Aging Clinical and Experimental Research (2023) 35:1293–1303

https://doi.org/10.1007/s40520-023-02413-y

ORIGINAL ARTICLE

Development and validation of a nomogram for predicting dysphagia

in long‑term care facility residents
Jinmei Liu1,2 · Mingshu Liao1 · Hui Yang2 · Xiaofang Chen1 · Yang Peng2 · Jing Zeng1

Received: 5 January 2023 / Accepted: 12 April 2023 / Published online: 6 May 2023
© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2023

Abstract
Background Dysphagia is a common problem that can seriously affect the health of elderly residents in long-term care
facilities. Early identification and targeted measures can significantly reduce the incidence of dysphagia.
Aim This study aims to establish a nomogram to evaluate the risk of dysphagia for elderly residents in long-term care
facilities.
Methods A total of 409 older adults were included in the development set, and 109 were included in the validation set.
Least absolute shrinkage selection operator (LASSO) regression analysis was used to select the predictor variables, and
logistic regression was used to establish the prediction model. The nomogram was constructed based on the results of logistic
regression. The performance of the nomogram was evaluated by receiver operating characteristic (ROC) curve, calibration,
and decision curve analysis (DCA). Internal validation was performed using tenfold cross-validation with 1000 iterations.
Results The predictive nomogram included the following variables: stroke, sputum suction history (within one year), Barthel
Index (BI), nutrition status, and texture-modified food. The area under the curve (AUC) for the model was 0.800; the AUC
value for the internal validation set was 0.791, and the AUC value for the external validation set was 0.824. The nomogram
showed good calibration in both the development set and validation set. Decision curve analysis (DCA) demonstrated that
the nomogram was clinically valuable.
Discussion This predictive nomogram provides a practical tool for predicting dysphagia. The variables included in this
nomogram were easy to assess.
Conclusions The nomogram may help long-term care facility staff identify older adults at high risk for dysphagia.

Keywords Dysphagia · Aged · Long-term care facilities · Nomogram

Introduction individuals, approximately 50% among elderly inpatients,

Dysphagia is a common geriatric syndrome; it is defined
as difficulty forming or moving a bolus safely from the
oral cavity to the oesophagus [1]. Dysphagia is a wor-
risome problem among the geriatric population, and the
prevalence of dysphagia increases with age [2]. A sys-
tematic review showed that dysphagia was exceptionally
common among elderly individuals, with a prevalence
of approximately 30% in community-dwelling elderly
* Jing Zeng
zengjinger@163.com
1 facilities residents [9]. Dysphagia also imposes substantial
Chengdu Medical College, Chengdu 610083, Sichuan, China
2
The First Affiliated Hospital of Chengdu Medical College,
Chengdu 610500, Sichuan, China
and greater than 50% among elderly residents in long-
term care facilities [3]. Dysphagia is a severe condition
that may lead to various adverse physical, psychological,
social, and economic outcomes [4]. Elderly individuals
with dysphagia are more likely to suffer serious complica-
tions, such as dehydration, malnutrition, aspiration pneu-
monia, and choking [5-7]. These negative outcomes result
in a decreased quality of life and increased hospitalization
and mortality [8]. A study of 10 185 older adults in long-
term care facilities found that the 6-month mortality rate
was significantly higher in those with dysphagia than in
those without dysphagia; thus, dysphagia was identified as
an independent risk factor for mortality in long-term care
financial costs on society. In the United States, dyspha-
gia resulted in $4.3 billion to $7.1 billion in additional

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hospital costs annually, and the mortality rate for inpa-
tients with dysphagia was 1.7 times higher than that for
hospitalized patients without dysphagia [10].
In 2021, 267.36 million people were at least 60 years
old in China, accounting for 18.9% of the total popula-
tion [11]. China’s traditional “421” family structure (four
grandparents, two parents, and one child) has gradually
diminished the family ageing function, and the burden
of informal family caregivers is substantial. Due to the
increasing number of disabilities, elderly individuals, and
empty nests in China, as well as the low number of chil-
dren, an increasing number of older adults are choosing to
live in long-term care facilities [12]. By the end of 2021,
forty thousand long-term care facilities and 5.036 mil-
lion nursing beds were available in mainland China [13].
Therefore, it is crucial to focus on the health of institution-
alized older adults.
Early and timely assessment of the risk of dysphagia can
significantly reduce the incidence of pneumonia and fur-
ther reduce mortality [14, 15]. Nevertheless, unfortunately,
studies have shown suboptimal management of swallowing
disorders in long-term care facilities. In approximately 75%
of long-term care facilities, residents in Norway are not rou-
tinely screened or assessed for swallowing problems [16]. In
China, only 51.16% of the long-term care facilities conduct
swallowing function assessments, and fewer than half of the
institutions provide swallowing function training for elderly
residents [17]. In recent years, many risk factors related to
dysphagia in elderly adults in long-term care facilities have
been found. However, there is insufficient research on risk
prediction tools that integrate risk factors. The nomogram
is a convenient tool and has been widely used to predict
the risk or prognosis of various diseases. It can incorporate
multiple predictive factors to form a visual map that shows
the probability of risk prediction, and it is helpful in clini-
cal decision-making and in enhancing the management of
high-risk populations in advance [18]. Thus, this study aims
to develop a prediction model to identify elderly residents of
long-term care facilities at high risk of dysphagia.
Materials and methods
Study design
A multicentre cross-sectional study was conducted between
January and June 2022. All investigators underwent stand-
ardized training and were familiar with the objectives and
methodology. The Biomedical Ethics Committee approved
this research of Chengdu Medical College (2022NO.01),
which was conducted based on the principles in the Decla-
ration of Helsinki.
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Aging Clinical and Experimental Research (2023) 35:1293–1303
Participants
We selected three long-term care facilities in Chengdu,
Sichuan Province, via convenience sampling method. The
inclusion criteria were as follows: (1) age ≥ 60 years; (2)
all older adults who were present in the long-term care
facilities on the day of data collection; and (3) informed
consent was obtained from residents or guardians. The
exclusion criteria were as follows: (1) tube-fed residents;
(2) residents who failed to finish the Standardized Swal-
lowing Assessment (SSA) (e.g., some residents were not
permitted to drink or eat due to their condition); and (3)
physiological or mental severe illness.
Measures
Comprehensive assessments were conducted using a ques-
tionnaire. The questionnaire assessed four dimensions:
residents’ general characteristics, swallowing function,
levels of activities of daily living (ADL), and nutrition
status. The data were gathered through direct observations,
self-reports, primary caregivers’ reports, and medical files.
The general characteristics questionnaire of residents
was self-designed. It assessed demographic, clinical, and
oral medication information from residents. Demographic
characteristics included age, sex, marital status, education,
smoking history, drinking history, length of residence,
tooth defect, dentures, number of teeth, feeding time, and
diet texture. The clinical characteristics included diabetes,
hypertension, hyperlipidaemia, stroke, Parkinson’s dis-
ease, dementia, coronary heart disease, peptic ulcer, gas-
troesophageal reflux, constipation, chronic obstructive pul-
monary disease (COPD), chronic bronchitis, osteoporosis,
anaemia, tumour, history of pneumonia (within one year),
history of sputum suction (within one year) and history of
fracture (within one year). Oral medication information
consisted of antidepressants, antipsychotics, antipsychot-
ics, analgesics, and Chinese patent medicine. Sputum suc-
tion (within one year) was a history of mechanical inha-
lation of respiratory secretions through the mouth, nose,
or artificial airway within the year before data collection.
The Standardized Swallowing Assessment (SSA) was
applied to assess swallowing function. The SSA proce-
dure consists of 3 steps: clinical examination, a 5-ml water
swallow test, and a 60-ml water swallow test. The clinical
examination assesses eight indicators: level of conscious-
ness, head and trunk control, respiratory pattern, lip clo-
sure, soft palate movement, laryngeal function, pharyngeal
reflex, and voluntary cough. If any of the above indicators
were abnormal, the test was terminated, and the residents
were valued as dysphagia. Conversely, the following step
Aging Clinical and Experimental Research (2023) 35:1293–1303
was performed. In the 5-ml water swallow test, the resi-
dents were given 5 ml water three times consecutively
in an upright sitting position. We observed the elderly
residents for dribbling water from the mouth, repetitive
swallowing, coughing, stridor, and abnormal laryngeal
function after each swallowing. If either abnormality was
present, the 5-ml water swallow test failed. Once residents
passed the 5-ml water swallow test two out of three times,
they underwent the third part, which entailed drinking
60 ml of water. Only when the residents did not show
coughing, stridor, aspiration, or any abnormal laryngeal
function after drinking 60 ml of water were they assumed
not to have dysphagia. A systematic review showed that
the SSA is a reliable and sensitive tool for screening for
dysphagia in nursing facilities [19].
ADL was measured by the Barthel Index (BI). BI con-
tains ten items: feeding, bathing, grooming, dressing, stool
control, urination control, toilet use, transfers (bed to chair
and back), ascending and descending stairs, and walking
[20]. The total score ranges from 0 to 100 points. A higher
score indicates a lower level of physical dependence. It is
classified into four levels based on the total score: independ-
ent (100 points), mild dependence (61–99 points), moderate
dependence (41–60 points), and severe dependence (≤ 40
points).
The Mini-Nutritional Assessment-Short Form (MNA-
SF) questionnaire was used to assess nutrition status. The
MNA-SF questionnaire was used to record the residents’
diet, involuntary weight loss, mobility impairment, psycho-
logical stress or acute disease, neuropsychiatric disorders,
and body mass index (BMI) or calf circumference over the
past three months. It has good reliability and validity. The
MNA-SF score can range between 0 and 14 points, with
higher values indicating better nutritional status. A score of
12–14 points indicates normal nutritional status, 8–11 points
marks a population at risk of malnutrition, and a score of 7
points or lower indicates malnutrition. The MNA-SF has
been validated as an independent tool for nutritional screen-
ing in older adults, particularly in long-term care facility
residents [21].
Statistical analyses
SPSS 26.0 and R 4.2.1 were used to analyse the data. Par-
ticipants were divided into two groups: those with dysphagia
and those without dysphagia. Univariate analysis between
the two groups in categorical variables was conducted using
the chi-square test or Fisher's exact test.
Least absolute shrinkage and selection operator (LASSO)
regression analysis with tenfold cross-validation was con-
ducted to screen the most useful predictive variables using
the “glmnet” R package. The logistic regression model was
constructed using the filtered variables, with dysphagia
1295
as the prediction. The stepwise backwards method based
on the likelihood-ratio test with Akaike information crite-
rion (AIC) was applied to select the optimal model. The
“rms” R package was then used to visualize the model and
develop the nomogram. The area under the receiver operat-
ing characteristic (ROC) curve (AUC) was used to evalu-
ate predictive accuracy. Calibration curves were plotted to
assess the calibration of this model, accompanied by the
Hosmer‒Lemeshow test (P > 0.05 is considered the good-
ness of calibration); an ideal calibration curve would ideally
fit the 45-degree reference line. The clinical usefulness of
the model was evaluated by decision curve analysis (DCA).
P < 0.05 was considered to indicate statistical significance.
Results
Patient characteristics
A total of 518 study participants from three long-term care
facilities were included in this study, including 409 from
two facilities as the development set and 109 from the other
facilities as the validation set. The incidence of dysphagia
was 68.7% in the development set and 52.3% in the valida-
tion set. The demographic characteristics of the development
set were as follows: mean age 83.844 years, ranging from
61 to 98 years; 228 (55.7%) female; 229 (56.0%) unmar-
ried, including divorced and widowed. The demographic
characteristics of the validation set were as follows: mean
age 86.174 years, ranging from 66 to 103 years; 74 (67.9%)
female; 66 (60.6.0%) unmarried. The detailed characteristics
of residents in the development set are shown in Table 1. The
detailed characteristics of the residents in the validation set
are shown in Supplementary file 1.
Feature selection and prediction model
construction
A total of 39 variables were extracted from each resident.
To identify crucial variables associated with dysphagia in
elderly residents, 39 variables were screened using LASSO
regression. The results showed that when the lambda value
was selected as lambda.min (0.0370), a total of five vari-
ables with nonzero coefficients were screened out, including
stroke, sputum suction history (within one year), nutrition
status, BI, and texture-modified food (Fig. 1a, b). The five
variables were further identified by stepwise backwards
logistic regression analysis. The results of the logistic
regression analysis are given in Table 2. The predictive
model was presented as a nomogram to predict the risk
probability of dysphagia in elderly residents (Fig. 2). Each
predictor corresponds to a score by drawing its line in the
points line. The sum of the five predictors is located on the
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1296 Aging Clinical and Experimental Research (2023) 35:1293–1303

Table 1  Sample description Characteristics Total(n = 409) Dysphagia(n = 281) Nondysphagia(n = 128) P Value
and univariate analysis of the
development set Age 0.944
60 ~ 70 24(5.9) 16(5.7) 8(6.2)
71 ~ 80 85(20.8) 58(20.6) 27(21.1)
81 ~ 90 235(57.4) 164(58.4) 71(55.5)
≥ 91 65(15.9) 43(15.3) 22(17.2)
Gender 0.890
Male 181(44.3) 125(44.5) 56(43.8)
Female 228(55.7) 156(55.5) 72(56.3)
Marital status 0.616
Unmarried 229(56.0) 155(55.2) 74(57.8)
Married 180(44.0) 126(44.8) 54(42.2)
Education 0.325
Primary school and below 75(18.3) 58(20.6) 17(13.3)
Junior high 81(19.8) 56(19.9) 25(19.5)
High school 143(35.0) 94(33.5) 49(38.3)
College and above 110(26.9) 73(26.0) 37(28.9)
Length of residence 0.279
≤3 269(65.8) 180(64.1) 89(69.5)
>3 140(34.2) 101(35.9) 39(30.5)
Tooth defect 0.261
Yes 368(90.0) 256(91.1) 112(87.5)
No 41(10.0) 25(8.9) 16(12.5)
Number of teeth 0.060
≤ 10 198(48.4) 147(52.3) 51(39.8)
11 ~ 20 69(16.9) 45(16.0) 24(18.8)
> 20 142(34.7) 89(31.7) 53(41.4)
Dentures 0.018
Yes 115(28.1) 69(24.6) 46(35.9)
No 294(71.9) 212(75.4) 82(41.1)
Texture-modified food < 0.001
Yes 158(38.6) 139(49.5) 19(14.8)
No 251(61.4) 142(50.5) 109(85.2)
Time on having meal 0.377
≤ 20 285(69.7) 192(68.3) 93(72.7)
> 20 124(30.3) 89(31.7) 35(27.3)
Smoking history 0.496
Yes 75(18.3) 54(19.2) 21(16.4)
No 334(81.7) 227(80.8) 107(83.6)
Drinking history 0.852
Yes 40(9.8) 28(10.0) 12(9.4)
No 369(90.2) 253(90.0) 116(90.6)
Diabetes 0.745
Yes 136(33.3) 92(32.7) 44(34.4)
No 273(66.7) 189(67.3) 84(65.6)
Stroke < 0.001
Yes 190(46.5) 149(53.0) 41(32.0)
No 219(53.5) 132(47.0) 87(68.0)
Hypertension 0.311
Yes 270(66.0) 190(67.6) 80(62.5)
No 139(34.0) 91(32.4) 48(37.5)
Parkinson 0.995

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Aging Clinical and Experimental Research (2023) 35:1293–1303 1297

Table 1  (continued) Characteristics Total(n = 409) Dysphagia(n = 281) Nondysphagia(n = 128) P Value

Yes 32(7.8) 22(7.8) 10(7.8)

No 377(92.2) 259(92.2) 118(92.2)
Hyperlipidaemia 0.261
Yes 41(10.0) 25(8.9) 16(12.5)
No 368(90.0) 256(91.1) 112(87.5)
Dementia < 0.001
Yes 159(38.9) 128(45.6) 31(24.2)
No 250(61.1) 153(54.4) 97(75.8)
Coronary heart disease 0.210
Yes 105(25.7) 67(23.8) 38(29.7)
No 304(74.3) 214(76.2) 90(70.3)
Peptic ulcer 0.650a
Yes 5(1.2) 3(1.1) 2(1.6)
No 404(98.8) 278(98.9) 126(98.4)
COPD 0.372
Yes 85(20.8) 55(19.6) 30(23.4)
No 324(79.2) 226(80.4) 98(76.6)
Constipation 0.097
Yes 91(22.2) 69(24.6) 22(17.2)
No 318(77.8) 212(75.4) 106(82.8)
Osteoporosis 0.368
Yes 207(50.6) 138(49.1) 69(53.9)
No 202(49.4) 143(50.9) 59(46.1)
Chronic bronchitis 0.470
Yes 125(30.6) 89(31.7) 36(28.1)
No 284(69.4) 192(68.3) 92(71.9)
Gastroesophageal reflux 1.000a
Yes 10(2.4) 7(2.5) 3(2.3)
No 399(97.6) 274(97.5) 125(97.7)
Anaemia 0.636
Yes 56(13.7) 40(14.2) 16(12.5)
No 353(86.3) 241(85.8) 112(87.5)
Tumour 0.224
Yes 29(7.1) 17(6.0) 12(9.4)
No 380(92.9) 264(94.0) 116(90.6)
Pneumonia history(within one year) 0.010
Yes 104(25.4) 82(29.2) 22(17.2)
No 305(74.6) 199(70.8) 106(82.8)
Fracture history(within one year) 0.568
Yes 47(11.5) 34(12.1) 13(10.2)
No 362(88.5) 247(87.9) 115(89.8)
Sputum suction history(within one year) 0.007
Yes 21(5.1) 20(7.1) 1(0.8)
No 388(94.9) 261(92.9) 127(99.2)
Polypharmacy 0.191
Yes 340(83.1) 229(81.5) 111(86.7)
No 69(16.9) 52(18.8) 17(13.3)
Antidepressant 0.654
Yes 53(13.0) 35(12.5) 18(14.1)
No 356(87.0) 246(87.5) 110(85.9)
Antipsychotics 0.079

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1298 Aging Clinical and Experimental Research (2023) 35:1293–1303

Table 1  (continued) Characteristics Total(n = 409) Dysphagia(n = 281) Nondysphagia(n = 128) P Value

Yes 113(27.6) 85(30.2) 28(21.9)

No 296(72.4) 196(69.8) 100(78.1)
Antibiotic 0.355a
Yes 12(2.9) 10(3.6) 2(1.6)
No 397(97.1) 271(96.4) 126(98.4)
Analgesic 0.091
Yes 139(34.0) 88(31.3) 51(39.8)
No 270(66.0) 193(68.7) 77(60.2)
Sleep medicine 0.047
Yes 132(32.3) 82(29.2) 50(39.1)
No 277(67.7) 199(70.8) 78(60.9)
Chinese patent medicine 0.373
Yes 160(39.1) 114(40.6) 46(35.9)
No 249(60.9) 167(59.4) 82(64.1)
Nutrition status < 0.001
Eutrophy 95(23.2) 45(16) 50(39.1)
Risk of malnutrition 178(43.5) 117(41.6) 61(47.7)
Malnutrition 136(33.3) 119(42.3) 17(13.3)
BI < 0.001
Independent 11(2.7) 2(0.7) 9(7.0)
Mild dependence 78(19.1) 30(10.7) 48(30.5)
Moderate dependence 80(19.6) 48(17.1) 32(25.0)
Severe dependence 240(58.7) 201(71.5) 39(58.7)
a
Using Fisher's exact test
COPD chronic obstructive pulmonary disease, BI Barthel Index, polypharmacy, having more than two
drugs

Fig. 1  LASSO regression a Lasso coefficient profiles of 39 features. model misclassification rate, and the horizontal axis shows the log(λ).
b Feature selection for the predictive model. Turning parameter (λ) The two vertical dashed lines represent the minimum value and one
selection used tenfold cross-validation. The vertical axis shows the standard deviation on one side from the minimum value

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Aging Clinical and Experimental Research (2023) 35:1293–1303 1299

Table 2  Multivariate predictors of dysphagia for elderly patients in total points line, and a vertical line is drawn downwards from
long-term care facilities the total points axis to the risk of dysphagia. For example,
Variable β SE OR CI P value if one resident had stroke (approximately 21 points), had a
regular diet (0 points), had a sputum suction history within
Stroke 0.481 0.255 1.617 0.981–2.666 0.059
one year (approximately 82 points), had a risk of malnutri-
Sputum suction − 1.870 1.089 6.489 0.018–1.303 0.086
tion (approximately 12 points), and had mild dependence
history(within
one year) (approximately 40 points), the total points for the resident
BI − 0.680 0.151 0.507 0.377–0.681 < 0.001 were approximately 155 points. The risk of dysphagia for
Nutrition status − 0.485 0.185 0.616 0.428–0.885 0.009 this resident was approximately 82%.
Texture modified 0.942 0.306 2.566 1.409–4.675 0.002
food

BI Barthel index

Fig. 2  Nomogram of dysphagia

prediction for elderly residents
in long-term care facilities. The
probability of dysphagia is cal-
culated by drawing a line to the
point on the axis for each of the
following features. The points
for each feature are summed and
located on the total point line.
Next, a vertical line is projected
from the total point line to the
predicted probability scale line
to obtain the elderly residents’
probability of dysphagia

Fig. 3  The receiver operating characteristic (ROC) curve of the dysphagia risk prediction nomogram [a: development set; b validation set]

13
1300
Prediction model verification
For the prediction model, the area under the ROC curve
of the nomogram was 0.800 (95% confidence interval,
0.755–0.844) (Fig. 3a). Internal validation was performed
using tenfold cross-validation with 1000 iterations, and the
average AUC value calculated was 0.808. The AUC in the
external validation set was 0.824 (95% confidence interval,
Fig. 4  Calibration curves of the dysphagia prediction model. The
x-axis represents the calibration curve for predicting dysphagia risk.
The y-axis represents the actually diagnosed dysphagia. The solid line
Fig. 5  Decision curve analysis (DCA) for dysphagia risk predictive
nomogram. The y-axis measures the net benefit. The red line rep-
resents the dysphagia risk nomogram. The grey line represents the
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Aging Clinical and Experimental Research (2023) 35:1293–1303
0.747–0.901) in the training set (Fig. 3b). The calibration
curves of the present predictive model showed good agree-
ment between prediction and observation in the development
set and the external validation set, and the Hosmer–Leme-
show test showed nonsignificant p values of 0.763 and 0.512,
respectively (Fig. 4a, b). DCA curves were used to evaluate
the clinical usefulness of the nomogram. DCA showed that
the model had greater net benefits than the “treat all” or “no
close to the 45-degree diagonal line represents a better prediction [a:
development set; b validation set]
assumption that all residents develop dysphagia. The black line repre-
sents the assumption that no residents develop dysphagia [a: develop-
ment set; b validation set]
Aging Clinical and Experimental Research (2023) 35:1293–1303
treatment” strategies when the development set and vali-
dation set threshold probabilities were in the risk range of
30–94% and 16–100%, respectively (Fig. 5a, b). The results
showed that the nomogram had excellent predictive value for
dysphagia in elderly residents of long-term care facilities.
Discussion
Our study found that the prevalence rate of dysphagia was
65.3% among elderly residents of long-term care facilities,
which was similar to the rate reported by a study in Brazil
(69.9%) [22]. However, the dysphagia rate was higher than
that reported in domestic and foreign studies [3]. Chinese
people are influenced by traditional ideology and culture
(e.g., Confucianism), and even though children have a heavy
burden of care, family pensions are still the mainstream.
They choose long-term care facilities when elderly individu-
als suffer from serious problems that are difficult for family
members, such as disability or dementia, or older adults with
no spouse or children [23, 24]. In this study, the long-term
care facilities were integrated with medical and nursing care
facilities, and the prevalence of disability among elderly
individuals was much higher [25]. This may be the reason
for the higher prevalence of dysphagia observed herein.
There are many risk factors for swallowing disorders,
and this study found that stroke and sputum suction his-
tory (within one year) were predictors of dysphagia in older
adults in long-term care facilities. Stroke is a common
disease that may cause dysphagia [26], and residents with
stroke are more than twice as likely to be admitted to long-
term care facilities than residents with other conditions [27].
Swallowing is a complex and coordinated process regulated
and controlled by multiple regions within the central nervous
system; therefore, damage to brain tissue after stroke often
results in dysphagia [28]. Residents with dysphagia had
significantly more sputum than those with normal swallow-
ing [29]. Sputum suction is also an invasive technique that
can cause mechanical damage to the patient’s pharyngeal
mucosa, thereby increasing the risk of swallowing disorders
[3]. Therefore, we need to pay more attention to residents
with increased sputum, particularly those with a history of
sputum suction within one year.
In the model, the most critical risk factor was the extent
to which elderly people depended on others for activities of
daily living (ADL). Chen et al. [25] showed similar asso-
ciations between dysphagia and ADL levels as defined by
the BI. A multicentre study in Spain showed that patients
with dysphagia had lower scores on the BI scale [22].
Nutritional problems were also a significant factor associ-
ated with dysphagia. A strong relationship exists between
malnutrition and dysphagia in elderly individuals [30].
Malnutrition is one of the most common complications of
1301
swallowing disorders, while geriatric complications asso-
ciated with malnutrition, such as sarcopenia, are among
the leading causes of swallowing disorders [31, 32]. Tran
et al. reported that dysphagia and malnutrition coexist in
long-term care facilities, with a higher prevalence of mal-
nutrition for those with dysphagia, and malnutrition was
also an independent predictor of the risk of dysphagia [30,
33]. Saito et al. suggested assessing nutritional status to
predict the risk of dysphagia in patients in the acute phase
[34].
When there is difficulty chewing, bolus formation, or
transportation, elderly residents often prefer to have tex-
ture-modified foods. Chopped, semiliquid, or liquid diets
are thought to more easily handle food during the oral prepa-
ration and oral push period for swallowing [35]. However,
long-term consumption of texture-modified foods will lead
to less movement of the muscles and organs associated with
swallowing in elderly individuals, thus reducing their abil-
ity to chew and forming a vicious cycle of reduced swal-
lowing function. Previous studies have also shown a strong
link between dysphagia and texture-modified food [36]. This
suggests that institutional staff should pay attention to older
adults with texture-modified foods and provide early inter-
ventions in swallowing.
As a visual evaluation tool, a nomogram can be used to
predict dysphagia among long-term care facility residents,
which incorporates five variables: stroke, sputum suction
history (within one year), BI, nutrition status, and texture-
modified food. Importantly, our primary goal was to build a
prediction model and attempt to achieve the best discrimi-
natory ability and calibration possible. Therefore, although
stroke and sputum suction history (within one year) were
not statistically significant (P > 0.05), they were included in
our final model. All predictors included in the nomogram
were easy to assess, and the nomogram showed good dis-
criminatory ability, calibration, and clinical usefulness in
both the development and validation sets, which suggests
that the nomogram is well transferable and generalisable.
The five variables included in the nomogram are independ-
ent of race and population, so we can be confident that the
nomogram can be applied in other countries and regions,
but due to cultural and other differences, it should still be
externally validated with a small sample before use. Never-
theless, it must be acknowledged that there are limitations
to this study. First, Convenience sampling may lead to selec-
tion bias, however, to some extent, external validation also
shows well predictive value of the nomogram which can
indicate a good extrapolation of the nomogram. Second, risk
factors may have missed some potential variables that may
affect dysphagia, such as psychological factors. The inclu-
sion of pharmacological factors was also not comprehen-
sive enough, such as antiepileptic drugs. Thirdly, due to lack
of equipment and technology, the nomogram does not use
13
1302
videofluoroscopy as the standard to evaluate its discrimina-
tion and calibration.
Conclusions
In conclusion, this study constructed an accurate nomogram
to help measure the risk of dysphagia in older adults in long-
term care facilities. Our model performs well in terms of
discrimination and calibration in predicting dysphagia. The
risk factors in the model are simple and easy to obtain. The
model will assist long-term care facility staff in identify-
ing residents at risk for dysphagia, intervening promptly to
prevent further dysphagia development, and reducing the
complications associated with dysphagia. Further prospec-
tive studies should be conducted to confirm our results.
Supplementary Information The online version contains supplemen-
tary material available at https://​doi.​org/​10.​1007/​s40520-​023-​02413-y.
Acknowledgements We want to acknowledge and thank the partici-
pants of the three long-term care facilities. We also thank the admin-
istrators, nurses, and facility workers who supported the study at each
nursing home.
Author contributions Conceptualization, JZ and JL.; methodology,
XC software, JL; validation, JZ, XC; formal analysis, YP and HY;
investigation, JL and ML; data curation, JZ; writing—original draft
preparation, JL and ML; writing—review and editing, JZ, HY; visu-
alization, ML and HY.; supervision, JZ project administration, JZ and
JL; funding acquisition, JZ All authors have read and agreed to the
published version of the manuscript.
Funding This research was funded by the Science and Technology
project of Chengdu (grant number 2021-YF05-01286-SN).
Data availability The datasets supporting the results of this article
are included in the article and supplementary file. Further reasonable
enquiries can be directed to the corresponding author.
Declarations
Conflicts of interest The authors have no relevant financial or non-
financial interests to disclose.
Ethical approval The study was conducted in accordance with the Dec-
laration of Helsinki and approved by the Biomedical Ethics Committee
of Chengdu Medical College (2022NO.01). All participant data were
anonymized. Moreover, informed consent was obtained from partici-
pants or their guardians included in the study.
References
1. Baijens LW, Clavé P, Cras P et al (2016) European society for
swallowing disorders - European union geriatric medicine society
white paper: oropharyngeal dysphagia as a geriatric syndrome.
Clin Interv Aging 11:1403–1428. https://​doi.​org/​10.​2147/​CIA.​
S1077​50
13
Aging Clinical and Experimental Research (2023) 35:1293–1303
2. Zhang M, Li C, Zhang F et al (2021) Prevalence of Dysphagia in
China: an epidemiological survey of 5943 Participants. Dysphagia
36:339–350. https://​doi.​org/​10.​1007/​s00455-​020-​10138-7
3. Doan TN, Ho WC, Wang LH et al (2022) Prevalence and meth-
ods for assessment of oropharyngeal dysphagia in older adults:
a systematic review and meta-analysis. J Clin Med. https://​doi.​
org/​10.​3390/​jcm11​092605
4. McCarty EB, Chao TN (2021) Dysphagia and swallowing dis-
orders. Med Clin North Am 105:939–954. https://​doi.​org/​10.​
1016/j.​mcna.​2021.​05.​013
5. Leibovitz A, Baumoehl Y, Lubart E et al (2007) Dehydration
among long-term care elderly patients with oropharyngeal dys-
phagia. Gerontology 53:179–183. https://​doi.​org/​10.​1159/​00009​
9144
6. Sue EE (2010) Dysphagia and aspiration pneumonia in older
adults. J Am Acad Nurse Pract 22:17–22. https://​doi.​org/​10.​
1111/j.​1745-​7599.​2009.​00470.x
7. Banda KJ, Chu H, Chen R et al (2022) Prevalence of oropharyn-
geal dysphagia and risk of pneumonia, malnutrition, and mortal-
ity in adults aged 60 years and older: a meta-analysis. Gerontol-
ogy 68:841–853. https://​doi.​org/​10.​1159/​00052​0326
8. Poulsen SH, Rosenvinge PM, Modlinski RM et al (2021)
Signs of dysphagia and associated outcomes regarding mortal-
ity, length of hospital stay and readmissions in acute geriat-
ric patients: observational prospective study. Clin Nutr Espen
45:412–419. https://​doi.​org/​10.​1016/j.​clnesp.​2021.​07.​009
9. Wirth R, Pourhassan M, Streicher M et al (2018) The impact
of dysphagia on mortality of nursing home residents: results
from the nutritionday project. J Am Med Dir Assoc 19:775–778.
https://​doi.​org/​10.​1016/j.​jamda.​2018.​03.​016
10. Patel DA, Krishnaswami S, Steger E et al (2018) Economic and
survival burden of dysphagia among inpatients in the United
States. Dis Esophagus 31:1–7. https://​d oi.​o rg/​1 0.​1 093/​d ote/​
dox131
11. National Health Commission of the People’s Republic of China.
2021 China’s health and health care development statistics bul-
letin. (2022–07–12) [2022–12–3]. http://​www.​nhc.​gov.​cn/​guihu​
axxs/ s3586s/202207/ 51b55216c2154332a660157abf28b09d.
shtml.
12. Wang C, Zhang F, Pan C et al (2022) The willingness of the
elderly to choose nursing care: evidence from in China. Front
Psychol 13:865276. https://​doi.​org/​10.​3389/​fpsyg.​2022.​865276
13. National Health Commission of the People’s Republic of China.
2021 China’s health and health care development statistics bul-
letin. (2022–07–12) [2022–12–3].http://​www.​nhc.​gov.​cn/​guihu​
axxs/ s3586s/202207/ 51b55216c2154332a660157abf28b09d.
shtml.
14. Eltringham SA, Kilner K, Gee M et al (2018) Impact of dys-
phagia assessment and management on risk of stroke-associated
pneumonia: a systematic review. Cerebrovasc Dis 46:99–107.
https://​doi.​org/​10.​1159/​00049​2730
15. Wieseke A, Bantz D, Siktberg L et al (2008) Assessment and
early diagnosis of dysphagia. Geriatr Nurs 29:376–383. https://​
doi.​org/​10.​1016/j.​gerin​urse.​2007.​12.​001
16. Engh MCN, Speyer R (2021) Management of dysphagia in
nursing homes: a national survey. Dysphagia. https://​doi.​org/​
10.​1007/​s00455-​021-​10275-7
17. Wang Z, Cui N, Zhao, et al (2020) Current status of asphyxia
prevention and management for the elderly in 43 elderly care
institutions. Chin J Mod Nurs 34:3373–3381. https://​doi.​org/​10.​
3760/​cma.j.​cn115​682-​20210​127-​00437
18. Xiao S, Dong Y, Huang B et al (2022) Predictive nomogram for
coronary heart disease in patients with type 2 diabetes mellitus.
Front Cardiovasc Med 9:1052547. https://​doi.​org/​10.​3389/​fcvm.​
2022.​10525​47
Aging Clinical and Experimental Research (2023) 35:1293–1303
19. Park YH, Bang HL, Han HR et al (2015) Dysphagia screen-
ing measures for use in nursing homes: a systematic review. J
Korean Acad Nurs 45:1–13. https://​doi.​org/​10.​4040/​jkan.​2015.​
45.1.1
20. Mahoney FI, Barthel DW (1965) Functional evaluation: the Bar-
thel index. Md State Med J 14:61–65
21. Donini LM, Poggiogalle E, Molfino A et al (2016) Mini-nutri-
tional assessment, malnutrition universal screening tool, and
nutrition risk screening tool for the nutritional evaluation of older
nursing home residents. J Am Med Dir Assoc 17:911–959. https://​
doi.​org/​10.​1016/j.​jamda.​2016.​06.​028
22. Sarabia-Cobo CM, Perez V, de Lorena P et al (2016) The inci-
dence and prognostic implications of dysphagia in elderly patients
institutionalized: a multicenter study in Spain. Appl Nurs Res
30:e6–e9. https://​doi.​org/​10.​1016/j.​apnr.​2015.​07.​001
23. Qian Y, Qin W, Zhou C et al (2018) Utilisation willingness for
institutional care by the elderly: a comparative study of empty
nesters and non-empty nesters in Shandong. China. Bmj Open
8:e22324. https://​doi.​org/​10.​1136/​bmjop​en-​2018-​022324
24. Huang Z, Liu Q, Meng H et al (2018) Factors associated with
willingness to enter long-term care facilities among older adults
in Chengdu. China. Plos One 13:e202225. https://d​ oi.o​ rg/1​ 0.1​ 371/​
journ​al.​pone.​02022​25
25. Chen S, Cui Y, Ding Y et al (2020) Prevalence and risk factors
of dysphagia among nursing home residents in eastern China:
a cross-sectional study. Bmc Geriatr 20:352. https://​doi.​org/​10.​
1186/​s12877-​020-​01752-z
26. Martino R, Foley N, Bhogal S et al (2005) Dysphagia after stroke:
incidence, diagnosis, and pulmonary complications. Stroke
36:2756–2763. https://​doi.​org/​10.​1161/​01.​STR.​00001​90056.​
76543.​eb
27. Rorth R, Clausen MF, Fosbol EL et al (2021) Initiation of domi-
ciliary care and nursing home admission following first hospi-
talization for heart failure, stroke, chronic obstructive pulmonary
disease or cancer. Plos One 16:e255364. https://​doi.​org/​10.​1371/​
journ​al.​pone.​02553​64
28. Singh S, Hamdy S (2006) Dysphagia in stroke patients. Postgrad
Med J 82:383–391. https://​doi.​org/​10.​1136/​pgmj.​2005.​043281
29. Imaizumi M, Suzuki T, Ikeda M et al (2020) Implementing a flex-
ible endoscopic evaluation of swallowing at elderly care facilities
1303
to reveal characteristics of elderly subjects who screened posi-
tive for a swallowing disorder. Auris Nasus Larynx 47:602–608.
https://​doi.​org/​10.​1016/j.​anl.​2020.​02.​004
30. Tran TP, Nguyen LT, Hirose K et al (2021) Malnutrition is associ-
ated with dysphagia in Vietnamese older adult inpatients. Asia Pac
J Clin Nutr 30:588–594. https://​doi.​org/​10.​6133/​apjcn.​202112_​
30(4).​0005
31. Gallegos C, Brito-de LFE, Clave P et al (2017) Nutritional aspects
of Dysphagia management. Adv Food Nutr Res 81:271–318.
https://​doi.​org/​10.​1016/​bs.​afnr.​2016.​11.​008
32. Yuan J, Lin Y, Song J et al (2022) Associations of sarcopenic
parameters with dysphagia in older nursing home residents: a
cross-sectional study. J Nutr Health Aging 26:339–345. https://​
doi.​org/​10.​1007/​s12603-​022-​1768-x
33. Tran TP, Nguyen LT, Kayashita J et al (2020) Nutritional status
and feeding practice among dysphagic older adult inpatients in
vietnam. J Nutr Sci Vitaminol 66:224–228. https://​doi.​org/​10.​
3177/​jnsv.​66.​224
34. Saito T, Hayashi K, Nakazawa H et al (2018) A significant associ-
ation of malnutrition with dysphagia in acute patients. Dysphagia
33:258–265. https://​doi.​org/​10.​1007/​s00455-​017-​9855-6
35. van der Bilt A (2011) Assessment of mastication with implica-
tions for oral rehabilitation: a review. J Oral Rehabil 38:754–780.
https://​doi.​org/​10.​1111/j.​1365-​2842.​2010.​02197.x
36. Namasivayam-Macdonald AM, Steele CM, Carrier N et al (2019)
The relationship between texture-modified diets, mealtime dura-
tion, and dysphagia risk in long-term care. Can J Diet Pract Res
80:122–126. https://​doi.​org/​10.​3148/​cjdpr-​2019-​004
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