Recently through my work, I’ve been exposed to the issue of dysphagia (i.e. swallowing difficulties) which can be caused by conditions like Parkinson’s, stroke and cancer. Did a short literature review on it and thought why not share it as a resource (with some edits) 😊
Landscape of Dysphagia and Nutritional Intake amongst Seniors in Singapore
Prevalence of Dysphagia
A survey of nine nursing homes equivalent to 12.4% of total nursing home beds found a point prevalence of 385.6 per 1000 residents (38.6%) for swallowing/chewing impairment. The incidence rate for new cases of swallowing/chewing impairment was 433.0 per 1000 person-years (Wong et al.,2019). In a less recent study, 29.4% of elderly patients admitted to an acute geriatric unit had dysphagia on admission, and 28.2% on discharge. Conditions such as stroke and Parkinsonism were major contributors, with 47% of stroke patients and 59.4% of Parkinson patients experiencing dysphagia (Lee et al., 1999). The statistics from these two studies signals that a significant proportion of seniors, especially those with chronic conditions, experience swallowing difficulties.
—> In a culture where eating is a social activity, good food is highly valued. For seniors with limited mobility, it remains one of the few pleasures they can still enjoy in later years. Dysphagia is thus also a psychosocial issue that limits seniors with this condition from fully participating in the social activity of eating together with others.
Nutritional Health Amongst Seniors in Singapore
A community health-screening found that amongst older Chinese adults aged 55 and above, 25.5% had moderate nutritional risk and 4.6% had high nutritional risk (Yap et al., 2007). The study found that this was primarily due to chronic health issues, polypharmacy, and changes in food intake due to illness .
Data from the Singapore Longitudinal Ageing Study indicated that 62% of community-dwelling older adults aged 55 and above were found at risk of malnutrition, with common contributing factors including medication-related side effects, social isolation, and reduced intake of essential nutrients like fruits and vegetables. Moreover, seniors facing malnutrition are often more likely to experience functional decline, disability, and impaired quality of life, underscoring the need for regular nutritional assessments and support (Hai et al., 2021).
There is little known about the nutritional health of seniors in nursing homes. However, there are indicators of malnutrition risk. Residents on home enteral nutrition (HEN, i.e. tube feeding) had a mean energy intake of 29.1 kcal/kg and mean protein intake of 1.2 g/kg/day (Wong et al., 2019). The caloric intake is lower than the geriatric guidelines and while the protein intake is at the recommended level (Volkert et al.,2019), it may not be sufficient for the residents who often have chronic diseases, pressure injuries, or are malnourished. Further, there is a lack of dysphagia or speech therapy services in Singapore leading to lengthy wait times and gap in dysphagia education for patients and caregivers in acute and subacute settings (Poon et al., 2023a; Poon et al.,2023b). Wong and colleagues (2019) found that more than 50% of nursing home residents in their sample were fed via feeding tube for more than 36 months and posited that some residents may be on prolonged HEN despite having potential to regain oral diet due to this service lack.
—> Looking at the research on nutritional intake, dysphagia is not the only condition contributing to malnutrition risk. Attention needs to be paid to seniors ageing in place as well. The number of seniors living alone has almost doubled since 2014 to about 78,1000 in 2023 (Statista). They tend to buy ready cooked food which may not be the most nutritious and may buy less fresh food as they cannot finish them before it spoils. Addressing social isolation and the related lifestyle impact on eating habits is hence important. Share a Pot is a community-focused project that addresses this through exercise and a nutritious bowl of soup- a culturally familiar dish for seniors. Active Ageing Centres in Singapore have also been moving into communal dining where seniors prepare and cook meals for other seniors to share. On the other hand, within the “controlled environment” of nursing homes, menu revamps through new recipes and kitchen equipment have helped increase the appetites of the residents. At the same time, food is not just about caloric and nutritional intake. It is the whole experience of eating. How can nutrition be further improved in nursing homes? Overseas models highlight a few tried ways.
Innovations to Improve Nutrition in Nursing Homes
Improving nutrition in nursing homes often involves focusing on food and the dining experience (Bowman, 2010). A buffet-style meal service where residents serve themselves improves residents’ appetites by bringing in smells to the dining area and promotes residents’ autonomy (Roloff, 2006). Familiar food aromas to engage residents led to improved social interaction and nutritional intake (Schaeffer, 2008). Family-style dining can lead to weight gain and improved quality of life (Nijs et al., 2006).
Another culture change is honouring “refrigerator rights” where residents can choose food items in their living areas. This opens the opportunity for residents to “treat” their guests. Similarly, at another nursing home, a lounge with menu items allows residents to host (Bowman, 2010; The National Board of Health, n.d.).
As mealtimes are often social, group dining experiences where residents eat in small family-style groups can improve nutritional outcomes. Other than arranging residents to eat together, communal dining events have been held where staff and residents dine together or invited guests dine together with residents.
On the other hand, AI has been used to improve nutrition through the “Meal Vision Scanning Unit” for data insights into nutritional intake, flagging up at-risk residents and reducing food waste through tailoring to seniors’ meal preferences.
The common theme in these innovations is improving person-centricity in mealtimes.
Conclusion
There are evident gaps in allied health services or solutions to address dysphagia and nutritional health among nursing home seniors in Singapore. However, the various innovative mealtime solutions already adopted in Western nursing homes highlight the potential to transform mealtime experiences here, particularly for seniors at risk of malnutrition and those with dysphagia.
References
The National Board of Health. Beboere inviterer familie og venner til fællesspisning på plejecenter i Lemvig. (n.d.). Retrieved November 5, 2024, from http://www.sst.dk/da/Bedremaaltider/61_-Beboere-inviterer-familie-og-venner-til-faellesspisning-paa-plejecenter-i-Lemvig
Bowman, C. S. (2010). The food and dining side of the culture change movement: identifying barriers and potential solutions to furthering innovation in nursing homes. In Centers for Medicare & Medicaid Services (CMS) and Pioneer Network’s Creating Home in the Nursing Home II: A National Symposium on Culture Change and the Food and Dining Requirements.
Hai, S., Gao, Q., Gwee, X., Chua, D. Q. L., Yap, K. B., & Ng, T. P. (2021). Malnutrition risk, physical function decline and disability in middle-aged and older adults followed up in the Singapore Longitudinal Ageing Study. Clinical Interventions in Aging, 16, 1527-1539. https://doi.org/10.2147/CIA.S322696
Lee, A., Sitoh, Y. Y., Lieu, P. K., Phua, S. Y., & Chin, J. J. (1999). Swallowing impairment and feeding dependency in the hospitalised elderly. Annals of the Academy of Medicine, Singapore, 28(3), 371-376.
Nijs, K. A., de Graaf, C., Kok, F. J., & van Straveren, W. W. (2006). Effect of family style mealtimes on quality of life, physical performance, and body weight of nursing home residents: Cluster randomized controlled trial. BMJ, 332, 1180-1184.
Poon, F. M. M., Ward, E. C., & Burns, C. L. (2023). Identifying prioritised actions for improving dysphagia services in Singapore: Insights from concept mapping with patients and caregivers. International Journal of Language & Communication Disorders, 59, 1018-1031. https://doi.org/10.1111/1460-6984.12977
Poon, F. M. M., Ward, E. C., & Burns, C. L. (2023). Adult dysphagia services in acute and subacute settings in Singapore. Speech, Language and Hearing, 27(3), 163–175. https://doi.org/10.1080/2050571X.2023.2240988
Roloff, Shellee. “Rethinking the Dining Experience in Long-Term Care.” Dietary Manager, October 2006
Schaeffer, K. (2008). Soup’s On. Nourish the Body and Soul. Action Pact Press.
Volkert, D.; Beck, A.M.; Cederholm, T.; Cruz-Jentoft, A.; Goisser, S.; Hooper, L.; Kiesswetter, E.; Maggio, M.; Raynaud-Simon, A.; Sieber, C.C.; et al. (2019). ESPEN Guideline on Clinical Nutrition and Hydration in Geriatrics. Clinical Nutrition, 38, 10–47
Yap, K. B., Niti, M., & Ng, T. P. (2007). Nutrition screening among community-dwelling older adults in Singapore. Singapore Medical Journal, 48(10), 911-916.
Social Working, Everything 