The journal of nutrition, health & aging

, Volume 22, Issue 6, pp 739–747 | Cite as

Effect of a Minimal-Massive Intervention in Hospitalized Older Patients with Oropharyngeal Dysphagia: A Proof of Concept Study

  • A. Martín
  • O. Ortega
  • M. Roca
  • M. Arús
  • Pere Clavé Civit



Oropharyngeal dysphagia (OD) is a newly defined geriatric syndrome that causes nutritional and respiratory complications in older hospitalized patients. Following hospital discharge, OD also causes hospital readmission and mortality in this population.


Our aim was to assess the effect of a minimal-massive intervention (MMI) in reducing nutritional and respiratory complications in older hospitalized patients with OD.

Design and participants

An open label trial was performed on 186 hospitalized older patients (>70y) with OD; 62 of these patients with OD were treated with the MMI and paired by sex, age, functionality, comorbidities and body mass index with two controls.


The MMI consisted of: a) fluid thickening and texture-modified foods, b) caloric and protein supplementation; and c) oral health and hygiene recommendations during hospitalization and following discharge. The control group followed the standard clinical practice without MMI.


Main study outcomes were hospital readmissions, respiratory infections, nutritional status and survival after 6 months follow up.


Both groups had similar advanced age (84.87±6.02MMI and 84.42±5.31 years), poor functionality (Barthel 59.51±26.76 MMI and 58.84±26.87), and high comorbidities (Charlson 3.00±1.60 MMI and 3.06±1.45). Main results showed that MMI improved nutritional status (MNA 9.84±2.05 pre-MMI vs. 11.31±2.21 post-MMI; p=0.0038) and functionality (Barthel 62.34±25.43 pre-MMI vs. 73.44±25.19 post-MMI; p=0.007). In addition MMI decreased hospital readmissions (68.8 readmissions/100 persons-year (28.1–109.38) MMI vs. 190.8 (156.0–225.7); p=0.001), respiratory infections (12.50 readmissions/100 persons-year (0–29.82) MMI vs. 74.68 (52.86–96.50); p=0.002), and increased 6-month survival (84.13% MMI vs. 70.96%; p=0.044).


Our results suggest that a MMI in hospitalized older patients with OD improves nutritional status and functionality and reduces hospital readmissions, respiratory infections and mortality. MMI might become a new simple and cost-effective strategy to avoid OD complications in the geriatric population admitted with an acute disease to a general hospital.

Key words

Swallowing disorders deglutition aged geriatrics and oral hygiene 


  1. 1.
    World Health Organization. International Classification of Diseases (ICD). Geneva; 2010.Google Scholar
  2. 2.
    Altman KW, Yu G-P, Schaefer SD. Consequence of Dysphagia in the Hospitalized Patient. Arch Otolaryngol Neck Surg. 2010;136(8):784.CrossRefGoogle Scholar
  3. 3.
    Cabré M, Serra-Prat M, Force L, et al. Oropharyngeal dysphagia is a risk factor for readmission for pneumonia in the very elderly persons: Observational prospective study. Journals Gerontol - Ser A Biol Sci Med Sci. 2014;69A(3):330–337.CrossRefGoogle Scholar
  4. 4.
    Cabre M, Serra-Prat M, Palomera E, et al. Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing. 2010;39(1):39–45.CrossRefPubMedGoogle Scholar
  5. 5.
    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.CrossRefPubMedGoogle Scholar
  6. 6.
    Baijens L, Clave P, Cras P, et al. European Society for Swallowing Disorders -European Union Geriatric Medicine Society white Paper: Oropharyngeal Dysphagia as a Geriatric Syndrome. Clin Interv Aging. 2016;11:1–16.CrossRefGoogle Scholar
  7. 7.
    Carrión S, Cabré M, Monteis R, et al. Oropharyngeal dysphagia is a prevalent risk factor for malnutrition in a cohort of older patients admitted with an acute disease to a general hospital. Clin Nutr. 2015;34(3):436–442.CrossRefPubMedGoogle Scholar
  8. 8.
    Rofes L, Arreola V, Almirall J, et al. Diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly. Gastroenterol Res Pract. 2011;2011. pii: 818979.CrossRefPubMedGoogle Scholar
  9. 9.
    Clavé P, Shaker R. Dysphagia: current reality and scope of the problem. Nat Rev Gastroenterol Hepatol Adv online Publ. 2015;12(5):259–70.CrossRefGoogle Scholar
  10. 10.
    Cook IJ, Kahrilas PJ, Bloem B, et al. AGA technical review on management of oropharyngeal dysphagia. Gastroenterology. 1999;116(2):455–478.CrossRefPubMedGoogle Scholar
  11. 11.
    Clavé P, Terré R, de Kraa M, et al. Approaching oropharyngeal dysphagia. Rev Esp enfermedades Dig. 2004; 96(2):119–131.Google Scholar
  12. 12.
    Serra-Prat M, Palomera M, Gomez C, et al. Oropharyngeal dysphagia as a risk factor for malnutrition and lower respiratory tract infection in independently living older persons: A population-based prospective study. Age Ageing. 2012;41(3):376–381.CrossRefPubMedGoogle Scholar
  13. 13.
    Rofes L, Arreola V, Romea M, et al. Pathophysiology of oropharyngeal dysphagia in the frail elderly. Neurogastroenterol Motil. 2010;22(8):1–9.CrossRefGoogle Scholar
  14. 14.
    Ortega O, Martín A, Clavé P. Diagnosis and Management of Oropharyngeal Dysphagia Among Older Persons, State of the Art. J Am Med Dir Assoc. 2017;18(7):576–582.CrossRefPubMedGoogle Scholar
  15. 15.
    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. 2011;59(1):186–187.CrossRefPubMedGoogle Scholar
  16. 16.
    Suominen M, Muurinen S, Routasalo P, et al. Malnutrition and associated factors among aged residents in all nursing homes in Helsinki. Eur J Clin Nutr. 2005;59(4):578–583.CrossRefPubMedGoogle Scholar
  17. 17.
    Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest. 2003;124(1):328–336.CrossRefPubMedGoogle Scholar
  18. 18.
    Japanese T, Society R. Aspiration pneumonia. Respirology. 2004;9 Suppl 1:S35–7.Google Scholar
  19. 19.
    Ortega O, Cabre M, Clave P. Oropharyngeal dysphagia: Aetiology and effects of ageing. J Gastroenterol Hepatol Res. 2014;3(5):1049–1054.Google Scholar
  20. 20.
    Ortega O, Sakwinska O, Combremont S, et al. High prevalence of colonization of oral cavity by respiratory pathogens in frail older patients with oropharyngeal dysphagia. Neurogastroenterol Motil. 2015;27(12):1804–1816.CrossRefPubMedGoogle Scholar
  21. 21.
    Ortega O, Martin A, Clave P. Diagnosis and Management of Oropharyngeal Dysphagia Among Older Persons, State of the Art. J Am Med Dir Assoc. 2017; 18(7):576–582.CrossRefPubMedGoogle Scholar
  22. 22.
    Ortega O, Clavé P. Oral Hygiene, Aspiration, and Aspiration Pneumonia: From Pathophysiology to Therapeutic Strategies. Curr Phys Med Rehabil Reports. 2013;1(4):292–295.CrossRefGoogle Scholar
  23. 23.
    Yoneyama T, Yoshida M, Ohrui T, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc. 2002;50(3):430–433.CrossRefPubMedGoogle Scholar
  24. 24.
    Yoneyama T, Yoshida M, Matsui T, et al. Oral care and pneumonia. Oral Care Working Group. Lancet (London, England). 1999;354(9177):515.CrossRefGoogle Scholar
  25. 25.
    Tada A, Hanada N. Opportunistic respiratory pathogens in the oral cavity of the elderly. FEMS Immunol Med Microbiol. 2010;60(1):1–17.CrossRefPubMedGoogle Scholar
  26. 26.
    Tada A, Miura H. Prevention of aspiration pneumonia (AP) with oral care. Arch Gerontol Geriatr. 2012;55(1):16–21.CrossRefPubMedGoogle Scholar
  27. 27.
    Sorensen RT, Rasmussen RS, Overgaard K, et al. Dysphagia screening and intensified oral hygiene reduce pneumonia after stroke. J Neurosci Nurs. 2013;45(3):139–146.CrossRefPubMedGoogle Scholar
  28. 28.
    Zuckerman LM. Oral Chlorhexidine Use to Prevent Ventilator-Associated Pneumonia in Adults. Dimens Crit Care Nurs. 2016;35(1):25–36.CrossRefPubMedGoogle Scholar
  29. 29.
    Scannapieco FA, Yu J, Raghavendran K, et al. A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Crit Care. 2009;13(4):R117.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Seedat J, Penn C. Implementing oral care to reduce aspiration pneumonia amongst patients with dysphagia in a South African setting. South African J Commun Disord. 2016;63(1):1–11.CrossRefGoogle Scholar
  31. 31.
    Sjögren P, Nilsson E, Forsell M, et al. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: Effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc. 2008;56(11):2124–2130.CrossRefPubMedGoogle Scholar
  32. 32.
    Newman R, Vilardell N, Clavé P, et al. Effect of Bolus Viscosity on the Safety and Efficacy of Swallowing and the Kinematics of the Swallow Response in Patients with Oropharyngeal Dysphagia: White Paper by the European Society for Swallowing Disorders (ESSD). Dysphagia. 2016;31(5):719.CrossRefPubMedGoogle Scholar
  33. 33.
    Carrión S, Roca M, Costa A, 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.CrossRefPubMedGoogle Scholar
  34. 34.
    Clavé P, Arreola V, Romea M, et al. Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration. Clin Nutr. 2008;27(6):806–815.CrossRefPubMedGoogle Scholar
  35. 35.
    Reisberg B, Ferris SH, de Leon MJ, et al. The Global Deterioration Scale for assessment of primary degenerative dementia. Am J Psychiatry. 1982;139(9):1136–1139.CrossRefPubMedGoogle Scholar
  36. 36.
    Mahoney FI, Barthel DW. Functional evaluation: The Barthel index. Md State Med J. 1965;14:56–61.Google Scholar
  37. 37.
    Walter LC, Brand RJ, Counsell SR, et al. Development and validation of a prognostic index for 1-year mortality in older adults after hospitalization. Jama. 2001;285(23):2987–2994.CrossRefPubMedGoogle Scholar
  38. 38.
    Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–383.CrossRefPubMedGoogle Scholar
  39. 39.
    Fried L, Tangen C, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol. 2001;56A(3):M146–M156.CrossRefGoogle Scholar
  40. 40.
    Ortega O, Rofes L, Martin A, et al. A Comparative Study Between Two Sensory Stimulation Strategies After Two Weeks Treatment on Older Patients with Oropharyngeal Dysphagia. Dysphagia. 2016;31(5):706–716.CrossRefPubMedGoogle Scholar
  41. 41.
    Kaiser MJ, Bauer JM, Ramsch C, et al. Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging. 2009;13(9):782–788.CrossRefPubMedGoogle Scholar
  42. 42.
    Greene JC, Vermillion JR. The symplified oral hygiene index. J Am Dent Assoc. 1964;68:7–13.CrossRefPubMedGoogle Scholar
  43. 43.
    Ortega O, Parra C, Zarcero S, et al. Oral health in older patients with oropharyngeal dysphagia. Age Ageing. 2014;43(1):132–137.CrossRefPubMedGoogle Scholar
  44. 44.
    The British Dietetic Association and the Royal College of Speech and Language Therapists. National Dysphagia Diet: Standardization for Optimal Care.; 2011.Google Scholar
  45. 45.
    Carrion S. Doctoral Thesis. Fisiopatología de las complicaciones nutricionales asociadas a la disfagia orofaríngea en la población anciana. Universitat Autònoma de Barcelona. 2017. Scholar
  46. 46.
    Bass C. An effective method of personal oral hygiene. J La State Med Soc. 1954;106(2):57–73; contd.PubMedGoogle Scholar
  47. 47.
    Bass C. An effective method of personal oral hygiene; part II. J La State Med Soc. 1954;106(3):100–112.PubMedGoogle Scholar
  48. 48.
    Awano S, Ansai T, Takata Y, et al. Oral health and mortality risk from pneumonia in the elderly. J Dent Res. 2008;87(4):334–339.CrossRefPubMedGoogle Scholar
  49. 49.
    Terpenning MS, Taylor GW, Lopatin DE, et al. Aspiration pneumonia: Dental and oral risk factors in an older veteran population. J Am Geriatr Soc. 2001;49(5):557–563.CrossRefPubMedGoogle Scholar
  50. 50.
    Gomes-Filho IS, Passos JS, Da Cruz SS. Respiratory disease and the role of oral bacteria. J Oral Microbiol. 2010;2(2010):1–6.Google Scholar
  51. 51.
    Swan K, Speyer R, Heijnen BJ, Wagg B, Cordier R. Living with oropharyngeal dysphagia: effects of bolus modification on health-related quality of life—a systematic review. Qual Life Res. 2015;24(10):2447–2456.CrossRefPubMedGoogle Scholar
  52. 52.
    Gillman A, Winkler R, Taylor NF. Implementing the Free Water Protocol does not Result in Aspiration Pneumonia in Carefully Selected Patients with Dysphagia: A Systematic Review. Dysphagia. 2017;32(3):345–361.CrossRefPubMedGoogle Scholar
  53. 53.
    Rosenvinge SK, Starke ID. Improving care for patients with dysphagia. Age Ageing. 2005;34(6):587–593.CrossRefPubMedGoogle Scholar
  54. 54.
    Shim JS, Oh BM, Han TR. Factors associated with compliance with viscositymodified diet among dysphagic patients. Ann Rehabil Med. 2013;37(5):628–632.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Beck AM, Kjaersgaard A, Hansen T, et al. Systematic review and evidence based recommendations on texture modified foods and thickened liquids for adults (above 17 years) with oropharyngeal dysphagia–An updated clinical guideline. Clin Nutr. 2017; pii: S0261-5614(17)30317-5.Google Scholar
  56. 56.
    Rofes L, Arreola V, Mukherjee R, et al. The effects of a xanthan gum-based thickener on the swallowing function of patients with dysphagia. Aliment Pharmacol Ther. 2014;39(10):1169–1179.CrossRefPubMedGoogle Scholar
  57. 57.
    Vilardell N, Rofes L, Arreola V, et al. A Comparative Study Between Modified Starch and Xanthan Gum Thickeners in Post-Stroke Oropharyngeal Dysphagia. Dysphagia. 2016;31(2):169–179.CrossRefPubMedGoogle Scholar
  58. 58.
    Carrión S, Verin E, Clavé P, et al. Complications of Oropharyngeal Dysphagia: Malnutrition and Aspiration Pneumonia. In: Ekberg O, ed. Dysphagia Diagnosis and Treatment. Berlin: Springer; 2012:575–599.Google Scholar
  59. 59.
    Norman K, Pichard C, Lochs H, et al. Prognostic impact of disease-related malnutrition. Clin Nutr. 2008;27(1):5–15.CrossRefPubMedGoogle Scholar
  60. 60.
    Lang NP, Cumming BR, Löe H. Toothbrushing frequency as it relates to plaque development and gingival health. J Periodontol. 1973;44(7):396–405.CrossRefPubMedGoogle Scholar
  61. 61.
    Yellowitz JA, Schneiderman MT. Elder’s oral health crisis. J Evid Based Dent Pract. 2014;14 Suppl:191–200.CrossRefPubMedGoogle Scholar

Copyright information

© Serdi and Springer-Verlag France SAS, part of Springer Nature 2018

Authors and Affiliations

  • A. Martín
    • 1
  • O. Ortega
    • 1
    • 2
  • M. Roca
    • 3
  • M. Arús
    • 3
  • Pere Clavé Civit
    • 1
    • 2
    • 4
    • 5
  1. 1.GI Physiology Laboratory, CIBERehd CSdM-UABHospital de MataróBarcelonaSpain
  2. 2.Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)Instituto de Salud Carlos IIIBarcelonaSpain
  3. 3.Department of Dietetics and NutritionHospital de MataróBarcelonaSpain
  4. 4.Fundació Institut de Investigació Germans Trias i PujolBadalonaSpain
  5. 5.Universitat Autònoma de BarcelonaBarcelonaSpain

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