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A.F. Jacinto1, W. Achterberg2, P.A. Wachholz3, T. Dening4, K. Harrison Dening5, R. Devi6, D. Oliveira7, I. Everink8, P.S. Azevedo3, P.J.F .Villas Boas3, K. Hinsliff-Smith9, M. Hoedl10, J.M.G.A. Schols8, V. Shepherd11, A.C.M. Gratao12, R.C. de Melo13, H.A.W. Watanabe14, M.S. Zazzetta15, C. Goodman16,17, K. Spilsbury6, A.L. Gordon18,19


1. Disciplina de Geriatria e Gerontologia, Departamento de Medicina, Escola Paulista de Medicina – Universidade Federal de São Paulo (UNIFESP), Brazil; 2. Department of Public Health and Primary care, Leiden University Medical Center, Leiden, The Netherlands; 3. Disciplina de Clínica Médica, Departamento de Clínica Médica, Faculdade de Medicina de Botucatu – Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP), Brazil; 4. Division of Psychiatry & Applied Psychology, University of Nottingham, UK; 5. Dementia UK, London, UK; School of Health Sciences, University of Nottingham, UK; 6. School of Healthcare, University of Leeds, Leeds, UK; 7. Departamento de Psiquiatria, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), Brazil; 8. Maastricht University, Care and Public Health Research Institute, Department of Health Services Research, Maastricht, The Netherlands; 9. De Montfort University, Health and Life Sciences Faculty. Edith Murphy Building, Room 3.09, Leicester LE1 9BH, UK; 10. Institute of Nursing Science, Medical University of Graz, Graz, Austria; 11. Centre for Trials Research, Cardiff University, 4th floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS UK; 12. Department of Gerontology, Federal University of São Carlos (UFScar), Brazil; 13. Escola de Artes, Ciências e Humanidades – Universidade de São Paulo (USP), Brazil; 14. School of Public Health, University of São Paulo (USP), Brazil; 15. Departamento de Gerontologia, Universidade Federal de São Carlos (UFScar), Brazil; 16. Centre for Research in Public Health and Community Care, University of Hertfordshire, UK; 17. NIHR Applied Research Collaboration – East of England (ARC-EoE), Cambridge, UK; 18. Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, UK; 19. NIHR Applied Research Collaboration – East Midlands (ARC-EM), Nottingham, UK. Corresponding author: Alessandro Ferrari Jacinto, Rua Castanheiro, 16 – Vila Mariana, São Paulo – SP – 04023-040 – Brazil, E-mail: alessandrojacinto@uol.com.br, Phone:+55 (11)55752692,  https://orcid.org/0000-0002-1977-5880, Twitter: @JacintoFerrari

Jour Nursing Home Res 2020;6:109-113
Published online November 27, 2020, http://dx.doi.org/10.14283/jnhrs.2020.28



The Brazilian care home sector is underdeveloped, and the limited available evidence suggests that care quality falls below international standards. Development of the Brazilian care home sector could be associated with better outcomes for those receiving care, and more efficient use of resources across health and social care. Research has an important role to play. This article summarises research priorities for Brazilian long-term care homes developed as part of an international workshop held in Brazil and the UK, and attended by 71 clinicians and researchers from 6 Brazilian Universities, supported by an international faculty of 8 Brazilian, 8 British, 2 Dutch and 1 Austrian academics. The research priorities identified were: understanding and supporting multidisciplinary working in care homes, with emphasis on describing availability of multidisciplinary teams and how they operate; dignity and sensitivity to cultural needs, with emphasis on collating accounts from Brazilian stakeholders about dignity in care and how it can be delivered; enriching the care home environment with art, music and gardens, with a focus on developing arts in the care home space in a way that is sensitive to Brazilian cultural identity; and benchmarking quality of care, with emphasis on exploring how international quality benchmarking tools can be adapted for use in Brazilian care homes, taking account of new initiatives to include person-centred outcomes as part of benchmarking. Instrumental to research in these priority areas will be establishing care home research capacity in Brazil.

Key words: Long-term care, aged, Brazil, research.



In common with other BRICS (Brazil, Russia, India, China and South Africa) countries, Brazil is affected by rapid population ageing. In 2014, 14.6% of Brazilians were aged over 60 years, a proportion projected to grow to 33.5% by 2060 (1). Increases in average life expectancy have been accompanied by higher prevalence of multimorbidity and functional dependency, and unmet need for health and social care amongst older people.
All Brazilian citizens can access free healthcare at the point of delivery through a national health care system, the ‘Sistema Único de Saúde’ (SUS, or Unified Health System). This system, however, does not cover long-term care in care homes.
Care homes are facilities which provide 24 hour care, with or without specialist nursing input (2). They are a feature of most developed, and many developing, health and social care economies. They provide capacity to look after people with 24-hour care needs through support from dedicated staff, something which even the most generously funded healthcare systems struggle to reimburse in people’s own homes.
In Brazil, a small number of care homes (7%) are state-funded (3). A small and developing private sector provides care in facilities, akin to residential or nursing homes seen in high income countries, but these remain beyond the means of many (4) The bulk of current provision comes from small, localised organisations which are funded precariously through a combination of older people’s retirement benefits, community charities, and funding from municipalities.
The current estimated capacity of 100,000 beds across 3,549 institutions represents 0.03 beds per head of population over 80 years of age in Brazil (5). This differs considerably from England and the Netherlands, which have 0.12 and 0.23 beds per head of population over the age of 80 years respectively (6).
All Brazilian care homes are led by Technical Directors, many of whom do not have a healthcare degree. There is no requirement for health professionals (doctors, nurses and allied health professionals) to be employed by care homes, and the structure of healthcare input to care homes is highly variable. Healthcare in Brazilian care homes is mostly provided by doctors without any formal postgraduate training in primary care, geriatric medicine, gerontology or old age psychiatry. A cross-sectional study using objective quality indicators adapted from the United States found that quality of care in Brazilian care homes was variable and fell some way short of international standards (7).
Research in Brazilian care homes is underdeveloped, has not been a particular focus of the academic community and has not been supported or funded in a strategic way. Against this background, the Improving care in LOng-Term Care InstitUtionS in Brazil and Europe through Collaboration and Research (LOTUS) consortium was formed to develop research in Brazilian care homes through international learning and collaboration. It comprised two workshops, the first held at UNESP Medical School, Botucatu, Brazil, in April 2019, and the second held at University of Nottingham, United Kingdom (UK), in August 2019.
The workshops comprised visits to Brazilian and UK care homes and round-table sessions to identify priorities for future research in Brazilian care homes, harnessing links with international institutions to accelerate progress. We present here a summary of the identified priorities, in part as a manifesto to drive our research programme forward, and in part to inform similar collaborations around long-term care between high-, low- and middle-income countries elsewhere.


Choosing the priority areas

Workshop attendance was free-of-charge. Delegates were invited using e-mail lists for Brazilian national gerontology and geriatric medicine organisations. Registration was via a public webpage in English and Portuguese, which was publicised using Twitter. Brazilian organisers, comprising eight academics from a range of disciplines, consulted widely to ensure the programme represented a broad constituency with an interest in care homes. Using this approach we recruited 71 clinicians and academics from six Brazilian universities, including healthcare professionals, social scientists, demographers, gerontologists, designers and architects. Eleven academics from six UK, two Dutch and one Austrian universities were invited based upon expertise which matched the programme prepared by the Brazilian committee. The first two days comprised small group workshops and plenary sessions which enabled delegates to share experiences, with a focus on opportunities and challenges that could be addressed by research. At the end of day 2, delegates were presented with a list of nine possible research domains drawn from discussions, which they were asked to rank in terms of priority. The topics chosen were discussed and developed more fully over the remaining one day of Brazilian and two days of UK-based workshops.


Priority area 1 – Understanding and Supporting Multidisciplinary Working in Care Homes

Caring for older people with complex needs requires a multi-domain approach recognising the contributions of mental and physical wellbeing, functional capabilities, social networks and environment to overall health and wellbeing. From a nursing and social care perspective this is reflected in the evidence-base for person- and relationship-centred care (8) From a medical perspective, it is expressed through the evidence for comprehensive geriatric assessment (CGA) (9). Whilst person-centred care and CGA have exponents in Brazil, they are not yet widely accepted. The extent to which care homes are set-up to deliver them is not clear.
Comprehensive care approaches draw upon expertise of multiple professionals working as a team. In high income countries, multidisciplinary teams can be based in and employed by care homes – as in the Netherlands – or can be composed of numerous visiting professionals – as in the UK and Austria. The latter scenario can present challenges around co-ordinating assessments by different professionals and managing their inputs to ongoing care, with the need to take account of remote working and asynchronicity of inputs (10).
Surveys of care homes in Brazil have focussed mainly on the structure of institutions and the profile of the residents who receive care, particularly focussing on health status, falls and frailty (11–13). Data have not been collected hitherto on how such institutions are staffed, in terms of the disciplinary background of staff involved in care, or how such staff integrate into a multidisciplinary team.
Following the LOTUS workshops, we have commenced a survey to establish how multidisciplinary teams operate across ten care homes, five not-for-profit/philanthropic and five for-profit, spread across five Brazilian cities in São Paulo State (Botucatu, São Paulo City, Ourinhos, São Carlos and Campinas). Following this we propose more detailed qualitative research to understand in greater detail how professionals from multiple backgrounds connect and interact in care homes. Given the variation in geography, climate, culture and economic resource between Brazilian states, an explanatory approach will be required to accommodate and understand variability.


Priority area 2 – Dignity and Sensitivity to Cultural Needs

Dignity is defined in the Oxford English Dictionary as ‘the quality of being worthy or honourable; worthiness, worth, nobleness, and excellence’. The challenge lies in translating fine sentiments about maintaining dignity into care practice. Dignity can be complicated. For example, is it something that can be observed and measured objectively by meeting certain standards, or is it subjective and perceived at an individual or interpersonal level? Two people may observe the same interaction, such as a visit to the toilet, and come to different conclusions about how dignified it was.
Three main interactional qualities have been described (14) that help to preserve care home residents’ sense of dignity: experiencing love and confirmation; experiencing social inclusion and fellowship; and experiencing humane warmth and understanding within a caring culture, while being met as an equal human being.
There are several important cultural aspects of dignity (15). Staff and residents of care homes are often of differing backgrounds. This may include different socio-economic status, ethnic origins, speaking different languages, having differing sexualities or gender identities, or being of different faith. The linguistic issue, present in many countries due to dependence on migrant workers in long term care, can be particularly challenging in Brazil because, although Portuguese is the predominant language, the country is multi-lingual and not all older people speak Portuguese. Even where this is not the case, a care home of reasonable size will contain a diverse group of residents, with different educational and occupational experiences. They are likely to have different care preferences and needs. Some may observe a religion, others not. These aspects of individuality need to be understood and respected to support dignity in care.
Dignity is an important part of the realpolitik of care homes in developed countries. In the UK, for example, charitably funded national initiatives led by academics in partnership with care homes focus on dignity, whilst legislative and regulatory frameworks explicitly emphasise residents’ right to dignified care. The concept of dignity is less established in Brazilian care homes. There is a high level of stigma attached to care homes and their residents. Stigma leads to ageism, exertion of power, isolation, seclusion, poor quality care, and high professional turnover, all of which may impact upon provision of dignified care and impair the ability of staff to see individuals behind negative labels and stereotypes. Dignity is not used as a measure of care quality in Brazil.
We need to understand the levers required in Brazil to promote culture change from the current preoccupation with meeting physical care needs to a more person- and relationship-centred approach. It is likely that the answer will lie in staff feeling empowered and valued, so that they can prioritise dignity in care (16). There will be organisational and cultural issues specific to Brazil that influence how to empower and support staff and residents. Research needs to examine the perceptions of different stakeholders about what constitutes dignity and what different priorities for change may be. We propose that the first step should be a scoping review of the Brazilian literature of long-term care and dignity, followed by qualitative interview studies.


Priority area 3 – Enriching the Care Home Environment with Art, Music and Gardens

The proportion of care home residents with dementia, internationally, ranges from 30-60% (17). Activities such as art interventions are helpful in supporting people with dementia (18) and are one of the few effective non-pharmacological strategies in dementia care. Music, for example, is associated with improvement in cognitive performance and mood of care home residents (19).
There is evidence that residents from Brazilian care homes are less able to access stimulating recreational activities than in higher income countries (20). This could relate, again, to the emphasis placed on physical needs within Brazilian care homes. Initiatives that have developed around recreational activities have been led by research teams. One such project involved working with participants from two care homes and two day centres using museum objects as a focus (21). Sensory strategies like smell, tactile and sound experiences were explored in addition to reminiscence. Eight to 15 people participated every week, with additional trips to museums every two months. This museum project also incorporated a music experience, using exhibits and photos in the museum. Although similar to initiatives conducted in other countries, a key learning point was how evocative and stimulating the smells, flavours and sounds of Brazil were for residents living with dementia. The smell of coffee, and the sound of “serestas” were associated with a particularly strong affective response.
Further work is required to work out how to enrich care home environments in ways which are sensitive to Brazilian culture and hence work. It is also clear that research is central to establishing such approaches in the mainstream of Brazilian care homes.


Priority area 4 – Benchmarking quality of care

Care provider organisations have a duty of care to protect the safety of clients and to ensure that care meets, and exceeds, minimum acceptable standards. Approaches to quality control and governance in care homes internationally vary and include: professionalism-based regulatory systems, where groups of professionals or provider organisations take responsibility for quality control; inspection-based regulatory systems, where statutory providers send independent staff inspect care homes; and data measurement and reporting based regulatory systems, where audit of minimum dataset submissions are used (5).
Regardless of the approach adopted, there is increasing emphasis across high-income countries on reliable metrics about quality of care, which can enable providers to understand areas which require improvement and to act upon them. A highly established approach uses the international Resident Assessment Instrument (interRAI), an interlinked suite of resources, whereby resident-level assessment conducted by care home staff can inform care protocols and also generate institution level case-mix analyses and quality markers. There are, though, challenges associated with implementing such a detailed and comprehensive approach (22). A contrasting approach – adopted in the Netherlands, Austria, Switzerland, Turkey and one region of the UK – is the International Prevalence Measurement of Care Quality (in Dutch: Landelijke Prevalentiemeting Zorgkwaliteit, LPZ) – which takes a more straightforward, once-yearly audit-based approach to benchmarking and then uses the findings from these observations as the basis of quality improvement (23). These approaches are now being modified to take account of person- and relationship centred care, with inclusion of quality of care from the resident’s perspective included in the Individually Experienced Quality of Long-Term Care (INDEXQUAL) framework, and its adaptations to take account of professional caregivers’ and families’ perspectives (24).
Very little benchmarking data are available in the Brazilian care home sector. Benchmarking using a sub-component of the interRAI has been conducted on a small scale basis as part of a study in 35 homes conducted in Rio Grande do Norte State of Brazil (7). It is therefore feasible within the context of a cross-sectional research cohort study. Further work is required to consider the wider role of benchmarking, its feasibility, its implementation in routine practice, and how it can be used to drive quality improvement. As with other domains described above, the shift to resident- and relationship-centred benchmarking will need specific adaptation to the Brazilian cultural context.



Each of the above priority areas is challenged by the relative under-development of the Brazilian care home sector. It is well established that effective research in care homes requires collaboration, and co-design, between residents and relatives, staff from the care home sector, and academics. There are specific challenges to recruitment and retention of care home staff and residents in research, and to data collection and analysis in care home cohorts, that require sector-specific expertise which takes time to develop.
There is good evidence that an established care home research network can help cultivate the necessary competencies in academic and care home staff, and that the resulting research can drive up standards of care, and generate the case for capacity in the care home sector (25). A highly structured model, such as the South Holland Nursing Home Research Network (26), may be challenged by the limited capacity and relative under-development of Brazilian long-term care as it stands. Other examples, though, are available, such as the UK National Institute of Health Research Enabling Research in Care Homes (EnRICH) model (27), where care homes are recruited as research opportunities become available, with a network slowly developing over time. This might better suit the Brazilian situation.
Most of the work required to address the above priority areas will comprise mixed-methods research. Whilst both positivist biomedical research and inductive qualitative approaches are established in Brazil, researchers from these different backgrounds have not frequently come together. Relationship and team building will be required. In addition, new approaches that can make sense of complex interactive systems, need to be imported. Realist enquiry, with its ability to describe how context affects the mechanisms at play within complex systems, to deliver outcomes that matter, could be useful (28). Implementation science, with its insights into how to implement and sustain evidence-based approaches to care, will be able to provide approaches which can make sense of the wide variation in approaches to care home services across Brazil (29).
As we write this paper, the world in general, and Brazil in particular, is still in the grip of the COVID-19 pandemic. This pandemic has been associated with significant mortality in the care home sector. We do not yet fully understand the extent to which it has impacted upon the Brazilian care homes (3) Internationally COVID-19 has challenged models of healthcare delivery to care homes, remuneration and funding models, how data are collected and collated on care home residents, how staff are trained, and how buildings are designed to maximise quality of life and wellbeing for residents (30). Most of these areas of uncertainty are highlighted by the research priorities which we had already identified in our workshop before the arrival of COVID-19. That they have been reinforced by the pandemic highlights how research to understand each of these domains is central to the development and delivery of good care. The pandemic has laid bare how devastating it can be for care home residents, and society more generally, if we do not prioritise and focus upon these research areas.


Implications for practice and research

This document is presented to provoke discussion and thought. It makes no claims to be representative of all Brazilian academics with an interest in care home research. The strengths of our approach included the use of two face-to-face workshops, one held in Brazil, free-to-attend and publicised through national academic and clinical practice networks. Advanced planning and an open discursive approach at the meeting was designed to give full voice to Brazilian academics from diverse backgrounds, and to enable them to set the agenda and priorities going forward. Limitations are that Brazil is a large country and running our workshop in one city in São Paulo State may have limited the ability of colleagues from more remote parts of the country to attend. Not all Brazilian representatives were able to attend the second workshop in the UK. Brazilian colleagues are not all fluent in English and the workshop may have given prominence to the ideas of those who were most conversant in this language. Laying out in this paper the ideas developed through the workshop programme, represents a further opportunity to discuss important topics and to generate dialogue. We hope that colleagues that we have not hitherto engaged with, will feel empowered to join the debate.
We have highlighted in this paper the need for rapid development in the Brazilian long-term care sector. Close collaboration between care providers and researchers has the potential to accelerate the development of the sector, drive up standards and improve efficiency and effectiveness of care. International collaboration can help accelerate the development of a Brazilian care home research community to support this process.


Funding: The workshops were funded by the UK The Academy of Medical Sciences, Global Challenges Research Fund, reference number AAM 128769. The participation of Paula S Azevedo was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001. Adam Gordon and Claire Goodman are supported by the NIHR Applied Research Collaborations for East Midlands and East of England respectively. Professor Goodman also receives NIHR support as a NIHR Senior Investigator. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Conflict of interest: The authors have no conflict of interest to declare.

Ethical standards: This international collaborative workshop was exempt from the need for ethical approval under the guidelines of the host countries (Brazil and UK)

Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.



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F. Bortolazzi1,2, A. Calabrò2, M. Pesce2, U. Tortorolo1, T.F. Piccinno3, M. Masini3, C. Chiorri3,4


1. Korian srl, Italy; 2. Gruppo Insieme srl, Italy; 3. VIE srl, spin off of the Università degli Studi di Genova, Italy; 4. Università degli Studi di Genova, Italy. Corresponding author: T.F. Piccinno, VIE srl, spin off of the Università degli Studi di Genova, Italy, piccinno@vie-srl.com

Jour Nursing Home Res 2019;5:27-32
Published online June 12, 2019, http://dx.doi.org/10.14283/jnhrs.2019.6



Objectives: Dysphagia in elderly patients can cause serious health problems. The aim of this study was to investigate the effects of a new method for the identification of the elderly dysphagic patient. We hypothesized that a simple identification device could reduce errors in providing food and therefore reduce negative outcomes. Design: Two group of participants were enrolled (experimental and control). Each patient received a diagnosis of the severity of his/her own dysphagia disorder on a scale ranging from 1 (no swallowing problem) to 5 (unable to swallow). Inpatients of the experimental group only worn a bracelet with a specific color code for each level of the dysphagia disorder. Operators were trained to check the bracelet color and provide the corresponding diet to the patients. Participants were tested three times over a two months period. Setting: The participants were hospitalized in three nursing homes of the same institute. The colored bracelet method was adopted in two of these nursing homes. Participants: Fifty-five participants were enrolled for the study (44 in the experimental group, 78% female, mean age = 88.9±6.6 years). Forty-two operators (86% female, 64% of age between 36 and 55)) filled in an evaluation questionnaire. Measurements: Several measures of nutrition, hydration, and clinical condition were collected. Results: The method significantly improved hydration (p = .002) and BMI (p = .010) and reduced the risk of bedsore (p < .001) of the patients. Conclusion: The colored bracelet method is an effective instrument for managing the diet of elderly dysphagic inpatients.

Key words: Dysphagia, malnutrition, nutritional intervention, aged, nursing homes.



Background and objective

Dysphagia is an alteration in the swallowing process due to degeneration and ageing of involved organs.
The number of dysphagic inpatients in rehabilitation centres and residential structures is going to increase with the extension of life expectancy. Dysphagia occurs in 15% to 23% of older persons living in the general non-patient population and it is prevalent in hospitalized patients (1).
Dysphagia may lead to serious health and life-threatening complications such as malnutrition and aspiration pneumonia (2). Malnutrition from dysphagia is considered a risk factor for pressure ulcers in elderly people (3). Errors in providing the correct type of nutrition to the patients could have serious consequences such as suffocation, aspiration pneumonia, denutrition, dehydration and, eventually, death. A recent study (4) showed that patients who suffered from dysphagia or malnutrition had poor outcome with regard to mortality, and that patients suffering from both dysphagia and malnutrition had the poorest outcome.
Guidelines of the International Dysphagia Diet Standardisation Initiative (IDDSI) and of the Italian Society of Artificial Nutrition and Metabolism (SINPE) for the management of dysphagic patients recommended that all patients with dysphagia should be assessed by a specialist (speech therapist) and should be referred to a dietitian to develop individual nutrition care plans.
Functional severity of dysphagia makes recommendations for nutritional therapy. The primary aim of nutritional therapy is to meet nutritional requirements of individuals and prevent adverse events such as aspiration pneumonia.
A simple and fast method to identify the severity of dysphagia in elderly patients could reduce the probability of feeding errors and, consequently, increase the health quality of patients.

Aim of the study

In this study, we aimed at investigating the effects on patients and operators of a device for the identification of severity of inpatients’ dysphagia using colored bracelets.
We hypothesized that the introduction of this method could improve the health of the inpatients, and could reduce the number of adverse events, such as feeding errors and consequently aspiration pneumonia. Specifically, we are interested in measuring the effects of the colored bracelets method on:
a)    nutrition of the inpatients
b)    hydration of the inpatients
c)    risk of bedsore of the patients

Furthermore, we were interested in evaluating the operators’ perception of the usefulness and ease of use of the device.



Design of the study

At the beginning of the study each patient received an evaluation of the severity his/her own dysphagia disorder by a speech therapist using Bedside Swallowing Assessment and the Smithard’s Three-oz Water Swallow Test (5). Patients with the most severe clinical conditions took also an instrumental phoniatric examination with Fiberoptic Endoscopic Examination of Swallowing (FEES). The evaluation of the severity of the dysphagia disorder ranged from 1 (no swallowing problem) to 5 (unable to swallow),  it  was identified by a different color-code (1 = green, 2 = blue, 3 = yellow, 4 = orange, 5 = red) and was associated to a specific diet. Three nursing homes were involved in the study: the participants of the experimental group were enrolled from two of them, while the control group was sampled from the third nursing home. The three clinics had similar procedures, patients had similar health and personal characteristics, and staff were equally trained and experienced. A colored bracelet indicating the severity of dysphagia was always worn by the patient of the experimental group. A speech therapist trained the operators every six month in the physiopathology of the dysphagia disorder and in the management of the diet of dysphagic inpatients. During this course, the operators of the experimental group were also trained to check the bracelet color and provide the corresponding diet to the patients. Participants of both groups were tested at the beginning of the study, i.e., before the introduction of the bracelet method (T0), after one month from the beginning of the study (T1), and after two months (T2).


Fifty-five participants were enrolled in the study (78% female, mean age = 88.9±6.6 years). Three participants died before the end of the study, therefore there were only 52 observations in T2. The experimental group included 44 inpatients, while the control group comprised 11 inpatients. Furthermore, 42 operators (86% female, 64% of age between 36 and 55, 71% with secondary school degree or higher) working in the nursing homes of the experimental group were asked to fill in a questionnaire to evaluate their perception of the of the usefulness and ease of use of the device for the identification of the dysphagia severity.


Several measures were collected to evaluate the nutritional status of the patients: Body Mass Index (BMI), Mini Nutritional Assessment (MNA) (6), and calorie intake through food.
BMI was calculated with the classical formula W/H2 (W = weight [kilograms]; H = height [metres]).
The MNA test comprises simple measurements and brief questions that can be completed in about 10’-15’. The full MNA includes 18 items grouped in 4 rubrics: a) anthropometric assessment; b) general assessment; c) short dietary assessment; and d) subjective assessment. It provides a single, rapid assessment of nutritional status in elderly patients. The MNA score distinguishes between elderly patients with adequate nutritional status (MNA ≥ 24 up to 30), patients at risk of malnutrition (MNA between 17 and 23.5) and patients with protein-calorie malnutrition (MNA < 17).
Calorie intake was estimated from the patient’s diet. The diet was prescribed according to the nutritional needs of elderly population indicated by the Italian Human Nutrition Society (SINU) (7). Each diet of the inpatients was determined accordingly considering age, sex and clinical status. Therefore, the calorie intake is an esteem of the nutritional needs.
Hydration was evaluated using three measures collected by a physician: blood pressure, tongue moisture, and skin turgor (the degree of elasticity of skin). Furthermore, a subjective hydration score (ranging from 0 = very low hydration to 5 = good hydration) was provided by the physician after a physical examination of the patient. Given the high correlation of these indices, a general hydration index (GHI) was calculated performing a principal component analysis (PCA) on these measures.
The risk of bedsore of the patient was measured with the Braden Scale for Predicting Pressure Sore Risk (BS) (8). It comprises six subscales representing the most common risk factors for pressure ulcers. It ranges from 6 to 23, with higher scores indicating lower risk of developing sores. A cutoff score of 18 is generally used to designate increased risk of pressure ulcer development. It has been shown that this measure has adequate levels of validity and reliability (9, 10).
Several other variables were collected from the medical records to obtain a more detailed assessment of the health of the patients and to be used as control variables in the statistical analyses. Alzheimer dementia, Parkinson’s disease, and stroke data were collected. Furthermore, comorbidity was measured with the Cumulative Illness Rating Scale (CIRS) (11). CIRS provides two scores (a) severity of the illness; and (b) comorbidity.
Two items were administered to the operators to investigate their perception of the usefulness and ease of use of the bracelet method. Both item responses were collected on a Likert scale ranging from 1 = “not at all” to 5 = “a lot”. We considered mean ratings of no less than 4 on either characteristic as a satisfactory result (12).



Linear mixed models (LMMs) (13) were used to assess the effect of the use of bracelet on the measures of nutrition (BMI and MNA), hydration, and risk of bedsore while controlling for background and clinical characteristics.
Four LMMs were specified, one for each dependent variable (i.e., BMI, MNA score, GHI score, BS score). Predictors of the model were a) treatment (experimental or control), b) time of the observation (T0, T1, T2), c) daily calorie intake, d) severity of dysphagia, e) Alzheimer dementia diagnosis, f) Parkinson’s disease diagnosis, g) past stroke diagnosis, h) diabetes diagnosis, i) comorbidity (CIRS S and CIRS C scores), j) artificial nutrition with nasogastric intubation, k) sex, and l) age.. While the focus variables were treatment, and time, the rest of the predictors were included in order to reduce the bias in the estimate of the effect of the treatment due to the impossibility to randomly assign patients to treatment levels.
Results are reported in Figure 1 and in Tables 1. As for BMI, participants in the experimental group had a higher  BMI than controls (p = .035) and  an overall decrease of BMI over time (p = .031) was observed; also the group-by-time interaction was statistically significant (p = .014), due to  a decrease of BMI in the control group and a lack of substantial change  in the experimental group (Table 1 and Figure 1a).

Table 1
Results of the four linear mixed models performed (only fixed effects are shown)

Significance Codes: < 0.001 ‘***’; < 0.01 ‘**’; < 0.05 ‘*’; < 0.1 ‘.’

Figure 1
Group-time interaction effects for each dependent variable. Each dashed line represents a participant. Thick solid lines represent group means. Error bars represent 95% confidence intervals of the mean scores.


The LMM for MNA revealed a significant fixed-effect of diabetes on MNA (p = .018, inpatients with diabetes diagnosis had higher scores), but the group-by-time interaction was only marginally significant (p = .081). However, the mean score of the experimental group tended to increase from T0 to T2, while the mean score of the control group remained substantially stable (Table 1 and Figure 1b).

A significant fixed-effect of the amount of daily calorie intake (p < .001) on the GHI score was found, where higher amounts of daily calorie intake was associated to higher hydration scores. The group-by-time interaction was statistically significant (p = .002), showing an increase of the hydration level in the experimental group and a decrease in the control group form T0 to T2 (Table 1 and Figure 1c).
Finally, a significant fixed-effect of the group (p = .004) was found on the BS score: inpatients of the experimental group had lower scores on the BS and therefore higher risk of pressure sores; also the group-by-time interaction was statistically significant  (p < .001) due to a reduction of the sore risk in the experimental group from T0 to T2, while no change was observed in the control group (Table 1 and Figure 1d).
One-sample t-tests were used to test whether the operators’ ratings of usefulness and ease of the use of the device differed from the expected result (score 4). Both t-test revealed that the target rating was achieved since there were not a statically significant differences (Usefulness: M = 3.80±1.27; t(39) = -0.98, p = .331, d = 0.16; Ease of use: M = 3.75±1.31; t(39) = -1.19, , p = .241, d  = 0.19).



The aim of this study was to test the efficacy of a new method for the identification of elderly dysphagic patients in improving their health outcomes. The method uses a color code on a bracelet worn by the inpatients that indicates to the operator the severity of the dysphagia. Results supported the efficacy of the method as they showed an overall improvement of the health condition of the inpatients of the experimental group with respect to those of the control group. The average BMI of the patients in the experimental group was stable across time, while it decreased in the control group. Hydration level significantly increased in patients identified with bracelets, while it decreased in the other patients. Finally, participants of the experimental group had lower pressure sore risk over time. The method was also considered adequately useful and easy to use by operators. Taken together, these findings suggest that the colored bracelet method is an effective method to manage the diet of elderly inpatients and it has a positive impact on their nutritional status and health condition.
Some limitations of this study have to be acknowledged. It was not possible to randomly assign the participants in the experimental and control group. Then the sample resulted unbalanced, although its size is not small. In this study differences of the two groups were statistically controlled, but a different sampling with more participants could solve this issue in the future. Furthermore, the study last for only two months. Next studies should enrol a higher number of and they should be conducted for longer period. These changes in the design of the study should allow to evaluate the impact of the colored bracelet method on aspiration pneumonia and related death incidence in elderly dysphagic inpatients.


Conflict of interest: Dr. Bortolazzi (francesca.bortolazzi@email.it) reports personal fees from NOEMA CONGRESSI during the conduct of the study; to have other relationships with nursing homes in Genoa; and to be consultant of KORIAN group and GRUPPO INSIEME. Dr. Calabrò (alessiocalabro83@gmail.com) reports personal fees from NOEMA CONGRESSI during the conduct of the study; and to have other relationships with nursing homes in Genoa; and to be manager of GRUPPO INSIEME. Dr. Pesce (pesce.matteo1@gmail.com) reports to be consulent for SERENITA S.R.L. and CITTADELLA S.R.L. (GRUPPO INSIEME); Dr. Tortorolo (umberto.tortorolo@pcdo.it) reports to have other relationships with nursing homes in Genoa and to be health director in KORIAN group. Dr. Piccinno (piccinno@vie-srl.com) reports grants from Noema S.r.L. Unipersonale during the conduct of the study. Dr. Masini (masini@vie-srl.com) has nothing to disclose. Dr. Chiorri (carlo.chiorri@unige.it) has nothing to disclose.»

Ethical standard: All procedures performed in the study were in accordance with the ethical standards of the institutional and/or national research committee, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.



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