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The Journal of Nutrition, Health & Aging logoLink to The Journal of Nutrition, Health & Aging
. 2021 Nov 15;25(10):1145–1153. doi: 10.1007/s12603-021-1700-9

Factors Associated with Self-Reported Dysphagia in Older Adults Receiving Meal Support

A Kurosu 1, F Osman 2, S Daggett 2, R Peña-Chávez 3,4, A Thompson 5, SM Myers 6, P VanKampen 7, SS Koenig 8, M Ciucci 1,3, J Mahoney 9, Nicole Rogus-Pulia 1,3,9,10
PMCID: PMC8653989  NIHMSID: NIHMS1724503  PMID: 34866141

Abstract

Objectives

Dysphagia is common in older adults. However, there are no current estimates of dysphagia in community-dwelling older adults those receiving meal support. It is unknown whether dysphagia is associated with other measures of physical function (activities of daily living [ADL] ability or nutrition status). The study purposes were to determine the prevalence of self-reported dysphagia and to identify factors associated with self-reported dysphagia in community-dwelling older adults receiving meal support.

Design

A cross-sectional study.

Setting and Participants

476 community-dwelling older adults (78.5±0.51 years) across five Elder Nutrition Program meal services in Wisconsin participated in the study.

Measurements

Data were collected through administration of validated ADL and nutrition questionnaires (nutritional status, functional status with ADLs, chewing ability, dental conditions, and prior diagnoses of dysphagia, pneumonia, and dementia). For self-reported dysphagia, the validated 10-item eating assessment tool (EAT-10) was used.

Results

The prevalence of self-reported dysphagia (EAT-10 score of ≥ 3) was 20.4%. Multivariate logistic regression results indicated that poor nutritional status (OR=3.1, p=0.04), difficulty chewing (OR=2.2, p=0.03), prior dysphagia diagnosis (OR=34.8, p<0.001), prior pneumonia diagnosis (OR=2.1, p=0.04), and meal service site (OR=2.68, p=0.02) were associated with self-reported dysphagia.

Conclusion

Approximately one in five community-dwelling older adults receiving meal support had self-reported dysphagia. Increased risk for poor nutrition, reduced chewing ability, prior dysphagia and pneumonia diagnosis, and meal service site were identified as factors associated with dysphagia on the EAT-10. Results highlight the need for further studies across more sites to identify dysphagia risk indicators in community-dwelling older adults receiving meal support state-wide.

Key words: Dysphagia, screening, community-dwelling older adults, malnutrition

Abbreviation

ADL

activities of daily living

BMI

body mass index

CI

confidence interval

EAT-10

Eating Assessment Tool

ENP

Elder Nutrition Program

IADL

Instrumental Activities of Daily Living

OAA

Older Americans Act

OR

Odds Ratio

Introduction

Dysphagia, or swallowing difficulty, affects most of the world's aging population with approximately 10–30% of adults 65 years and older experiencing dysphagia (1, 2, 3, 4). Dysphagia is associated with negative health consequences, such as malnutrition, dehydration, aspiration pneumonia, reduced quality of life, and increased mortality (4, 5, 6, 7, 8). Patients with dysphagia also have longer hospital stays (9, 10) higher medical costs, and are 1.7 times more likely to die in the hospital than patients without dysphagia (10). Early identification of dysphagia is therefore crucial to reduce complications and additional medical costs. The population of older adults is estimated to include 2.1 billion individuals by 2050, which is more than twice the number of older adults in 2017 (11). In the U.S, this will constitute a 57% increase in the aging population with the likelihood of many older adults being diagnosed with dysphagia (11).

Dysphagia in community-dwelling older adults typically remains untreated until it results in hospital admission with or without dysphagia-related medical issues (1). Identifying the prevalence of dysphagia in community-dwelling older adults is essential to treatment and referrals. However, the prevalence of self-reported dysphagia in community-dwelling older adults varies across studies, ranging from 11.0% to 72.0% (1, 3, 12, 13, 14, 15, 16). Various questionnaires (validated and non-validated) have been used to identify self-reported dysphagia in the literature. These include the Dysphagia risk assessment, Dysphagia screening questionnaire, MD Anderson Dysphagia Inventory, 10-item Eating Assessment Tool (EAT-10), Sydney Swallow Questionnaire, and Swallowing Quality of Life questionnaire (17, 18, 19, 20, 21, 22). The variability in results could be in-part due to differences in the method of dysphagia measurement.

In the community-dwelling older adult population, dysphagia is associated with disability in activities of daily living (ADL) (12) and poorer nutritional status (23). Nutritional status can be positively impacted through meal support programs such as the community-based aging services network. The Older Americans Act (OAA), which provides grants to states to help support nutrition services for older adults in the United States and its territories, was signed into law in 1965 (24). The nutrition services authorized in the OAA Elder Nutrition Program (ENP) include both home-delivered meals and meals served in congregate settings, such as senior centers and faith-based locations (24). ENP meal services are made available to individuals aged 60 years or older who are homebound due to isolation, illness, or disability as well as their spouses/partners regardless of their age or conditions. Congregate meal services are available for individuals aged 60 or older, their spouses/partners aged 60 or older, and adults with disability of any age who reside in a housing facility with the eligible older individual (Wisconsin Department of Health Services, 2019). The ENP results in improved nutrient intake and diet quality as well as reduced food insecurity (25, 26, 35, 27, 28, 29, 30, 31, 32, 33, 34).

The prevalence of dysphagia in community-dwelling older adults who receive ENP services remains unknown. Factors associated with dysphagia in this population are also unknown. Community-dwelling older adults who need meal support, especially home-delivered meals, may suffer from more physical frailty and reduced ADL abilities than those without meal support needs (36). As a consequence, those adults requiring meal support may be at a higher risk of dysphagia. Regardless of the presence of dysphagia, dietary modifications (such as altering the texture or viscosity) are not typically available for participants of ENPs. Given this, it is important to determine whether dysphagia is present in community-dwelling older adults receiving meal support as they may require modified food and liquid therapeutically. As such, identifying the factors associated with dysphagia is important for service provision in this population.

The purpose of our study was to (1) determine the prevalence of self-reported dysphagia in community-dwelling older adults receiving meal support across five sites in Wisconsin, and (2) examine the relationship among self-reported dysphagia and factors associated with dysphagia, including measures of nutritional status and independence with ADLs. Self-reported dysphagia was assessed with the EAT-10 which is a validated dysphagia screening tool consisting of ten questions (20). We hypothesized that self-reported dysphagia would be associated with higher likelihood of malnutrition and reduced ADL abilities, which have been reported as factors associated with dysphagia in community dwelling older adults without meal support (12, 23).

Methods

Study Design and Participants

The study design was a cross-sectional study conducted at five ENPs in Wisconsin (Dodge, Fresh Meals on Wheels of Sheboygan County [Fresh], Kenosha, Washington, and Waukesha). These sites were selected among other sites in Wisconsin because they agreed to participate a quality improvement project in collaboration with the ENPs to improve identification of dysphagia in ENP participants. All data were collected as part of this quality improvement project. This study was approved by the University of Wisconsin-Madison Health Sciences Institutional Review Board for retrospective data access for research purposes.

All older adults participating the five ENP programs were surveyed. Participants from four of the ENP program sites (Dodge, Kenosha, Washington, and Waukesha) were community-dwelling older adults who were receiving home delivered or congregate meal support. Participants from one ENP program, which is a non-profit charitable organization (e.g., Fresh), were primarily homebound and received only home-delivered meals. Participants who opted not to complete the EAT-10 questionnaire during the standard ENP intake process were excluded from the analysis.

Procedures

Data were collected though administration of the following five questionnaires: a medical history and demographics form, a nutrition program intake form, an activities of daily living (ADL) form, an instrumental activities of daily living form (IADL), and the EAT-10. Trained staff or volunteers representing the ENP nutrition programs administered all study questionnaires at four program sites. If participants needed support for reading questions and selecting answers, staff or volunteers read aloud questions and answer choices for participants. Nurses administered all study questionnaires at one program site (Fresh). For participants who received home delivered meals, a trained staff, volunteers, or nurses who conducted home or telephone visits asked the questions and then filled out the questionnaires according to the participant responses. Participants at the community dining centers completed the questionnaires independently. The nutrition program intake, ADL, and IADL forms are routinely administered annually as part of the ENPs. The EAT-10 was added to improve screening for dysphagia. All completed questionnaires were de-identified, scanned, and shared with the University of Wisconsin-Madison for data analysis. All data were collected between August 2017 and May 2018.

Demographic and Medical History Information Form

Participants provided demographic information (e.g., age, sex, and race) as well as the following factors: body mass index (BMI), marital status, type of meal (home-delivered meals or meals in a community dining setting), living arrangement (either live alone or live with others), and income status (annual income below $11,880 for a one person household, or annual income below $16,020 for a two-person household). Participants also reported whether they had a prior dysphagia diagnosis, dementia diagnosis, pneumonia, hospitalization due to pneumonia, presence of missing teeth and dentures, or difficulty chewing (Table 1).

Table 1.

Questionnaires Administered to ENP Participants

Swallowing related questions
1. Have you ever had a diagnosis of dysphagia (difficulty swallowing)?
2. Do you have difficulty chewing?
3. Do you have missing teeth?
4. Have you ever had pneumonia?
5. Have you ever been hospitalized for pneumonia?
Nutrition Risk Screening Questions No Yes
1. I have an illness or condition that made me change the kind and/or amount of food eat 0 2
2. I eat fewer than 2 meals day 0 3
3. I eat few fruits or vegetables or milk products 0 2
4. I have tooth or mouth problems that make it hard for me to eat 0 2
5. I have three or more drinks of beer, liquor or wine almost every day 0 2
6. I don't always have enough money to buy the food that I need 0 4
7. I eat alone most of the time 0 1
8. I take 3 or more different prescribed or over-the-counter drugs daily 0 1
9. Without wanting to, I have lost or gained 10 pounds in the last six months. 0 2
10. I am not always able to physically shop, cook and/or feed myself 0 2
Activities of Daily Living questions — check each ADL that you/the client have/has difficulty in completing or need help with:
1. Getting in and out of the bath or shower or preparing the bath, washing and drying
2. Dressing and undressing
3. Completing toilet activities and personal care
4. Getting in and out of bed or a chair
5. Using utensils and eating without help
6. Walking up and down a flight of stairs or walking without assistance
Instrumental Activities of Daily Living questions — check each ADL that you/the client have/has difficulty in completing or need help with:
1. Preparing own meals
2. Medication management
3. Handling bill paying, banking, etc.
4. Doing heavy housework and outside chores
5. Doing light housework
6. Shopping for personal items and/or groceries
7. Traveling in a van, taxi, bus or car
8. Answering the telephone or calling out on the telephone
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Dysphagia Risk Screening Using 10-item Eating Assessment Tool (EAT-10)

Self-reported dysphagia was assessed using the EAT-10, a validated screening tool with ten questions to measure severity of dysphagia symptoms (20). Each question is scored from 0 (“no problem”) to 4 (“severe problem”), and the individual item scores are summed in order to determine a total EAT-10 score (20). For this study, the EAT-10 scores were then categorized in order to designate dysphagia severity level. An EAT-10 score of ≥3 was designated as abnormal (self-reported dysphagia) based on previous data from healthy adults (20). Also, the prevalence of participants who had a EAT-10 score of ≥ 15 was examined. This score has been shown to indicate a 2.4 times increased risk of aspiration on videofluoroscopy (37).

Nutrition Risk Screening

Risk for poor nutrition was assessed using the Nutrition Risk Screening questionnaire (also known as the “Determine Your Nutritional Health” questionnaire) which contains 10-items focused on assessment of nutritional status.38 A score between 0–2 indicates low risk, 3–5 indicates moderate risk, and >6 indicates high risk for poor nutrition (38).

ADL and IADL Risk Screening

The participants' functional status was assessed using both the ADL form, a self-administered 6-item questionnaire with items focused on basic self-care tasks, and the Instrumental Activities of Daily Living form (IADL), a self-administered 8-item questionnaire with items focused on more complex tasks necessary for maintaining independence in a community setting. Both forms are widely used to determine eligibility for services through public programs like Medicaid based on the individual's need for assistance with ADLs (39, 40). For each form, a total score of < 3 indicated dependence with all tasks while a score of ≥ 3 indicated independence with all tasks (39).

Statistical Analysis

Descriptive analysis was conducted using summary tables and frequencies. Differences between EAT-10 scores and categorical variables were examined using chi-squared tests. Continuous data were expressed as means and standard deviations and compared using independent samples t-tests. Univariate logistic regression analyses were conducted to determine factors significantly associated with EAT-10 as a binary variable (scores of ≥3 versus <3). Significant variables from the univariate model were then included in an adjusted multivariate logistic regression analysis to examine associations among EAT-10 and cumulative factors. A p-value of <0.05 was considered statistically significant. All statistical analyses were conducted using STATA SE 15 (Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC).

Results

Participant Characteristics and Prevalence of Self-reported Dysphagia

The study population comprised 476 subjects (35.6% male, 64.4% female) with a mean age of 78.5 ± 11.12 years (range=42–105 years). Ninety-seven (20.4%) participants had an EAT-10 score of ≥ 3, indicative of self-reported dysphagia. There were 18 participants (3.8%) with an EAT-10 score of ≥ 15. The prevalence of self-reported dysphagia was higher at one site (Fresh) compared to the other four sites (p=0.03).

Participants with self-reported dysphagia were younger (mean age=75 ± 1.2) than participants without self-reported dysphagia (mean age=79 ± 0.56) (p=0.004). There were proportionally more participants with self-reported dysphagia who had poorer nutritional status (nutrition risk score ± 6) (75.8%) than those without self-reported dysphagia (45.8%) (p<0.001). Chewing problems were present in both individuals with and without self-reported dysphagia; however, there were proportionally more participants with self-reported dysphagia who had difficulty chewing (30.9%) than those without dysphagia (10.1%) (p<0.001). While the majority of patients did not report a prior dysphagia diagnosis (90.6%), there were still proportionally more participants with self-reported dysphagia who had prior dysphagia diagnoses (34.8%) than those without (3.2%) (p=0.008). There were more participants with self-reported dysphagia who reported a prior pneumonia diagnosis (53.6%) compared to those without self-reported dysphagia (36.3%) (p=0.002). Participant characteristics are summarized in Table 2.

Table 2.

Participant characteristics based on EAT-10 score cut-off of 3

Variable Total EAT-10 < 3 EAT-10 ≥ 3 p-value
EAT-10, n(%) 476 379 (79.6) 97(20.4)
Age, (years) 78.5 ± 11.12 79 ± 0.6 75 ± 1.2 0.004*a
Gender, n(%)
Male 167 (35.6) 127 (76.1) 40 (23.9) 0.16b
Female 302 (64.4) 246 (81.5) 56 (18.5)
Black/American African, n(%) 9 (1.9) 5 (55.6) 4 (44.4) 0.39b
Marital Status, n(%) 0.003*b
Single 70 (14.9) 55 (78.6) 15 (21.4)
Married 105 (22.3) 88 (83.8) 17 (16.2)
Life Partner 212 (45.1) 177 (83.5) 35 (16.5)
Widowed 79 (16.8) 50 (63.3) 29 (36.7)
Divorced 4 (0.9) 3 (75.0) 1 (25.0)
Income (one), n(%) 101 (89.4) 73 (72.3) 28 (27.7) 0.68b
Home-delivered, n(%) 331 (70.6) 266 (80.4) 65 (19.6) 0.49b
BMI, kg/m2, mean (SD) 28.4 ± 0.4 28.5 ± 0.4 28.3 ± 0.8 0.83a
Site, n(%)
Dodge 45 (9.4) 33 (73.3) 12 (26.7) 0.03*b
Fresh 167 (35.1) 123 (73.6) 44 (26.4)
Kenosha 53 (11.1) 41 (77.4) 12 (22.6)
Washington 89 (18.7) 76 (85.4) 13 (14.6)
Waukesha 122 (26.5) 106 (86.9) 16 (13.1)
Nutrition, n(%)
Low 68 (14.9) 61 (89.7) 7 (10.3) <0.001*b
Moderate 150 (33.0) 134 (89.3) 16 (10.7)
High 237 (52.1) 165 (69.6) 72 (30.4)
ADL risk, n(%) 53 (16.0) 40 (75.5) 13 (24.5) 0.35b
IADL risk, n(%) 248 (74.2) 199 (80.2) 49 (19.8) 0.99b
Prior dysphagia diagnosis, n(%) 44 (9.4) 12 (27.3) 32 (72.7) <0.001*b
Difficulty chewing, n(%) 68 (14.4) 38 (55.9) 30 (44.1) <0.001*b
Missing Teeth, n(%) 338 (72.1) 260 (76.9) 78 (23.1) 0.01*b
Dentures, n(%), n(%) 192 (45.8) 144 (75.0) 48 (25.0) 0.16b
Prior pneumonia diagnosis 183 (39.2) 133 (35.7) 50 (53.3) 0.002*b
Prior hospitalization due to pneumonia, n(%) 89 (18.7) 63(17.6) 26 (29.2) 0.014*b
Prior dementia diagnosis, n(%) 19 (7.6) 14 (73.7) 5 (26.3) 0.73b
Lives Alone, n(%) 345 (73.4) 270 (78.3) 75 (21.7) 0.24b
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*Statistically significant at p<0.05; a=t-test, b=x^2-test

Factors Associated with Self-reported Dysphagia in Univariate Regression Analyses

The univariate logistic regression results indicated that age (OR=0.97 [95 % CI: 0.95 – 0.97], p=0.005), nutrition risk (OR=2.5[95 % CI: 1.67. – 3.67], p<0.001), difficulty chewing (OR=3.96 [95 % CI: 2.3 – 46.8], p<0.001), missing teeth (OR=2.01 [95 % CI: 1.13 – 3.55], p=0.01), prior dysphagia diagnosis (OR=16.08 [95 % CI: 7.8. – 32.9], p<0.001), prior pneumonia diagnosis (OR=1.88 [95 % CI: 1.23 – 2.87], p=0.004), prior hospitalization due to pneumonia (OR=1.88 [95 % CI: 1.23 – 2.87], p=0.004), and ENP site (OR=2.4 [95 % CI: 1.03 – 5.6], p=0.04 for Dodge site; OR=2.37 [95 % CI: 1.26 – 4.44], p=0.007 for Fresh site) were associated with self-reported dysphagia (based on EAT-10 scores). Results from the logistic regression model are shown in Table 3.

Table 3.

Risk factors for Self-reported Dysphagia in Univariate and Multivariate Models

Variable N Univariate Multivariate
OR 95% CI p-value OR 95% CI p-value
Age (years) 468 0.97 0.95 – 0.99 0.005* 0.97 0.94 – 0.99 0.01*
Gender (Male) 469 0.72 0.45 – 1.14 0.16
Race 476 0.90 0.69 – 1.16 0.42
BMI (kg/m2) 487
<18.5 1.75 0.62 – 4.9 0.29
18.5–24.9 Ref Ref Ref
24.9–29.9 1.33 0.73 – 2.4 0.35
>29 1.22 0.67 – 2.2 0.50
Type of meal 469 1.18 0.73 – 1.92 0.49
Marital Status 470 1.15 0.97 – 1.36 0.09
Lives Alone 470 1.37 0.80 – 2.3 0.24
Income Type 113 0.77 0.21 – 2.7 0.68
Nutrition Risk 455 2.50 1.67 – 3.67 <0.001* 3.1 1.04 – 9.4 0.04*
ADL risk 332 1.38 0.69 – 2.77 0.35
IADL risk 334 0.99 0.54 – 1.85 0.99
Difficulty chewing 471 3.96 2.3 – 6.8 <0.001* 2.2 1.1 – 4.66 0.03*
Missing Teeth 469 2.01 1.13–3.55 0.01* 1.03 0.48 – 2.2 0.93
Dentures 419 1.39 0.87 – 2.2 0.16
Prior dysphagia diagnosis 466 16.08 7.8 – 32.9 <0.001* 34.8 12.8 – 95.0 <0.001*
Prior pneumonia diagnosis 472 1.88 1.23–2.87 0.004* 2.1 1.04 – 4.2 0.04*
Prior hospitalization due to pneumonia 454 1.69 1.1–2.66 0.02* 0.70 0.34 – 1.43 0.33
Prior dementia diagnosis 251 1.20 0.41–3.50 0.73
Site
Waukesha 476 Referent Referent Referent Referent Referent Referent
Dodge 2.4 1.03 – 5.60 0.04* 2.3 0.61 – 8.5 0.21
Fresh 2.37 1.26 – 4.44 0.007* 2.68 1.2 – 6.2 0.02*
Kenosha 1.94 0.84 – 4.45 0.11 2.70 0.88 – 8.3 0.08
Washington 1.13 0.51 – 2.49 0.75 1.20 0.38 – 3.77 0.75
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*Statistically significant at p<0.05; ADL= activities of daily living; CI=confidence interval; IADL= Instrumental Activities of Daily Living form; OR=odds ratio

Factors Associated with Self-reported Dysphagia in Multivariate Regression Analysis

Based on the univariate logistic regression results, eight risk indicators were included in multivariate logistic regression analysis. Results of the multivariate regression indicated that nutrition risk (OR=3.1[95 % CI: 1.04 – 9.4], p=0.04), difficulty chewing (OR=2.2 [95 % CI: 1.1 – 4.66], p=0.03), prior dysphagia diagnosis (OR=34.8 [95 % CI: 12.8. – 95.0], p<0.001), prior pneumonia diagnosis (OR=2.1[95 % CI: 1.04 – 4.2], p=0.04), and meal service site (OR=2.68 [95 % CI: 1.2 – 6.2], p=0.02) were significant factors associated with self-reported dysphagia. Additionally, the results indicated that younger age (OR=0.97[95 % CI: 0.94 – 0.99], p=0.01) is associated with lower odds of self-reported dysphagia (41).

EAT-10 Item Analysis

Given that several ENP sites reported increased participant burden with completion of the EAT-10 in addition to the other intake questionnaires/forms, an EAT-10 item analysis was performed to determine whether there were particular items on the EAT-10 that were more highly associated with the overall score in this population. Spearman's correlations were conducted to determine relationships between each EAT-10 item and EAT-10 overall scores. The EAT-10 item 4 (“Swallowing solids takes extra effort.”) (rs=0.697, p<0.001), item 5 (“Swallowing pills takes extra effort.”) (rs= 0.718, p<0.001), item 8 (“When I swallow food sticks in my throat.”) (rs=0.699, p<0.001), and item 9 (“I cough when I eat.”) (rs=0.664, p<0.001) were strongly correlated with EAT-10 overall scores.

Discussion

Findings of this study include the prevalence of self-reported dysphagia and associations among self-reported dysphagia and various associated factors in community-dwelling older adults receiving meal support across five ENP sites in Wisconsin. Five factors were independently associated with self-reported dysphagia in this population: poor nutritional status, reduced chewing ability, prior dysphagia diagnosis, prior pneumonia diagnosis, and meal service site. These results partially supported our hypothesis that malnutrition and reduced ADL abilities would be associated with self-reported dysphagia.

Although slightly lower, the prevalence of self-reported dysphagia in our current study (20.4%) is similar to the reported prevalence of self-reported dysphagia in another study of 510 independently-living community-dwelling older adults without meal support (25.1%) (14). This is the only other study that included a self-reported dysphagia prevalence assessment through administration of the EAT-10 in this population. However, the study was conducted in Japan, and the results may not be comparable to the findings of the current study.

Among individuals identified with self-reported dysphagia using the EAT-10, more than half did not report a prior dysphagia diagnosis. Through a sub-analysis of participants with an EAT-10 score of ≥ 15, we found that 67% did not report a prior dysphagia diagnosis. These results suggest that community-dwelling older adults receiving meal support may not be aware of their swallowing issues or that dysphagia may not have been identified as a persistent concern by healthcare providers.

Consistent with the findings of a prior study (23), greater risk of poor nutrition was significantly associated with self-reported dysphagia in those receiving meal support. This is consistent with research findings that show a higher rate of malnutrition in specific patient populations vulnerable to dysphagia, such as those with stroke (42), motoric and/or cognitive decline (43), and neurological diseases (44). It may be that individuals with dysphagia have lower nutritional status due to reduced food and liquid intake6 and the type or variety of dietary intake (45, 46). Additionally, the current study did not test the causal relationship between self-reported dysphagia and factors associated with self-reported dysphagia. The directional nature of the relationship between lower nutritional status and self-reported dysphagia cannot be confirmed. It is plausible that poor nutrition may have contributed to sarcopenia or frailty of swallowing-related musculature which could negatively impact swallowing function in older individuals (47, 48).

Reduced chewing ability also was significantly associated with self-reported dysphagia. Impaired mastication, which is common in older individuals (49, 50) is likely to affect bolus formation as well as swallow initiation (42). The older adult population may be at increased risk for difficulties with mastication due to changes in the masticatory muscle density and mass with advancing age (51, 52), as well as issues with inadequate dentition or poor-fitting dentures (53, 54, 55). Reduced chewing ability is problematic in that it can place older adults at increased risk for asphyxiation, especially in combination with oropharyngeal dysphagia (56).

Report of a prior pneumonia diagnosis was also significantly associated with self-reported dysphagia in this population. This is consistent with results of prior studies reporting dysphagia to be an independent predictor of both aspiration and non-aspiration pneumonia in older adults (57). Repeated aspiration episodes that are likely to occur in individuals with dysphagia lead to this increased risk of respiratory infection (58). Pneumonia has serious effects on increased mortality and morbidity, and lower quality of life for older adults (59, 60, 61).

Additionally, meal service site was significantly associated with self-reported dysphagia. The prevalence of self-reported dysphagia was higher at one site (n=44 [45.4%]) compared to the other four sites (p=0.03). This site had a greater number of participants in the study overall. This program site only provides home-delivered meals to homebound individuals who are more likely to demonstrate diminished physical conditions (60.5% were identified as dependent with ADL tasks) which may explain this finding.

Contrary to our hypothesis, ADL disability was not associated with self-reported dysphagia. This result is not consistent with a previous study that found community-dwelling older adults who needed partial ADL assistance to be at higher risk of self-reported dysphagia (12). However, this prior study was conducted in South Korea, and employed a different dysphagia screen test (e.g., modified dysphagia risk assessment for the community-dwelling elderly) and ADL screening test (Korean Activities of Daily Living). Similar to the current study, a binary measure was employed for the ADL screening. However, different categories (independence and partial dependence) were used, and details regarding the ADL screening and categorization of scores were not reported. These differences in methods could partially explain the discrepancy between the results.

Consistent with the findings in the literature, younger age was associated with lower odds of self-reported dysphagia. In other words, younger participants were less likely to self-report dysphagia than older participants. This finding is supported by evidence that age-related decline in swallowing-related neural innervation, muscle structure and function, and physiologic reserve negatively impacts swallowing in older individuals (62). The prevalence of diseases that may cause dysphagia also increases with advancing age (47, 48, 63, 64). However, despite this finding from the multivariate regression, our descriptive analysis results indicated that participants with self-reported dysphagia were younger than those without self-reported dysphagia. A possible explanation for this discrepancy could be that younger participants in our cohort were homebound (84.2%) and, as a result, possibly prone to worse overall physical condition which could impact swallowing function.

Given these findings, we suggest integration of a swallow screening tool in the intake process for congregate and home delivered meal programs as well as into the clinical practice of providers who regularly assess and follow community-dwelling older adults. Implementation of a validated swallowing screening test, in combination with information about how to seek evaluation of swallowing function (e.g., through physician referral to speech-language pathology), would help federally-funded nutrition support programs facilitate more timely referral for swallowing evaluation and treatment in community-dwelling older adults receiving meal support. This could result in avoidance of negative health consequences of dysphagia. Additionally, if a ENP participant is found to have dysphagia, s/he may require a modified diet, which could affect their eligibility for the ENP depending upon whether such dietary adjustments are available. If the participant is unable to receive modified diets through the ENP, then education regarding food preparation as well as other community supports may need to be identified.

The EAT-10 item analysis revealed four items on this questionnaire that were strongly correlated with the total score (4, 5, 8, and 9). A recent study also reported that most participants in their study rated three of the same items as abnormal (4, 5, and 9) (65). Going forward, it will be important to further examine whether asking these 4 items alone will effectively identify risk of dysphagia in this community-dwelling older adult population.

Limitations of the study

Instrumental swallowing examinations (e.g., videofluoroscopic swallow studies or fiberoptic endoscopic evaluation of swallowing) were not employed to confirm the presence of dysphagia. Prior dysphagia diagnosis, pneumonia diagnosis, and hospitalization due to pneumonia were also determined only by self-report. An improved measure would entail retrieval of documented dysphagia diagnosis status through medical records or prospective data collection with incorporation of instrumental assessments. Cognitive screen test was not administered for the current study. Although the EAT-10 is a validated tool, a self-report questionnaire relies on the recall and cognitive ability of participants. Despite our efforts to obtain complete data for all participants, some participants did not complete questionnaire forms and thus were eliminated from our analysis. Although this was not studied, as with all questionnaires that require reading and writing, literacy may have influenced the response rate and/or accuracy. Lastly, data were collected from five ENP sites. The results of the current study may not represent the characteristics of the community-dwelling older adults receiving meal support across Wisconsin.

Conclusion

Approximately one in five community-dwelling older adults receiving meal support had self-reported dysphagia identified by the EAT-10. Self-reported dysphagia was associated with increased risk for poor nutrition, reduced chewing ability, prior dysphagia diagnosis, prior pneumonia diagnosis, and meal service site. Screening for dysphagia in the community-dwelling older adult population receiving meal support through implementation of a validated swallowing questionnaire may facilitate timely referral for swallowing evaluation and treatment, thus preventing negative health outcomes associated with dysphagia. Data collection should be expanded across more sites in Wisconsin to estimate the prevalence of self-reported dysphagia in community-dwelling older adults receiving meal support state-wide.

Acknowledgments

Financial Disclosure: This work was supported by National Institutes of Health (NIH) Grants 1K23AG057805-01A1 (awarded to N.R.P.) and T32DC009401 (supporting A.K.). Additionally, the study was supported by the Community-Academic Aging Research Network (CAARN) through funding from NIH Grant 1RC4AG038175-01, the UW-Madison School of Medicine and Public Health, the UW-Madison Office of the Vice Chancellor for Research and Graduate Education, and the UW-Madison Institute for Clinical and Translational Research through funding from NIH CTSA grant 1UL1TR002373 and UW-Madison SMPH Wisconsin Partnership Program grant 3086. The article was partially prepared at the William S. Middleton Veteran Affairs Hospital in Madison, WI; GRECC manuscript 002-2022.

Conflict of Interest

The authors have no conflicts of interest.

Sponsor's Role

The views and content expressed in this article are solely the responsibility of the authors and do not necessarily reflect the position, policy, or official views of the Department of Veteran Affairs, the U.S. government, or the NIH.

Author contributions

A.K. contributed substantially to the study design, data analysis, data interpretation, and drafting and revising the article and approved the final submitted version. F.O. contributed substantially to data abstraction, data analysis, data interpretation, revising the article, and approved the final submitted version. S.D. contributed substantially to the study design, data abstraction, data acquisition, and revising the article, and approved the final submitted version. A.T., S.M.M., P.V., and S.K. contributed substantially to the data acquisition, revising the article and approved the final submitted version. R.P.C. and M.C.contributed to revising the article and approved the final submitted version. J.M. and N.R.P. contributed substantially to the study design, data acquisition and interpretation, and revising the article and approved the final submitted version.

References

  • 1.Madhavan A, Lagorio LA, Crary MA, Dahl WJ, Carnaby GD. Prevalence of and risk factors for dysphagia in the community dwelling elderly: A systematic review. J Nutr Health Aging. 2016;20(8):806–815. doi: 10.1007/s12603-016-0712-3. 10.1007/s12603-016-0712-3 PubMed PMID: 27709229. [DOI] [PubMed] [Google Scholar]
  • 2.Barczi S R, Sullivan P A, Robbins J. How should dysphagia care of older adults differ? Establishing optimal practice patterns. Semin Speech Lang. 2000;21(4):347–361. doi: 10.1055/s-2000-8387. 10.1055/s-2000-8387 PubMed PMID: 11085258. [DOI] [PubMed] [Google Scholar]
  • 3.Roy N, Stemple J, Merrill RM, Thomas L. Dysphagia in the Elderly: Preliminary Evidence of Prevalence, Risk Factors, and Socioemotional Effects. Ann Otol Rhinol Laryngol. 2007;116(11):858–865. doi: 10.1177/000348940711601112. 10.1177/000348940711601112 PubMed PMID: 18074673. [DOI] [PubMed] [Google Scholar]
  • 4.Wirth R, Dziewas R, Beck AM, et al. Oropharyngeal dysphagia in older persons - from pathophysiology to adequate intervention: A review and summary of an international expert meeting. Clin Interv Aging. 2016;11:189–208. doi: 10.2147/CIA.S97481. 10.2147/CIA.S97481 PubMed PMID: 26966356, PMCID 4770066. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Logemann J. Evaluation and Treatment of Swallowing Disorders. 2nd ed. PRO-ED; 1998.
  • 6.Sura L, Madhavan A, Carnaby-Mann G, Crary M. Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging. Published online 2012:287. doi: 10.2147/cia.s23404. [DOI] [PMC free article] [PubMed]
  • 7.Namasivayam AM, Steele CM. Malnutrition and Dysphagia in Long-Term Care: A Systematic Review. J Nutr Gerontol Geriatr. 2015;34(1):1–21. doi: 10.1080/21551197.2014.1002656. 10.1080/21551197.2014.1002656 PubMed PMID: 25803601. [DOI] [PubMed] [Google Scholar]
  • 8.Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest. 2003;124(1):328–336. doi: 10.1378/chest.124.1.328. 10.1378/chest.124.1.328 PubMed PMID: 12853541. [DOI] [PubMed] [Google Scholar]
  • 9.Patel DA, Krishnaswami S, Steger E, et al. Economic and survival burden of dysphagia among inpatients in the United States. Dis Esophagus. 2018;31(1):1–7. doi: 10.1093/dote/dox131. 10.1093/dote/dox131 PubMed PMID: 29155982. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Attrill S, White S, Murray J, Hammond S, Doeltgen S. Impact of oropharyngeal dysphagia on healthcare cost and length of stay in hospital: A systematic review. BMC Health Serv Res. 2018;18(1) doi: 10.1186/s12913-018-3376-3. 10.1186/s12913-018-3376-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.United Nations, Department of Economic and Social Affairs PD. World Population Ageing 2017.; 2017. http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2017_Highlights.pdf.
  • 12.Byeon H. Analysis of dysphagia risk using the modified dysphagia risk assessment for the community-dwelling elderly. J Phys Ther Sci. Published online 2016. doi: 10.1589/jpts.28.2507. [DOI] [PMC free article] [PubMed]
  • 13.González-Fernández M, Humbert I, Winegrad H, Cappola AR, Fried LP. Dysphagia in Old-Old Women: Prevalence as Determined According to Self-Report and the 3-Ounce Water Swallowing Test. J Am Geriatr Soc. 2014;62(4):716–720. doi: 10.1111/jgs.12745. 10.1111/jgs.12745 PubMed PMID: 24635053, PMCID 4609899. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Igarashi K, Kikutani T, Tamura F. Survey of suspected dysphagia prevalence in home-dwelling older people using the 10-Item Eating Assessment Tool (EAT-10) PLoS One. 2019;14(1) doi: 10.1371/journal.pone.0211040. 10.1371/journal.pone.0211040 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Nimmons D, Michou E, Jones M, Pendleton N, Horan M, Hamdy S. A Longitudinal Study of Symptoms of Oropharyngeal Dysphagia in an Elderly Community-Dwelling Population. Dysphagia. 2016;31(4):560–566. doi: 10.1007/s00455-016-9715-9. 10.1007/s00455-016-9715-9 PubMed PMID: 27307155, PMCID 4938845. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Serra-Prat M, Hinojosa G, Lõpez D, et al. Prevalence of oropharyngeal dysphagia and impaired safety and efficacy of swallow in independently living older persons. J Am Geriatr Soc. Published online 2011. doi: 10.1111/j.1532-5415.2010.03227.x. [DOI] [PubMed]
  • 17.Whang SA. Prevalence and influencing factors of dysphagia risk in the community-dwelling elderly. J Kor Gerontol Soc. 2014;34:37–48. [Google Scholar]
  • 18.Ohkuma R, Fujishima I, Kojima C, Hojo K, Takehara I MY. Developlnent of a questionnaire to screen dysphagia. Jpn J Dysphagia Rehabil. 2002;6:3–8. [Google Scholar]
  • 19.Chen AY, Frankowshi R, Bishop-Leone J, et al. The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: The M. D. Anderson Dysphagia Inventory. Arch Otolaryngol - Head Neck Surg. 2001;127(7):870–876. PubMed PMID: 11448365. [PubMed] [Google Scholar]
  • 20.Belafsky PC, Pryor JC, Allen J, et al. Validity and Reliability of the Eating Assessment Tool (EAT-10) Ann Otol Rhinol Laryngol. 2014;117(12):919–924. doi: 10.1177/000348940811701210. 10.1177/000348940811701210 [DOI] [PubMed] [Google Scholar]
  • 21.Dwivedi RC, Rose SS, Roe JWG, et al. Validation of the Sydney Swallow Questionnaire (SSQ) in a cohort of head and neck cancer patients. Oral Oncol. 2010;46(4):e10–e14. doi: 10.1016/j.oraloncology.2010.02.004. 10.1016/j.oraloncology.2010.02.004 PubMed PMID: 20219415. [DOI] [PubMed] [Google Scholar]
  • 22.Leow LP, Huckabee ML, Anderson T, Beckert L. The impact of dysphagia on quality of life in ageing and parkinson’s disease as measured by the Swallowing Quality of Life (SWAL-QOL) questionnaire. Dysphagia. 2010;25(3):216–220. doi: 10.1007/s00455-009-9245-9. 10.1007/s00455-009-9245-9 PubMed PMID: 19680723. [DOI] [PubMed] [Google Scholar]
  • 23.Takeuchi K, Aida J, Ito M, Furuta M, Yamashita Y, Osaka K. Community-Dwelling Frail Older Adults. J Nutr Health Aging. 2014;18(4):1–6. doi: 10.1007/s12603-014-0025-3. 10.1007/s12603-014-0025-3 [DOI] [PubMed] [Google Scholar]
  • 24.Lloyd J WN. Older Americans Act Nutrition Programs: A Community-Based Nutrition Program Helping Older Adults Remain at Home. J Nutr Gerontol Geriatr. 2015;34(2):90–109. doi: 10.1080/21551197.2015.1031592. 10.1080/21551197.2015.1031592 PubMed PMID: 26106983. [DOI] [PubMed] [Google Scholar]
  • 25.Campbell AD, Godfryd A, Buys DR, Locher JL. Does Participation in Home-Delivered Meals Programs Improve Outcomes for Older Adults? Results of a Systematic Review. J Nutr Gerontol Geriatr. Published online 2015. doi: 10.1080/21551197.2015.1038463. [DOI] [PMC free article] [PubMed]
  • 26.Cantor MH, MacMillan T, Frongillo EA, et al. Who Are the Recipients of Meals-on-Wheels in New York City? A Profile of Based on a Representative Sample of Meals-on-Wheels Recipients, Part II. Care Manag Journals. Published online 2010. doi: 10.1891/1521-0987.11.2.129. [DOI] [PMC free article] [PubMed]
  • 27.Cederholm T, Saletti A, Wissing U, Johansson L, Österberg K, Yifter-Lindgren E. Nutritional Status and a 3-Year Follow-Up in Elderly Receiving Support at Home. Gerontology. Published online 2005. doi: 10.1159/000083993. [DOI] [PubMed]
  • 28.Cho J, Thorud JL, Marishak-Simon S, Hammack L, Stevens AB. Frequency of Hospital Use Before and After Home-Delivery Meal by Meals On Wheels, of Tarrant County, Texas. J Nutr Heal Aging. Published online 2018. doi: 10.1007/s12603-017-0973-5. [DOI] [PubMed]
  • 29.Dosa DM, Gadbois EA, Thomas KS, Morris AM, Akobundu U, Shield RR. “It’s Not Just a Simple Meal. It’s So Much More”: Interactions Between Meals on Wheels Clients and Drivers. J Appl Gerontol. Published online 2018. doi: 10.1177/0733464818820226. [DOI] [PMC free article] [PubMed]
  • 30.Frongillo EA, Isaacman TD, Horan CM, Wethington E, Pillemer K. Adequacy of and satisfaction with delivery and use of home-delivered meals. J Nutr Elder. Published online 2010. doi: 10.1080/01639361003772525. [DOI] [PMC free article] [PubMed]
  • 31.Gualtieri MC, Donley AM, Wright JD, Strickhouser Vega S. Home Delivered Meals to Older Adults:A critical reviwe of the literature. Home Heal now. 2018;36(3):159–168. doi: 10.1097/NHH.0000000000000665. 10.1097/NHH.0000000000000665 [DOI] [PubMed] [Google Scholar]
  • 32.Keller HH. Meal Programs Improve Nutritional Risk: A Longitudinal Analysis of Community-Living Seniors. J Am Diet Assoc. Published online 2006. doi: 10.1016/j.jada.2006.04.023. [DOI] [PubMed]
  • 33.Ogarek JA, Dosa D, Kler S, et al. A New Data Resource to Examine Meals on Wheels Clients’ Health Care Utilization and Costs. Med Care. Published online 2018. doi: 10.1097/mlr.0000000000000951. [DOI] [PMC free article] [PubMed]
  • 34.Zhu H, An R. Impact of home-delivered meal programs on diet and nutrition among older adults: A review. Nutr Health. Published online 2013. doi: 10.1177/0260106014537146. [DOI] [PubMed]
  • 35.Vailas LI, Nitzke SA, Becker M, Gast J. Risk indicators for malnutrition are associated inversely with quality of life for participants in meal programs for older adults. J Am Diet Assoc. 1998;98(5):548–553. doi: 10.1016/S0002-8223(98)00123-0. 10.1016/S0002-8223(98)00123-0 PubMed PMID: 9597027. [DOI] [PubMed] [Google Scholar]
  • 36.Hutchins-Wiese H WS. Frailty and Nutrition Risk Screening in Home-Delivered Meal Clients. J Nutr Gerontol Geriatr. 2020;39(2):114–130. doi: 10.1080/21551197.2020.1719258. 10.1080/21551197.2020.1719258 PubMed PMID: 32009572. [DOI] [PubMed] [Google Scholar]
  • 37.Cheney DM, Tausif Siddiqui M, Litts JK, Kuhn MA, Belafsky PC. The ability of the 10-item eating assessment tool (EAT-10) to predict aspiration risk in persons with dysphagia. Ann Otol Rhinol Laryngol. 2015;124(5):351–354. doi: 10.1177/0003489414558107. 10.1177/0003489414558107 PubMed PMID: 25358607. [DOI] [PubMed] [Google Scholar]
  • 38.MacLellan DL, Van Til LD. Screening for nutritional risk among community-dwelling elderly on Prince Edward Island. Can J Public Heal. 1998;89(5):342–346. doi: 10.1007/BF03404488. 10.1007/BF03404488 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Wiener JM, Hanley RJ, Clark R, Van Nostrand JF. Measuring the activities of daily living: Comparisons across national surveys. Journals Gerontol. 1990;45(6):229–237. doi: 10.1093/geronj/45.6.s229. [DOI] [PubMed] [Google Scholar]
  • 40.Gabrel CS. Characteristics of elderly nursing home current residents and discharges: data from the 1997 National Nursing Home Survey. Adv Data. 2000;(312):1–15. [PubMed]
  • 41.Szumilas M. Explaining odds ratios. J Can Acad Child Adolesc Psychiatry. 2010;19(3):227–229. PubMed PMID: 20842279, PMCID 2938757. [PMC free article] [PubMed] [Google Scholar]
  • 42.Saito T, Hayashi K, Nakazawa H, Yagihashi F, Oikawa LO, Ota T. A Significant Association of Malnutrition with Dysphagia in Acute Patients. Dysphagia. 2018;33(2):258–265. doi: 10.1007/s00455-017-9855-6. 10.1007/s00455-017-9855-6 PubMed PMID: 29022113. [DOI] [PubMed] [Google Scholar]
  • 43.Tagliaferri S, Lauretani F, Pelá G, Meschi T, Maggio M. The risk of dysphagia is associated with malnutrition and poor functional outcomes in a large population of outpatient older individuals. Clin Nutr. 2019;38(6):2684–2689. doi: 10.1016/j.clnu.2018.11.022. 10.1016/j.clnu.2018.11.022 PubMed PMID: 30583964. [DOI] [PubMed] [Google Scholar]
  • 44.Carrión S, Arreola V, Ortega O, et al. Nutritional status of older patients with oropharyngeal dysphagia in a chronic versus an acute clinical situation. Clin Nutr. 2017;36(4):1110–1116. doi: 10.1016/j.clnu.2016.07.009. 10.1016/j.clnu.2016.07.009 PubMed PMID: 27499393. [DOI] [PubMed] [Google Scholar]
  • 45.O’Keeffe ST. Use of modified diets to prevent aspiration in oropharyngeal dysphagia: Is current practice justified? BMC Geriatr. 2018;18(1):1–10. doi: 10.1186/s12877-018-0839-7. 10.1186/s12877-018-0839-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Keller H, Chambers H, Niezgoda H, Duizer L. Issues associated with the use of modified texture foods. J Nutr Heal Aging. 2012;16(3):195–200. doi: 10.1007/s12603-011-0160-z. 10.1007/s12603-011-0160-z [DOI] [PubMed] [Google Scholar]
  • 47.Ney DM, Weiss JM, Kind AJH, Robbins J. Senescent swallowing: Impact, strategies, and interventions. Nutr Clin Pract. 2009;24(3):395–413. doi: 10.1177/0884533609332005. 10.1177/0884533609332005 PubMed PMID: 19483069, PMCID 2832792. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Nawaz S, Tulunay-Ugur OE. Dysphagia in the Older Patient. Otolaryngol Clin North Am. 2018;51(4):769–777. doi: 10.1016/j.otc.2018.03.006. 10.1016/j.otc.2018.03.006 PubMed PMID: 29779617. [DOI] [PubMed] [Google Scholar]
  • 49.Mann T, Heuberger R, Wong H. The association between chewing and swallowing difficulties and nutritional status in older adults. Aust Dent J. 2013;58(2):200–206. doi: 10.1111/adj.12064. 10.1111/adj.12064 PubMed PMID: 23713640. [DOI] [PubMed] [Google Scholar]
  • 50.Peyron MA, Woda A, Bourdiol P, Hennequin M. Age-related changes in mastication. J Oral Rehabil. 2017;44(4):299–312. doi: 10.1111/joor.12478. 10.1111/joor.12478 PubMed PMID: 28029687. [DOI] [PubMed] [Google Scholar]
  • 51.Newton JP, Yemm R, Abel RW, Menhinick S. Changes in human jaw muscles with age and dental state. Gerodontology. 1993;10(1):16–22. doi: 10.1111/j.1741-2358.1993.tb00074.x. 10.1111/j.1741-2358.1993.tb00074.x PubMed PMID: 8300113. [DOI] [PubMed] [Google Scholar]
  • 52.Watanabe Y, Hirano H, Arai H, et al. Relationship Between Frailty and Oral Function in Community-Dwelling Elderly Adults. J Am Geriatr Soc. 2017;65(1):66–76. doi: 10.1111/jgs.14355. 10.1111/jgs.14355 PubMed PMID: 27655106. [DOI] [PubMed] [Google Scholar]
  • 53.Furuya J, Tamada Y, Sato T, et al. Wearing complete dentures is associated with changes in the three-dimensional shape of the oropharynx in edentulous older people that affect swallowing. Gerodontology. 2016;33(4):513–521. doi: 10.1111/ger.12197. 10.1111/ger.12197 PubMed PMID: 25939853. [DOI] [PubMed] [Google Scholar]
  • 54.Onodera S, Furuya J, Yamamoto H, Tamada Y, Kondo H. Effects of wearing and removing dentures on oropharyngeal motility during swallowing. J Oral Rehabil. 2016;43(11):847–854. doi: 10.1111/joor.12437. 10.1111/joor.12437 PubMed PMID: 27611827. [DOI] [PubMed] [Google Scholar]
  • 55.Singh KA, Brennan DS. Chewing disability in older adults attributable to tooth loss and other oral conditions. Gerodontology. 2012;29(2):106–110. doi: 10.1111/j.1741-2358.2010.00412.x. 10.1111/j.1741-2358.2010.00412.x PubMed PMID: 22356168. [DOI] [PubMed] [Google Scholar]
  • 56.Kramarow E, Warner M, Chen LH. Food-related choking deaths among the elderly. Inj Prev. 2014;20(3):200–203. doi: 10.1136/injuryprev-2013-040795. 10.1136/injuryprev-2013-040795 PubMed PMID: 24003082. [DOI] [PubMed] [Google Scholar]
  • 57.Almirall J, Rofes L, Serra-Prat M, et al. Oropharyngeal dysphagia is a risk factor for community-acquired pneumonia in the elderly. Eur Respir J. 2013;41(4):923–926. doi: 10.1183/09031936.00019012. 10.1183/09031936.00019012 PubMed PMID: 22835620. [DOI] [PubMed] [Google Scholar]
  • 58.DiBardino DM, Wunderink RG. Aspiration pneumonia: A review of modern trends. J Crit Care. 2015;30(1):40–48. doi: 10.1016/j.jcrc.2014.07.011. 10.1016/j.jcrc.2014.07.011 PubMed PMID: 25129577. [DOI] [PubMed] [Google Scholar]
  • 59.Mangen MJJ, Huijts SM, Bonten MJM, de Wit GA. The impact of community-acquired pneumonia on the health-related quality-of-life in elderly. BMC Infect Dis. 2017;17(1):1–9. doi: 10.1186/s12879-017-2302-3. 10.1186/s12879-017-2302-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 60.Lanspa MJ, Jones BE, Brown SM, Dean NC. Mortality, morbidity, and disease severity of patients with aspiration pneumonia. J Hosp Med. 2013;8(2):83–90. doi: 10.1002/jhm.1996. 10.1002/jhm.1996 PubMed PMID: 23184866. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Welte T, Torres A, Nathwani D. Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax. 2012;67(1):71–79. doi: 10.1136/thx.2009.129502. 10.1136/thx.2009.129502 PubMed PMID: 20729232. [DOI] [PubMed] [Google Scholar]
  • 62.Robbins J, Hamilton JW, Lof GL, Kempster GB. Oropharyngeal swallowing in normal adults of different ages. Gastroenterology. 1992;103(3):823–829. doi: 10.1016/0016-5085(92)90013-o. 10.1016/0016-5085(92)90013-O PubMed PMID: 1499933. [DOI] [PubMed] [Google Scholar]
  • 63.Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: Management and nutritional considerations. Clin Interv Aging. 2012;7:287–298. doi: 10.2147/CIA.S23404. PubMed PMID: 22956864, PMCID 3426263. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 64.Namasivayam-Macdonald AM, Riquelme LF. Presbyphagia to dysphagia: Multiple perspectives and strategies for quality care of older adults. Semin Speech Lang. 2019;40(3):227–242. doi: 10.1055/s-0039-1688837. 10.1055/s-0039-1688837 PubMed PMID: 31158906. [DOI] [PubMed] [Google Scholar]
  • 65.Molfenter SM, Lazarus C, Herzberg E, Noorani M, Brates D. The Swallowing Profile of Healthy Aging Adults: Comparing Noninvasive Swallow Tests to Videofluoroscopic Measures of Safety and Efficiency. J Speech, Lang Hear Res. Published online 2018. doi: 10.1044/2018Jslhr-s-17-0471. [DOI] [PMC free article] [PubMed]

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