Journal of Oral Rehabilitation 2007 34; 422427

Evaluation of chewing and swallowing disorders among frail community-dwelling elderly individuals
H. MIURA*, M. KARIYASU*, K. YAMASAKI & Y. ARAI
*Department of Speech Therapy, Faculty of Health Science, Kyushu University of Health and Welfare, Miyazaki, Japan Department of Welfare Administration and Management, Faculty of Social Welfare, Kyushu University of Health and Welfare, Miyazaki, Japan and Department of Health Policy for the Aged, National Institute for Longevity Science, Aichi, Japan

The purpose of the present study was to develop a new assessment scale to evaluate the risk of chewing and swallowing disorders among frail community-dwelling elderly individuals. Subjects were 85 frail elderly individuals (29 men and 56 women) living in southern Japan. First, we pooled 18 subjectively evaluated variables identied by previous studies as being related to chewing and swallowing disorders. Secondly, using factor analysis, we extracted 12 variables as the dysphagia risk assessment for the community-dwelling elderly (DRACE) and examined its reliability using Cronbachs alpha coefcient. Thirdly, we examined the validity of the DRACE by comparing it with an existing method for evaluating dysphagia. Cronbachs alpha coefcient of the DRACE was 088, indicating satisfactory reliability. Dysphagia risk
SUMMARY

assessment for the community-dwelling elderly scores were signicantly related to the results of the 3-oz water test (P < 001). Furthermore, DRACE scores were closely associated with activities of daily living as evaluated by the Barthel index, a tendency that was consistent with previous studies. These ndings suggest that the DRACE is a useful tool with sufcient reliability and validity to detect latent risk of chewing and swallowing disorders among frail community-dwelling elderly individuals. KEYWORDS: risk assessment, frail elderly, community-dwelling elderly, swallowing disorder, chewing disorder Accepted for publication 27 January 2007

Introduction
Chewing and swallowing disorders are prevalent in the frail elderly (1, 2). Furthermore, it is very difcult to detect early-stage swallowing disorders because they are often clinically silent (3). Especially in the homecare setting, most family caregivers of the communitydwelling elderly with physical or mental impairment cannot correctly assess swallowing function and ingestion (4). Nonetheless, dysphagia in the frail elderly can cause serious problems such as malnutrition, dehydration, declining quality of diet and aspiration pneumonia (5, 6). To improve the quality of health care for the elderly, the precise evaluation of dysphagia is very important. However, few previous studies have reported epidemi-

ological data related to chewing and swallowing disorders among frail community-dwelling elderly individuals. Dysphagia can be divided into anticipatory, preparatory, oral, pharyngeal and oesophageal stages (7); however, many clinical studies of dysphagia evaluations have not sufciently focused on the anticipatory and preparatory stages. This is despite the fact that the community-dwelling elderly frequently experience difculty with mastication, which is often associated with preparatory stage of dysphagia (810). To improve the quality and safety of care for the community-dwelling elderly, it is very important to include chewing disorders when evaluating dysphagia risk. The purpose of the present study was to extract questionnaire items signicantly related to
doi: 10.1111/j.1365-2842.2007.01741.x

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dysphagia, including masticatory problems, among the community-dwelling elderly with declining activities of daily living (ADL). The ndings obtained in the present study will contribute to further analysis of care methods targeting dysphagia among the frail community-dwelling elderly. year, which were frequently found in previous studies (12, 13): (i) at least one episode of pneumonia, (ii) weight loss, (iii) at least one episode of pyrexia, (iv) decreasing appetite, (v) taking a long time to eat, (vi) difculties with swallowing, (vii) difculties with chewing hard food, (viii) food falling from the mouth, (ix) food debris staying in the mouth, (x) choking during a meal, (xi) choking when swallowing liquid, (xii) food rising into the nasal cavity, (xiii) sensation of food being stuck in the throat, (xiv) hoarseness after eating, (xv) sputum being expectorated during the meal, (xvi) coughing during the night, (xvii) sensation of food being stuck in the oesophagus and (xviii) sensation of food or liquid rising into the throat from the stomach. For these dysphagia-related events, a 3-point scale was applied according to severity of the events over a 1-year period as follows: 0, none; 1, mild and 2, severe. The difference between mild and severe was dependent upon the frequency and degree of each symptom. Severe indicates frequent or noticeable while mild indicates occasional or slight. A 3-oz water test, which is a representative clinical screening test for dysphagia, was also conducted (14). Subjects with abnormal swallowing function during and after drinking water were dened as frail elderly with clinical dysphagia in the present study. Coughing during, or for up to 1 min after completion was considered a positive sign of an abnormality, as was the presence of a wet or hoarse voice quality after swallowing. As an indicator of frailness, ADL were evaluated using the Barthel index, with scores ranging from 0 to 100 (15). The average score of Barthel index among the present subjects was 813 151. Cognitive impairment was rated using the revised Hasegawa Dementia Rating Scale (HDS-R), a Japanese screening test for dementia that measures overall cognitive function, including verbal communication and memory, with scores ranging from 0 to 30 (16). The average score of HDS-R was 214 58. Analyses An exploratory factor analysis was employed to extract the indices useful in developing new risk assessments related to dysphagia for frail and community-dwelling elderly. First, the 18 items were examined using principal factor analysis. Some factors were identied

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Subjects and methods

Subjects The present survey was conducted from December 2005 to February 2006 in Miyazaki Prefecture, southern Japan. As the rst step, a random sampling method was used to select 120 frail elderly individuals (60 men and 60 women) aged more than 65 years. These individuals resided in the community with their family and received a public welfare service under the national long-term care insurance system for a slight decline of daily living (11). However, they have remained satisfactory physical activities to spend with their family using public welfare service and informal supports from their family members. In the second step, all frail elderly individuals and their principal family caregivers were contacted by mail to explain the objectives of the present study. Informed consent to participate in the present study was obtained from 85 dependent elderly individuals (29 men and 56 women). The response rate was 708%. The remaining 35 individuals were excluded because they had severe dementia or inadequate verbal communication to participate in the present study. The mean age of the elderly subjects was 808 76 years. Additionally, principal medical histories were as follows: hypertension (353%), cardiopathy (212%), diabetes (106%), cerebrovascular accident (94%), arthritis (59%), respiratory disease (59%) and carcinoma (47%).

Measurements for impaired elderly Survey items were grouped as follows: (i) demographic variables, (ii) physical symptoms related to chewing and swallowing disorders, (iii) clinical swallowing function test, (iv) basic ADL and (v) screening test of cognitive function. We used a questionnaire to examine physical symptoms related to dysphagia. First, we pooled 18 items based upon physical symptoms of chewing and swallowing disorders during the previous

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and rotated using the varimax method to obtain a clearer pattern of factor loading which revealed more than 060 for the most concerned factor, and below 040 for the other factors (17). The number of components was determined by the solution that produced a simple structure of the factor loading, with a minimum number of factors needed to account for the majority of the variance in the 18 items. These extracted items were dened as the dysphagia risk assessment for the community-dwelling elderly (DRACE), and its reliability was examined using Cronbachs alpha coefcients. Secondly, we examined whether DRACE had sufcient construct validity by comparing its results with those of clinical decisions based on the 3-oz water test. The statistical relationship between these two assessments were determined using an unpaired t-test. We also examined the relationship between DRACE and ADL using Spearman rank correlation coefcients. These serial statistical analyses were performed using SPSS version 13.0.*
Table 1. Distribution of 18 symptoms related to dysphagia during the previous year among frail community-dwelling elderly individuals Degree of symptoms Severe Mild None (%) (%) (%) 1. At least one episode of pneumonia 2. Weight loss 3. At least one episode of pyrexia 4. Decreased appetite 5. Taking a long time to eat 6. Difculties with swallowing 7. Difculties with chewing hard food 8. Food falling from the mouth 9. Debris remaining in the mouth 10. Choking during a meal 11. Choking when swallowing liquid 12. Food rising into the nasal cavity 13. Sensation of food being stuck in the throat 14. Hoarseness after meals 15. Expectoration of sputum during meals 16. Coughing during the night 17. Sensation of food being stuck in the oesophagus 18. Sensation of food or liquid rising into the throat from the stomach 24 129 23 47 400 212 141 141 47 94 71 12 12 00 47 12 24 12 164 612 330 353 577 271 447 447 259 271 341 82 247 94 212 177 165 153 812 259 647 600 23 517 412 412 694 659 588 906 741 906 741 812 812 835

Results
Table 1 shows the distribution of clinical symptoms related to dysphagia. In these symptoms, items that respondents most frequently rated as severe were (i) taking a long time to eat, (ii) difculties with chewing hard food, (iii) food falling from the mouth and (iv) difculties with swallowing. Table 2 shows the factor loading matrix for the 18 variables after varimax rotation. Four factors explained 578% of the total variance in the initial 18 variables. Factor I incorporated difculties with swallowing, difculties with chewing hard food, food falling from the mouth, choking during a meal, choking when swallowing liquid, food rising into the nasal cavity and sputum being expectorated during meals. Factor I was determined to represent early stage swallowing disorders involving the preparatory stage, oral stage and the early pharyngeal stage. Factor II consisted only of taking a long time to eat involving the preparatory stage and oral stage and factor III consisted only of past episodes of pyrexia involving silent aspiration. Factor IV incorporated the sensation that food was getting stuck in the throat, hoarseness after meals and the sensation that food was getting stuck in the oesophagus. This factor was determined to represent late stage swallow*SPSS, Chicago, IL, USA.

ing disorders including the late part of the pharyngeal stage and the oesophageal stage. Finally, these 12 items were extracted as the DRACE. Table 3 shows the relationship between the DRACE score and clinical evaluation based upon the 3-oz water test. Abnormal swallowing function was detected in 353% of subjects according to the 3-oz water test. A signicant association was found between the clinical evaluation and DRACE (P < 001). Moreover, the Cronbachs alpha coefcient of the DRACE was 088. Table 4 shows the relationship between the DRACE score and general factors such as age, ADL and cognitive function. Dysphagia risk assessment for the community-dwelling elderly was signicantly related to ADL as evaluated by Barthel index (r 035, P < 001). However, it had no signicant relationship to either age or cognitive status as evaluated by HDS-R.

Discussion
The present ndings revealed that most frail community-dwelling elderly individuals with physical impairment or disability had some symptoms related to

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Table 2. Factor loading matrix for 18 variables after varimax rotation Factor I II )0135 0256 0154 III 0294 017 0969 IV 0418 002 0182 Age Score of Barthel Index Score of HDS-R Table 4. Relationship between DRACE score and general factors such as age, ADL and cognitive function Correlation coefcient 011 )035 )016 P-value NS <001 NS

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1. At least one episode of 0367 pneumonia 2. Weight loss 0068 3. At least one episode of 0048 pyrexia 4. Decreased appetite 0066 5. Taking a long time to eat 0187 6. Difculties with swallowing 0646 7. Difculties with chewing 0717 hard food 8. Food falling from the mouth 0679 9. Staying debris in the mouth 0588 10. Choking during a meal 0824 11. Choking when swallowing 0897 liquid 12. Food rising into the nasal 0643 cavity 13. Sensation of food being 0114 stuck in the throat 14. Hoarseness after meals 0136 15. Expectoration of sputum 0614 during meals 16. Coughing during the night 0562 17. Sensation of food being 0151 stuck in the oesophagus 0132 18. Sensation of food or liquid rising into the throat from the stomach %variance 276 Cumulative % variance 276

004 0289 0309 0980 )0042 0048 0186 0062 0289 0095 0020 )0051 0379 0055 0042 0244 0110 )0016 0045 0023 0196 0068 0155 )0150 )0043 0015 )0140 0012 0025 0032 0065 0185 0173 0171 0073 0148 0120 0059 0535 0783 0788 0270 0465 0777 0631

DRACE, dysphagia risk assessment for the community-dwelling elderly; NS, not signicant; ADL, activities of daily living.

126 402

104 506

72 578

Note: Each bold value means a factor loading which reveals more than 0.60 for the most concerned factor, and below 0.40 for the other factors. Table 3. Relationship between DRACE score and clinical dysphagia risk based upon 3-oz water test among the frail community-dwelling elderly Clinical dysphagia risk High risk (n 30) Score of DRACE 49 09 Low risk (n 55) 21 08

T-value 147

P-value <001

DRACE, dysphagia risk assessment for the community-dwelling elderly.

dysphagia. Some previous studies have reported a signicant decline in swallowing function among frail or impaired elderly individuals (18, 19). These results suggest that it is necessary to determine the risk

of dysphagia for the frail and community-dwelling elderly. Several investigators have demonstrated the following variables are effective predictors of dysphagia and aspiration: delayed oral transit, incomplete oral clearance, change of voice quality, abnormal gag reex and abnormal voluntary cough (2022). However, masticatory disorder has been used in relatively few studies as a predictor of dysphasia. Many previous studies have reported that masticatory problems in impaired elderly are frequently related to tooth loss and poor-tting dentures (23, 24). Satisfactory mastication is necessary to produce the bolus (25), and inadequate mastication can therefore be responsible for dysphagia symptoms particularly in the frail elderly. The DRACE included an assessment item related to masticatory ability, thus it has the benet of being able to comprehensively evaluate the risks related to dysphagia. On the other hand, factor analysis is a statistical tool used to analyse scores of a larger number of variables and to determine whether any identiable dimensions can be used to describe many of the variables. It allows the researchers to summarize data by grouping variables that are inter-related. In the present study, 12 variables obtained by the questionnaire were grouped into four factors. The DRACE, which incorporated these 12 items, had sufcient reliability on the basis of its Cronbachs alpha coefcient of 088. The most accurate diagnostic test for dysphagia is videouoroscopy; however, this involves the risk of exposure to radiation. Thus, we applied an alternative indicator. The 3-oz water test is a common international screening tool for dysphagia (13), and has been frequently and widely applied in clinical examinations. Dysphagia risk assessment for the community-dwelling elderly scores were signicantly related to 3-oz water test (P < 001), suggesting that it is a valid assessment tool for evaluating the risks associated with swallowing disorders for the frail and community-dwelling elderly.

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In the present study, the percentage of subjects with a clinically high risk of dysphagia determined by the 3-oz water test was relatively high at 353%. Furthermore, this proportion was very similar to that found in a previous study (26). In the present study, the sample size was relatively small, thus it is difcult to generalize the present ndings to the community as a whole. Nevertheless, the majority of frail and communitydwelling elderly individuals have a latent risk of dysphagia. Home-care based upon suitable risk assessment of dysphagia will contribute to improving over all health and quality of life in the community-dwelling elderly. A limitation of the present study was the exclusion of elderly persons with severe dementia. Furthermore, to evaluate events that occurred subjectively during eating or drinking, satisfactory verbal communication was a requisite for the respondents used in this study. As the population of the elderly with moderate or severe dementia is gradually increasing, it is necessary to develop a suitable assessment tool to detect dysphagia risks for those who lack verbal communication. The present ndings suggest that DRACE is a powerful assessment tool for detecting chewing and swallowing disorders, yet only a few DRACE items include evaluations related to chewing disorders. This is another limitation of the present study. Thus, additional items such as the number of remaining teeth or bite force may be added to the assessment in the future to improve its ability to detect chewing disorders. Maintaining chewing and swallowing function contribute to not only physical health, but also well-being in the frail elderly. The present study revealed that most of the community-dwelling elderly with declined ADL had risks of dysphagia. To conduct safe home-care, the level of dysphagia risk should be evaluated using a scale with sufcient validity and reliability. Furthermore, it is desirable for most family caregivers to use a simple method, such as the present one, to assess the risks of early stage chewing and swallowing disorders. In the future, further epidemiological verication using a larger sample will be necessary due to the small sample size of the present study. Moreover, the DRACE score needs to be evaluated in terms of cut-off score indicating dysphagia risk. In conclusion, the present study suggests that the DRACE is a useful tool with sufcient validity and reliability to detect latent risk factors of chewing and swallowing disorders among the frail communitydwelling elderly.

Acknowledgments
The present study was supported in part by a Grant in Aid for Scientic Research from the Japan Society for the Promotion of Science and by Health Sciences Research Grants (Comprehensive Research on Ageing and Health) from the Japanese Ministry of Health, Labour and Welfare.

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Correspondence: Dr Hiroko Miura, Department of Speech Therapy, Faculty of Health Science, Kyushu University of Health and Welfare, 1714-1 Yoshino-cho, Nobeoka-shi, Miyazaki 882-8508, Japan. E-mail: hmiura@phoenix.ac.jp

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