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S. Pasqualini1, A.M. Barisic2, M. Serris3, C. Rio4, I. Prêcheur1,5


1. Dental Surgeon, Université Côte d’Azur, UFR Odontologie, Laboratoire MICORALIS EA7354, Nice, France; 2. Physician, Hôpital Gériatrique Les sources, Nice, France; 3. Speech Therapist, Université Côte d’Azur, Centre Hospitalier Universitaire de Nice, Institut Universitaire de la Face et du Cou, GCS Centre Antoine Lacassagne, Nice, France; 4. Dietician, Private activity, Paris, France; 5. Dental Surgeon, Université Côte d’Azur, Centre Hospitalier Universitaire de Nice, Hôpital l’Archet, Pôle Odontologie UF 7647, Nice, France. Corresponding author: Isabelle Prêcheur, Pôle Odontologie UF 7647, Hôpital l’Archet 1, CHU de Nice, 151 route de Saint Antoine, 06200 Nice, e-mail: isabelle.precheur@univ-cotedazur.fr, Telephone: +33492034457, Fax: +33492035834

Jour Nursing Home Res 2019;5:76-79
Published online November 13, 2019, http://dx.doi.org/10.14283/jnhrs.2019.13



Some older adults with a poor dental state, but not suffering from swallowing disorders (dysphagia), could be given crushed drugs unnecessarily, just because they are given texture modified food. Thirty-nine residents were included in this analysis of nursing home practices: mainly women (28/39); mean age 86.8 +/-7.7; Groupe Iso-Ressource (GIR) 1.7 +/- 0.6; Mini Mental State (MMS) 16.5 +/- 6.0; crushed drugs 26/38; swallowing disorders 14/39; mixed and mashed food 25/38. Crushed drugs were associated with mixed and mashed food (P = 0.001), male gender (P = 0.008) and lower mastication ability (P = 0.015), but not with swallowing disorders (P = 1). Seventeen patients not recorded as having swallowing disorders were given crushed drugs. In conclusion, a poor dental health is frequently but not systematically related to swallowing disorders. This is not an indication for crushing drugs, because tablets and capsules don’t have to be chewed before being swallowed.

Key words: Crushed drugs, dysphagia, dental state, swallowing disorders, texture modified food.



Nursing homes residents are often given mixed or mashed food because they suffer from poor dental state (1) or swallowing disorders (dysphagia) (2, 3). Eight levels of texture modified food and/or thickened liquids are adapted, ranging from regular diet (level 7: regular and regular easy to chew) to severe dysphagia (level 0) (4). Additionally, when patients suffer from swallowing disorders or cognitive impairment, it is also necessary to crush tablets and to open capsules because there is a risk of choking, potentially lethal. Crushed drugs are secondly mixed into soft food or thickened beverage, and nurses’ aides give them with a spoon (5). However, many drugs are not to be crushed and others should be crushed and given separately, but it is not always easy to follow these recommendations (6, 7). Many crushed drugs have a bitter taste – leading to drug refusal – and spoil the appetite (8), and many have unwanted antimicrobial effects (9). For all these reasons, unnecessary drug crushing should be avoided.
Besides, tablets and capsules don’t need to be chewed before being swallowed. The problem at stake is that some older adults displaying a poor dental state, but not suffering from swallowing trouble, could be unnecessarily given crushed drugs, just because they are given mixed and mashed food. The research question was to find out a possible link between crushed drugs and poor dental health, rather than dysphagia, in nursing home residents.



This analysis of crushing drug habits in nursing home residents  was carried out at the private geriatric hospital Les Sources, Nice, France. The project was validated by the Ethics Committee of the institution. For this pilot study, the physician in charge of the geriatric ward included the 46 patients of a nursing home unit. There was no inclusion criteria, because it was an observation study of food and drugs delivery habits. At this stage, there was no power evaluation. Medical data were anonymously retrieved from patients’ medical charts. Out of 46 residents’ files, seven were excluded because oral examination had been impossible.
Four main criteria were evaluated: i) crushed drugs, ii) swallowing disorders, iii) cognitive impairment and iv) mixed or mashed food (“yes” vs “no”). Characteristics of “yes” groups were compared to “no” groups. Medical data have been recorded by the ward physicians. Some oro-dental data have been routinely recorded by nurses: daily number of brushings of teeth / cleanings of the mouth, regular use of antiseptic mouthwashes, visible microbial deposits in the mouth, dental pain, wearing one or two removable dentures. Swallowing disorders had been diagnosed by the speech therapist. Eating difficulties as a consequence of missing teeth had been recorded by the dietician. Diet was supervised by the dietician, working with cooks. For this study, the dental-surgeon recorded: periodontitis, oral dryness, oral candidiasis symptoms, DMFT index (decayed, missing, filled teeth), patients needing a scaling, dental filling, teeth to be extracted or new removable dentures and assessed masticatory ability (10). Masticatory ability is a dental index adapted to frail older adults (11).
For every patient, we secondly looked for potential associations among the four main criteria and other patients’ characteristics. For qualitative variables, the Chi-2 test was used or replaced by the exact test of Fisher for small samples (n<5). For quantitative variables, the Student’s T test was used (software: BiostaTGV). Statistical significance was accepted at 5% (P<0.05). Only significant or borderline associations are reported below.



Patients included in the study

Among the 39 included patients, the two variables «crushed drugs» and «mixed or mashed food» were not available for two patients.
In this nursing home unit, patients’ mean values or proportions were as follows: age 86.8 +/-7.7 years; weight 61.4 +/- 13.7 kg; Body Mass Index (BMI) 23.1 +/- 4.6 kg/m²; albuminemia 37.4 +/-3.4 g/L; C Reactive Protein (CRP) 16.2 +/- 19.6 mg/L; Groupe Iso-Ressource (GIR: frailty index ranging from 1 to best score 6) 1.7 +/- 0.6; Mini Mental State (MMS, best score 30) 16.5 +/- 6.0; current episode of bedsores 2/39; current episode of diarrhea 9/39; crushed drugs 26/38; swallowing disorders 14/39; mixed and mashed food 25/38; protein rich diet 14/39; brushing of the teeth / cleaning of the mouth 1.2 +/-0.5 times daily; regular use of antiseptic mouthwashes 7/39; periodontitis 18/39; visible microbial deposits in the mouth 31/39; dental pain 12/39; oral dryness 26/39; eating difficulties as a consequence of missing teeth 25/39; wearing one or two removable dentures 11/39; needing new removable dentures 25/39; DMFT index (Decayed, Missing, Filled Teeth) 18.8 +/- 6.7; mastication ability (0% to 100% best score) 29.6 +/- 27.5%; masticatory ability < 70% (chewing impairment) 35/39 ; mastication ability equal to 0% (fully edentulous or no pair of opposite teeth) 14/39; patients with teeth to be extracted 22/39; needing a scaling 30/39; oral candidiasis 8/39 and decayed teeth needing a filling 12/39. Evaluation of mastication performance can be also determined with color-changeable chewing gum (12).

Crushed drugs

The main characteristics of patients who were given crushed drugs are detailed in Table 1. The use of crushed drugs has two indications: swallowing disorders and cognitive impairment (2, 3). However, in this study, lower MMS and poor dental state (more frequent use of mouthwashes, lower masticatory ability, fewer teeth, higher DMFT index and more difficulties to eat because of missing teeth) were prominent indications for taking crushed drugs, but not swallowing disorders (9/26 vs 4/12; P = 1). In particular, masticatory ability of residents who were given crushed drugs was lower than masticatory ability of residents who were not given crushed drugs (22.0 + 24.6 % (n = 26) vs 45.2 + 28.8 % (n=12); P = 0.015). So, patients displaying a poor dental state were given mixed and mashed food and, as a consequence, crushed drugs.

Swallowing disorders

Swallowing disorders were directly linked to feeding difficulties with loss of weight and decreased BMI (Table 1). Resulting malnutrition is frequent (1-3), and in addition to the risk of choking during meal it is often difficult to design new dentures (10). Actually, it may be impossible to take impressions, because there is a risk of choking with impression paste (13, 14). However, in the present study, a total of 17 patients who did not suffer from swallowing disorders were given crushed drugs, while 14 out of these 17 patients were given mixed and mashed food.

Table 1
Characteristics of patients who were given crushed drugs, suffering from swallowing disorders or who were given mixed-mashed food. In italics: borderline significance

*MMS: ranging from 30 (normal) to 0; values less than 24: suspicion of altered state of consciousness; †DMFT index: ranging from 0 (no decayed, missing of filled teeth) to 32 (32 decayed, missing of filled teeth); ‡BMI: for adults >20 years, underweight: BMI is less than 18.5; normal weight: BMI is 18.5 to 25; overweight: BMI is 25 to 30; obese: BMI si 30 or more


Cognitive impairment

A first analysis compared the group of patients with a MMS < 15 (n = 11; mean MMS 10.0 +/-4.0) to the group of patients having a MMS > 15 (n = 21, mean MMS 20.0 +/-3.5). In the group of residents who had the lowest MMS, there were no more crushed drugs than in the other group (8/11 vs 12/21; P = 0.465), no more swallowing disorders (3/11 vs 8/21; P = 0.703), and no more mixed or mashed food (8/11 vs 13/21; P = 0.703).
A second analysis compared the group of the patients with a MMS < 16 (n = 16; mean MMS 11.9 +/- 4.4) to the group of the patients having a MMS > 16 (n = 16, mean MMS 21.2 +/- 3.1). Results were similar. In the group of residents who had the lowest MMS, there were no more crushed drugs than in the other group (12/16 vs 8/16; P = 0.273), no more swallowing disorders (6/16 vs 5/16; P = 1), and no more mixed or mashed food 11/16 vs 10/16; P = 1).



The present results confirmed the study hypothesis: a poor oral state not combined with swallowing disorders should not be an indication for crushing drugs. The first limit of this study is the low patient enrolment, limited to 39 subjects, which did not show a link between mixed and mashed food and swallowing disorders. However, it showed that dental state, rather than swallowing disorders, was linked to the choice of a mixed and mashed food and consequently to the use of crushed drugs in food (Table 1). The second limit to this study is that IDDSI descriptions of texture modified foods and thickened liquids had not been recorded (4). The criterion “mixed or mashed food” corresponds to IDDSI levels 6 to 4, but anyway the present analysis lacks of precision.
In the present series, cognitive impairment was not specifically associated to swallowing disorders, and it was not the main indication for crushing drugs or mixing food (6, 7). This work showed that nursing staff takes the greatest care to avoid any risk of choking with food and drugs (13). But another possibility would be that nursing staff tends to routinely crush drugs whenever the patient is given soft food. In order to avoid excessive crushing, these results demonstrated the need for speech therapists, dieticians and dental surgeons in care facilities for older people, as well as the need for a multidisciplinary approach and re-evaluation in order to avoid empiric decision to crush drugs (14, 15).



We observed that nursing home residents suffering from dental impairment such as missing teeth, low masticatory ability and needing new dentures were generally given mixed and mashed food. We also observed that patients who had soft food were given crushed drugs mixed in the food. From these results, it cannot be excluded that some patients, who did not suffer from swallowing disorders or severe cognitive impairment, were given crushed drugs only because of their poor dental state (lower masticatory ability, more missing teeth and needing new dentures). Nevertheless, tablets or capsules are supposed to be swallowed, not chewed. Therefore, crushing drugs should be limited to people suffering from swallowing disruptions. A frequent re-evaluation of dental status, dysphagia and choking risks is time-consuming for the medical and nursing staff, but crushing drugs is time-consuming too for nurses and nurses’ aides. Besides, limiting this practice would also contribute to improving the quality of frail older adults’ daily lives, because several crushed drugs have a very bitter taste, persistent, spoiling food taste and meals pleasure.


Funding: No funding.

Conflict of interest: None related to this work.

Ethical standard: The procedures followed were in accordance with the ethical standards of the institutional responsible committee (Private geriatric hospital Les Sources, Nice, France) and with the Helsinki Declaration of 1975, as revised in 2000.



1.    HAS. Haute Autorité de Santé 2007 (page consultée le 27/04/2019). Stratégie de prise en charge en cas de dénutrition protéino-énergétique chez la personne âgée. Recommandations professionnelles. https://www.has-sante.fr/portail/upload/docs/application/pdf/denutrition_personne_agee_2007_-_recommandations.pdf
2.    Sura L, Madhayan A, Carnaby G, Crary MA. Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging 2012;7:287-298.
3.    Khan A, Carmona R, Traube M. Dysphagia in the elderly. Clin Geriatr Med 2014;30:43-53.
4.    International Dysphagia Diet Standardization Initiative (IDDSI). Complete IDDISI framework and descriptors. CreativeCommons Attribution–Sharealike 4.0 International License https://creativecommons.org/licenses/by–sa/4.0/ October 10,  2016
5.    Thong MY, Manrigue YJ, Steadman KJ. Drug loss while crushing tablets: comparison of 24 tablet crushing devices. PLoS One 2018 Mar 1;13(3):e0193683. doi: 10.1371/journal.pone.0193683. eCollection 2018.
6.    Bourdenet G, Giraud S, Artur M et al. Impact of recommendations on crushing medications in geriatrics: from prescription to administration. Fundam Clin Pharmacol 2015; 29: 316-320.
7.    Clauson H, Rull F, Thibault M, Ordekyan A, Tavernier J. Crushing oral solid drugs: assessment of nursing practices in health-care facilities in Auvergne, France. Int J Nurs Pract 2016;22:384-390.
8.    Lamure J, Brocker P, Schneider SM et al. The taste of ten drugs frequently prescribed in nursing homes crushed in food: observational study with 16 healthy volunteers. Journal of Nursing Home Research 2015;1:55-61.
9.    Lamure J, Chevalier M, Rathelot P, Mignolet F, Prêcheur I. In vitro screening of the antibacterial and anti-Candida properties of crushed nonantimicrobial drugs frequently prescribed in nursing homes. Res Gerontol Nurs 2018;11:82-90.
10.    Marchini L, Hartshorn JE, Cowen H, Dawson DV, Johnsen DC. A teaching tool for establishing risk or oral health deterioration in elderly patients: development, implementation, and evaluation at a U.S. dental school. J Dent Educ 2017;81:1283-1290.
11.    Madinier I, Starita-Géribaldi M, Berthier F, Pesci-Bardon C, Brocker P. Detection of mild hyposalivation in the elderly based on the chewing time of specifically-designed disc-tests: diagnostic accuracy. J Am Geriatr Soc 2009;57:691-696.
12.    Wada S, Kawate N, Mizuma M. What type of food can older adults masticate?: Evaluation of mastication performance using color-changeable chewing gum. Dysphagia 2017;32:636-643.
13.    Chen CF, Chen YF, Chan CH, Lan TH, Loh el-W. Common factors associated with choking in psychiatric patients. J Nurs Res 2015;23:94-100.
14.    Sugimura M, Kudo C, Hanamoto H et al. Considerations during intravenous sedation in geriatric dental patients with dementia. Clin Oral Investig 2015; 19:1107-1114.
15.    Ullrich S, Crichton J. Older people with dysphagia: transitioning to texture-modified food. Brit J Nurs 2015;24:686-692.



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.



1.    Payne M, & Morley JE; Dysphagia, Dementia and Frailty. J Nutr Health Aging, 2018, https://doi.org/10.1007/s12603-018-1033-5
2.    Eglseer D, Halfens RJG, Schols JMGA et al. Dysphagia in hospitalized older patients:associated factors and nutritional interventions. J Nutr Health Aging, 2018, https://doi.org/10.1007/s12603-017-0928-x
3.    Neloska L, Damevska K, Nikolchev A, Pavleska L, Petreska-Zovic B & Kostov M. The association between malnutrition and pressure ulcers in elderly in long-term care facility. Open access Macedonian journal of medical sciences, 2016;4(3), 423 10.3889/oamjms.2016.094
4.    Huppertz VA, Halfens RJ, 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;1-7 https://doi.org/10.1007/s12603-018-1103-8
5.    Smithard DG. Dysphagia management and stroke units. Current physical medicine and rehabilitation reports, 2016;4(4), 287-294.
6.    Vellas, BJ, Garry PJ, & Guigoz Y (Eds.). Mini Nutritional Assessment (MNA): research and practice in the elderly (Vol. 1). Karger Medical and Scientific Publishers, 1999
7.    Società Italiana di Nutrizione Umana SINU. LARN Livelli di Assunzione di Riferimento di Nutrienti ed Energia per la Popolazione Italiana–IV Revisione. SIdN Umana, Rome, 2014.
8.    Bergstrom N, Braden BJ, Laguzza A, Holman V . The Braden Scale for Predicting Pressure Sore Risk. Nurs Res; 1987;36: 205–10.
9.    Bergstrom N, Braden B, Kemp M, Champagne M, & Ruby E.  Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale. Nurs Res, 1998;47(5), 261-269
10.    Braden BJ, Bergstrom N. Predictive validity of the Braden Scale for pressure sore risk in a nursing home population. Res Nurs Health, 1994;17(6), 459-470
11.    Linn BS, Linn, MW, & Gurel LEE. Cumulative illness rating scale. Jour Americ Geriat Soc, 1968;16(5), 622-626.
12.    Rosson MB, Carroll JM. Usability engineering. Scenario-based development of human-computer interaction. Morgan Kaufmann Publishers, San Francisco, 2001.
13.    Henderson CR. Applications of linear models in animal breeding (Vol. 462). University of Guelph, Guelph 1984.