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Oropharyngeal dysphagia frequency in older adults living in nursing homes: an integrative review

ABSTRACT

Purpose

To synthesize the scientific knowledge on the frequency of oropharyngeal dysphagia in older adults living in nursing homes.

Research strategies

The study question followed the PECO strategy and the search was performed in the Pubmed/Medline, Web of Science, Scopus, LILACS and SciELO databases, using keywords and specific free terms.

Selection criteria

articles with no time or language restrictions that reported the frequency of oropharyngeal dysphagia in older adults living in nursing homes and the diagnostic criteria.

Data analysis

it was analyzed the population characteristics, the concept of “oropharyngeal dysphagia”, the methods for identifying the outcome and the frequency of oropharyngeal dysphagia. The evaluation of the methodological quality of the articles followed the criteria of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

Results

Fifteen articles were included. There was great variability in relation to the sample size, with a predominance of longevous old women. The concept of dysphagia, when mentioned, was heterogeneous. Diagnostic criteria were diverse and mostly comprised of questionnaires or clinical trials results. No studies used instrumental tests. The frequency of oropharyngeal dysphagia in the studied population ranged from 5.4% to 83.7%, being higher in studies that used clinical tests, but with greater precision of confidence intervals in studies that used questionnaires and large sample size.

Conclusion

The frequency of oropharyngeal dysphagia in older adults living in nursing homes has wide variability. Methodological discrepancies among studies compromise the reliability of frequency estimates and highlight the need for research with better defined and standardized methodological criteria.

Keywords
Swallowing Disorders; Deglutition; Aging; Aged; Homes for the Aged

RESUMO

Objetivo

Sintetizar o estado do conhecimento científico sobre a frequência de disfagia orofaríngea em idosos institucionalizados.

Estratégia de pesquisa

A pergunta de pesquisa foi formulada de acordo com a estratégia PECO e a busca foi realizada nas bases de dados Pubmed/Medline, Web of Science, Scopus, LILACS e SciELO, utilizando descritores e termos livres específicos.

Critérios de seleção

Artigos sem restrição de tempo ou idioma, que relatassem a frequência de disfagia orofaríngea em idosos institucionalizados e o critério utilizado para diagnóstico.

Análise dos dados

Foram analisadas as características da população, conceito de “disfagia orofaríngea”, métodos para identificação do desfecho e a frequência de disfagia orofaríngea. A avaliação da qualidade metodológica dos artigos seguiu os critérios do Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

Resultados

Foram incluídos quinze artigos. Houve grande variabilidade quanto ao tamanho da amostra, com predomínio de idosos longevos do sexo feminino. O conceito de disfagia, quando mencionado, foi heterogêneo. Os critérios diagnósticos foram diversos e compostos, em sua maioria, por resultados de questionários ou testes clínicos. Nenhum estudo utilizou exames instrumentais. A frequência de disfagia orofaríngea na população estudada oscilou entre 5.4% e 83.7%, sendo mais elevada nos estudos que utilizaram testes clínicos, porém, com intervalos de confiança mais precisos naqueles que usaram questionários e amostras maiores.

Conclusão

A frequência de disfagia orofaríngea em idosos institucionalizados possui ampla variabilidade. As discrepâncias metodológicas entre os estudos comprometem a confiabilidade das estimativas de frequência e apontam a necessidade de pesquisas com critérios metodológicos mais bem definidos e padronizados.

Descritores
Transtornos de Deglutição; Deglutição; Envelhecimento; Idoso; Instituição de Longa Permanência para Idosos

INTRODUCTION

The proportion of elderly people in the world is increasing and population aging is one of the most significant phenomena of the 21st century(11 United Nations. World population prospects 2019 highlights. New York: United Nations; 2019.,22 United Nations. World population prospects 2019 volume II: demographic profiles. New York: United Nations; 2019.). In 2018, the number of elderly people exceeded the number of children under five years old(11 United Nations. World population prospects 2019 highlights. New York: United Nations; 2019.). It is estimated that the proportion of elderly people in the world will reach 11.7% in 2030, 15.9% in 2050, and 22.6% in 2100(11 United Nations. World population prospects 2019 highlights. New York: United Nations; 2019.,22 United Nations. World population prospects 2019 volume II: demographic profiles. New York: United Nations; 2019.). The number of people over 80 years old is increasing even faster, since in 1990 there were only 54 million people aged 80 or over in the world and in 2019 that number almost tripled to 143 million(11 United Nations. World population prospects 2019 highlights. New York: United Nations; 2019.). In Brazil, according to the 2010 Census, there are more than 20 million people aged 60 or over, who represent 10.8% of the total population(33 IBGE: Instituto Brasileiro de Geografia e Estatística. 2010 census [Internet]. 2010 [citado em 2020 Maio 28]. Disponível em: https://censo2010.ibge.gov.br/sobre-censo.html
https://censo2010.ibge.gov.br/sobre-cens...
). Thus, the Brazilian population presents a standard age structure, in which the base of the age pyramid is narrowing due to decreasing fertility levels and the top is widening due to decreasing mortality levels(33 IBGE: Instituto Brasileiro de Geografia e Estatística. 2010 census [Internet]. 2010 [citado em 2020 Maio 28]. Disponível em: https://censo2010.ibge.gov.br/sobre-censo.html
https://censo2010.ibge.gov.br/sobre-cens...
).

Aging is inevitably associated with functional decline, which is characterized by impairment in the performance of activities of daily living, including limitations related to eating(44 Sander M, Oxlund B, Jespersen A, Krasnik A, Mortensen EL, Westendorp RG, et al. The challenges of human population ageing. Age Ageing. 2015;44(2):185-7. http://dx.doi.org/10.1093/ageing/afu189. PMid:25452294.
http://dx.doi.org/10.1093/ageing/afu189...
). Feeding dynamics has an important cultural role in society and in the expression of the personal identity of the elderly(55 Chen PH, Golub JS, Hapner ER, Johns MM 3rd. Prevalence of perceived dysphagia and quality-of-life impairment in a geriatric population. Dysphagia. 2009;24(1):1-6. http://dx.doi.org/10.1007/s00455-008-9156-1. PMid:18368451.
http://dx.doi.org/10.1007/s00455-008-915...
). Since it is related to the act of eating, swallowing ensures pleasure and is inserted into a context of social and affective relationships(66 Langmore SE, Skarupski KA, Park PS, Fries BE. Predictors of aspiration pneumonia in nursing home residents. Dysphagia. 2002;17(4):298-307. http://dx.doi.org/10.1007/s00455-002-0072-5. PMid:12355145.
http://dx.doi.org/10.1007/s00455-002-007...
). In this scenario, the swallowing function is extremely essential, from the visual presentation of food to ingestion(77 Brodsky MB, McNeil MR, Martin-Harris B, Palmer CV, Grayhack JP, Abbott KV. Effects of divided attention on swallowing in healthy participants. Dysphagia. 2012;27(3):307-17. http://dx.doi.org/10.1007/s00455-011-9367-8. PMid:21892783.
http://dx.doi.org/10.1007/s00455-011-936...
).

From the age of 60, individuals are more vulnerable to various types of diseases and disabilities. Among them, a greater risk of developing deglutition disorders due to the natural changes that occur in the dynamics of this function, and specific diseases or degenerative conditions that may interfere with this function, such as cerebral vascular accident and dementias(88 Logemann JA, Curro FA, Pauloski B, Gensler G. Aging effects on oropharyngeal swallow and the role of dental care in oropharyngeal dysphagia. Oral Dis. 2013;19(8):733-7. http://dx.doi.org/10.1111/odi.12104. PMid:23574512.
http://dx.doi.org/10.1111/odi.12104...
).

The main characteristics of deglutition difficulty in the elderly include decreased taste sensitivity and perception of food viscosity, weakening of the lingual musculature for bolus propulsion, slowness at the beginning of the pharyngeal response for deglutition, slowness on hyoid elevation, and changes in swallowing efficiency due to the presence of oropharyngeal residues, with signs of laryngotracheal penetration/aspiration(99 Rofes L, Arreola V, Romea M, Palomera E, Almirall J, Cabré M, et al. Pathophysiology of oropharyngeal dysphagia in the frail elderly. Neurogastroenterol Motil. 2010;22(8):851-8, e230. http://dx.doi.org/10.1111/j.1365-2982.2010.01521.x. PMid:20529208.
http://dx.doi.org/10.1111/j.1365-2982.20...

10 Cabré M, Serra-Prat M, Force L, Almirall J, Palomera E, Clavé P. Oropharyngeal dysphagia is a risk factor for readmission for pneumonia in the very elderly persons: observational prospective study. J Gerontol A Biol Sci Med Sci. 2014;69(3):330-7. http://dx.doi.org/10.1093/gerona/glt099. PMid:23833199.
http://dx.doi.org/10.1093/gerona/glt099...
-1111 Serra-Prat M, Palomera M, Gomez C, Sar-Shalom D, Saiz A, Montoya JG, 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. http://dx.doi.org/10.1093/ageing/afs006. PMid:22311895.
http://dx.doi.org/10.1093/ageing/afs006...
). In addition to anatomo-physiological aspects, changes in pleasure from eating and the negative impact on socialization should also be considered(1212 Bomfim FMS, Chiari BM, Roque FP. Factors associated to suggestive signs of oropharyngeal dysphagia in institutionalized elderly women. CoDAS. 2013;25(2):154-63. http://dx.doi.org/10.1590/S2317-17822013000200011. PMid:24408245.
http://dx.doi.org/10.1590/S2317-17822013...
).

The whole scenario can make swallowing in the elderly less efficient, contributing to the onset of oropharyngeal dysphagia(1313 Aslam M, Vaezi MF. Dysphagia in the elderly. Gastroenterol Hepatol. 2013;9(12):784-95. PMid:24772045.). Swallowing is the act of moving food from the oral cavity into the stomach in order to maintain the nutritional and water status, without allowing material to enter the airways(1414 Furkim AM. Disfagia orofaríngea neurogênica. In: Marchesan IC, editor. Fundamentos em fonoaudiologia: aspectos clínicos da motricidade oral. Rio de Janeiro: Guanabara Koogan. 2005. p. 121-32.). When disorders arise in this process and neurological, anatomical or physiological changes of pathological order are added, oropharyngeal dysphagia appears(1515 Langmore SE, Skarupski KA, Park PS, Fries BE. Predictors of aspiration pneumonia in nursing home residents. Dysphagia. 2002;17(4):298-307. http://dx.doi.org/10.1007/s00455-002-0072-5. PMid:12355145.
http://dx.doi.org/10.1007/s00455-002-007...
).

It is observed that the occurrence of oropharyngeal dysphagia ranges according to the group studied and can reach rates of 70% to 90% in older populations(1616 Santoro PP. Disfagia orofaríngea: panorama atual, epidemiologia, opções terapêuticas e perspectivas futuras. Rev CEFAC. 2008;10(2). http://dx.doi.org/10.1590/S1516-18462008000200002.
http://dx.doi.org/10.1590/S1516-18462008...
), constituting one of the major health problems present in older adults living in nursing homes(1717 Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest. 2003;124(1):328-36. http://dx.doi.org/10.1378/chest.124.1.328. PMid:12853541.
http://dx.doi.org/10.1378/chest.124.1.32...
,1818 Van der Maarel-Wierink CD, Meijers JM, De Visschere LM, de Baat C, Halfens RJ, Schols JM. Subjective dysphagia in older care home residents: a crosssectional, multi-centre point prevalence measurement. Int J Nurs Stud. 2014;51(6):875-81. http://dx.doi.org/10.1016/j.ijnurstu.2013.10.016. PMid:24238894.
http://dx.doi.org/10.1016/j.ijnurstu.201...
). In the United States, it is estimated that 40% to 60% of the elderly living in long-term care facilities (LTCF) have clinical evidence of oropharyngeal dysphagia compared to 13% to 33% of non-institutionalized elderly people(1919 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):858-65. http://dx.doi.org/10.1177/000348940711601112. PMid:18074673.
http://dx.doi.org/10.1177/00034894071160...
).

Some studies have found that oropharyngeal dysphagia in LTCF residents is frequently related to cerebral vascular accident, dependency, advanced dementia, poor oral hygiene, multiple diagnoses, and environmental factors(2020 Van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, de Baat C. Risk factors for aspiration pneumonia in frail older people: a systematic literature review. J Am Med Dir Assoc. 2011;12(5):344-54. http://dx.doi.org/10.1016/j.jamda.2010.12.099. PMid:21450240.
http://dx.doi.org/10.1016/j.jamda.2010.1...

21 Palmu AA, Saukkoriipi A, Snellman M, Jokinen J, Torkko P, Ziegler T, et al. Incidence and etiology of community-acquired pneumonia in the elderly in a prospective population-based study. Scand J Infect Dis. 2014;46(4):250-9. http://dx.doi.org/10.3109/00365548.2013.876509. PMid:24475952.
http://dx.doi.org/10.3109/00365548.2013....
-2222 Sue Eisenstadt E. Dysphagia and aspiration pneumonia in older adults. J Am Acad Nurse Pract. 2010;22(1):17-22. http://dx.doi.org/10.1111/j.1745-7599.2009.00470.x. PMid:20074192.
http://dx.doi.org/10.1111/j.1745-7599.20...
). In addition, there is also sarcopenia, a geriatric syndrome to which dysphagia can be associated(2323 Sakai K, Sakuma K. Sarcopenic dysphagia as a new concept. In: Dionyssiotis Y, editor. Frailty sarcopenia: onset, development and clinical challenges. London: IntechOpen; 2017. http://dx.doi.org/10.5772/intechopen.68791.
http://dx.doi.org/10.5772/intechopen.687...
) that is characterized by a decline of physical function due to decreased muscle strength caused by the loss of skeletal muscle mass(2424 Fujishima I, Fujiu-Kurachi M, Arai H, Hyodo M, Kagaya H, Maeda K, et al. Sarcopenia and dysphagia: position paper by four professional organizations. Geriatr Gerontol Int. 2019;19(2):91-7. http://dx.doi.org/10.1111/ggi.13591. PMid:30628181.
http://dx.doi.org/10.1111/ggi.13591...
). In addition, the problems experienced by the elderly during meals are not restricted to dysphagic signs, including cognitive, behavioral, physical, and environmental changes which, together, can predispose the elderly to a change in feeding dynamics and risks of bronchoaspiration pneumonia, malnutrition, and dehydration(2525 Steele CM, Greenwood C, Ens I, Robertson C, Seidman-Carlson R. Mealtime difficulties in a home for the aged: not just dysphagia. Dysphagia. 1997;12(1):43-50. http://dx.doi.org/10.1007/PL00009517. PMid:8997832.
http://dx.doi.org/10.1007/PL00009517...
).

Dysphagia impairs swallowing safety and efficiency, causing pneumonia and damaging the nutritional and water needs of the elderly, respectively(2626 Almirall J, Cabré M, Clavé P. Neumonía aspirativa. Med Clin. 2007;129(11):424-32. http://dx.doi.org/10.1157/13110467. PMid:17927938.
http://dx.doi.org/10.1157/13110467...
). Thus, understanding the frequency of oropharyngeal dysphagia frequency in older adults living in nursing homes allows to knowing the impact of this condition in the health of the elderly, enabling the management of the feeding and swallowing problems of this population in order to determine individual and collective interventions, both by speech therapy and interdisciplinary, aimed to the well-being of each older adult and to the reduction of health costs(2727 Shanley C, O’Loughlin G. Dysphagia among nursing home residents: an assessment and management protocol. J Gerontol Nurs. 2000;26(8):35-48. http://dx.doi.org/10.3928/0098-9134-20000801-09. PMid:11276612.
http://dx.doi.org/10.3928/0098-9134-2000...
).

There is a notable variability in the literature regarding the records of oropharyngeal dysphagia frequency in older adults living in nursing homes, which impairs more accurate dimensioning of the magnitude of this health condition in older adults residing in LTCF. Understanding this scenario is important for the proper planning and execution of care and attention actions for oropharyngeal dysphagia aimed to this population.

PURPOSE

The aim of this study was to synthesize the scientific knowledge on the frequency of oropharyngeal dysphagia in older adults living in nursing homes.

RESEARCH STRATEGY

This study is an integrative literature review. Therefore, there was no need for submission to evaluation by the institution's Ethics and Human Research Committee. The methodological procedures followed the steps recommended in the literature for this type of review(2828 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64. http://dx.doi.org/10.1590/S0104-07072008000400018.
http://dx.doi.org/10.1590/S0104-07072008...
).

Initially, the research question was formulated according to the PECO approach, an acronym that represents the elements Patient, Exposure, Comparator, and Outcomes, respectively. The first element of the strategy (P) corresponded to older adults residing in nursing homes; the second element (E) corresponded to “oropharyngeal dysphagia”; the third element (C), equivalent to the “comparison group”, was not applied in this review; and the fourth element (O) was the frequency of oropharyngeal dysphagia. Thus, the research question was defined as follows: “What is the frequency of oropharyngeal dysphagia in older adults residing in LTCF?”.

The search included the electronic databases Medline/PubMed, Web of Science, Scopus, SciELO, and Lilacs. The search strategies included combinations between Medical Subjects Headings (MeSH) descriptors and free terms considered relevant to the search (Appendix A Appendix A Search strategies used in databases Database Descriptors Pubmed/Medline ((((“nursing homes”[MeSH Terms]) OR (“nursing home”[Title/Abstract])) OR (“long term care facilities”[Title/Abstract])) OR (“home for the aged”[Title/Abstract])) AND (((((“deglutition”[MeSH Terms]) OR (deglutition disorder[MeSH Terms])) OR (dysphagia[Title/Abstract])) OR (swallowing[Title/Abstract])) OR (deglutition[Title/Abstract])) Web of Science TS=((dysphagia OR (deglutition OR swallow*)) AND (“nursing home” OR (“nursing homLes” OR “long term care facility” OR “long term care facilities”))) Scopus TITLE-ABS-KEY((dysphagia OR (deglutition OR swallow*)) AND (“nursing home” OR (“nursing homes” OR “long term care facility” OR “long term care facilities”))) LILACS “DISFAGIA” [Palavras] and “INSTITUICAO DE LONGA PERMANENCIA PARA IDOSOS” [Palavras] SciELO “DISFAGIA” [Palavras] and “INSTITUICAO DE LONGA PERMANENCIA PARA IDOSOS” [Palavras] ).

SELECTION CRITERIA

The following selection criteria were applied: articles that investigated the frequency of oropharyngeal dysphagia in older adults living in nursing homes, without time or language restrictions. The exclusion criteria applied were, as follows: review articles of any kind, editorials, letters to the editor, conference proceedings, theses, and dissertations. Articles that did not describe the diagnostic criterion to determine the presence of oropharyngeal dysphagia and those that included older adults living in nursing homes in the sample but did not present the frequency of oropharyngeal dysphagia in this population group were also excluded.

DATA ANALYSIS

The studies were independently evaluated by two researchers. Subsequently, they compared analyzes and the disagreements were resolved by a third reviewer. After identifying the articles in the databases and filtering them to exclude duplicates, the screening was conducted, in which the respective titles and abstracts were read and those that did not meet the selection criteria were excluded. In the stage of eligibility, the other articles that potentially addressed the subject were subjected to a full text review. In this stage, the reference lists of the articles were also checked manually and studies not previously identified by the search strategy were investigated.

The articles that met the eligibility criteria were subjected to the extraction of the following data to compose the analysis matrix: study location, population, sample size, sex of participants, age, conclusion of the study, diagnostic instruments, concept of oropharyngeal dysphagia, and frequency of oropharyngeal dysphagia. In order to determine the accuracy of frequency estimates in each study, the authors of this review calculated the confidence interval (CI) and the margin of error of the CI.

The evaluation of the methodological quality of the studies followed the criteria of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)(2929 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg. 2014;12(12):1495-9. http://dx.doi.org/10.1016/j.ijsu.2014.07.013. PMid:25046131.
http://dx.doi.org/10.1016/j.ijsu.2014.07...
,3030 Malta M, Cardoso LO, Bastos FI, Magnanini MMF, Silva CMFP. STROBE Initiative: grants paragraph communication observational studies. Rev Saude Publica. 2010;44(3):559-65. http://dx.doi.org/10.1590/S0034-89102010000300021. PMid:20549022.
http://dx.doi.org/10.1590/S0034-89102010...
).

RESULTS

A total of 1,361 articles were initially found. After applying the filters of eligibility, the final sample consisted of fifteen articles. The selection process is shown in Figure 1.

Figure 1
Flowchart for article selection

The analysis matrix with the characteristics of the studies that met the eligibility criteria(1212 Bomfim FMS, Chiari BM, Roque FP. Factors associated to suggestive signs of oropharyngeal dysphagia in institutionalized elderly women. CoDAS. 2013;25(2):154-63. http://dx.doi.org/10.1590/S2317-17822013000200011. PMid:24408245.
http://dx.doi.org/10.1590/S2317-17822013...
,1818 Van der Maarel-Wierink CD, Meijers JM, De Visschere LM, de Baat C, Halfens RJ, Schols JM. Subjective dysphagia in older care home residents: a crosssectional, multi-centre point prevalence measurement. Int J Nurs Stud. 2014;51(6):875-81. http://dx.doi.org/10.1016/j.ijnurstu.2013.10.016. PMid:24238894.
http://dx.doi.org/10.1016/j.ijnurstu.201...
,3131 Roque FP, Bomfim FMS, Chiari BM. Descrição da dinâmica de alimentação de idosas institucionalizadas. Rev Soc Bras Fonoaudiol. 2010;15(2):256-63. http://dx.doi.org/10.1590/S1516-80342010000200018.
http://dx.doi.org/10.1590/S1516-80342010...

32 Camacho MJT, Perozo MV, Sabaté AP, Acosta MEG. Disfagia en ancianos que viven en residencias geriátricas de Barcelona. Gerokomos. 2011;22(1):20-4.

33 Ferrero López MI, García Gollarte JF, Botella Trelis JJ, Juan Vidal O. Detección de disfagia en mayores institucionalizados. Rev Esp Geriatr Gerontol. 2012;47(4):143-7. http://dx.doi.org/10.1016/j.regg.2011.09.004. PMid:22264749.
http://dx.doi.org/10.1016/j.regg.2011.09...

34 Park Y, Han HR, Oh BM, Lee J, Park JA, Yu SJ, et al. Prevalence and associated factors of dysphagia in nursing home residents. Geriatr Nurs. 2013;34(3):212-7. http://dx.doi.org/10.1016/j.gerinurse.2013.02.014. PMid:23528180.
http://dx.doi.org/10.1016/j.gerinurse.20...

35 Nogueira D, Reis E. Swallowing disorders in nursing home residents: how can the problem be explained? Clin Interv Aging. 2013;8:8. http://dx.doi.org/10.2147/CIA.S39452. PMid:23449951.
http://dx.doi.org/10.2147/CIA.S39452...

36 Sarabia-Cobo CM, Pérez V, de Lorena P, Domínguez E, Hermosilla C, Nuñez MJ, et al. The incidence and prognostic implications of dysphagia in elderly patients institutionalized: a multicenter study in Spain. Appl Nurs Res. 2016;30:e6-9. http://dx.doi.org/10.1016/j.apnr.2015.07.001. PMid:26235494.
http://dx.doi.org/10.1016/j.apnr.2015.07...

37 Yatabe N, Takeuchi K, Izumi M, Furuta M, Takeshita T, Shibata Y, et al. Decreased cognitive function is associated with dysphagia risk in nursing home older residents. Gerodontology. 2018;35(4):1-6. http://dx.doi.org/10.1111/ger.12366. PMid:30028036.
http://dx.doi.org/10.1111/ger.12366...

38 Streicher M, Wirth R, Schindler K, Sieber CC, Hiesmayr M, Volkert D. Dysphagia in nursing homes: results from the NutritionDay Project. J Am Med Dir Assoc. 2018;19(2):141-147.e2. http://dx.doi.org/10.1016/j.jamda.2017.08.015. PMid:29030310.
http://dx.doi.org/10.1016/j.jamda.2017.0...

39 Namasivayam-MacDonald AM, Morrison JM, Steele CM, Keller H. How swallow pressures and dysphagia affect malnutrition and mealtime outcomes in long-term care. Dysphagia. 2017;32(6):785-96. http://dx.doi.org/10.1007/s00455-017-9825-z. PMid:28733775.
http://dx.doi.org/10.1007/s00455-017-982...

40 Fernández-Getino Sallés C. Prevalencia de disfagia orofaríngea en ancianos institucionalizados y su relación con síndromes geriátricos. Rev Logop Fon Audiol. 2018;38(2):69-76. http://dx.doi.org/10.1016/j.rlfa.2017.09.001.
http://dx.doi.org/10.1016/j.rlfa.2017.09...

41 Jukic Peladic N, Orlandoni P, Dell’Aquila G, Carrieri B, Eusebi P, Landi F, et al. Dysphagia in nursing home residents: management and outcomes. J Am Med Dir Assoc. 2019;20(2):147-51. http://dx.doi.org/10.1016/j.jamda.2018.07.023. PMid:30249360.
http://dx.doi.org/10.1016/j.jamda.2018.0...

42 Huppertz VAL, Halfens RJG, Van Hel Voort A, De Groot LCPGM, Baijens LWJ, Schols JMGA. Association between oropharyngeal dysphagia and malnutrition in dutch nursing home residents: results of the national prevalence measurement of quality of care. J Nutr Health Aging. 2018;22(10):1246-52. http://dx.doi.org/10.1007/s12603-018-1103-8. PMid:30498833.
http://dx.doi.org/10.1007/s12603-018-110...
-4343 Hoshino D, Watanabe Y, Edahiro A, Kugimiya Y, Igarashi K, Motokawa K, et al. Association between simple evaluation of eating and swallowing function and mortality among patients with advanced dementia in nursing homes: 1-year prospective cohort study. Arch Gerontol Geriatr. 2020;87:103969. http://dx.doi.org/10.1016/j.archger.2019.103969. PMid:31783307.
http://dx.doi.org/10.1016/j.archger.2019...
) is shown in Box 1.

Box 1
Analysis matrix with the characteristics of the studies included in the integrative review

The articles included were published between 2010 and 2020, with emphasis on the greater concentration of studies published by European researchers. The samples were heterogeneous regarding the number of LTCF participants and the number of older alduts, with the smallest sample consisting of 30 older adults and the largest of 23,549 in a multicenter study. In all articles, the population was predominantly female, with a mean age above 80 years old.

The concept of oropharyngeal dysphagia was different between studies and without an explicit definition in three cases. None of the methods described in the articles reported the use of instrumental exams for the evaluation and diagnosis of oropharyngeal dysphagia. Eleven studies used the clinical evaluation of swallowing and four developed their own questionnaires to determine the presence of oropharyngeal dysphagia.

The frequency of oropharyngeal dysphagia ranged widely between 5.4% (CI of 95%: 4.34-6.45)(3232 Camacho MJT, Perozo MV, Sabaté AP, Acosta MEG. Disfagia en ancianos que viven en residencias geriátricas de Barcelona. Gerokomos. 2011;22(1):20-4.) and 83.7% (CI of 95%: 79.60-87.79)(4343 Hoshino D, Watanabe Y, Edahiro A, Kugimiya Y, Igarashi K, Motokawa K, et al. Association between simple evaluation of eating and swallowing function and mortality among patients with advanced dementia in nursing homes: 1-year prospective cohort study. Arch Gerontol Geriatr. 2020;87:103969. http://dx.doi.org/10.1016/j.archger.2019.103969. PMid:31783307.
http://dx.doi.org/10.1016/j.archger.2019...
). Frequency estimates were higher in studies that used clinical tests(1212 Bomfim FMS, Chiari BM, Roque FP. Factors associated to suggestive signs of oropharyngeal dysphagia in institutionalized elderly women. CoDAS. 2013;25(2):154-63. http://dx.doi.org/10.1590/S2317-17822013000200011. PMid:24408245.
http://dx.doi.org/10.1590/S2317-17822013...
,3333 Ferrero López MI, García Gollarte JF, Botella Trelis JJ, Juan Vidal O. Detección de disfagia en mayores institucionalizados. Rev Esp Geriatr Gerontol. 2012;47(4):143-7. http://dx.doi.org/10.1016/j.regg.2011.09.004. PMid:22264749.
http://dx.doi.org/10.1016/j.regg.2011.09...
,3434 Park Y, Han HR, Oh BM, Lee J, Park JA, Yu SJ, et al. Prevalence and associated factors of dysphagia in nursing home residents. Geriatr Nurs. 2013;34(3):212-7. http://dx.doi.org/10.1016/j.gerinurse.2013.02.014. PMid:23528180.
http://dx.doi.org/10.1016/j.gerinurse.20...
,3939 Namasivayam-MacDonald AM, Morrison JM, Steele CM, Keller H. How swallow pressures and dysphagia affect malnutrition and mealtime outcomes in long-term care. Dysphagia. 2017;32(6):785-96. http://dx.doi.org/10.1007/s00455-017-9825-z. PMid:28733775.
http://dx.doi.org/10.1007/s00455-017-982...
,4040 Fernández-Getino Sallés C. Prevalencia de disfagia orofaríngea en ancianos institucionalizados y su relación con síndromes geriátricos. Rev Logop Fon Audiol. 2018;38(2):69-76. http://dx.doi.org/10.1016/j.rlfa.2017.09.001.
http://dx.doi.org/10.1016/j.rlfa.2017.09...
,4343 Hoshino D, Watanabe Y, Edahiro A, Kugimiya Y, Igarashi K, Motokawa K, et al. Association between simple evaluation of eating and swallowing function and mortality among patients with advanced dementia in nursing homes: 1-year prospective cohort study. Arch Gerontol Geriatr. 2020;87:103969. http://dx.doi.org/10.1016/j.archger.2019.103969. PMid:31783307.
http://dx.doi.org/10.1016/j.archger.2019...
). However, more precise confidence intervals were observed, that is, with lower margins of error, in studies with larger samples and that used questionnaires(1818 Van der Maarel-Wierink CD, Meijers JM, De Visschere LM, de Baat C, Halfens RJ, Schols JM. Subjective dysphagia in older care home residents: a crosssectional, multi-centre point prevalence measurement. Int J Nurs Stud. 2014;51(6):875-81. http://dx.doi.org/10.1016/j.ijnurstu.2013.10.016. PMid:24238894.
http://dx.doi.org/10.1016/j.ijnurstu.201...
,3232 Camacho MJT, Perozo MV, Sabaté AP, Acosta MEG. Disfagia en ancianos que viven en residencias geriátricas de Barcelona. Gerokomos. 2011;22(1):20-4.,3838 Streicher M, Wirth R, Schindler K, Sieber CC, Hiesmayr M, Volkert D. Dysphagia in nursing homes: results from the NutritionDay Project. J Am Med Dir Assoc. 2018;19(2):141-147.e2. http://dx.doi.org/10.1016/j.jamda.2017.08.015. PMid:29030310.
http://dx.doi.org/10.1016/j.jamda.2017.0...
,4242 Huppertz VAL, Halfens RJG, Van Hel Voort A, De Groot LCPGM, Baijens LWJ, Schols JMGA. Association between oropharyngeal dysphagia and malnutrition in dutch nursing home residents: results of the national prevalence measurement of quality of care. J Nutr Health Aging. 2018;22(10):1246-52. http://dx.doi.org/10.1007/s12603-018-1103-8. PMid:30498833.
http://dx.doi.org/10.1007/s12603-018-110...
).

The methodological quality of the studies included in this review is shown in Box 2. According to the STROBE guidelines, the most unsatisfactory items were 12c, 13c, 14b, and 22. None of the fifteen studies met all the evaluation criteria of methodological quality.

Box 2
Classification of methodological quality of studies according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines

DISCUSSION

This review indicated wide variability in the frequency of oropharyngeal dysphagia in older adults living in LTCF, besides indicating heterogeneous methodological approaches between studies. There was a greater concentration of research in European countries, in which the occurrence of oropharyngeal dysphagia in older adults living in nursing homes exceeded 60%(3333 Ferrero López MI, García Gollarte JF, Botella Trelis JJ, Juan Vidal O. Detección de disfagia en mayores institucionalizados. Rev Esp Geriatr Gerontol. 2012;47(4):143-7. http://dx.doi.org/10.1016/j.regg.2011.09.004. PMid:22264749.
http://dx.doi.org/10.1016/j.regg.2011.09...
,3636 Sarabia-Cobo CM, Pérez V, de Lorena P, Domínguez E, Hermosilla C, Nuñez MJ, et al. The incidence and prognostic implications of dysphagia in elderly patients institutionalized: a multicenter study in Spain. Appl Nurs Res. 2016;30:e6-9. http://dx.doi.org/10.1016/j.apnr.2015.07.001. PMid:26235494.
http://dx.doi.org/10.1016/j.apnr.2015.07...
,4444 Baijens LW, Clavé P, Cras P, Ekberg O, Forster A, Kolb GF, et al. European Society for Swallowing Disorders – European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome. Clin Interv Aging. 2016;11:1403-28. http://dx.doi.org/10.2147/CIA.S107750. PMid:27785002.
http://dx.doi.org/10.2147/CIA.S107750...
). It is estimated that up to 40 million Europeans, 16 million Americans, and 8 million Japanese are in need of care for dysphagia(4545 Dziewas R, Beck AM, Clave P, Hamdy S, Heppner HJ, Langmore SE, et al. Recognizing the importance of dysphagia: stumbling blocks and stepping stones in the twenty-first century. Dysphagia. 2017;32(1):78-82. http://dx.doi.org/10.1007/s00455-016-9746-2. PMid:27571768.
http://dx.doi.org/10.1007/s00455-016-974...
), figures that should increase even more with the increasing number of very old adults, that is, those over 85 years old in developed countries and over 80 in underdeveloped countries(22 United Nations. World population prospects 2019 volume II: demographic profiles. New York: United Nations; 2019.).

In all articles, the mean age of the individuals was above 80 years old. In general, the profile of very old adults comprises individuals who require more assistance for to the presence of dementia(4646 Irles Rocamora JA, Sánchez-Duque MJ, de Valle Galindo PB, Bernal López E, Fernández Palacín A, Almeida González C, et al. A prevalence study of dysphagia and intervention with dietary counselling in nursing home from Seville. Nutr Hosp. 2009;24(4):498-503. PMid:19721932.), dependency, and various comorbidities that impair various activities of daily living, including feeding(4747 Simmons SF, Schnelle JF. Feeding assistance needs of long-stay nursing home residents and staff time to provide care. J Am Geriatr Soc. 2006;54(6):919-24. http://dx.doi.org/10.1111/j.1532-5415.2006.00812.x. PMid:16776786.
http://dx.doi.org/10.1111/j.1532-5415.20...
). Studies have already shown, in these cases, family’s absence, family’s difficulty in caring, and conflictual family relations combined with the lack of income and homelessness as factors associated with the increased need of these older adults for support from long-term care facilities(4848 OMS: Organização Mundial de Saúde. Relatório mundial de envelhecimento e saúde. OMS; 2015.,4949 Souza IAL, Massi G. Rev. A saúde fonoaudiológica a partir do discurso do idoso institucionalizado. CEFAC. 2015;17(1):300-7. http://dx.doi.org/10.1590/1982-0216201519413.
http://dx.doi.org/10.1590/1982-021620151...
).

The sample profile of all studies included was presented predominance of females. The predominance of females among individuals aged 60 years or older is reported in several other studies and is related to what is called the feminization of aging, characterized by women's higher rates in the population of older adults, especially at older ages(5050 Drummond A, Alves ED. Perfil socioeconômico e demográfico e a capacidade funcional de idosos atendidos pela Estratégia Saúde da Família de Paranoá, Distrito Federal. Rev Bras Geriatr Gerontol. 2013;16(4):727-38. http://dx.doi.org/10.1590/S1809-98232013000400007.
http://dx.doi.org/10.1590/S1809-98232013...

51 Confortin SC, Antes DL, Pessini J, Schneider IJC, d’Orsi E, Barbosa AR. Comparação do perfil socioeconômico e condições de saúde de idosos residentes em áreas predominantemente rural e urbana da Grande Florianópolis, Sul do Brasil. Cad Saude Colet. 2016;24(3):330-8. http://dx.doi.org/10.1590/1414-462x201600030034.
http://dx.doi.org/10.1590/1414-462x20160...
-5252 Sousa NFS, Lima MG, Cesar CLG, Barros MBA. Envelhecimento ativo: prevalência e diferenças de gênero e idade em estudo de base populacional. Cad Saude Publica. 2018;34(11):e00173317. http://dx.doi.org/10.1590/0102-311x00173317. PMid:30484561.
http://dx.doi.org/10.1590/0102-311x00173...
). This is caused by aspects such as better and more frequent self-care in health, less exposure to death from external causes when younger, less exposure to unhealthy occupational environments, stricter care with food, and preservation of a lifestyle that is less harmful to health(5353 Silva SPC, Menandro MCS. As representações sociais da saúde e de seus cuidados para homens e mulheres idosos. Saude Soc. 2014;23(2):626-40. http://dx.doi.org/10.1590/S0104-12902014000200022.
http://dx.doi.org/10.1590/S0104-12902014...
,5454 Oliveira AC, Santos AA, Pavirini SCI. Relação entre sintomas depressivos e a funcionalidade familiar de idosos institucionalizados. Rev Esc Enferm USP. 2014;48(1):66-72. PMid:24676110.).

Contrary to the age and sex profile, the samples showed great heterogeneity regarding the number of older adults in terms of the number of people living in LTCFs. The smallest sample comprised 30 older adult women(1212 Bomfim FMS, Chiari BM, Roque FP. Factors associated to suggestive signs of oropharyngeal dysphagia in institutionalized elderly women. CoDAS. 2013;25(2):154-63. http://dx.doi.org/10.1590/S2317-17822013000200011. PMid:24408245.
http://dx.doi.org/10.1590/S2317-17822013...
,3131 Roque FP, Bomfim FMS, Chiari BM. Descrição da dinâmica de alimentação de idosas institucionalizadas. Rev Soc Bras Fonoaudiol. 2010;15(2):256-63. http://dx.doi.org/10.1590/S1516-80342010000200018.
http://dx.doi.org/10.1590/S1516-80342010...

32 Camacho MJT, Perozo MV, Sabaté AP, Acosta MEG. Disfagia en ancianos que viven en residencias geriátricas de Barcelona. Gerokomos. 2011;22(1):20-4.

33 Ferrero López MI, García Gollarte JF, Botella Trelis JJ, Juan Vidal O. Detección de disfagia en mayores institucionalizados. Rev Esp Geriatr Gerontol. 2012;47(4):143-7. http://dx.doi.org/10.1016/j.regg.2011.09.004. PMid:22264749.
http://dx.doi.org/10.1016/j.regg.2011.09...

34 Park Y, Han HR, Oh BM, Lee J, Park JA, Yu SJ, et al. Prevalence and associated factors of dysphagia in nursing home residents. Geriatr Nurs. 2013;34(3):212-7. http://dx.doi.org/10.1016/j.gerinurse.2013.02.014. PMid:23528180.
http://dx.doi.org/10.1016/j.gerinurse.20...

35 Nogueira D, Reis E. Swallowing disorders in nursing home residents: how can the problem be explained? Clin Interv Aging. 2013;8:8. http://dx.doi.org/10.2147/CIA.S39452. PMid:23449951.
http://dx.doi.org/10.2147/CIA.S39452...

36 Sarabia-Cobo CM, Pérez V, de Lorena P, Domínguez E, Hermosilla C, Nuñez MJ, et al. The incidence and prognostic implications of dysphagia in elderly patients institutionalized: a multicenter study in Spain. Appl Nurs Res. 2016;30:e6-9. http://dx.doi.org/10.1016/j.apnr.2015.07.001. PMid:26235494.
http://dx.doi.org/10.1016/j.apnr.2015.07...

37 Yatabe N, Takeuchi K, Izumi M, Furuta M, Takeshita T, Shibata Y, et al. Decreased cognitive function is associated with dysphagia risk in nursing home older residents. Gerodontology. 2018;35(4):1-6. http://dx.doi.org/10.1111/ger.12366. PMid:30028036.
http://dx.doi.org/10.1111/ger.12366...

38 Streicher M, Wirth R, Schindler K, Sieber CC, Hiesmayr M, Volkert D. Dysphagia in nursing homes: results from the NutritionDay Project. J Am Med Dir Assoc. 2018;19(2):141-147.e2. http://dx.doi.org/10.1016/j.jamda.2017.08.015. PMid:29030310.
http://dx.doi.org/10.1016/j.jamda.2017.0...

39 Namasivayam-MacDonald AM, Morrison JM, Steele CM, Keller H. How swallow pressures and dysphagia affect malnutrition and mealtime outcomes in long-term care. Dysphagia. 2017;32(6):785-96. http://dx.doi.org/10.1007/s00455-017-9825-z. PMid:28733775.
http://dx.doi.org/10.1007/s00455-017-982...
-4040 Fernández-Getino Sallés C. Prevalencia de disfagia orofaríngea en ancianos institucionalizados y su relación con síndromes geriátricos. Rev Logop Fon Audiol. 2018;38(2):69-76. http://dx.doi.org/10.1016/j.rlfa.2017.09.001.
http://dx.doi.org/10.1016/j.rlfa.2017.09...
) and the largest 23,549 older adults(3838 Streicher M, Wirth R, Schindler K, Sieber CC, Hiesmayr M, Volkert D. Dysphagia in nursing homes: results from the NutritionDay Project. J Am Med Dir Assoc. 2018;19(2):141-147.e2. http://dx.doi.org/10.1016/j.jamda.2017.08.015. PMid:29030310.
http://dx.doi.org/10.1016/j.jamda.2017.0...
). Differences in sample size in the different studies and geographical locations highlight the difficulty to accurately determine the frequency of oropharyngeal dysphagia in older adults living in nursing homes, which was evident when the margins of error of the estimates were observed. Thus, it is worth highlighting the importance of the sample calculation design and the sampling process for obtaining more accurate and reliable data. The conduction of prevalence studies, that is, with representative and population-based samples, should be encouraged in order to have the real dimension of the problem in the community of older adults residing in LTCF.

The results revealed a heterogeneous understanding of the researchers on the conceptual definition of oropharyngeal dysphagia. In general, most articles recognized this outcome as a change, difficulty, discomfort, disorder, or impairment in swallowing(1212 Bomfim FMS, Chiari BM, Roque FP. Factors associated to suggestive signs of oropharyngeal dysphagia in institutionalized elderly women. CoDAS. 2013;25(2):154-63. http://dx.doi.org/10.1590/S2317-17822013000200011. PMid:24408245.
http://dx.doi.org/10.1590/S2317-17822013...
,1919 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):858-65. http://dx.doi.org/10.1177/000348940711601112. PMid:18074673.
http://dx.doi.org/10.1177/00034894071160...
,3232 Camacho MJT, Perozo MV, Sabaté AP, Acosta MEG. Disfagia en ancianos que viven en residencias geriátricas de Barcelona. Gerokomos. 2011;22(1):20-4.

33 Ferrero López MI, García Gollarte JF, Botella Trelis JJ, Juan Vidal O. Detección de disfagia en mayores institucionalizados. Rev Esp Geriatr Gerontol. 2012;47(4):143-7. http://dx.doi.org/10.1016/j.regg.2011.09.004. PMid:22264749.
http://dx.doi.org/10.1016/j.regg.2011.09...

34 Park Y, Han HR, Oh BM, Lee J, Park JA, Yu SJ, et al. Prevalence and associated factors of dysphagia in nursing home residents. Geriatr Nurs. 2013;34(3):212-7. http://dx.doi.org/10.1016/j.gerinurse.2013.02.014. PMid:23528180.
http://dx.doi.org/10.1016/j.gerinurse.20...

35 Nogueira D, Reis E. Swallowing disorders in nursing home residents: how can the problem be explained? Clin Interv Aging. 2013;8:8. http://dx.doi.org/10.2147/CIA.S39452. PMid:23449951.
http://dx.doi.org/10.2147/CIA.S39452...

36 Sarabia-Cobo CM, Pérez V, de Lorena P, Domínguez E, Hermosilla C, Nuñez MJ, et al. The incidence and prognostic implications of dysphagia in elderly patients institutionalized: a multicenter study in Spain. Appl Nurs Res. 2016;30:e6-9. http://dx.doi.org/10.1016/j.apnr.2015.07.001. PMid:26235494.
http://dx.doi.org/10.1016/j.apnr.2015.07...
-3737 Yatabe N, Takeuchi K, Izumi M, Furuta M, Takeshita T, Shibata Y, et al. Decreased cognitive function is associated with dysphagia risk in nursing home older residents. Gerodontology. 2018;35(4):1-6. http://dx.doi.org/10.1111/ger.12366. PMid:30028036.
http://dx.doi.org/10.1111/ger.12366...
,3939 Namasivayam-MacDonald AM, Morrison JM, Steele CM, Keller H. How swallow pressures and dysphagia affect malnutrition and mealtime outcomes in long-term care. Dysphagia. 2017;32(6):785-96. http://dx.doi.org/10.1007/s00455-017-9825-z. PMid:28733775.
http://dx.doi.org/10.1007/s00455-017-982...
,4141 Jukic Peladic N, Orlandoni P, Dell’Aquila G, Carrieri B, Eusebi P, Landi F, et al. Dysphagia in nursing home residents: management and outcomes. J Am Med Dir Assoc. 2019;20(2):147-51. http://dx.doi.org/10.1016/j.jamda.2018.07.023. PMid:30249360.
http://dx.doi.org/10.1016/j.jamda.2018.0...
). Only two studies mentioned efficacy and/or insecurity in their definitions(3838 Streicher M, Wirth R, Schindler K, Sieber CC, Hiesmayr M, Volkert D. Dysphagia in nursing homes: results from the NutritionDay Project. J Am Med Dir Assoc. 2018;19(2):141-147.e2. http://dx.doi.org/10.1016/j.jamda.2017.08.015. PMid:29030310.
http://dx.doi.org/10.1016/j.jamda.2017.0...
,4040 Fernández-Getino Sallés C. Prevalencia de disfagia orofaríngea en ancianos institucionalizados y su relación con síndromes geriátricos. Rev Logop Fon Audiol. 2018;38(2):69-76. http://dx.doi.org/10.1016/j.rlfa.2017.09.001.
http://dx.doi.org/10.1016/j.rlfa.2017.09...
) and three did not make the concept explicit(3131 Roque FP, Bomfim FMS, Chiari BM. Descrição da dinâmica de alimentação de idosas institucionalizadas. Rev Soc Bras Fonoaudiol. 2010;15(2):256-63. http://dx.doi.org/10.1590/S1516-80342010000200018.
http://dx.doi.org/10.1590/S1516-80342010...
,4242 Huppertz VAL, Halfens RJG, Van Hel Voort A, De Groot LCPGM, Baijens LWJ, Schols JMGA. Association between oropharyngeal dysphagia and malnutrition in dutch nursing home residents: results of the national prevalence measurement of quality of care. J Nutr Health Aging. 2018;22(10):1246-52. http://dx.doi.org/10.1007/s12603-018-1103-8. PMid:30498833.
http://dx.doi.org/10.1007/s12603-018-110...
,4343 Hoshino D, Watanabe Y, Edahiro A, Kugimiya Y, Igarashi K, Motokawa K, et al. Association between simple evaluation of eating and swallowing function and mortality among patients with advanced dementia in nursing homes: 1-year prospective cohort study. Arch Gerontol Geriatr. 2020;87:103969. http://dx.doi.org/10.1016/j.archger.2019.103969. PMid:31783307.
http://dx.doi.org/10.1016/j.archger.2019...
). This result indicates that the lack of conceptual standardization is critical and limits obtaining valid, accurate, and reliable information on the frequency of oropharyngeal dysphagia in LTCFs.

The results of this review showed that the estimate of the frequency of oropharyngeal dysphagia in older adults living in nursing homes has wide variation in the literature (5.4% to 83.7%), which evidenced the difficulty in determining this data in the studied population. Besides aspects aforementioned, such as sample size and the concept of oropharyngeal dysphagia, another characteristic that may explain this wide variation of frequency is the use of different instruments to determine the presence of the outcome.

In this review, the lowest frequencies were observed in research that used questionnaires and the highest when the clinical evaluation of swallowing was conducted. Questionnaires are faster and cheaper alternatives in studies with more robust samples, in which diagnosis through clinical tests is less viable, and when the objective is to conduct an epidemiological diagnosis. In this review, frequent use of questionnaires in studies with larger samples was observed, which resulted in lower estimates, although being more accurate if compared to those obtained by clinical tests. It is necessary to emphasize that, to date, there are no questionnaires with methodological quality and sufficient psychometric properties for screening oropharyngeal dysphagia in older adults(5555 Magalhães HV Jr, Pernambuco LA, Lima KC, Ferreira MAF. Screening for oropharyngeal dysphagia in older adults: A systematic review of self-reported questionnaires. Gerodontology. 2018;35(3):162-9. http://dx.doi.org/10.1111/ger.12333. PMid:29611876.
http://dx.doi.org/10.1111/ger.12333...
), although there are efforts in this direction, especially considering the applicability in epidemiological studies(5656 Magalhães HV Jr, Pernambuco LA, Cavalcanti RVA, Lima KC, Ferreira MAF. Validity evidence of an epidemiological oropharyngeal dysphagia screening questionnaire for older adults. Clinics. 2020;75:e1425.; published online Jan 10, 2020. http://dx.doi.org/10.6061/clinics/2020/e1425. PMid:31939561.
http://dx.doi.org/10.6061/clinics/2020/e...
). Thus, the questionnaires used in the studies included in this review have this limitation and this is an aspect that must be considered when analyzing the frequency estimates found.

In addition, it is known that the population of older adults accepts swallowing disorders as an untreatable and natural event of aging(5757 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. http://dx.doi.org/10.1007/s00455-001-0113-5. PMid:11956839.
http://dx.doi.org/10.1007/s00455-001-011...
), which ends up impairing the recognition of oropharyngeal dysphagia symptoms and the reliability of self-reported information. The absence of questionnaires validated together with a possible attitude of resignation to the symptom by the population can help explain the result observed in this review. Considering this scenario, it is clear that there is a lack of prevalence studies that use appropriate instruments for the epidemiological diagnosis of oropharyngeal dysphagia in older adults. Thus, we recommend researchers to be careful and select to use the instrument with the best evidence of validity and reliability possible when planning their research.

Regarding the clinical resources to detect oropharyngeal dysphagia in older adults, there is no consensus on the use of a single instrument(5858 Leder SB, Suiter DM, Warner HL. Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia. 2009;24(3):290-5. http://dx.doi.org/10.1007/s00455-008-9204-x. PMid:19263106.
http://dx.doi.org/10.1007/s00455-008-920...
), which was observed in this review by the diversity found. In addition, no study used instrumental exams to evaluate oropharyngeal dysphagia. It is known that the clinical evaluation of swallowing in some situations is not sufficient to accurately detect the presence of dysphagia, since it is not sensitive, for example, to the detection of residues in difficult locations, which can lead to delayed aspiration, requiring the use of instrumental methods for evaluation(5959 Sordi M, Mourão LF, Silva AA, Flosi LCL. Importância da interdisciplinaridade na avaliação das disfagias: avaliação clínica e videofluoroscópica da deglutição. Rev Bras Otorrinolaringol. 2009;75(6):776-87.).

However, the use of instrumental diagnostic procedures is not always accessible in daily practice for economic restrictions, limitation of professionals, and lack of equipment(6060 Hammond CAS, Goldstein LB. Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1, Supl):154S-68S. http://dx.doi.org/10.1378/chest.129.1_suppl.154S. PMid:16428705.
http://dx.doi.org/10.1378/chest.129.1_su...
). In addition, it is not necessary or viable to conduct a complete evaluation on all individuals(6161 Suiter D. Dysphagia Screening: challenges and controversies. Perspect ASHA Spec Interest Groups. 2018;3(13):82-8. http://dx.doi.org/10.1044/persp3.SIG13.82.
http://dx.doi.org/10.1044/persp3.SIG13.8...
), and for these reasons non-instrumental diagnostic procedures should be focused on producing results with the best accuracy possible.

Accuracy is a property of efficiency of the diagnostic procedure and represents the degree of agreement between the result of the procedure and the outcome of the best method available to determine the presence or absence of a health condition(6262 Schünemann HJ, Oxman AD, Brozek J, Glasziou P, Jaeschke R, Vist GE, et al. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ. 2008;336(7653):1106-10. http://dx.doi.org/10.1136/bmj.39500.677199.AE. PMid:18483053.
http://dx.doi.org/10.1136/bmj.39500.6771...

63 Rutjes AW, Reitsma JB, Coomarasamy A, Khan KS, Bossuyt PM. Evaluation of diagnostic tests when there is no gold standard: a review of methods. Health Technol Assess. 2007;11(50):iii-51. http://dx.doi.org/10.3310/hta11500. PMid:18021577.
http://dx.doi.org/10.3310/hta11500...
-6464 Umemneku Chikere CM, Wilson K, Graziadio S, Vale L, Allen AJ. Diagnostic test evaluation methodology: a systematic review of methods employed to evaluate diagnostic tests in the absence of gold standard: an update. PLoS One. 2019;14(10):e0223832. http://dx.doi.org/10.1371/journal.pone.0223832. PMid:31603953.
http://dx.doi.org/10.1371/journal.pone.0...
), which in the case of oropharyngeal dysphagia could be the videofluoroscopy or videoendoscopy of swallowing(6161 Suiter D. Dysphagia Screening: challenges and controversies. Perspect ASHA Spec Interest Groups. 2018;3(13):82-8. http://dx.doi.org/10.1044/persp3.SIG13.82.
http://dx.doi.org/10.1044/persp3.SIG13.8...
). Accuracy determines the power of the diagnostic test to discriminate who is affected or not by the health condition investigated(6464 Umemneku Chikere CM, Wilson K, Graziadio S, Vale L, Allen AJ. Diagnostic test evaluation methodology: a systematic review of methods employed to evaluate diagnostic tests in the absence of gold standard: an update. PLoS One. 2019;14(10):e0223832. http://dx.doi.org/10.1371/journal.pone.0223832. PMid:31603953.
http://dx.doi.org/10.1371/journal.pone.0...
) and reflects the various relationships between true and false positives and negatives through indicators such as sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio. and ROC curve (receiver operator characteristic curve)(6565 Pernambuco L, Espelt A, Magalhães HV, Lima KC. Recommendations for elaboration, transcultural adaptation and validation process of tests in Speech, Hearing and Language Pathology. CoDAS. 2017;29(3):e20160217. PMid:28614460.).

The different evaluation instruments used in the studies included in this integrative review also have different or even uninvestigated accuracy, which directly interferes with the reliability and accuracy of the estimates found and reflects the difficulty in determining an evaluation or tracing instrument that gathers sufficient evidence to be implemented in practice.

Thus, the results presented in this review attested that although oropharyngeal dysphagia is a condition known to be present in older adults residing in LTCFs, the studies available so far addressing the frequency of this condition in this population are very different methodologically and do not allow estimating data accurately. In addition, it is necessary to reflect on the conceptual standardization on the outcome, the need for epidemiological studies, and the development of viable instruments that produce valid and reliable results for the diagnosis of oropharyngeal dysphagia in older adults living in nursing homes.

CONCLUSION

The frequency of oropharyngeal dysphagia in older adults living in nursing homes ranged between 5.4% and 83.7%, with methodological discrepancies regarding sample size, the concept of oropharyngeal dysphagia, and evaluation instruments used for diagnosis.

Appendix A Search strategies used in databases

Database Descriptors
Pubmed/Medline ((((“nursing homes”[MeSH Terms]) OR (“nursing home”[Title/Abstract])) OR (“long term care facilities”[Title/Abstract])) OR (“home for the aged”[Title/Abstract])) AND (((((“deglutition”[MeSH Terms]) OR (deglutition disorder[MeSH Terms])) OR (dysphagia[Title/Abstract])) OR (swallowing[Title/Abstract])) OR (deglutition[Title/Abstract]))
Web of Science TS=((dysphagia OR (deglutition OR swallow*)) AND (“nursing home” OR (“nursing homLes” OR “long term care facility” OR “long term care facilities”)))
Scopus TITLE-ABS-KEY((dysphagia OR (deglutition OR swallow*)) AND (“nursing home” OR (“nursing homes” OR “long term care facility” OR “long term care facilities”)))
LILACS “DISFAGIA” [Palavras] and “INSTITUICAO DE LONGA PERMANENCIA PARA IDOSOS” [Palavras]
SciELO “DISFAGIA” [Palavras] and “INSTITUICAO DE LONGA PERMANENCIA PARA IDOSOS” [Palavras]
  • Study conducted at Programa Associado de Pós-graduação em Fonoaudiologia, Universidade Federal da Paraíba – UFPB - João Pessoa (PB), Brasil.
  • Financial support: nothing to declare.

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Publication Dates

  • Publication in this collection
    16 June 2021
  • Date of issue
    2021

History

  • Received
    28 May 2020
  • Accepted
    13 July 2020
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