1.24) | <.001 |
Abbreviations: CI, confidence interval; OR, odds ratio.
aPercentages in the first row are based on total dementia. All other percentages reflect the corresponding column.
b P values based on comparison to age less than 65 years.
c P values based on comparison to male.
d P values are based on comparison to white.
e P values are based on comparison to Medicare.
fMedian household income national quartile for patient zip code; P values are based on comparison to the lowest quartile.
Clinical Comorbidities and Outcomes
The patients having DWD had significantly higher odds of having PEG placement during the hospitalization (OR: 13.68, 95% CI: 12.53-14.95, P < .001), aspiration pneumonia (OR: 6.27, 95% CI: 5.87-6.72, P < .001), pneumonia (OR: 2.84, 95% CI: 2.67-3.02, P < .001), malnutrition (OR: 2.5, 95% CI: 2.27-2.75, P < .001), requiring mechanical ventilation (OR: 1.69, 95% CI: 1.51-1.90, P < .001), sepsis (OR: 1.52, 95% CI: 1.39-1.67, P < .001), and anorexia (OR: 1.29, 95% CI: 1.01-1.65), P = .04) than the patients having DWOD. These variables remained statistically significant even after adjusting for demographic covariates and stroke (Table 2). The odds of having a diagnosis of depression in the DWD cohort were lower than that of the DWOD cohort (OR: 0.74, 95% CI: 0.68-0.81, P < .001).
Table 2.
Associated Comorbidities of Patients Having Dementia With and Without Dysphagia.
| Outcome | Dementia Without Dysphagia, n (%) | Dementia With Dysphagia, n (%) | Univariate Odds Ratio | 95% CI | P Value | Multivariate Odds Ratio | 95% CI | P Value |
|---|---|---|---|---|---|---|---|---|
| Total | 229,448 | 4558 | ||||||
| PEG (n = 3691) | 2993 (1.30) | 698 (15.31) | 13.68 | (12.53-14.95) | <.001 | 12.54 | (11.47-13.72) | <.001 |
| Aspiration pneumonia (n = 13,826) | 12,607 (5.49) | 1219 (26.74) | 6.27 | (5.87-6.72) | <.001 | 6.05 | (5.65-6.48) | <.001 |
| Pneumonia (n = 43,807) | 42,033 (1.83) | 1774 (38.92) | 2.84 | (2.67-3.02) | <.001 | 2.92 | (2.75-3.10) | <.001 |
| Malnutrition (n = 17,495) | 16,750 (7.30) | 745 (16.34) | 2.48 | (2.29-2.69) | <.001 | 2.51 | (2.32-2.72) | <.001 |
| ICU staya (n = 10,121) | 9801 (4.27) | 320 (7.02) | 1.69 | (1.51-1.90) | <.001 | 1.67 | (1.43-1.71) | <.001 |
| Sepsis (n = 18,893) | 18,360 (8.00) | 533 (11.69) | 1.52 | (1.39-1.67) | <.001 | 1.56 | (1.43-1.71) | <.001 |
| Anorexia (n = 2648) | 2582 (1.13) | 66 (1.45) | 1.29 | (1.01-1.65) | .04 | 1.31 | (1.03-1.68) | .03 |
| Mortality (n = 9993) | 9766 (4.26) | 227 (4.98) | 1.18 | (1.03-1.34) | .02 | 1.15 | (1.01-1.32) | .04 |
| Depression (n = 36,715) | 36,127 (15.75) | 588 (12.90) | 0.79 | (0.73-0.86) | <.001 | 0.80 | (0.73-0.87) | <.001 |
Abbreviations: CCS, Clinical Classification Software; CI, confidence interval; ICU, intensive care unit; PEG, percutaneous endoscopic gastrostomy.
aHealthcare Cost and Utilization Project procedure CCS code 216 for respiratory mechanical ventilation and mechanical ventilation was used as a surrogate marker for ICU stay.
Operational and Quality Outcomes
Multivariate analyses adjusting for stroke and patient characteristics revealed a significantly longer LOS for patients having DWD than for patients having DWOD (difference = 2.14 days, 95% CI: 1.95-2.32, P < .001). Mean charge per case was US$10,703 higher (95% CI: US$9,396-US$12,010, P < .001) if patients with dementia had superimposed dysphagia than if they had dementia alone, and US$10,310.54 (95% CI: 9005.39-11,615.69, P < .001) after adjusting for confounders. The odds of in-hospital mortality were significantly higher for patients having DWD than patients having DWOD even after adjusting for stroke and patient characteristics (OR: 1.15, 95% CI: 1.01-1.32, P = .04) (Table 3).
Table 3.
Quality and Operational Outcomes of Patients Having Dementia With and Without Dysphagia.
| Outcome | Dementia Without Dysphagia | Dementia With Dysphagia | Difference | 95% CI | P Value | Difference Adjusted for Stroke and Other Covariatesa | 95% CI | P Value |
|---|---|---|---|---|---|---|---|---|
| Mean length of stay, in days | 5.64 | 7.8 | 2.16 | (1.98-2.35) | <.001 | 2.14 | (1.95-2.32) | <.001 |
| Mean charge per case, US$ | 35,182 | 45,885 | 10,703.00 | (9396-12 010) | <.001 | 10,310.54 | (9005.39-11 615.69) | <.001 |
| Mean number of procedures | 0.97 | 1.33 | 0.36 | (0.31-0.41) | <.001 | 0.36 | (0.31-0.41) | <.001 |
| OR | ||||||||
| Discharge to facilitya | 124,542 | 2977 | 1.59 | (1.49-1.69) | <.001 | 1.57 | (1.47-1.67) | <.001 |
Abbreviations: CI, confidence interval; OR, odds ratio.
aFacilities include skilled nursing facility, rehabilitation facilities, intermediate care facilities, and other facilities.
At the time of discharge, the odds of going to a nonhome setting were 1.6 times higher (95% CI: 1.49-1.69, P < .001) in the DWD subset when compared to their DWOD counterparts. After adjusting for demographic variables and dying in the hospital, mechanical ventilation was associated with an increase of US$50,531.80 (95% CI: US$45,517.38-US$55,546.23, P < .001) in mean total charges and an increase of 3.11 days (95% CI: (2.12-4.11), P < .001) in LOS for patients having DWD. Aspiration pneumonia increased the odds of requiring mechanical ventilation by 2.80 in patients having DWD (P < .001, 95% CI: 2.23-3.53).
Discussion
As the first population-based study of dysphagia in patients with dementia, our study reiterates that coexistence of dysphagia with dementia worsens clinical outcomes and increases resource utilization, even after adjusting for stroke and demographic effect modifiers. Dysphagia was associated with higher odds of having resource-intensive comorbidities, including aspiration pneumonia, a potentially preventable complication 19 ; higher odds of undergoing invasive procedures; a 38% longer LOS; and a 30% higher total hospital charges in hospitalized patients who have dementia.
One in every 5 Medicare dollars is spent on people with dementia. By 2050, 1 in every 3 Medicare dollars will be spent on patients with dementia. 4 As an effort to change the trajectory of Alzheimer’s and related dementias, in January 2011, President Barak Obama signed into law, The National Alzheimer’s Project Act. 20 When patients with dementia have conditions such as congestive heart failure, cancer, stroke, diabetes, coronary artery disease, chronic kidney disease, and chronic obstructive pulmonary disease, costs and comorbidities multiply. 21 By uncovering the impact of dysphagia on dementia, our study identifies a subset of patients within the already vulnerable population with dementia who are at particularly high risk of increased morbidity, mortality, and resource utilization.
Although we expected the DWD cohort to have more PEG tubes than the DWOD cohort, the 13-fold increase in the odds of having a PEG tube placed during hospitalization was striking. Given that diagnoses such as dysphagia and dementia are often undercoded, these findings may represent the tip of the iceberg. The issue of PEG tubes in the population having DWD is of particular interest because PEG tubes have been shown to increase aspiration risk 22 and offer no survival benefit in patients with dementia. 23 -26 Moreover, the incremental cost on hospital stays attributed to aspiration pneumonia has been reported to be US$13,000 per patient using Medicare claims’ data, 27 and our study attributes a 6-fold increase in odds of aspiration pneumonia to dysphagia in patients with dementia. Despite the 13-fold increase in the PEG tube odds, we found the odds of malnutrition to be 2.5 times higher in the population having DWD. It may be necessary to be more selective and judicious in the use of PEG tubes in patients with dementia, and to explore alternative options for nutrition in the population having DWD.
In 2005, Dasta reported the mean incremental cost of mechanical ventilation in ICU patients was US$1522 per patient. 28 Ten years later, our study found that if patients having DWD are mechanically ventilated, the cost of hospitalization increases by US$50,531. We also found that dysphagia increases the adjusted odds of sepsis by 56% in patients with dementia. In 2011, the United States spent US$20 billion on sepsis, and patients with sepsis stayed in the hospital 75% longer than average. 29 Because aspiration may be a trigger for sepsis and the need for mechanical ventilation in patients having DWD, it may be reasonable to enforce strict aspiration precautions in patients having DWD.
Using the 2005 national discharge database, Altman et al 10 reported that dysphagia increased LOS by 1.64 days in the general inpatient population. We found that in patients having DWD increased LOS by 2.16 days. Extrapolating the US$10,703 in increased hospital charges and the 2.16 day increase in LOS for our DWD cohort, the impact of dysphagia in patients with dementia potentiates a staggering US$245 million increase in hospital charges and 49,226 extra hospital days. These numbers do not account for the costs associated with the subsequent discharge to skilled nursing, rehabilitation, or long-term care facilities. These substantially higher costs suggest the need for heightened awareness about the impact of dysphagia in patients with dementia who are admitted to our hospitals and this raises the question of screening. The costs of a video fluoroscopic swallow study or flexible endoscopic evaluation of swallowing with sensory testing are both less than US$500. 30 -32 The AHRQ found that even bedside examinations can detect aspiration risk with 80% accuracy. 33 Once dysphagia is identified, it can trigger screening for malnutrition and occult aspiration. This red flag may alert health-care teams to be particularly vigilant given the risk for suboptimal clinical and quality outcomes. Increased awareness of the implications for dysphagia on hospitalized patients with dementia may help clinicians, payers, administrators, and policymakers to better use primary, secondary, and even tertiary prevention of aspiration in patients with dementia to help mitigate the costs and comorbidities associated with dementia.
Several limitations of this study should be considered. First, the NIS database does not account for readmissions. Thus, multiple encounters could be based on the same patient. However, the large sample size should reduce the impact of this limitation. Second, using the NIS requires dependence on accurate coding, and dementia or dysphagia may not be coded consistently because they may not be the primary diagnoses responsible for the acute admission. Furthermore, both of these diagnoses can go undetected, with substantive lead time, before being obvious to all. Third, the etiology of pneumonia may not always be clear. As such, aspiration pneumonias may be coded as “unspecified pneumonia.” To account for misdiagnosed or miscoded cases of pneumonia due to aspiration, we also included all types of “pneumonias” in our analyses. Finally, as is the case for all cross-sectional studies, the findings described in this manuscript represent associations and they do not prove causality.
Conclusion
Our study emphasizes that when a patient with dementia is admitted to the hospital, the coexistence of dysphagia represents the potential for complications and increased utilization of health-care resources. Future prospective studies might explore whether inpatient screening and adherence to speech and language pathology diet recommendations (including aspiration precautions) could reduce comorbidities and improve outcomes.
Acknowledgments
The authors thank Dr Thomas Finucane for expert review, Dr Marwan Abougergi, from Catalyst Medical Consulting, LLC for data assembly, Dr Venkat Gundareddy for data acquisition and assembly, and Dr M. A. Sattar Shariq for graphics and data assembly.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Scott Wright is a Miller-Coulson Family Scholar supported by the Johns Hopkins Center for Innovative Medicine.
Supplemental Material: The online Supplemental Appendix is available at http://journals.sagepub.com/doi/suppl/10.1177/1533317516673464.
References
- 1. US Census Bureau. International programs—world population by age and sex. Web site. https://www.census.gov/population/international/data/worldpop/tool_population.php. Accessed January 27, 2016.
- 2. Millennials outnumber baby boomers and are far more diverse. Web site: http://www.census.gov/newsroom/press-releases/2015/cb15-113.html. Accessed January 16, 2016.
- 3. WHO. 10 facts on dementia. Web site. http://www.who.int/features/factfiles/dementia/en/. Accessed January 16, 2016.
- 4. Alzheimer’s Association. 2015 Alzheimer’s disease facts and figures. Alzheimers Dement. 2015;11(3):332. [DOI] [PubMed] [Google Scholar]
- 5. Easterling CS, Robbins E. Dementia and dysphagia. Geriatr Nurs. 2008;29(4):275–285. doi:10.1016/j.gerinurse.2007.10.015. [DOI] [PubMed] [Google Scholar]
- 6. Suh MK, Kim H, Na DL. Dysphagia in patients with dementia: Alzheimer versus vascular. Alzheimer Dis Assoc Disord. 2009;23(2):178–84. doi:10.1097/WAD.0b013e318192a539. [DOI] [PubMed] [Google Scholar]
- 7. Ikeda M, Brown J, Holland AJ, Fukuhara R, Hodges JR. Changes in appetite, food preference, and eating habits in frontotemporal dementia and Alzheimer’s disease. J Neurol Neurosurg Psychiatry. 2002;73(4):371–376. doi:10.1136/jnnp.73.4.371. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Alagiakrishnan K, Bhanji RA, Kurian M. Evaluation and management of oropharyngeal dysphagia in different types of dementia: a systematic review. Arch Gerontol Geriatr. 2013;56(1):1–9. doi:10.1016/j.archger.2012.04.011. [DOI] [PubMed] [Google Scholar]
- 9. Humbert IA, McLaren DG, Kosmatka K, et al. Early deficits in cortical control of swallowing in Alzheimer’s disease. J Alzheimers Dis. 2010;19(4):1185–1197. doi:10.3233/JAD-2010-1316. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Altman KW, Yu GP, Schaefer SD. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg. 2010;136(8):784–789. doi:10.1001/archoto.2010.129. [DOI] [PubMed] [Google Scholar]
- 11. Roden DF, Altman KW. Causes of dysphagia among different age groups: a systematic review of the literature. Otolaryngol Clin North Am. 2013;46(6):965–987. doi:10.1016/j.otc.2013.08.008. [DOI] [PubMed] [Google Scholar]
- 12. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12):2756–2763. doi:10.1161/01.STR.0000190056.76543.eb. [DOI] [PubMed] [Google Scholar]
- 13. Forster A, Samaras N, Gold G, Samaras D. Oropharyngeal dysphagia in older adults: a review. Eur Geriatr Med. 2011;2(6):356–362. doi:10.1016/j.eurger.2011.08.007. [Google Scholar]
- 14. DeFabrizio ME. Contemporary approaches to dysphagia management. J Nurse Pract. 2010;6(8):622–630. doi:10.1016/j.nurpra.2010.11.010. [Google Scholar]
- 15. Gordon C, Hewer RL, Wade DT. Dysphagia in acute stroke. Br Med J (Clin Res Ed). 1987;295(6595):411–414. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Guyomard V, Fulcher RA, Redmayne O, Metcalf AK, Potter JF, Myint PK. Effect of dysphasia and dysphagia on inpatient mortality and hospital length of stay: a database study. J Am Geriatr Soc. 2009;57(11):2101–2106. doi:10.1111/j.1532-5415.2009.02526.x. [DOI] [PubMed] [Google Scholar]
- 17. Altman KW, Schaefer SD, Yu GP, et al. ; Neurolaryngology Subcommittee of the American Academy of Otolaryngology-Head and Neck Surgery. The voice and laryngeal dysfunction in stroke: a report from the Neurolaryngology Subcommittee of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg. 2007;136(6):873–881. doi:10.1016/j.otohns.2007.02.032. [DOI] [PubMed] [Google Scholar]
- 18. Houchens RL, Ross DN, Elishauser A, Jiang J. Nationwide Inpatient Sample Redesign Final Report. 2014. Rockville, MD: US Agency for Healthcare Research and Quality; 2014. [Google Scholar]
- 19. Hughes JS, Averill RF, Goldfield NI, et al. Identifying potentially preventable complications using a present on admission indicator. Health Care Financ Rev. 2006;27(3):63–82. [PMC free article] [PubMed] [Google Scholar]
- 20. State Alzheimer’s Disease Plan Resource Center. The National Alzheimer’s Project Act (NAPA). Web site. http://napa.alz.org/national-alzheimers-project-act-backgroun. Accessed February 5, 2016.
- 21. Alzheimer’s Association. 2014 Alzheimer’s disease facts and figures. Alzheimers Dement. 2014;10(2): e47–e92. [DOI] [PubMed] [Google Scholar]
- 22. Galicia-Castillo M. The PEG dilemma: feeding tubes are not the answer in advanced dementia. Geriatrics. 2006;61(6):12–13. [PubMed] [Google Scholar]
- 23. Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med. 1997;157(3):327–332. [PubMed] [Google Scholar]
- 24. Sanders DS, Carter MJ, D’Silva J, James G, Bolton RP, Bardhan KD. Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia. Am J Gastroenterol. 2000;95(6):1472–1475. doi:10.1111/j.1572-0241.2000.02079.x. [DOI] [PubMed] [Google Scholar]
- 25. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999;282(14):1365–1370. [DOI] [PubMed] [Google Scholar]
- 26. Finucane TE, Christmas C. Aspiration pneumonia. N Engl J Med. 2001;344(24):1869; author reply 1869-1870. [PubMed] [Google Scholar]
- 27. Fuller RL, McCullough EC, Bao MZ, Averill RF. Estimating the costs of potentially preventable hospital acquired complications. Health Care Finance Rev. 2008;30(4):17–32. [PMC free article] [PubMed] [Google Scholar]
- 28. Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med. 2005;33(6):1266–1271. [DOI] [PubMed] [Google Scholar]
- 29. CDC. The Cost of Sepsis—Safe Healthcare Blogs. Web site. http://blogs.cdc.gov/safehealthcare/2015/09/08/the-cost-of-sepsis/. Accessed February 6, 2016.
- 30. Aviv JE, Sataloff RT, Cohen M, et al. Cost-effectiveness of two types of dysphagia care in head and neck cancer: a preliminary report. Ear Nose Throat J. 2001;80(8):553. [PubMed] [Google Scholar]
- 31. How much does video fluoroscopic Swallowing Study Cost? What is a video fluoroscopic swallowing study? Web site. https://www.mdsave.com/procedures/videofluoroscopic-swallowing-study/d785fdcc. Accessed February 6, 2016.
- 32. The Henry J. Kaiser Family Foundation. Hospital Adjusted Expenses per Inpatient Day. Web site. http://kff.org/other/state-indicator/expenses-per-inpatient-day/. Accessed February 6, 2016.
- 33. Frequently asked questions: swallowing and feeding (dysphagia). Web site. http://www.asha.org/slp/clinical/dysphagia/dysphagia_faqs/. Accessed February 4, 2016.