Efficacy of a Comprehensive Dysphagia Intervention Program Tailored for the Residents of Nursing Homes

Abstract

Oropharyngeal dysphagia is a widespread condition in older people and thus poses a serious health threat to the residents of nursing homes. The management of dysphagia relies mainly on compensatory strategies, such as diet and environmental modification. This study investigated the efficacy of an intervention program using a single-arm interventional study design. Twenty-two participants from nursing homes were included and had an average of 26 hours of intervention, including oromotor exercises, orosensory stimulation and exercises to target dysphagia and caregiver training. Four of the 22 participants exhibited improvement in functional oral intake scale (FOIS) but was not statistically significant as a group. All oromotor function parameters, including the range, strength, and coordination of movements, significantly improved. These results indicate that this intervention program could potentially improve the oromotor function, which were translated into functional improvements in some participants' recommended diets. The validity of this study could be improved further by using standardized swallowing and feeding assessment methods or an instrumental swallowing assessment.

Full text

1
Received March 25, 2020
Accepted for publication July 10, 2020
BRIEF REPORTS
The Journal of Frailty & Aging
Introduction
Oropharyngeal dysphagia is widespread in older adults
(1). The risk of diseases that may lead to dysphagia increases
with age and so does dysphagia (2). With aging, there is
a progressive decline of muscle mass and strength as well
as a decrease in connective tissue elasticity resulting in a
diminishment in range of movements (3). This change with
aging has been termed as primary sarcopenia whereas
secondary sarcopenia refers to the same phenomenon due to
diseases or a lack of nutrition (3). Swallowing dysfunction
can be aggravated by sarcopenia (4). Dysphagia has adverse
effects on self-esteem, socialization, and the quality of life
(5). Dysphagia also has a significant impact on the nutritional
status, because with difficulty in food/liquid intake, the
individual is more at risk of having lowered nutritional
status (2, 6). A close association has been identified between
dysphagia and aspiration pneumonia (7, 8). Langmore,
Skarupski (9) concluded that swallowing difficulty is a
predictor of pneumonia in residents of nursing home. These
findings indicate that clinicians should aim to prevent declines
in swallowing in older adults to prevent nutritional and
respiratory complications.
The high prevalence and fatal consequences of dysphagia
in older adults have led to investigations intended to improve
the prevention and management of dysphagia. One focus of
swallowing rehabilitation is to improve the swallow through
exercises (10). Numerous exercises targeting different
structures and subsystems of the swallow have been proposed,
including lingual resistance exercises, exercises on the
suprahyoid muscle group and expiratory muscle strength
training (2). Physiological benefit and functional gain with a
reduction of frequency of malnutrition and pneumonia have
been reported in older people with dysphagia after doing
these exercises (2). The use of multidisciplinary interventions
provides another perspective. In one study, Arahata, Oura
(11) provided an average of 4.3 interventional strategies to
90 patients, including range-of-movement oromotor and
swallowing structures, feeding and swallowing foods or liquids
(11). The 1-year artificial nutrition-free rate was significantly
higher than the historical control rates. However, that study
also used interventional strategies besides swallowing therapy,
including oral hygiene and other nursing interventions. The
current prospective pilot study was designed to investigate the
effectiveness of a set of direct swallowing therapies intended to
target the swallowing functions of residents in nursing homes.
The effectiveness was determined by two outcomes: Functional
oral intake scale (FOIS) and a self-devised oromotor function
scale.
Methods
Ethical approval was received from the Joint Chinese
University of Hong Kong – New Territories East Cluster
Clinical Research Ethics Committee (CREC Ref. No.
2019.699). All participants provided informed consent. This
study was conducted at two nursing homes and two daycare
centers from April 2018 to March 2019. Participants were
included if their FOIS score was at 3-6 and was able to provide
consent. Twenty-five participants meeting the inclusion criteria
were recruited.
EFFICACY OF A COMPREHENSIVE DYSPHAGIA INTERVENTION PROGRAM
TAILORED FOR THE RESIDENTS OF NURSING HOMES
R. FONG1,2, S.W.K. WONG3, J.K.L. CHAN3, M.C.F. TONG1,2, K.Y.S. LEE1,2
1. Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong; 2. Institute of Human Communicative
Research, The Chinese University of Hong Kong, Hong Kong; 3. Hong Kong Christian Service, Hong Kong.
Corresponding author: Raymond Fong, Rm 303, Academic Building No. 2, The Chinese University of Hong Kong, Tel: +85239439602, Email: raymondfong@ent.cuhk.edu.hk
Abstract: Oropharyngeal dysphagia is a widespread condition in older people and thus poses a serious health
threat to the residents of nursing homes. The management of dysphagia relies mainly on compensatory strategies,
such as diet and environmental modification. This study investigated the efficacy of an intervention program
using a single-arm interventional study design. Twenty-two participants from nursing homes were included and
had an average of 26 hours of intervention, including oromotor exercises, orosensory stimulation and exercises
to target dysphagia and caregiver training. Four of the 22 participants exhibited improvement in functional oral
intake scale (FOIS) but was not statistically significant as a group. All oromotor function parameters, including
the range, strength, and coordination of movements, significantly improved. These results indicate that this
intervention program could potentially improve the oromotor function, which were translated into functional
improvements in some participants’ recommended diets. The validity of this study could be improved further by
using standardized swallowing and feeding assessment methods or an instrumental swallowing assessment.
Key words: Dysphagia, swallowing treatment, aspiration.
J Frailty Aging 2020;in press
Published online October 13, 2020, http://dx.doi.org/10.14283/jfa.2020.56
© Serdi and Springer Nature Switzerland AG 2020

EFFECT OF A DYSPHAGIA TREATMENT PROGRAM FOR OLDER PEOPLE LIVING IN NURSING HOMES
The Journal of Frailty & Aging
2
The pre-intervention assessment included a clinical
swallowing evaluation for determining the FOIS score
and devising the personalized treatment. The clinical
swallowing evaluation consisted of communication ability
screening, physical examination and swallow trials (10). The
recommendation of diet was a clinical decision based on the
components of the evaluation as above. The diets available in
the nursing homes include puree, minced, soft and regular diet,
which corresponded to IDDSI Level 4, 5, 6 and 7 respectively.
The FOIS is a 7-point ordinal scale that documents the patient’s
functional eating status, with 1 being fully dependent on tube
feeding and 7 indicating no restriction or special preparation
(10). The participants were assessed by four qualified speech
therapists with 2–10 years of clinical experience in dysphagia
management. These therapists also performed the intervention.
The FOIS score was the primary outcome of treatment,
as the goal of the intervention was to improve the overall
swallowing competence of the participants. The secondary
outcome of treatment was an improvement in oromotor
function. The range of movement, strength and rate of the
tongue, lips, and jaw were measured. Individual scores were
assigned for the measured range of movement (jaw, lips
protrusion and spreading, tongue protrusion, lateralization,
elevation/depression, and elevation of the velum), strength (jaw
opening and closing, lip seal, tongue protrusion, lateralization,
and elevation/depression), and rate of movement (jaw, lips,
tongue protrusion, lateralization, and elevation/depression).
Each structure was rated in each domain (range, strength
and rate) using a 0 (no abnormality) – 5 (severe impairment)
scale. A higher score indicated greater impairment of that
domain. After excluding three more participants at this stage,
the data analysis included 22 participants. The study population
included 16 female and 6 male participants with a mean age of
86.13 (standard deviation, S.D.: 8.91) years. The demographics,
medical conditions, pre- and post-treatment diet and the FOIS
scores of the participants are listed in Table 1.
After the initial assessment, the participants were provided
with a personalized intervention program targeted three main
areas: oromotor exercises (range of movement, strength and
coordination), dysphagia intervention (orosensory stimulation
Table 1
Details of the participants
Age Gender Medical diagnoses Pre-treatment Post-treatment
Diet FOIS Diet FOIS
1 90 F Cancer Puree 4 Minced 5
2 81 F Nil Minced 5 Regular 7
3 83 F Dementia; stroke Puree 4 Puree 4
4 89 F Dementia Minced 5 Minced 5
5 93 F Dementia; mental illness Soft 6 Soft 6
6 104 F Dementia; stroke Puree 4 Minced 5
7 94 F Dementia; stroke Soft 6 Soft 6
8 90 F Dementia; stroke Puree 4 Puree 4
9 81 M Parkinson’s disease Puree 4 Puree 4
10 89 F Nil Minced 5 Minced 5
11 89 F Psychiatric disorder Puree 4 Puree 4
12 63 M Stroke; mental illness Minced 5 Minced 5
13 73 M Dementia; Parkinson’s disease Soft 6 Minced 5
14 84 F Dementia Puree 4 Puree 4
15 79 M Dementia Minced 5 Minced 5
16 88 F Dementia; mental illness; respiratory problem Minced 5 Puree 4
17 77 M Dementia; Parkinson’s disease Minced 5 Minced 5
18 86 F Stroke Minced 5 Minced 5
19 86 F Dementia; stroke Soft 6 Soft 6
20 94 M Dementia; stroke Puree 4 Minced 5
21 82 F Dementia Soft 6 Soft 6
22 100 F Dementia Soft 6 Soft 6

THE JOURNAL OF FRAILTY & AGING
The Journal of Frailty & Aging
3
and exercises) and caregiver training. The three main areas
and examples of treatment goals are detailed in Table 2. The
exercises were based on the principles of resistance loading,
as advocated by Sura, Madhavan (2). Although the use of
thermal-tactile stimulation and its effectiveness for dysphagia
management remain controversial, especially in stroke patients
(12), this study applied a combination of thermal, mechanical,
and chemical sensory stimuli based on the reported conclusion
of Rofes, Cola (13). Each participant received an average
of 26.23 hours of therapy in weekly sessions. The post-
intervention assessment was conducted within 2 weeks after
treatment completion and the FOIS score was calculated. The
investigator who performed the post-intervention assessment
was blinded to the initial FOIS score and the treatment received.
Statistical analyses were performed using SPSS software ver.
23.0 (IBM, Armonk, NY, USA). The pre-treatment and post-
treatment data were compared using the Wilcoxon signed rank
test. A p value of <0.05 was considered to indicate statistical
significance.
Results
Of the 22 participants, 4 (18.2%) had a change of FOIS
score, 16 (73.7%) remained unchanged and 2 (9.1%) regressed
from the pre-intervention period. The changes in FOIS was
not statistically significant (Z = -1.000, p = 0.317). For the
secondary outcomes, a significant change in the range of
movement (Z = -3.933, p < 0.001) with the mean difference
of -4.59 (S.D. = 2.82). For strength, the mean difference was
-4.57 (S.D. = 4.78) and this was also significant (Z = -3.712,
p < 0.001). For rate of movement, mean difference was -4.68
(S.D. = 4.00) and this was also significant (Z = -3.830, p <
0.001).
Discussion
Dysphagia management strategies for older adults,
particularly residents of nursing homes, have focused largely
on the use of compensatory strategies. The results of this
pilot study demonstrate that a personalized treatment program
could improve the function of underlying structures needed
for swallowing. However, the effect on the overall swallowing
function was not significant.
Although not all participants exhibited positive changes
in terms of functional swallowing outcomes, significant
improvements were observed in all three domains measured for
the secondary outcome of the intervention program. Previous
studies have supported the use of oromotor exercises for
improving the swallowing mechanism (10). Specifically, lip
and tongue resistive training has been shown to improve both
the strengths of these structures and the swallowing ability
(10). In most participants, improvements were noted across
all three domains of oromotor function. This result indicates
that participation in a robust weekly therapy program for six
months could induce changes in the oromotor functioning of
the treatment recipients. However, sensory aspects and the
pharyngeal phase of swallowing also contribute to the overall
swallowing competence. Therefore, a significant improvement
in oromotor function alone may not induce adequate changes
in the overall swallowing competence of the participants, as
reflected by a change in the FOIS score.
In this study cohort, most of the participants were older than
90 years, and over half of the participants had a background of
dementia. Therefore, the participants may have found it difficult
to comprehend and retain the instructions for daily active
swallowing exercises. Some of the exercises may have been
performed only once per week during the therapy session. In
Table 2
Content of the tailored comprehensive intervention program
Area of intervention Example of treatment goal
Oromotor function – Strengthening Improve tongue strength via isometric tongue exercise: resisting a tongue
depressor for 15 seconds
Oromotor function – Range of movement Improve jaw-opening by increasing the inter-incisor distance from 2.0 to 2.5
cm using jaw exercises
Improve tongue agility via a tongue lateralization exercise: sustained
touching of tongue tip to left and right corners of lips for 5 seconds
Oromotor function – Coordination Improve tongue-lip coordination by holding a 5-ml liquid bolus on the
tongue surface for 5 seconds without spillage, while maintaining the
breathing pattern
Dysphagia intervention – Orosensory stimulation and exercises Improve the initiation of swallowing using thermal tactile stimulation
Improve bolus transfer and clearance by repeating the tongue-hold
maneuver exercise twice daily, 10 times each
Caregiver’s skills The main caregiver could perform oral massage of the cheek, lips and
tongue as a pre-meal stimulation

EFFECT OF A DYSPHAGIA TREATMENT PROGRAM FOR OLDER PEOPLE LIVING IN NURSING HOMES
The Journal of Frailty & Aging
4
other cases, some exercises might not have been possible, and
only passive exercises would have been performed. Treatment
compliance and issues with exercise selection due to limited
cognitive ability might also explain why this treatment did not
lead to changes in diet recommendations and FOIS scores,
despite improvements in oromotor functioning. However, this
study could not determine whether this type of intervention
would only be efficacious for patients without dementia
because of the small participant cohort.
Limitations
The degree of cognitive impairment due to dementia, or
other medical conditions, could have affected the exercise
selection, treatment compliance and ultimately treatment
outcome. However, no uniform documentation of the cognitive
ability could be retrieved across participants for a valid
comparison. In the future, all participants should undergo a
cognitive screening with validated tools such as the Hong
Kong Brief Cognitive Test (14). The validity of this study
could be improved by the inclusion of outcome measures such
as the Iowa Oral Performance Instrument (IOPI Medical LLC,
Redmond, WA), videofluoroscopy, endoscopy, which would
enable investigators to delineate changes in the swallowing
physiology and function more objectively. However, these
measures were not routinely applied to people living in
local nursing homes, and therefore this analysis could not be
performed. To improve the validity and reliability of future
studies involving residential care homes, a standardized clinical
assessment such as the Mann Assessment of Swallowing
Ability or the McGill Ingestive Skills Assessment (10) could
be used to standardize the documentation of changes in
swallowing and related functions.
Conclusions and implications
Few studies have investigated the treatment efficacies of
swallowing and feeding intervention programs designed for
residents in aged-care facilities. This study provides a good
foundation for further studies of larger cohorts. The ability to
extrapolate the study findings to a more general population of
residents in nursing homes would enable better management of
the risks associated with dysphagia and the associated quality
of life. Future studies could focus on investigating the treatment
efficacy in patients who can comply with all prescribed active
oromotor and swallowing exercises. Alternatively, dysphagic
individuals may require a more intensive intervention program
or a protocol involving more passive forms of treatment. The
efficacies of these alternative treatment options also require
further investigation.
Conflict of interest: The authors declare that there is no conflict
of interest.
Acknowledgments: The authors gratefully acknowledge the
input from staff members at the Cheung Fat Home for the Elderly,
Shun Lee Home for the Elderly, Chin Wah Day Care Centre for
the Elderly, and Sham Shui Po Day Care Centre for the Elderly,
as well as the speech therapists affiliated with the Hong Kong
Christian Service.
Funding: This study was based on a pilot project, the “Good
to Taste: Swallowing Enhancement Project for Elderly,” carried
out by the Hong Kong Christian Service. This pilot project was
supported financially by The Community Chest of Hong Kong.
The sponsors had no role in the design and conduct of the study;
in the collection, analysis, and interpretation of data; in the
preparation of the manuscript; or in the review or approval of the
manuscript.
References
1. Di Pede C, Mantovani ME, Del Felice A, Masiero S. Dysphagia in the elderly: focus
on rehabilitation strategies. Aging Clin Exp Res. 2016;28(4):607-17. doi:10.1007/
s40520-015-0481-6
2. Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: management
and nutritional considerations. Clinical interventions in aging. 2012;7:287-98.
doi:10.2147/CIA.S23404
3. Dellis S, Papadopoulou S, Krikonis K, Zigras F. Sarcopenic Dysphagia. A Narrative
Review. J Frailty Sarcopenia Falls. 2018;3(1):1-7. doi:10.22540/JFSF-03-001
4. Azzolino D, Damanti S, Bertagnoli L, Lucchi T, Cesari M. Sarcopenia and swallowing
disorders in older people. Aging Clin Exp Res. 2019;31(6):799-805. doi:10.1007/
s40520-019-01128-3
5. Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P. Social and
psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia.
2002;17(2):139-46. doi:10.1007/s00455-001-0113-5
6. 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):376-81.
doi:10.1093/ageing/afs006
7. Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest.
2003;124(1):328-36. doi:10.1378/chest.124.1.328
8. Hollaar VRY, van der Putten G-J, van der Maarel-Wierink CD, et al. Nursing home-
acquired pneumonia, dysphagia and associated diseases in nursing home residents: A
retrospective, cross-sectional study. Geriatric Nursing. 2017;38:437-41. doi:10.1016/j.
gerinurse.2017.02.007
9. Langmore SE, Skarupski KA, Park PS, Fries BE. Predictors of aspiration pneumonia
in nursing home residents. Dysphagia. 2002;17:298-307. doi:10.1007/s00455-002-
0072-5
10. Groher ME, Crary MA. Dysphagia: Clinical Management in Adults and Children:
Mosby; 2016.
11. Arahata M, Oura M, Tomiyama Y, et al. A comprehensive intervention following
the clinical pathway of eating and swallowing disorder in the elderly with dementia:
historically controlled study. BMC Geriatrics. 2017;17:146. doi:10.1186/s12877-017-
0531-3
12. Power ML, Fraser CH, Hobson A, et al. Evaluating Oral Stimulation as a Treatment
for Dysphagia after Stroke. Dysphagia. 2006;21:49-55. doi:10.1007/s00455-005-9009-
0
13. Rofes L, Cola PC, Clavé P. The Effects of Sensory Stimulation on Neurogenic
Oropharyngeal Dysphagia. Journal of Gastroenterology and Hepatology Research.
2014;3. doi:10.6051/
14. Chiu HFK, Zhong BL, Leung T, et al. Development and validation of a new cognitive
screening test: The Hong Kong Brief Cognitive Test (HKBC). Int J Geriatr Psychiatry.
2018;33(7):994-9. doi:10.1002/gps.4883