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Prevalence and management of dysphagia in nursing home residents in Europe and Israel: the SHELTER Project



Dysphagia is a frequent condition in older nursing home residents (NHRs) which may cause malnutrition and death. Nevertheless, its prevalence is still underestimated and there is still debate about the appropriateness and efficacy of artificial nutrition (AN) in subjects with severe dysphagia. The aim is to assess the prevalence of dysphagia in European and Israeli NHRs, its association with mortality, and the relationship of different nutritional interventions, i.e. texture modified diets and AN—with weight loss and mortality.


A prospective observational study of 3451 European and Israeli NHRs older than 65 years, participating in the SHELTER study from 2009 to 2011, at baseline and after 12 months. All residents underwent a standardized comprehensive evaluation using the interRAI Long Term Care Facility (LTCF). Cognitive status was assessed using the Cognitive Performance Scale (CPS), functional status using Activities of Daily Living (ADL) Hierarchy scale. Trained staff assessed dysphagia at baseline by clinical observation. Data on weight loss were collected for all participants at baseline and after 12 months. Deaths were registered by NH staff.


The prevalence of dysphagia was 30.3%. During the one-year follow-up, the mortality rate in subjects with dysphagia was significantly higher compared with that of non-dysphagic subjects (31.3% vs 17.0%,p = 0,001). The multivariate analysis showed that NHRs with dysphagia had 58.0% higher risk of death within 1 year compared with non-dysphagic subjects (OR 1.58, 95% CI, 1.31–1.91). The majority of NHRs with dysphagia were prescribed texture modified diets (90.6%), while AN was used in less than 10% of subjects. No statistically significant difference was found concerning weight loss and mortality after 12 months following the two different nutritional treatments.


Dysphagia is prevalent among NHRs and it is associated with increased mortality, independent of the nutritional intervention used. Noticeably, after 12 months of nutritional intervention, NHRs treated with AN had similar mortality and weight loss compared to those who were treated with texture modified diets, despite the clinical conditions of patients on AN were more compromised.

Peer Review reports


Age-related physiological changes of the swallowing mechanism, the so-called presbyphagia, predominantly consist of a slowing and weakening of the different stages of deglutition: oral, pharyngeal and esophageal [1]. These changes are not always indicative of an impairment and may even be functional to safe swallowing [2,3,4,5,6,7]. In some cases, though, age-related changes could contribute to the onset of dysphagia i.e. the difficulty or impossibility in forming or moving a bolus efficiently and safely from the oral cavity to the esophagus [8]. The most common type among older subjects is oropharyngeal dysphagia [9]. Although some studies have identified the age as a significant single risk factor for dysphagia, changes in swallowing resulting from ageing are more frequently co-responsible for it, along with some diseases and the medicines used to treat them [6, 10,11,12]. Dysphagia is closely related to neurological and neurodegenerative diseases such as stroke, dementia and Parkinson’s disease, but also to sarcopenia, a skeletal muscle disorder due to loss of strength and muscle mass. [13,14,15,16]. Medication related adverse events, i.e. xerostomia, cognitive impairment and reduction of alertness, as well as polypharmacy, i.e. taking five or more medications daily, are also important risk factors for dysphagia [17,18,19,20]. In its initial stages, dysphagia may cause distress and anxiety, negatively affecting the quality of life of affected subjects [21]. Over time it may cause many life-threatening clinical conditions, such as undernutrition and dehydration, respiratory infections, aspiration pneumonia, and even death [22,23,24]. Nevertheless, despite the progressive aging of the population has made dysphagia an important concern for the public health, the knowledge on its prevalence and on the most appropriate methods of treatment presents still important knowledge gaps [25].

Studies have been performed using different screening and assessment tools, often including only small samples [26,27,28], thus making it difficult to define its prevalence, although it is known that dysphagia is particularly common among NHRs who have several risk factors: old age, neurological diseases, multimorbidity and polypharmacy [29,30,31,32].

Moreover, despite the evidence supporting the effectiveness of texture modified diets is still incomplete, the management of dysphagia in older subjects mainly consists in the adoption of that compensatory strategy whose aim is to prevent the onset of complications [33,34,35,36]. In the case of severe dysphagia, (AN)—enteral (EN) or parenteral (PN) -, is often prescribed [37]. However, the use of AN in severe dysphagia is still controversial and its effectiveness is often disputed.

We analyzed data from a large sample of NHRs who participated in the SHELTER study—the Services and Health for Elderly in Long TERm Care -, in order to investigate the prevalence of dysphagia in NHs, its association with mortality, and the effect of different types of nutritional intervention on weight loss and mortality.


SHELTER study sample

The SHELTER study is a prospective multinational cohort study that was performed from 2009 to 2011 in 57 Nursing Homes (NHs) of 7 European Union countries (Czech Republic, England, Finland, France, Germany, Italy, and The Netherlands) and 1 non-EU country (Israel). The detailed methodology of the study has been previously described [38]. Older adults residing in participating NHs at the beginning of the study and those admitted in the 3-month enrolment period following the initiation of the study were invited by each NH to participate in the study. Ethical approval was obtained from the ethics committees of the participating centers and informed consent was obtained from all subjects or their legal guardian. Subjects who accepted to participate and signed the written consent were assessed at baseline and reassessed after 12 months. The study was in Accordance with the Declaration of Helsinki. All experiments were performed in accordance with relevant guidelines and regulations.

Data collection

Independent variables

Trained staff of each NH collected the data. At baseline, and after 12 months subjects underwent a standardized comprehensive evaluation using a validated instrument, i.e. the interRAI LTCF translated from the original English version into the languages of participating countries [39]. Multi-item summary scales embedded in the interRAI LTCF were used to measure residents’ characteristics. Cognitive status was assessed using the 7-point Multidimensional scaling (MDS) CPS, which combines information on memory impairment, level of consciousness, and executive function [40]. CPS score ranges from 0 to 6: a score ≥ 2 is diagnostic for dementia (comparable to MiniMental Status Examination (MMSE) ≤ 19), and a score higher than 4 indicates the presence of severe dementia. To evaluate functional status, the seven points MDS ADL Hierarchy scale, which groups activities of daily living according to the stage of the disablement process, was used [41]. The ADL Hierarchy scale ranges from 0 (no impairment) to 6 (total dependence). Medical history was obtained from the clinical records. Dysphagia was assessed by trained staff at baseline by clinical observation, without instrumental procedures. The evaluation included gathering information regarding the current swallowing problem, reviewing medical history, observing signs relevant to the residents’ medical status, observing the speech and swallowing structure, observing a patient during trial swallows, collecting data on nutrition therapy and diets and interviewing the personnel responsible for feeding assistance during meals. Subjects were grouped into two categories: dysphagic and non-dysphagic. Data on weight loss ≥ 5.0% in the last 3 months and/or ≥ 10.0% in the last 6 months were collected for all participants. Weight was registered after 12 months and the deaths have been recorded.

Statistical analysis

Continuous variables were described with means and standard deviations, while categorical ones were reported as count and percentages. The data were analyzed to test for significant differences of clinical and demographic variables between patients with and without dysphagia. Student T test was used for continuous variables and chi-square test for categorical ones. Nonparametric alternatives were used whenever appropriate. Predictors of mortality in the whole population were assessed using multivariate Cox proportional hazards regression models. In the absence of a conversion event, data were censored at the most recent clinic visit. After having assessed the role of each risk factor, a p-value lower than 0.20 was used as screening criterion to consider the risk factor as candidate for the multivariate analysis. This decreased the probability of incorrect rejection of potentially important variables due to uncontrolled confounding. Backward elimination based on the Akaike’s information criterion was used to select a final model. NHs were considered as strata in the Cox regression. Hazard proportionality was assessed through analysis of scaled Schoenfeld residuals whereas martingale residuals were plotted against continuous covariates to detect nonlinearity. A regression logistic model was used to compare weight loss in subjects with dysphagia treated with artificial nutrition vs those treated with modified diet. Multivariate Cox proportional hazards regression model was used to compare mortality in subjects with dysphagia treated with artificial nutrition vs those treated with modified diet. Significance level of 5% was assumed for all the analyses. Statistical analyses were performed using R software version 4.1


A total of 3451 NHRs were enrolled in the SHELTER study and were assessed for dysphagia. Swallowing difficulties were registered in 30.3% of subjects. Residents with dysphagia were significantly older than non-dysphagic residents and the prevalence of multimorbidity and other risk factors for dysphagia—severe dementia Parkinson’s disease, cerebrovascular diseases—was also significantly higher in subjects with swallowing difficulties (see Table 1). The number of drugs was higher in non-dysphagic residents.

Table 1 Baseline sociodemographic, functional, and clinical parameters according to the presence or absence of dysphagia N (%) or mean ± SD

At the time of the first assessment, 14.0% of the subjects with dysphagia had already registered the unintentional weight loss in the previous months compared with 6.9% of non dysphagic patients. The number of subjects who needed the assistance during meals was also significantly higher among dysphagic NHRs (90.0% vs. 51.1% respectively, p < 0.0001).

Dysphagia was identified as a significant risk factor for mortality. At 1-year follow up, the mortality rate in NHRs with dysphagia was statistically significantly higher than in non-dysphagic subjects (31.3% vs. 17.0%, p < 0.001). In the cox survival analysis NHRs with dysphagia had 58% higher risk of death within 1 year versus non dysphagic subjects (HR 1.58, 95% CI, 1.31–1.91), after adjustment for age, sex, loss of weight, pressure ulcer, congestive heart failure, cancer, COPD, disability, previous hospitalization, and nationality.

NHRs with dysphagia were mainly prescribed texture modified diets (90.6%). Less than 10% of residents with swallowing problems were treated with AN. The overall clinical conditions of subjects treated with EN and PN were particularly compromised: the prevalence of severe dementia was 86.2% compared with 59.1% in subjects with modified diet (p < 0.0001), and ADL disability score was higher, i.e. 5.7 against 4.8 (p < 0.0001).

At 1-year follow up, the prevalence of weight loss decreased in dysphagic subjects treated with AN, (from 11.0% at baseline to 9.1%) while it increased in those treated with modified diet (from 9.4% at baseline to 11.4%), but the difference was not statistically significant. Even in a logistic regression model, adjusted for statistically significant differences between the two groups—age, number of diseases, weight loss, pressure ulcers, CPS score, cerebrovascular disease, and depression—no relation between the AN and reduction of weight loss was found. Differently from the weight loss, after 12 months, the mortality was slightly higher in residents treated with AN when compared to those treated with texture modified diets (35.1% vs. 30.8%, respectively). However, the Cox survival model, after the adjustment for age, number of diseases, weight loss, pressure ulcers, CPS score, cerebrovascular disease, and depression, showed that the AN does not affect the survival (HR = 1.19 (95% CI = 0.73–1.94, p ns).


We retrospectively analyzed data of 3451 NHRs who participated in the SHELTER study to determine dysphagia prevalence, its association with mortality and the effect of different nutritional strategies adopted for its management on weight loss and mortality. In our study dysphagia was observed in 30.3% of NHRs, result in line with findings of previously published studies that, depending on screening and assessment tools used and on the number of participants enrolled, reported figures ranging from 9.0% to over 70% [28, 42]. As already reported in the literature, we found that dysphagia was associated with the greater occurrence of weight loss: 14.0% of subjects with dysphagia experienced weight loss in the months preceding the start of our study vs. 6.9% of non-dysphagic residents [43]. Subjects with dysphagia had a 1.58 higher 1-year risk of death compared to non-dysphagic subjects, which is again in range with findings of previously published studies [9, 32, 44,45,46,47]. Our findings on the prevalence and consequences of dysphagia confirm that it represents an issue of primary importance in NHs, which must be addressed and managed through specific protocols that provide clear indications for its diagnosis and specific management measures.

Concerning the management of dysphagia, some studies suggest that the feeding practice and assistance might be very helpful in preventing the aspiration pneumonia in subjects with dysphagia [48]. But despite the evidence supporting the effectiveness of texture modified diets in improving the nutritional status and preventing aspiration pneumonia is scant, diet modification is the most common intervention used to manage dysphagia in NHRs, as also observed in our study [34, 49,50,51,52,53]. On the contrary, the use of AN is a matter of intense dispute. In light of ethical considerations and considering that, according to most studies, EN and PN do not increase survival in subjects with advanced dementia, its initiation in those subjects has long been contested by most authors [54, 55]. Although other authors have shown that such criticisms are not entirely plausible, considering the low level of evidence supporting them, and that the AN does not have all the disadvantages attributed to it, this practice is actually decreasing, especially in the United States [56]. In the SHELTER cohort, texture modified diet was administered to subjects whose overall clinical conditions allowed feeding by mouth, while the AN was prescribed to only 9.4% of subjects, mostly with severe dementia. This figure is much lower than previously reported in the literature where the prevalence of AN in NHRs with dysphagia reaches up to 40.0% [32]. Nevertheless, despite the fact that the overall clinical conditions of subjects treated with AN were more compromised when compared to dysphagic residents treated with texture modified diets, we did not find that the outcomes of the two groups differed significantly. Diet modification and tube feeding did not affect differently either the loss of weight or mortality in dysphagic NHRs. These results confirm the finding of Wirth et al. who also found that the mortality rate of dysphagic residents receiving tube feeding was not significantly different from the mortality of other dysphagic residents, questioning the effectiveness of the modified diet in the prevention of weight loss in dysphagic subjects [44].

The strength of our study is that it was carried out in a large sample of European and Israeli NHRs but there are also some limitations. In the first place, dysphagia was diagnosed using only clinical observation. Observation is very important since it allows identifying signs of possible dysphagia like coughing, choking and drooling, or refusal to eat [28]. It represents indeed the most frequently used method to diagnose dysphagia in NHs. However, there are more accurate techniques and tools for dysphagia assessment, which might have identified a different and likely higher prevalence of dysphagia and provided also information on its severity [57]. EAT-10 for example is a very simple screening tool, which was found to be very effective in identifying subjects with swallowing difficulties [58,59,60]. Furthermore, modified diets include a large variety of diets of different textures suitable for different severity grades of swallowing problems, which we did not differentiate in this study. In addition, to evaluate the effectiveness of the modified diet in the management of the nutritional status, the calorie-protein needs, food provided and the intake should be assessed. For the assessment of nutritional status, which is an important outcome of nutrition therapy in subjects with dysphagia, no validated screening tools such as MUST or MNA were used, and only the weight loss was considered. Although numerous authors suggest the weight loss as the most relevant single indicator of nutritional status, other indicators should also be considered [61, 62].


Our study, which was performed in a large sample of European and Israeli NHs, confirmed that dysphagia is a common problem in that setting and that it represents an important risk factor for mortality. The main interventions adopted for dysphagia management are the modification of diet texture and AN but clinical outcomes—weight loss and mortality – of the subjects from the two intervention groups do not differ significantly. Further studies are needed to clarify the correct indications for diet consistency changes and AN in this vulnerable population.

Availability of data and materials

The datasets generated and/or analyzed during this current study are not publicly available due to ongoing use of data set but are available from the corresponding author on reasonable request.



Nursing home


Nursing home residents


Artificial nutrition


Enteral nutrition


Parenteral nutrition


Long term care facility


Mini mental state examination


Activities of daily living MMSE


Cognitive Performance Scale


Chronic obstructive pulmonary disease


  1. Muhle P, Suntrup-Krueger S, Wirth R, Warnecke T, Dziewas R. Schlucken im Alter: Physiologische Veränderungen, Schluckstörungen, Diagnostik und Therapie [Swallowing in the elderly: Physiological changes, dysphagia, diagnostics and treatment]. Z Gerontol Geriatr. 2019;52(3):279–89. (German).

    Article  CAS  PubMed  Google Scholar 

  2. Nakajima J, Karaho T, Kawahara K, et al. Latent changes in the pharyngeal stage of swallowing in non-aspirating older adults. Eur Geriatr Med. 2022;13:655–61.

    Article  PubMed  Google Scholar 

  3. Ekberg O, Feinberg MJ. Altered swallowing function in elderly patients without dysphagia: radiologic findings in 56 cases. AJR Am J Roentgenol. 1991;156(6):1181–4.

    Article  CAS  PubMed  Google Scholar 

  4. Tracy JF, Logemann JA, Kahrilas PJ, Jacob P, Kobara M, Krugler C. Preliminary observations on the effects of age on oropharyngeal deglutition. Dysphagia. 1989;4(2):90–4.

    Article  CAS  PubMed  Google Scholar 

  5. Schindler JS, Kelly JH. Swallowing disorders in the elderly. Laryngoscope. 2002;112(4):589–602.

    Article  PubMed  Google Scholar 

  6. Leslie P, Drinnan MJ, Ford GA, Wilson JA. Swallow respiratory patterns and aging: presbyphagia or dysphagia? J Gerontol A Biol Sci Med Sci. 2005;60(3):391–5.

    Article  PubMed  Google Scholar 

  7. Wirth R, et al. Oropharyngeal dysphagia in older persons — from pathophysiology to adequate intervention: a review and summary of an international expert meeting. Clin Interv Aging. 2016;11:189–208.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Namasivayam-MacDonald AM, Riquelme LF. Presbyphagia to Dysphagia: Multiple Perspectives and Strategies for Quality Care of Older Adults. Semin Speech Lang. 2019;40(3):227–42.

    Article  PubMed  Google Scholar 

  9. Baijens LW, Clavé P, Cras P, Ekberg O, Forster A, Kolb GF, Leners JC, Masiero S, Mateos-Nozal J, Ortega O, Smithard DG, Speyer R, Walshe M. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Andrade PA, Santos CAD, Firmino HH, Rosa COB. The importance of dysphagia screening and nutritional assessment in hospitalized patients. Einstein (Sao Paulo). 2018;16(2):eAO4189.

    Article  PubMed Central  Google Scholar 

  11. Humbert IA, Robbins J. Dysphagia in the elderly. Phys Med Rehabil Clin N Am. 2008;19(4):853–x.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Langmore SE, Olney RK, Lomen-Hoerth C, Miller BL. Dysphagia in patients with frontotemporal lobar dementia. Arch Neurol. 2007;64:58–62.

    Article  Google Scholar 

  13. Dellis S, Papadopoulou S, Krikonis K, Zigras F. Sarcopenic Dysphagia. A Narrative Review. J Frailty Sarcopenia Falls. 2018;3(1):1–7.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Christmas C, Rogus-Pulia N. Swallowing Disorders in the Older Population. J Am Geriatr Soc. 2019;67(12):2643–9.;

    Article  PubMed  PubMed Central  Google Scholar 

  15. Wakabayashi H. Presbyphagia and Sarcopenic Dysphagia: Association between Aging, Sarcopenia, and Deglutition Disorders. J Frailty Aging. 2014;3(2):97–103.

    Article  CAS  PubMed  Google Scholar 

  16. Cosentino G, Avenali M, Schindler A, Pizzorni N, Montomoli C, Abbruzzese G, Antonini A, Barbiera F, Benazzo M, Benarroch EE, Bertino G, Cereda E, Clavè P, Cortelli P, Eleopra R, Ferrari C, Hamdy S, Huckabee ML, Lopiano L, Marchese Ragona R, Masiero S, Michou E, Occhini A, Pacchetti C, Pfeiffer RF, Restivo DA, Rondanelli M, Ruoppolo G, Sandrini G, Schapira AHV, Stocchi F, Tolosa E, Valentino F, Zamboni M, Zangaglia R, Zappia M, Tassorelli C, Alfonsi E. A multinational consensus on dysphagia in Parkinson’s disease: screening, diagnosis and prognostic value. J Neurol. 2022;269(3):1335–52.

    Article  PubMed  Google Scholar 

  17. Barbe AG. Medication-Induced Xerostomia and Hyposalivation in the Elderly: Culprits, Complications, and Management. Drugs Aging. 2018;35(10):877–85.

    Article  PubMed  Google Scholar 

  18. Stoschus B, Allescher HD. Drug-induced dysphagia. Dysphagia. 1993;8(2):154–9.

    Article  CAS  PubMed  Google Scholar 

  19. Onder G, Liperoti R, Fialova D, Topinkova E, Tosato M, Danese P, Gallo PF, Carpenter I, Finne-Soveri H, Gindin J, Bernabei R, Landi F, SHELTER Project. Polypharmacy in nursing home in Europe: results from the SHELTER study. J Gerontol A Biol Sci Med Sci. 2012;67(6):698–704.

    Article  PubMed  Google Scholar 

  20. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17(1):230.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Farri A, Accornero A, Burdese C. Social importance of dysphagia: its impact on diagnosis and therapy. Acta Otorhinolaryngol Ital. 2007;27(2):83–6.

    CAS  PubMed  PubMed Central  Google Scholar 

  22. Ahn DH, Yang HE, Kang HJ, et al. Changes in etiology and severity of dysphagia with aging. Eur Geriatr Med. 2020;11:139–45.

    Article  PubMed  Google Scholar 

  23. Namasivayam-MacDonald AM, Shune SE. The Burden of Dysphagia on Family Caregivers of the Elderly: A Systematic Review. Geriatrics (Basel). 2018;3(2):30.

    Article  PubMed Central  Google Scholar 

  24. Namasivayam AM, Steele CM. Malnutrition and Dysphagia in long-term care: A systematic review. J Nutr Gerontol Geriatr. 2015;34:1–21.

    Article  Google Scholar 

  25. Pagnamenta E, Longhurst L, Breaks A, et al. Research priorities to improve the health of children and adults with dysphagia: a National Institute of Health Research and Royal College of Speech and Language Therapists research priority setting partnership. BMJ Open. 2022;12:e049459.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Sarabia-Cobo CM, Pérez V, De Lorena P, Domínguez E, Hermosilla C, Nuñez MJ, Vigueiro M, Rodríguez L. The incidence and prognostic implications of dysphagia in elderly patients institutionalized: A multicenter study in Spain. Appl Nurs Res. 2016;30:e6–9.

    Article  Google Scholar 

  27. Ortega O, Martín A, Clavé P. Diagnosis and Management of Oropharyngeal Dysphagia Among Older Persons, State of the Art. J Am Med Dir Assoc. 2017;18(7):576–82.

    Article  PubMed  Google Scholar 

  28. Madhavan A, Lagorio LA, Crary MA, et al. Prevalence of and risk factors for dysphagia in the community dwelling elderly: A systematic review. J Nutr Health Aging. 2016;20:806–15.

    Article  CAS  PubMed  Google Scholar 

  29. Almirall J, Rofes L, Serra-Prat M, Icart R, Palomera E, Arreola V, Clavé P. Oropharyngeal dysphagia is a risk factor for community-acquired pneumonia in the elderly. Eur Respir J. 2013;41(4):923–8.

    Article  PubMed  Google Scholar 

  30. Engh MCN, Speyer R. Management of Dysphagia in Nursing Homes: A National Survey. Dysphagia. 2021.

    Article  PubMed  PubMed Central  Google Scholar 

  31. 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.

    Article  PubMed  Google Scholar 

  32. Jukic Peladic N, Orlandoni P, Dell’Aquila G, Carrieri B, Eusebi P, Landi F, Volpato S, Zuliani G, Lattanzio F, Cherubini A. Dysphagia in Nursing Home Residents: Management and Outcomes. J Am Med Dir Assoc. 2019;20(2):147–51.

    Article  PubMed  Google Scholar 

  33. Cavallero S, Dominguez LJ, Vernuccio L, Barbagallo M. Presbyphagia and dysphagia in old age. Geriatric Care. 2020;6(3).

  34. Andersen UT, Beck AM, Kjaersgaard A, Hansen T, Poulsen I. Systematic review and evidence based recommendations on texture modified foods and thickened fluids for adults (above18 years) with oropharyngeal dysphagia, e-SPEN Journal.2013; (8): e127ee134;

  35. Painter V, Le Couter DG, Waite LM. Texture-modified food and fluids in dementia and residential aged care facilities. Clin Interv Aging. 2017;12:1193–203.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Ballesteros-Pomar, Cherubini A, Keller H, Lam P, Rolland Y, Simmons SF. Texture-Modified Diet for Improving the Management of Oropharyngeal Dysphagia in Nursing Home Residents: An Expert Review. J Nutr Health Aging. 2020;24(6):576–81.

    Article  CAS  PubMed  Google Scholar 

  37. Gomes CA Jr, Andriolo RB, Bennett C, Lustosa SA, Matos D, Waisberg DR, Waisberg J. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. Cochrane Database Syst Rev. 2015(5):CD008096.;

  38. Onder G, Carpenter GI, Finne-Soveri H, et al. Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study. BMC Health Serv Res. 2012;12:5.

    Article  Google Scholar 

  39. Mor V. A comprehensive clinical assessment tool to inform policy and practice: applications of the minimum data set. Med Care. 2004;42(4 Suppl):III 50-9.

    Google Scholar 

  40. Morris JN, Fries BE, Mehr DR, et al. MDS Cognitive Performance Scale. J Gerontol. 1994;49(4):M174-182.

    Article  CAS  Google Scholar 

  41. Morris JN, Fries BE, Morris SA. Scaling ADL’s within the MDS. J Gerontol. 1999;4:M546-53.

    Article  Google Scholar 

  42. Nogueira D, Reis E. Swallowing disorders in nursing home residents: how can the problem be explained? Clin Interv Aging. 2013;8:221–7.

    Article  Google Scholar 

  43. Huppertz VAL, Halfens RJG, van Helvoort 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Wirth R, Pourhassan M, Streicher M, Hiesmayr M, Schindler K, Sieber CC, Volkert D. The Impact of Dysphagia on Mortality of Nursing Home Residents: Results From the nutritionDay Project. J Am Med Dir Assoc. 2018;19(9):775–8.

    Article  PubMed  Google Scholar 

  45. Melgaard D, Baandrup U, Bøgsted M, Bendtsen MD, Hansen T. Rehospitalisation and mortality after hospitalisation for orapharyngeal dysphagia and community-acquired pneumonia: A 1-year follow-up study. Cogent Medicine. 2017;4:1.

    Article  Google Scholar 

  46. Feng MC, Lin YC, Chang YH, Chen CH, Chiang HC, Huang LC, Yang YH, Hung CH. The Mortality and the Risk of Aspiration Pneumonia Related with Dysphagia in Stroke Patients. J Stroke Cerebrovasc Dis. 2019;28(5):1381–7.

    Article  PubMed  Google Scholar 

  47. Cabre M, Serra-Prat M, Palomera E, Almirall J, Pallares R, Clavé P. Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing. 2010;39(1):39–45.

    Article  PubMed  Google Scholar 

  48. Chen S, Kent B, Cui Y. Interventions to prevent aspiration in older adults with dysphagia living in nursing homes: a scoping review. BMC Geriatr. 2021;21(1):429.

    Article  PubMed  PubMed Central  Google Scholar 

  49. O’Keeffe ST. Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified? BMC Geriatr. 2018;18(1):167.

    Article  PubMed  PubMed Central  Google Scholar 

  50. A Reyes-Torres C, Castillo-Martínez L, Reyes-Guerrero R, Ramos-Vázquez AG, Zavala-Solares M, Cassis-Nosthas L, Serralde-Zúñiga AE. Design and implementation of modified-texture diet in older adults with oropharyngeal dysphagia: A randomized controlled trial. Eur J Clin Nutr. 2019;73:989–96.

    Article  Google Scholar 

  51. Zanini M, Bagnasco A, Catania G, Aleo G, Sartini M, Cristina ML, Ripamonti S, Monacelli F, Odetti P, Sasso L. A Dedicated Nutritional Care Program (NUTRICARE) to reduce malnutrition in institutionalized dysphagic older people: A quasi-experimental study. J Clin Nurs. 2017;26(23–24):4446–55.

    Article  PubMed  Google Scholar 

  52. Germain I, Dufresne T, Gray-Donald K. A novel dysphagia diet improves the nutrient intake of institutionalized elders. J Am Diet Assoc. 2006;106(10):1614–23.

    Article  CAS  PubMed  Google Scholar 

  53. Wu XS, Miles A, Braakhuis A. Nutritional Intake and Meal Composition of Patients Consuming Texture Modified Diets and Thickened Fluids: A Systematic Review and Meta-Analysis. Healthcare (Basel). 2020;8(4):579.

  54. Shirai Y, Ueshima J, Shimizu A, et al. Ethical decision-making process for percutaneous endoscopic gastrostomy in patients with dysphagia. Eur Geriatr Med. 2021;12:1305–6.

    Article  PubMed  Google Scholar 

  55. Volkert D, Chourdakis M, Faxen-Irving G, Frühwald T, Landi F, Suominen MH, Vandewoude M, Wirth R, Schneider SM. ESPEN guidelines on nutrition in dementia. Clin Nutr. 2015;34(6):1052–73.

    Article  PubMed  Google Scholar 

  56. Mitchell SL, Mor V, Gozalo PL, Servadio JL, Teno JM. Tube Feeding in US Nursing Home Residents With Advanced Dementia, 2000–2014. JAMA. 2016;316(7):769–70.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Langmore SE. Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior? Curr Opin Otolaryngol Head Neck Surg. 2003;11(6):485–9.

    Article  PubMed  Google Scholar 

  58. Orlandoni P, Jukic Peladic N. Health-related Quality of Life and Functional Health status questionnaires in Oropharyngeal Dysphagia. J Aging Res Clin Practice. 2016;5(1):31–7.

    Google Scholar 

  59. Schindler A, Mozzanica F, Monzani A, Ceriani E, Atac M, Jukic-Peladic N, Venturini C, Orlandoni P. Reliability and validity of the Italian Eating Assessment Tool. Ann Otol Rhinol Laryngol. 2013;122(11):717–24.

    Article  PubMed  Google Scholar 

  60. Donohue C, Tabor Gray L, Anderson A, DiBiase l, Chapin J, Wymer JP, Plowman EK. Discriminant Ability of the Eating Assessment Tool‐10 to Detect Swallowing Safety and Efficiency Impairments. Laryngoscope. 2022.;

  61. Loh KW, Vriens MR, Gerritsen A, Borel Rinkes IH, van Hillegersberg R, Schippers C, Steenhagen E, Ong TA, Moy FM, Molenaar IQ. Unintentional weight loss is the most important indicator of malnutrition among surgical cancer patients. Neth J Med. 2012;70(8):365–9.

    CAS  PubMed  Google Scholar 

  62. de van der Schueren MAE, de Smoker M, Leistra E, Kruizenga HM. The association of weight loss with one-year mortality in hospital patients, stratified by BMI and FFMI subgroups. Clin Nutr. 2018;37(5):1518–25. (Epub 2017 Aug 31. PMID: 28890273).

    Article  PubMed  Google Scholar 

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We thank all the health care professionals and nursing home residents participating in the SHELTER project. The participating nursing homes have been previously listed.


This research received no external funding.

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Authors and Affiliations



G. DA., A.C., P.O., N.J.P. conceived and designed the analysis; G. DA., R.L., A.C., G.O. collected the data; P.E., G.DA., A.C., N.J.P., V.N., M.F., F.S., B.C. contributed data and analysis tools; G. DA., M.F., P.E. performed the analysis; G. DA., N.J.P., V.N., P.O., A.C. wrote the paper. All authors reviewed the manuscript. The author(s) read and approved the final manuscript.

Corresponding authors

Correspondence to Vanessa Nunziata or Fabio Salvi.

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Ethics approval and consent to participate

Ethics approval for the SHELTER study was obtained for all participating countries and specifically from the following ethics committees: METC VUmc Amsterdam, METC University, University Cattolica del Sacro Cuore Rome, METC National Committee, THL Helsinki, METC Hospital Saint Périne Paris, METC Haifa University, Kaplan Medical Center, The Schools Research Committee Ethical Panel, University of Kent Canterbury, METC University of Ulm, Multi-centric Ethics Committee, General Faculty Hospital Prague.

The study was in Accordance with the Declaration of Helsinki. All participants gave written informed consent to participate in the study. The coordinating ethics committee of the University Cattolica del Sacro Cuore Rome approved the experiments. All experiments were performed in accordance with relevant guidelines and regulations.

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The authors declare that they have no competing interests.

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Dell’Aquila, G., Peladic, N.J., Nunziata, V. et al. Prevalence and management of dysphagia in nursing home residents in Europe and Israel: the SHELTER Project. BMC Geriatr 22, 719 (2022).

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  • Nursing home
  • Dysphagia
  • Artificial nutrition
  • Texture modified diet
  • Loss of weight
  • Mortality