Best Evidence Summary for Integrated Care Management of Dysphagia in Hospitalized Older Adults

Abstract

Purpose

To evaluate and summarize the best available evidence on integrated care management of dysphagia in hospitalized older adults, providing an evidence-based reference for clinical practice.

Methods

Evidence was systematically retrieved from Chinese and international databases, clinical practice guideline repositories, and professional association websites. Eligible publications included best practice recommendations, evidence summaries, clinical practice guidelines, expert consensus statements, and systematic reviews published between January 1, 2015, and January 31, 2026. Two trained researchers independently appraised the methodological quality of included literature using standardized quality assessment tools, graded the evidence using the JBI evidence pre-grading system, and synthesized the extracted findings.

Results

A total of 28 documents were included, comprising 3 best practice recommendations, 9 evidence summaries, 3 clinical guidelines, 10 expert consensus statements, and 3 systematic reviews. From this synthesis, 43 recommendations were derived across seven key domains: (I) establishment of multidisciplinary teams, (II) dysphagia screening, (III) comprehensive assessment, (IV) integrated care management, (V) rehabilitation interventions, (VI) prevention and management of complications, and (VII) discharge planning and follow-up.

Conclusion

This study provides a comprehensive summary of best evidence for integrated care management of dysphagia in hospitalized older adults, offering a robust evidence base to inform standardized clinical pathways and practice guidelines.

Introduction

The United Nations World Population Prospects 2022 projects that the global proportion of individuals aged 65 years and older will rise from 10% in 2022 to 16% by 2050, at which point the older adult population will be more than twice the size of the global population under 5 years of age.¹ This unprecedented demographic shift directly drives an escalating demand for healthcare services. Older adults, owing to their high burden of chronic diseases, multimorbidity, and increased susceptibility to acute illness, account for a disproportionately large share of hospital admissions.² In the United States, nearly 17% of Americans aged 65 years and older are hospitalized at least once annually, a proportion substantially higher than that observed in middle-aged adults.³

Age-related physiological changes—including diminished laryngopharyngeal sensation, reduced motor function, prolonged oral transit time, and decreased neuroplasticity—collectively erode functional reserves in older adults.^4,5 Of particular concern is the concept of presbyphagia, defined as the age-related physiological alterations in swallowing mechanics that occur in the absence of overt disease. These subclinical changes, while not necessarily pathological in themselves, markedly increase vulnerability to clinically significant dysphagia when compounded by additional stressors such as acute illness or polypharmacy.^6,7 Dysphagia is pandemic across different phenotypes of older people, affecting approximately 27% of independently living older adults.⁸ In institutional and hospital settings, the prevalence is substantially higher. A systematic review and meta-analysis by Rivelsrud reported pooled prevalence estimates of 36.5% (95% CI 29.9–43.6).⁹

Despite its well-documented epidemiological and clinical significance, systematic screening and evidence-based management of dysphagia remain inconsistent in routine clinical practice. Dysphagia is frequently underrecognized or underestimated, particularly in patients without obvious neurological diagnoses.¹⁰ A large U.S. cohort study by Sevitz et al, which included 195,782 older adults hospitalized with pneumonia across 943 hospitals, found that only 23.6% received a clinical evaluation for dysphagia, 6.8% underwent instrumental assessment, and 11.2% received therapy.¹¹ Overall, there is a significant gap between clinical needs and actual service provision.

To address this gap, the World Health Organization has proposed the Integrated Care for Older Persons (ICOPE) model as a systematic service provision framework, aiming to promote a more patient-centered and coordinated direction for health and social services.¹² The core principle of integrated care lies in breaking down barriers between various professional fields, institutions, and care stages within the traditional medical system, emphasizing multidisciplinary collaboration, service coordination, and continuity of care to meet the increasingly complex health needs of elderly patients.¹³ The concept of integrated care has increasingly permeated dysphagia management practices. A 2024 study by Obata et al examined 732 older patients with cardiovascular disease (mean age 86.0 ± 7.8 years) and found that approximately 55.1% required dysphagia rehabilitation. Notably, integrating dysphagia rehabilitation into routine cardiac care programs significantly improved oral caloric intake, body mass index, and activities of daily living at discharge.¹⁴ These positive findings notwithstanding, the existing evidence base on dysphagia management in hospitalized older adults remains fragmented, often focusing narrowly on single interventions or specific disease conditions, with a notable lack of systematic synthesis from an integrated care perspective. Therefore, this study aims to systematically summarize the best available evidence on integrated care for dysphagia in hospitalized older adults, providing clinicians and other healthcare professionals with a comprehensive, evidence-informed reference to guide the care and management of this vulnerable population.

Materials and Methods

Formulation of the Evidence-Based Question

The PIPOST framework, developed by the Evidence-Based Nursing Center at Fudan University,¹⁵ was used to structure the clinical question: P (Population): aged 65 years or older. I (Intervention): Integrated care interventions for dysphagia in older adults, encompassing screening, assessment, diagnosis, management, and follow-up; specific components include dysphagia screening and assessment, oral care, dietary and nutritional management, enteral feeding techniques, swallowing exercises, respiratory muscle training, speech therapy, and prevention and management of complications. P (Professionals): Healthcare professionals engaged in dysphagia management in older adults, including physicians, nurses, rehabilitation therapists, dietitians, and other relevant clinicians.O (Outcomes): Clinical outcomes such as swallowing function, nutritional status, quality of life, and complication rates (eg, incidence of aspiration pneumonia, hospital readmission rate). S (Setting): Clinical settings including neurology, geriatrics, and rehabilitation departments. T (Type of Evidence): Published guidelines, expert consensus statements, evidence summaries, best practice recommendations, and systematic reviews in both Chinese and English languages. This evidence synthesis has been registered with the Evidence Summary Registry Platform of the Evidence-Based Nursing Center at Fudan University (Registration No.: ES20259434).

Search Strategy

The following search strategies were developed using a combination of subject headings and free-text terms, aligned with the 6S evidence hierarchy model,¹⁶ and applied systematically from the top (synthesized evidence) down to primary studies. English search terms and strategy: (aged OR elderly OR old people OR older adult* OR geriatric* OR senior* OR adult*) AND (swallowing disorder* OR swallow difficult* OR deglutition disorder* OR dysphagia OR pharyngeal swallowing) AND (prevention OR screening OR evaluation OR assessment OR management OR rehabilitation OR intervention OR train* OR nursing OR therapy OR exercise) AND (guideline OR expert consensus OR summary OR evidence OR recommendation OR best practice OR systematic review OR meta-analysis). Databases and guideline repositories searched included: UpToDate, BMJ Best Practice, the Joanna Briggs Institute (JBI) Evidenced-Based Healthcare Database, the Guidelines International Network (GIN), the Registered Nurses’Association of Ontario (RNAO), the National Institute for Health and Care Excellence (NICE) guidelines library, Cochrane Library, Embase, PubMed, CINAHL, Medlive, Chinese Medical Journal Full-text Database (CMJ), CNKI, Wanfang, and VIP.The search was limited to literature published between January 1, 2015, and January 31, 2026. The detailed steps for searching English databases, using PubMed as an example, can be found in Figure 1.

Figure 1.

Literature search strategy of PubMed.# search history line numbers; * truncation operator.

Inclusion and Exclusion Criteria

Inclusion criteria: (I) Study type: clinical decision, guideline, expert consensus, systematic review, recommended practice, evidence summary, meta-analysis, randomized controlled trial; (II) Subjects: Individuals aged 65 years or older diagnosed with dysphagia; (III) Outcomes: Interventions or recommendations related to integrated care for dysphagia management, including screening, assessment, management, treatment, prevention and management of complications, discharge planning, and follow-up; (IV) Language: Publications in either Chinese or English.

Exclusion criteria: (I) Studies focusing exclusively on patients with specific comorbid conditions that significantly confound the management of dysphagia (eg, acute stroke, advanced neurodegenerative diseases, or head and neck cancer), unless the recommendations were generalizable to older adults with dysphagia in general; (II) Incomplete data or unavailability of full-text versions; (III) Documents rated as low quality following critical appraisal using appropriate methodological checklists; (IV) Repeated published or translated literature; (V) Research proposal or report; (VI) Conference abstracts.

Quality Appraisal of Included Literature

Two trained researchers independently appraised the methodological quality of all included documents using predefined appraisal tools. Disagreements were resolved through discussion or, if necessary, by consultation with a third researcher.

The appraisal approach was tailored to the type of evidence:

(I) Best Practice Recommendations: These were considered high-quality synthesized evidence and were directly included without further critical appraisal.

(II) Evidence Summaries: Appraised using the Criteria for Appraisal of Synthesis Evidence (CASE) tool.¹⁷

(III) Guidelines: Evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.¹⁸ The AGREE II comprises 23 items across six domains, each rated on a 7-point Likert scale (1 = “strongly disagree” to 7 = “strongly agree”). For each guideline, standardized domain scores were calculated, and recommendation levels were assigned based on the following criteria: guidelines with all six domains scoring 70% or higher are classified as Grade A; guidelines with all six domains scoring 30% or higher and at least three domains scoring 60% or higher are classified as Grade B; guidelines with at least three domains scoring below 30% are classified as Grade C.

(IV) Expert Consensus Statements and Systematic Reviews: Assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklists (2016 edition).¹⁹ The checklist for expert consensus includes 6 items, while that for systematic reviews contains 11 items. Each item is rated as “Yes,” “No,” “Unclear,” or “Not Applicable.” Only documents meeting acceptable quality thresholds were included in the final evidence synthesis.

Evidence Extraction and Synthesis

Two trained researchers independently extracted data from the included studies. Discrepancies in translation or interpretation were resolved through consultation with a subject-matter expert fluent in English and experienced in dysphagia and rehabilitation research. During evidence synthesis, concordant or complementary findings were integrated or summarized; conflicting evidence was adjudicated according to the following hierarchy: (I) highest level of evidence (eg, systematic reviews, randomized controlled trials), (II) highest methodological quality (eg, low risk of bias), (III) most recent publication date, and (IV) preference for nationally endorsed clinical guidelines.

Evidence Grading and Recommendation Strength

The strength of each recommendation extracted from the included studies was graded using the 2014 Joanna Briggs Institute (JBI) Evidence Pre-Grading and Recommendation System.²⁰ For each recommendation, the supporting references were reviewed, and the underlying evidence was assigned a level (1–5) based on study design. According to this system, Level 1 denotes the highest quality evidence (eg, systematic reviews of randomized controlled trials), whereas Level 5 represents the lowest (eg, expert opinion or case reports). Subsequently, a multidisciplinary panel of experts—comprising geriatricians, rehabilitation specialists, and neurologists—assessed each recommendation against the FAME criteria, which evaluate its feasibility, appropriateness, meaningfulness, and effectiveness. Based on this appraisal, recommendations were designated with a strength rating (eg, “strong,” “moderate,” or “weak”). Panel members were selected based on meeting all of the following criteria: (I) a minimum of 10 years of clinical or research experience in dysphagia management; (II) possession of a master’s degree or higher, or a senior professional title (eg, Associate/Full Professor or Chief Physician); (III) demonstrated competence in evidence-based practice; and (IV) voluntary participation in the study.

Results

Literature Search Results

A total of 4,702 records were initially identified; the study selection process is detailed in Figure 2. Ultimately, 28 publications met the inclusion criteria, comprising 3 clinical decision aids,^21–23 3 clinical practice guidelines,^24–26 3 systematic reviews,^27–29 10 expert consensus statements,^30–39 and 9 evidence syntheses.^40–48 Key characteristics of the included publications are summarized in Table 1.

Figure 2.

Screening process and results.

Table 1.

Characteristics of Included Studies

Included Studies	Publication Year	Source	Type of Articles	Topic
Colleen et al,21	2025	UpToDate	Clinical Decision-Making	Assessment and Management of Dysphagia and Aspiration in Palliative Care
Anthony et al,22	2025	UpToDate	Clinical Decision-Making	Clinical Features, Diagnosis, and Management of Dysphagia
Mark et al,23	2025	UpToDate	Clinical Decision-Making	Application and Management of Percutaneous Endoscopic Gastrostomy (PEG) in Adults
National Institute for Health and Care Excellence24	2025	NICE	Guideline	Management of Oral Nutritional Support, Enteral Tube Feeding, and Parenteral Nutrition in Adults
Umay et al,25	2022	Embase	Guideline	Best Practice Recommendations for Dysphagia in Older Adults
Swallowing Disorders Rehabilitation Committee of Chinese Association of Rehabilitation Medicine26	2023	CMJ	Guideline	Chinese Guidelines for the Rehabilitation Management of Dysphagia
Morais et al,27	2025	PubMed	Systematic review	Factors Associated with Dysphagia in Hospitalized Older Adults
Chen et al,28	2025	Embase	Systematic review	Rehabilitation Management of Dysphagia in Older Adults
Gillman et al,29	2017	Embase	Systematic review	Management of Free Water Protocols in Patients with Dysphagia
Swallowing Disorders Rehabilitation Professional Committee of Chinese Association of Rehabilitation Medicine et al30	2025	CMJ	Expert Consensus	Chinese Expert Consensus on Rehabilitation Management of Presbyphagia
Nutrition and Food Safety Branch of Chinese Geriatrics Society et al,31	2024	CNKI	Expert Consensus	Chinese Expert Consensus on Home-Based Nutritional Management for Older Adults
Oncology Nutrition and Therapeutics Branch of Zhejiang Medical Association et al,32	2023	CNKI	Expert Consensus	Expert Consensus on Nutritional Assessment and Management for Older Adults
Nutrition and Food Safety Branch of Chinese Geriatrics Society et al33	2018	CNKI	Expert Consensus	Expert Consensus on Home-Based Nutritional Management for Older Adults with Dysphagia
Rehabilitation Nursing Professional Committee of Chinese Association of Rehabilitation Medicine34	2021	CNKI	Expert Consensus	Expert Consensus on Rehabilitation Nursing Care for Dysphagia
Chinese Expert Consensus Group on Dietary Nutrition Management of Dysphagia.35	2019	CMJ	Expert Consensus	Chinese Expert Consensus on Dietary and Nutritional Management of Dysphagia
Chinese Expert Consensus Group on Dietary Nutrition Management of Dysphagia.36	2017	CMJ	Expert Consensus	Chinese Expert Consensus on Dysphagia Assessment
Chinese Expert Consensus Group on Dietary Nutrition Management of Dysphagia.37	2017	CMJ	Expert Consensus	Chinese Expert Consensus on the Treatment and Rehabilitation of Dysphagia
He et al,38	2025	CNKI	Expert Consensus	Chinese Expert Consensus on Screening for Oral Hypofunction and Dietary Rehabilitation Prescriptions
Zhang et al,39	2022	PubMed	Expert Consensus	Delphi Consensus on the Management of Dysphagia in Older Adults
Xia et al40	2020	CNKI	Evidence summary	Evidence Summary of Specialized Oral Feeding Care for Adults with Dysphagia
Fei et al,31	2021	CNKI	Evidence summary	Best Evidence Summary for Medication Management in Patients with Dysphagia
Magtoto et al,42	2022	JBI	Evidence summary	Application and Management of Percutaneous Endoscopic Gastrostomy versus Nasogastric or Nasoenteric Feeding in Older Adults with Dysphagia
Odhiambo et al,43	2023	JBI	Evidence summary	Medication Management in Dietary Care for Older Adults with Dysphagia
Overall et al,44	2025	JBI	Evidence summary	Screening and Assessment of Dysphagia in Older Adults
Bellman et al,45	2023	JBI	Evidence summary	Management of Oral Nutritional Interventions for Malnutrition in Older Adults
Bellman et al,46	2023	JBI	Evidence summary	Dietary Management of Dysphagia in Older Adults Residing in Long-Term Care Facilities
Bayuo et al,47	2023	JBI	Evidence summary	Medication Management with Oral Dosage Forms in Older Adults with Dysphagia
Liu et al,48	2024	PubMed	Evidence summary	Best Evidence Summary for the Management of Dysphagia in Older Adults

Results of Literature Quality Evaluation

Quality Assessment of Guidelines

Three clinical practice guidelines^24–26 were included in this evidence summary. Two guidelines^25,26 received an overall recommendation grade of “A,” indicating that 60% or more of the AGREE II domains achieved standardized domain scores exceeding the 60% threshold. The third guideline²⁴ attained scores above 60% in five domains and above 30% in one domain, resulting in a grade of “B.” Detailed domain-level scores are presented in Table 2.

Table 2.

Quality Assessment of Guidelines

	Standardized percentage score for the quality domain (%)						≥70% Domain	≥30% Domain	Strength of Recommendation
Literature	Scope and Objectives	Stakeholders Involved	Rigor of Development	Clarity of Presentation	Applicability	Independence
NICE.24	86%	71%	75%	86%	50%	57%	4	2	B
Umay et al,25	95%	90%	73%	100%	78%	100%	6	0	A
Swallowing Disorders Rehabilitation Committee of Chinese Association of Rehabilitation Medicine et al,26	95%	100%	89%	90%	82%	86%	6	0	A

Quality Assessment of Expert Consensus Statements

Ten expert consensus statements^30–39 were included in this evidence summary. All statements met the predefined quality criteria, with each item rated “Yes,” indicating high methodological rigor and transparency. Consequently, all ten were retained for synthesis.

Quality Assessment of Systematic Reviews

Three systematic reviews^27–29 were included. Two reviews^28,29 fulfilled all quality criteria (all items rated “Yes”). The remaining review²⁷ received an “Unclear” rating for Item 4 (assessment of risk of bias in individual studies), with all other items rated “Yes.” Overall, all three systematic reviews demonstrated high methodological quality and were retained.

Quality Assessment of Evidence Summaries

Nine evidence summaries^40–48 were included. Among these, two^40,41 received an “Unclear” rating for Item 9 (clarity of conclusions and implications for practice). Six summaries^42–47 were rated “Unclear” for both Item 3 (comprehensiveness and transparency of the search strategy) and Item 4 (appropriateness of study selection and data extraction methods). All other items were rated “Yes” across all nine evidence summaries. Despite these minor methodological limitations, the overall quality was deemed sufficient to warrant inclusion. Detailed quality ratings are presented in Table 3.

Table 3.

Quality Assessment of Evidence Summaries

Literature	①	②	③	④	⑤	⑥	⑦	⑧	⑨	⑩	⑪
Xia et al,40	YES	YES	YES	YES	YES	YES	YES	YES	UNCLEAR	YES	YES
Fei et al,41	YES	YES	YES	YES	YES	YES	YES	YES	UNCLEAR	YES	YES
Magtoto et al,42	YES	YES	UNCLEAR	UNCLEAR	YES	YES	YES	YES	YES	YES	YES
Odhiambo et al,43	YES	YES	UNCLEAR	UNCLEAR	YES	YES	YES	YES	YES	YES	YES
Overall et al,44	YES	YES	UNCLEAR	UNCLEAR	YES	YES	YES	YES	YES	YES	YES
Bellman et al,45	YES	YES	UNCLEAR	UNCLEAR	YES	YES	YES	YES	YES	YES	YES
Bellman et al,46	YES	YES	UNCLEAR	UNCLEAR	YES	YES	YES	YES	YES	YES	YES
Bayuo et al,47	YES	YES	UNCLEAR	UNCLEAR	YES	YES	YES	YES	YES	YES	YES
Liu et al,48	YES	YES	YES	YES	YES	YES	YES	YES	YES	YES	YES

Notes: Quality appraisal criteria were adapted from the AGREE II instrument and supplemented with domain-specific items relevant to evidence synthesis in dysphagia care: ① Clarity and specificity of scope and target population; ② Transparency of authorship and affiliations; ③ Transparency and rigor of the review/consensus process (eg, Delphi rounds, voting thresholds); ④ Comprehensiveness and transparency of search strategy (databases, keywords, timeframes, language restrictions); ⑤ Explicit, reproducible system for grading underlying evidence (eg, JBI, GRADE); ⑥ Clarity, actionability, and clinical relevance of recommendations; ⑦ Appropriate citation and traceability of supporting evidence for each recommendation; ⑧ Explicit statement on currency (eg, date of literature search, planned review interval); ⑨ Disclosure of competing interests among authors or panel members; ⑩ Applicability to the target population of this study; ⑪ Inclusion decision (whether the document was included in the final synthesis).

Evidence Appraisal and Synthesis

A multidisciplinary expert panel of 15 clinicians from tertiary Class-A hospitals in Zhejiang Province participated in the evidence appraisal and synthesis process. The panel comprised 3 rehabilitation physicians, 2 rehabilitation therapists, 2 rehabilitation nurses, 2 neurologists, 2 neurology nurses, 2 geriatricians, and 2 geriatric nurses. The panel’s authority coefficient (Cr) was 0.89, indicating a high expert credibility (Table 4).

Table 4.

Expert Authority Coefficient

ID	Educational Qualification	Professional Title	Specialty/Area of Expertise	Years of Professional Experience	Basis for Judgment	Level of Familiarity	Authority Coefficient
1	Bachelor’s Degree	Senior Professional Title	Rehabilitation Nursing	20	1	1	1
2	Master’s Degree	Associate Senior Professional Title	Rehabilitation Medicine	20	1	0.8	0.9
3	Master’s Degree	Senior Professional Title	Rehabilitation Medicine	16	1	0.8	0.9
4	Master’s Degree	Associate Senior Professional Title	Rehabilitation Nursing	18	0.9	0.8	0.85
5	Master’s Degree	Intermediate Professional Title	Rehabilitation Therapy	13	0.8	1	0.9
6	Master’s Degree	Intermediate Professional Title	Rehabilitation Therapy	13	1	1	1
7	Bachelor’s Degree	Senior Professional Title	Rehabilitation Nursing	30	0.85	0.8	0.825
8	Associate Senior Professional Title	Associate Senior Professional Title	Geriatrics	12	0.95	1	0.975
9	Bachelor’s Degree	Associate Senior Professional Title	Geriatrics	25	1	0.8	0.9
10	Bachelor’s Degree	Associate Senior Professional Title	Gerontological Nursing	19	0.95	0.8	0.875
11	Master’s Degree	Associate Senior Professional Title	Gerontological Nursing	12	1	0.8	0.9
12	Master’s Degree	Intermediate Professional Title	Neurological Nursing	22	0.8	0.8	0.8
13	Bachelor’s Degree	Associate Senior Professional Title	Neurological Nursing	16	0.8	0.8	0.8
14	Master’s Degree	Senior Professional Title	Neurology	15	0.9	0.8	0.85
15	Doctoral Degree	Associate Senior Professional Title	Neurology	13	0.9	0.8	0.85

Based on the FAME framework—which evaluates feasibility, appropriateness, meaningfulness, and effectiveness—the initial evidence set underwent iterative refinement. Specifically, one recommendation was excluded due to insufficient applicability or supporting evidence; 14 recommendations were revised to enhance clarity, clinical precision, and contextual relevance; two recommendations were merged owing to conceptual overlap; and one new recommendation was added based on expert input and emerging evidence.

Summary of Key Findings

This evidence summary synthesized 43 evidence-based statements into a comprehensive, seven-domain framework for integrated dysphagia care in hospitalized older adults. The framework encompasses multidisciplinary collaboration, standardized screening and risk stratification, individualized nutritional support, oral hygiene and medication safety, multimodal rehabilitation, complication prevention with psychosocial support, and structured discharge planning with continuity of care. The detailed descriptions and quality levels of the evidence are listed in Table 5.

Table 5.

Best Evidence for Integrated Care Management of Dysphagia in Hospitalized Older Adults

Evidence Theme		Evidence Statement	Evidence of Level
Establish a multidisciplinary team.		1.Establish a multidisciplinary integrated care management model comprising physicians (specializing in rehabilitation, geriatrics, otolaryngology, neurology, and dentistry), nurses, rehabilitation therapists (including physical, occupational, and speech-language therapists), clinical dietitians, psychotherapists, and patient caregivers or family members.21,24,31,33,37,39,40,46	5A
		2.Provide regular training (every 3–6 months) for multidisciplinary team members on topics including swallowing assessment, safe eating practices, and oral hygiene maintenance, and document the outcomes of these training sessions.24,31,33,39,48	1A
Dysphagia screening	Screening population	3.Hospitalized older adults aged 65years and above.26,36,39	5A
	Screening timing	4.Complete screening within 24 hours of admission or prior to any oral intake of food or medication.26,35	5A
	Screening personnel	5.Conducted by healthcare professionals who have received relevant specialized training.36,44	5A
	Screening tools	6.It is recommended to use validated assessment tools or methods, such as the Water Swallowing Test (WST), the Eating Assessment Tool-10 (EAT-10), the Repetitive Saliva Swallowing Test (RSST), the Dye Test, the Mucus–Volume Test, and the Functional Oral Intake Scale (FOIS).21,25,32,36,39,44,48	1A
Dysphagia assessment and diagnosis		7.Patients who screen positive should undergo a comprehensive clinical assessment, including evaluation of swallowing-related medical history, mental status, cooperation level, cognitive and communication abilities, nutritional status, oral hygiene, respiratory function, general motor function, orofacial and laryngeal function, as well as the caregiver’s capacity to provide adequate support.36,44	5A
		8.Perform bedside feeding assessments using the Volume–Viscosity Swallow Test (V–VST) for all patients who meet the eligibility criteria. To standardize the recording of functional outcomes, it is recommended to use the Functional Oral Intake Score (FOIS) to assess the overall oral dietary status of the patients.36	5.A
		9.Conduct dynamic reassessments for patients at increased risk of dysphagia or those experiencing clinical changes.21,22,25,26,36,39,44,48	1A
		10. Videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) is recommended for patients with positive screening results to confirm the diagnosis and guide individualized treatment. During VFSS, the Penetration-Aspiration Scale (PAS) is recommended as the standardized metric for quantifying the severity of airway invasion.21,22,25,36,44	5A
Integrated care management of dysphagia	Nutritional Support	11.Nutritional risk screening should be completed within 24 hours of admission, preferably using a combination of the Mini Nutritional Assessment–Short Form (MNA-SF) and the Nutritional Risk Screening 2002 (NRS-2002). Patients identified as being at nutritional risk during hospitalization should be reassessed once weekly.24,31,32,39,48	5A
		12.Nutritional support routes—including oral intake, intermittent nasogastric tube feeding, or enteral tube feeding—should be selected based on a comprehensive assessment of the patient’s nutritional status, swallowing function, disease severity, aspiration risk, and cognitive capacity.24,25,32,39,40,48	5A
		13.For older adults with dysphagia who are managed with oral intake, it is recommended to modify food and fluid consistencies according to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework to enhance swallowing safety and efficacy.21,25,26,31,33,35,38–40,48	1A
		14.It is recommended to enhance the sensory properties and nutrient density of texture-modified diets to address inadequate nutritional intake in patients with dysphagia.21,38,46	1B
		15.For patients receiving oral intake who are unable to meet their nutritional requirements through diet alone, oral nutritional supplementation (ONS) is recommended as an adjunctive strategy, provided that gastrointestinal function is intact.24,32,35,45,46	5B
		16.Patients whose oral energy intake falls below 60% of the target feeding requirement should receive early enteral nutrition support.35,40	5B
		17.For patients with an anticipated treatment duration exceeding four weeks, percutaneous endoscopic gastrostomy (PEG) feeding may be initiated following multidisciplinary evaluation and informed consent from the patient or their family, if the patient declines nasogastric tube placement, demonstrates intolerance to nasogastric feeding after a trial, or experiences difficulty maintaining secure tube fixation.23,39,42	2B
		18.Continuous infusion is recommended for patients with jejunal or duodenal tube placement, a history of gastroesophageal reflux, or those at high risk of aspiration.23	2B
		19.Healthcare professionals should develop individualized nutrition plans—including nutritional goals and dietary regimens—tailored to each patient’s clinical condition and needs.32,45,48	5A
	Oral Care	20.It is recommended to assess patients’oral hygiene, dentition or denture status, severity of xerostomia (dry mouth), and masticatory and speech abilities.21,25,27,39,48	5A
		21.Oral hygiene should be maintained using toothbrushes, foam swabs, toothpaste, dental floss, and mouth rinses. For patients at risk of aspiration, a suction-assisted toothbrushing technique with low-foaming toothpaste is recommended. Mouth rinse is advised to reduce dental plaque and gingival bleeding.40,48	5A
		22.For patients who are not receiving oral intake, oral care should be performed twice daily. For those receiving oral intake, oral care should be provided both before and after each meal.40	1B
	Medication Management	23.Medication administration methods must be reviewed and approved by a physician; patients or caregivers must not crush extended-release, controlled-release, enteric-coated, or film-coated formulations without explicit authorization.21,37,41,47	5A
		24.For patients capable of partial oral intake, medications in tablet or capsule form may be administered using a gel-based delivery system to facilitate safe swallowing.21,37	5B
Swallowing Function Rehabilitation Therapy	Compensatory Strategies	25.It is recommended to initiate feeding therapy as early as possible using appropriate compensatory strategies once the following five essential criteria for safe oral intake are met: Swallowing compensatory postures (eg, chin-up or chin-down swallow, head rotation, lateralized swallow, and effortful or repeated swallows); Optimized feeding positioning (eg, sitting upright or semi-reclined with the neck slightly flexed or in neutral alignment); Use of adaptive utensils (eg, long-handled shallow spoons, thick-rimmed or blunt-edged spoons, and cut-out cups);Appropriate bolus volume, typically 5–20 mL per swallow; Ensured feeding safety, including a quiet and well-lit environment, caregiver standing on the patient’s unaffected side, and placement of the bolus onto the posterior tongue or buccal cavity on the unaffected side.21,22,25,26,33,37,39,40,48	5A
	Traditional Rehabilitation Training	26.Individualized rehabilitation interventions should be selected for each patient, Oral sensory training: such as thermal (cold) stimulation, olfactory stimulation, K-point stimulation, vibratory stimulation, and air-pulse sensory stimulation;Oral motor exercises: including the Masako maneuver and Shaker exercise; Airway protection techniques: such as the Mendelsohn maneuver, supraglottic swallow, super-supraglottic swallow, and effortful swallow.21,22,25,26,28,37,39	2A
	Traditional Chinese Medicine Therapy	27.It is recommended to employ adjunctive therapeutic approaches—including acupuncture at local acupoints in the neck, tongue, and pharynx; external traditional Chinese medicine (TCM) interventions such as TCM medicated ice pops for cold stimulation or TCM herbal sprays; and acupoint massage—to improve swallowing function.26,37–39	1B
	Adjunctive Technology-Based Therapies	28.It is recommended that appropriate patients receive adjunctive neuromodulatory and neurorehabilitative techniques—such as repetitive transcranial magnetic stimulation (rTMS), transcranial electrical stimulation (tES), electromyographic biofeedback, and neuromuscular electrical stimulation (NMES)—as complementary interventions to standard dysphagia therapy.22,25,26,37,39,48	1A
		29.For patients with cricopharyngeal achalasia, balloon catheter dilation is recommended to improve the coordination of swallowing movements.22,26,34	1B
		30.For tracheostomized patients who meet the appropriate criteria, early use of a speaking valve is recommended to enhance subglottic pressure, thereby improving swallowing function and reducing the risk of aspiration.26	4B
	Pharmacological Therapy	31.Botulinum toxin injection is recommended for patients with cricopharyngeal dysfunction who are not candidates for surgical intervention or balloon catheter dilation.22,26,39	1B
Prevention and Management of Complications	Aspiration and Pneumonia	32.All patients with dysphagia should undergo assessment of aspiration risk, which may be performed using flexible or transnasal endoscopy (FEES), as well as adjunctive modalities such as ultrasound imaging, manometric pressure monitoring, and secretion analysis.21,34,39,40	4B
		33.Implement postural management during feeding (maintaining an upright sitting position or elevating the head of the bed to at least 30° for 30–60 minutes) and ensure rigorous oral hygiene to prevent aspiration.21,26,37,40	1A
		34.Monitor patients’ vital signs, cough and sputum production, and relevant laboratory markers to enable early detection of pulmonary infection.21,39,48	5A
		35.Develop a standardized aspiration emergency protocol, including measures such as the Heimlich maneuver, readiness for suctioning, and a rapid referral pathway.21,37	5A
	Dehydration	36.The hydration status of patients with dysphagia who are receiving oral intake should be closely monitored. Clinicians should watch for clinical signs of dehydration, including thirst, reduced urine output, fatigue, dry lips and tongue, poor skin turgor, sunken eyes, and restlessness. Regular assessment of hydration markers is essential to ensure adequate fluid intake.31,33,40,48	5A
		37.For patients with inadequate fluid intake or dehydration via oral or enteral routes, initial rehydration should be achieved through nasogastric water administration or intravenous crystalloid solutions, with fluid volume gradually increased in a stepwise manner.40	5A
		38.Patients who are cognitively intact and able to maintain sitting balance may undergo a free water protocol under supervision.29,40	2B
	Psychological and Social Interaction Impairments	39.It is recommended to regularly assess patients’psychological status using validated instruments such as the Swallowing-Related Quality of Life (SWAL-QOL) scale, the Hospital Anxiety and Depression Scale (HADS), and the shortened Geriatric Depression Scale (GDS), with particular attention to emotional changes arising from feeding difficulties.21,39,48	1B
		40.Patients identified with psychological distress should receive targeted interventions, such as cognitive behavioral therapy (CBT) and relaxation techniques, to foster confidence in managing their condition and enhance adherence to swallowing rehabilitation.25,48	2A
Discharge Guidance and Follow-up	Discharge Guidance	41.Within one week prior to discharge, if swallowing function has not fully recovered, both the patient and their caregiver should receive refresher training. Additionally, healthcare providers should supply written educational materials (eg, a care handbook) or access to no-cost resources (eg, telehealth counseling) to support continued management at home.21,31,33,37,39,40	1A
	Follow-up Frequency	42.The follow-up schedule should be individualized based on the patient’s adherence, severity and stability of dysphagia, risk of complications, and frequency and control of symptoms. Routine follow-up is generally recommended at 1 week, 2 weeks, 1 month, 2 months, and 3–6 months post-discharge.25,31,48	2B
	Follow-up Content	43.Follow-up assessments should include nutritional screening, nutritional status evaluation, review of therapeutic goals, assessment of treatment adherence, and monitoring for complications.31	5A

Notes: A/B grades according to JBI Levels of Evidence.Grade A (high evidence, strong recommendation); Grade B (moderate evidence, conditional recommendation).

Discussion

Establish Multidisciplinary Collaboration and Governance for Coordinated, Person-Centered Care

Effective multidisciplinary management is essential for reducing complication risks in older adults with dysphagia, whose care is complicated by frailty, polypharmacy, and multimorbidity.⁴⁹ In this study, evidence items 1–2 summarize the core composition of the multidisciplinary team and the governance mechanisms required for effective collaboration. The evidence recommends that an integrated dysphagia care model should comprise physicians, nurses, rehabilitation therapists (including speech-language pathologists), clinical dietitians, psychotherapists, and caregivers, with regular competency-based training every 3–6 months. Effective collaboration helps identify subtle clinical changes early. For example, a nurse may notice a new cough after meals, a pharmacist may identify difficulty with medication swallowing, or a rehabilitation therapist may observe declining tongue strength. Early reporting of these changes can facilitate timely intervention and prevent complications from worsening. However, current practice remains fragmented, particularly in China, where speech-language pathologists are underutilized and interprofessional communication is limited.^50,51 Patients and families often lack adequate knowledge of dysphagia management. Providing healthcare professionals with structured team composition and governance mechanisms can help them detect problems early and reduce the incidence of complications.^25,39 Therefore, clinical institutions should adopt effective organizational measures and conduct targeted training for multidisciplinary team members.

Implement Standardized Screening to Enable Early Identification and Timely Intervention

Early identification through standardized screening is pivotal to preventing life-threatening complications, as aspiration pneumonia, malnutrition, and dehydration can develop within the first days of hospitalization.¹¹ In this study, evidence items 3–10 summarize the recommended screening population, timing, personnel, tools, and assessment pathway. The evidence recommends that hospitalized patients aged 65 years or older should undergo structured dysphagia screening within 24 hours of admission and before any oral intake, conducted by trained healthcare professionals. Validated tools include the WST, EAT-10, RSST, Dye Test, Mucus–Volume Test, and FOIS. Patients who screen positive should receive comprehensive clinical assessment.

Effective screening can facilitate timely identification of swallowing impairment. Early detection of silent aspiration or reduced oral intake may facilitate timely intervention, thereby preventing the progression of aspiration pneumonia and malnutrition.^28,36,52 However, current practice remains inconsistent. Screening timing varies, and tools are heterogeneous, contributing to underdiagnosis in high-risk older adults. Some studies have noted that time-bound screening protocols are often difficult to fully implement due to staffing shortages and competing clinical priorities.^53,54 Providing healthcare professionals with standardized screening protocols and validated tools can help them detect problems early and reduce the incidence of complications.^55,56 Therefore, clinical institutions should adopt standardized screening strategies and ensure they are implemented by trained healthcare professionals, so that high-risk older patients with dysphagia can receive early intervention, thereby improving prognosis and quality of life.

Provide Individualized Nutritional Support Based on Swallowing Capacity and Nutritional Risk

Nutritional support is a core determinant of clinical outcomes in older adults with dysphagia.⁴⁹ In this study, evidence items 11–19 summarize the recommended screening tools, support routes, and criteria for enteral nutrition. Specifically, evidence items 11–12 recommend dual-tool screening with MNA-SF and NRS-2002 within 24 hours of admission, weekly reassessment for at-risk patients, and selection of nutritional support routes based on nutritional status, swallowing function, disease severity, aspiration risk, and cognitive capacity. Based on the screening results, evidence items 13–14 further recommend that patients able to maintain oral intake receive texture-modified diets aligned with the IDDSI framework, with enhanced sensory properties and nutrient density to address inadequate intake. If oral intake remains insufficient despite these modifications, evidence item 15 recommends oral nutritional supplementation.

Malnutrition and dysphagia are mutually reinforcing.⁴⁹ Reduced oral intake leads to loss of lean body mass, including swallowing musculature, which further impairs swallowing and reduces intake even more. This vicious cycle accelerates functional decline and increases mortality risk.⁴⁹ Breaking it therefore requires simultaneous attention to both nutrition and swallowing. However, nutrition and swallowing are often managed by separate teams with limited communication.⁵⁷ Patients and caregivers may also lack knowledge about texture-modified diets and safe feeding practices. This fragmentation perpetuates the problem. Therefore, evidence items 16–18 provide recommendations for early enteral nutrition and PEG placement, while evidence item 19 recommends individualized nutrition plans that include nutritional goals and dietary regimens tailored to each patient’s clinical condition and needs. Clinical professionals should integrate these recommendations into the dysphagia care pathway, using the IDDSI framework and the 60% threshold as objective criteria for decision-making. Caregivers should also receive training in safe feeding techniques.^31,35

Ensure Oral Hygiene and Safe Medication Administration for Patient Safety

Poor oral health is a well-established contributor to aspiration pneumonia in older adults with dysphagia. Dental plaque and gingival inflammation persistently harbor pathogenic bacteria, and when swallowing safety is compromised, these bacteria can be aspirated into the lower respiratory tract, leading to aspiration pneumonia.⁵⁸ In this study, evidence items 20–22 summarize the recommended oral hygiene practices. Evidence item 20 recommends routine assessment of oral hygiene, dentition, xerostomia, and masticatory and speech abilities. This assessment identifies specific oral health needs and aspiration risks, which guide the selection of appropriate care tools and techniques. Accordingly, evidence item 21 recommends oral care using toothbrushes, foam swabs, toothpaste, dental floss, and mouth rinses, with suction-assisted toothbrushing and low-foaming toothpaste for patients at risk of aspiration. Oral care requirements also vary with feeding route; therefore, evidence item 22 specifies that patients not receiving oral intake should receive oral care twice daily, while those receiving oral intake should receive care before and after each meal.

Medication safety is another critical component of integrated care for this population. Inappropriate modification of oral dosage forms carries direct risks: sustained-release tablets are designed to release medication gradually over hours, and when crushed, the entire dose is released at once, causing rapid peak plasma concentrations and potential toxicity; similarly, enteric coatings protect drugs from gastric acid, and when disrupted, the drug may be degraded in the stomach before reaching the intestine, reducing efficacy.⁵⁹ Accordingly, evidence item 23 recommends that all modifications of oral dosage forms be reviewed and approved by a physician, and that extended-release, controlled-release, enteric-coated, or film-coated formulations should not be crushed without authorization. When oral dosage forms must be modified, evidence item 24 recommends gel-based delivery systems for patients capable of partial oral intake. However, implementation of both oral care and medication safety protocols remains suboptimal. Fewer than 40% of hospitalized older adults receive guideline-concordant oral care.⁶⁰ Barriers include inadequate training, time constraints, and ambiguous role responsibility. Patients and caregivers may also lack awareness of the importance of daily oral hygiene and safe medication practices. Given these gaps, clinical nurses should perform oral assessments and provide oral care according to each patient’s feeding route. For medication safety, nurses must confirm that all dosage form modifications have been reviewed and approved by a physician before administration, and must not adjust the administration method without authorization.^31,40

Integrate Compensatory Strategies, Active Rehabilitation, and Adjunctive Technologies to Maximize Recovery

A study has pointed out that patients with dysphagia often experience fear of swallowing, which leads them to avoid oral intake or reduce swallowing attempts. This causes progressive decline in swallowing musculature function.⁶¹ When rehabilitation is delayed, the risk of subsequent pulmonary complications increases.⁶¹ These observations underscore the importance of timely rehabilitation for older adults with dysphagia.

Based on this, this study has aggregated the relevant evidence in three aspects, namely compensatory strategies, active rehabilitation, and adjunctive technologies. The evidence suggests that feeding therapy should be initiated as early as possible using compensatory strategies once safe oral intake criteria are met.²⁵ For patients who can tolerate active training, oral sensory training, oral-motor exercises, and airway protection maneuvers are recommended to strengthen swallowing musculature and promote cortical reorganization.²⁶ For those who do not respond adequately to conventional therapy, adjunctive technologies such as rTMS, NMES, and balloon catheter dilation may provide additional benefit.^27–31 However, current rehabilitation practice often relies on fragmented, protocol-driven approaches, and many patients receive only one type of intervention without individualized treatment.⁶¹ Therefore, it is necessary for clinical professionals to formulate personalized rehabilitation plans for patients in the future, combine compensatory strategies with active training and adjunctive technologies according to each patient’s pathophysiological mechanisms, and conduct more high-quality research to explore rehabilitation programs that are specific, safe, and effective for older adults with dysphagia.

Systematically Monitor and Manage Aspiration, Dehydration, and Psychological Distress

Aspiration, dehydration, and psychological distress represent three interrelated complications that can significantly worsen outcomes in older adults with dysphagia.^11,52,62 Aspiration may lead to pneumonia, dehydration can exacerbate swallowing difficulty and cause delirium, and psychological distress—often triggered by the loss of eating—can reduce adherence to rehabilitation. These complications share a common feature: they develop silently and are often unrecognized until they become severe. A patient may aspirate without coughing, or gradually reduce fluid intake without reporting thirst. By the time clinical signs appear, the opportunity for prevention may have passed. This silent progression explains why proactive monitoring is essential in this population.

In this study, evidence items 32–40 summarize the recommended strategies for monitoring and managing these complications. For aspiration, the evidence recommends universal risk assessment using FEES and bedside cervical ultrasound, postural management with head-of-bed elevation ≥30° for 30–60 minutes after feeding, rigorous oral hygiene, monitoring of vital signs and sputum production, and a standardized aspiration emergency protocol. For dehydration, close monitoring of clinical signs such as thirst, reduced urine output, poor skin turgor, and sunken eyes is recommended, with nasogastric water administration or intravenous crystalloid solutions for patients with inadequate intake. For psychological distress, routine screening with validated instruments such as SWAL-QOL, HADS, and GDS-15 is advised, with targeted interventions for patients scoring above validated cut-offs.⁶² However, current practice often focuses on physical complications while neglecting routine psychosocial screening and systematic dehydration monitoring. This gap reflects a broader limitation in dysphagia care: the tendency to treat swallowing as a mechanical problem rather than a multidimensional experience. Therefore, clinical teams should integrate physical and psychological assessments into standard dysphagia care, recognizing that recovery involves not only physiological restoration but also the restoration of dignity and participation in meaningful life activities.

Strengthen Structured Discharge Planning and Follow-Up for Continuity of Care

The transition from hospital to home is a period of heightened vulnerability for older adults with dysphagia.⁶³ Professional supervision is suddenly withdrawn, caregivers assume responsibility for complex tasks they may not feel prepared for, and early signs of deterioration—such as reduced oral intake or new-onset cough—may go unrecognized until complications become severe. Discharge planning, therefore, should not be treated as a discharge-day formality. It must begin early, involve both patient and caregiver, and continue beyond the hospital stay. In this study, evidence items 41–43 summarize the recommended strategies for discharge planning and follow-up. These include initiating discharge readiness planning no later than 7 days prior to discharge, providing refresher training and written materials for patients and caregivers, and scheduling individualized follow-up to monitor nutrition, treatment adherence, and complications.

However, care transitions remain fragmented in many settings.⁶³ Coordination between hospital and community care is limited, and follow-up is often inconsistent. This fragmentation undermines the potential benefits of inpatient dysphagia management and increases the risk of readmission. Therefore, clinical teams should establish a formalized discharge transition protocol that integrates pre-discharge education, coordinated referrals, and scheduled follow-up. Such a protocol creates a closed-loop, integrated care continuum—spanning acute assessment, supported reintegration into the home, and sustained functional maintenance in the community—which is essential for achieving equitable, person-centered outcomes in this population.

The Contributions and Boundaries of a Chinese Evidence-Led Framework

A defining characteristic of our evidence base is its substantial reliance on Chinese consensus statements and guidelines^{26,30,31,33–38}. This reflects both the local research context and the search strategy employed, but it also raises important questions about the framework’s generalizability. Three areas of cross-contextual variation warrant explicit discussion: (a) the availability of instrumental assessment (VFSS/FEES) and the thresholds for its use, which vary considerably between high-resource and low-resource settings; (b) the composition, funding, and professional recognition of multidisciplinary teams, particularly the availability and scope of practice of SLPs; and (c) cultural norms and regulatory frameworks surrounding artificial nutrition, which influence the thresholds for enteral feeding initiation and the acceptability of PEG placement.

We have deliberately integrated international references and discussed these differences transparently, not to mask them but to make them visible to readers from diverse healthcare systems. This approach—acknowledging contextual variation while maintaining a coherent evidence-informed framework—enhances rather than diminishes the framework’s utility. It enables clinicians, managers, and policymakers to identify which components are immediately applicable, which require adaptation, and which may be aspirational until resources and infrastructure can be developed.

Practical and Research Implications

From a clinical standpoint, this framework provides a structured template for systematically auditing existing dysphagia care pathways and prioritizing quality improvement initiatives. The seven-domain structure enables institutions to identify specific gaps—whether in screening compliance, MDT coordination, or discharge transition—and to target interventions accordingly. The emphasis on competency-based training (every 3–6 months) and accountability mechanisms (shared documentation, regular MDT case conferences) offers actionable levers for organizational redesign. Critically, the integration of patient- and caregiver-centered components—including shared decision-making prior to PEG placement and multimodal education—aligns with contemporary person-centered care paradigms and addresses the often-neglected psychosocial dimension of dysphagia, which is associated with social isolation, eating-related anxiety, and diminished quality of life.⁶²

From a research perspective, three priority areas should guide future investigations. First, prospective validation studies are urgently needed to test the feasibility, acceptability, and effectiveness of the full framework across diverse settings—including community hospitals, long-term care facilities, and rehabilitation centers—with particular attention to contextual barriers (eg, staffing ratios, SLP availability, cost constraints) and facilitators (eg, institutional leadership, interprofessional training culture). Second, cost-effectiveness analyses should be conducted to inform resource allocation, as many recommended components (VFSS/FEES, IDDSI implementation, MDT training) require upfront investment with downstream savings that are yet to be quantified. Third, comparative effectiveness research should evaluate alternative staffing models (eg, nurse-SLP collaborative models, telehealth-supported rehabilitation) in settings where full MDT composition is unattainable, providing evidence to guide task-shifting and phased implementation.

Strengths

First, the systematic methodology—comprehensive search strategy spanning multiple databases and guideline repositories, predefined inclusion criteria aligned with the PIPOST framework, and dual independent appraisal using validated tools (AGREE II, CASE, JBI checklists)—ensured rigorous and reproducible evidence synthesis. Second, the framework was developed by a multidisciplinary expert panel (nursing, rehabilitation, geriatrics, neurology) with a high authority coefficient (Cr=0.89), enhancing clinical credibility and applicability. Third, all recommendations were graded using the standardized JBI system, enabling users to prioritize based on evidence strength. Fourth, the explicit integration of standardized outcome measures (PAS, FOIS) into the clinical workflow facilitates future cross-study comparisons and meta-analyses, addressing a critical gap in dysphagia research where heterogeneity in outcome measurement has historically limited synthesis.

Limitations

Several methodological limitations should be acknowledged. First, the predominance of Chinese sources—reflecting both our search strategy and the local evidence landscape—means that some recommendations may not fully reflect international practice patterns or resource availability. While we have integrated international references and explicitly discussed cross-contextual variations, the framework’s recommendations are inevitably shaped by the evidence available at the time of the search. We encourage readers from other settings to critically assess each recommendation’s applicability to their local context.

Second, as a best evidence summary, this framework synthesizes existing evidence rather than generating primary data. Prospective validation across diverse settings remains essential before widespread implementation can be recommended.

Third, heterogeneity in study designs, outcome measures, and reporting quality among the included documents precluded quantitative meta-analysis. We have explicitly recommended standardized outcome measures (PAS, FOIS) to address this limitation in future research.

Conclusion

This evidence summary provides a comprehensive, seven-domain framework to guide integrated dysphagia care in hospitalized older adults. By integrating these domains, the framework promotes a shift from fragmented, task-centered care toward coordinated, person-centered management across the care continuum.

Successful implementation requires organizational commitment to workflow redesign, interprofessional education, and continuous quality monitoring. Future research should evaluate the framework’s feasibility, acceptability, and effectiveness across diverse clinical settings, with particular attention to resource availability and cultural adaptation.

Disclosure

The authors report no conflicts of interest in this work.