Developing strategies “SATIA”: How to manage dysphagia in older people? A Delphi panel consensus

Abstract

Aim

To develop a set of evidence-informed strategies to assist older people to improve swallowing functions and prevent further damage from complications.

Design

A two-round Delphi survey.

Methods

An initial set of dysphagia care strategies with 74 relevant items for older people was formed based on a literature review by seven researchers. An online survey was conducted by 21 panellists, and data of experts' opinions were collected and analysed by improved Delphi method.

Results

The positive coefficients in the two rounds of expert consultation were 85.71% and 83.33%, respectively. Consensus was reached with 53 items included and was allocated into the following five sections: (1) screening, (2) assessment, (3) training, (4) interventions and (5) management. These strategies were named with the acronym of each section—“SATIA”. The management strategy can be applied to guide the management of older people with dysphagia.

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What does this paper contribute to the wider global clinical community?

• The 53 items and five constructs identified in this study gave the basis for evaluating the safety and quality of dysphagia care strategies.
• This study established a set of comprehensive strategies including screening, assessment, training, intervention and administration for dysphagia management in older people.
• This study incorporates the perspectives of senior doctors, nurse managers in the geriatric ward and speech therapists, ensuring broad care perspectives from different disciplines.

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INTRODUCTION

Dysphagia has been recognized as a medical disability involving the digestive system by the WHO (World Health Organization, 2001). In Mosby's Medical, Nursing & Allied Health Dictionary, dysphagia is defined as difficulty in swallowing, commonly associated with obstruction or motor disorders of the oesophagus. People with obstructive disorders like oesophageal tumour or lower oesophageal ring are unable to swallow solids but can tolerate liquids. The prevalence of dysphagia increases with age, and it is an increasingly common problem in older people worldwide. A systematic review including research around the world indicated that the average prevalence of dysphagia in the community-dwelling aging population was approximately 15% (Madhavan et al., 2016). An epidemiological survey covering 14 Chinese provinces indicated that dysphagia had a high prevalence of 39.4% in people aged over 65, constituting a large burden of disease, which might due to the prevalence of related diseases, selection of participants, medical resources, race, etc. (Zhang et al., 2021). Nevertheless, with 190 million older people accounting for 13.5% of the Chinese population (National Bureau of Statistics of China, 2021) and the high prevalence of dysphagia among them, dysphagia became a serious health issue in China. Dysphagia-related consequences such as malnutrition or dehydration caused by the impaired efficacy and safety of swallowing function (Poisson et al., 2016), an increased risk of aspiration (Sura et al., 2012), and even pneumonia (Cabré et al., 2014) greatly threaten the older people as they are more susceptible to those consequences. The Chinese government is focusing on preventive care for this group in the community and the hospital, especially for those who are totally dependent. However, the elder population with dysphagia has not received enough attention from the government. It may be caused by that a few researchers began to focus on swallowing disorders in older people until the last 10 years.

Dysphagia has a wide variety of etiologies in older people. The intervention and prognosis of dysphagia vary with the underlying aetiology. For dysphagia in older people, neurologic and neuromuscular disorders are the principal risks, and head and neck involved pathologies can compromise the swallowing muscles directly (Di Pede et al., 2016). Dysphagia has been frequently associated with disorders such as stroke, neurodegenerative diseases and cancer of head and neck (Rommel & Hamdy, 2016). For patients with stroke, most traditional dysphagia therapies, such as volume and texture modification, head turn and effortful swallow have been confirmed as being effective, while for dysphagia in Parkinson's diseases, nutrition combined with nasogastric tube feeding or percutaneous endoscopic gastrostomy feeding is considered (Umemoto & Furuya, 2020). In addition, loss of muscle strength and muscle mass can also cause dysphagia, which is common in people with multiple sclerosis. The degree of disability and disease duration are significant predictors of dysphagia after multiple sclerosis (Tarameshlu et al., 2017). Thus, individual-targeted management and rehabilitation plans are needed for people with dysphagia with different etiologies.

BACKGROUND

Despite high prevalence and potential severity, dysphagia in older people is rarely systemically investigated, and many older adults with swallowing problems remain undiagnosed. The diagnosis of dysphagia is a multidisciplinary process, starting with the bedside screening by nurses or physicians, progressing to speech language therapists and then radiographic or endoscopic assessments (O'Rourke et al., 2014). Studies have shown that dysphagia screening could effectively reduce the incidence of pneumonia (Palli et al., 2017; Sørensen et al., 2013). Early assessment including clinical evaluation and instrumental assessment, such as videofluoroscopic swallowing study (VFSS), fiberoptic endoscopic evaluation of swallowing (FEES) and pharyngoesophageal manometry (Di Pede et al., 2016) can detect the abnormal swallowing function of older people in a timely fashion, and targeted nursing rehabilitation can be implemented to reduce the incidence of aspiration and improve the quality of life. In addition, the management of dysphagia consisting of therapeutic approaches and intervention is needed to reduce morbidity and mortality associated with poor nutritional status and chest infections. Unfortunately, studies have shown that in most nursing homes, oral hygiene strategies were lacking, and almost half did not have access to external experts, for example, speech therapists (Engh & Speyer, 2022). Thus, it is significant to recognize dysphagia as an important healthcare issue and to have a good dysphagia management strategy in place for better management of the patients.

A comprehensive dysphagia management strategy is known to be effective in some developed countries (Di Pede et al., 2016; Wirth et al., 2016). For example, dietary guidelines for people with swallowing disorders have been developed in the United States, Britain, Japan and Australia. In China, there are three consensuses on nutritional management of dysphagia after stroke. China expert consensus on home nutrition administration for the older people with dysphagia established a nutrition management system corresponding to the swallowing function classification and emphasized the multidisciplinary team cooperation mode to develop personalized and phased nutrition management plans (Chinese Gerontological Society of Nutrition and Food Safety Association, 2018). Expert consensus on rehabilitation nursing and care of swallowing dysfunction in the Chinese community developed community rehabilitation nursing and care process for dysphagia, swallowing function grading assessment process, focusing on the roles and practices of nurses (Aging Health Service and Standardization Branch of Chinese Geriatric Health Care Medical Research Association, 2019). Various assessment methods and treatments for adults, especially those with acute and chronic dysphagia caused by neurological diseases, were described in great detail (Chinese Expert Consensus Group on Rehabilitation Assessment and Treatment of dysphagia, 2017). However, there has not been a systematic and comprehensive standard strategy, including screening, assessment, training and rehabilitation for managing swallowing disorders in China. The establishment of cultural-relevant strategies for older people with dysphagia is urgent. Using literature review and the Delphi method, this study aimed to develop a set of evidence-informed strategies to assist older people to improve swallowing functions and prevent them from severe complications.

MATERIAL AND METHODS

A two-round modified Delphi method was used to develop strategies among a panel of experts. This method allows to define a consensus in a panel of experts on a specific topic from a large number of pre-defined items with a technique for the indirect confrontation of opinions (Keeney et al., 2001). The Delphi method uses interactions between panel members via questionnaires rather than face-to-face communication, which retains participant anonymity and avoids mutual interference, especially from authoritative experts. A five-point scale Delphi consensus study was used to identify the importance and operability of each strategy for dysphagia management.

This study report complied with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist (see Appendix S1).

Literature review and drawing up the developing strategies

Seven participants of the research team were responsible for research design including defining the initial survey and frame structure, literature review, coordination, implementation and quality control. Two participants searched the following databases: PubMed; Cochrane; CINAHL; Medline; Elsevier Science Direct; CNKI; WAN FANG; and CQVIP to obtain a large number of relevant studies. Data were available for the period 2010–2019 with search terms (“dysphagia” OR “swallowing disorder”) and (“aging” OR “older” OR “senile” OR “elderly”) in title or abstract. Finally, a total of 2,576 articles were retrieved (Table 1). After duplicates were removed, and the title and abstract screened, 339 articles were included. The articles were graded and quality evaluated based on “Johns Hopkins Evidence Based Practice: evidence level and quality guide” by two researchers back-to-back. If the result was inconsistent, a third researcher arbitrated. In addition, if the quality of the literature was rated C, it was excluded. Articles (n = 105) were finally included which showed strong evidence (Figure 1). The nursing process was used as a framework to guide in looking for the strategies for assessment, diagnosis, planning, implementation and evaluation. After discussion by the research team, a preliminary management strategy with 74 items was obtained which were grouped into five sections namely screening, assessment, training, intervention and administration. The initial questionnaire was developed for the first round of panellist review.

TABLE 1 Final strategies—screening (13 items)

[Table omitted. See PDF]

Black in a cell indicated that the value was not measured.

Establishing the questionnaire

The questionnaire consisted of three parts: the opening script, items on dysphagia with rating column and the information of experts. The opening script explained the background, purpose and main content of the study and why he or she was invited to attend the project to the consulting experts. It also contained a deadline for the questionnaire to be returned. The second part mainly gave the judgement table for management strategies for dysphagia in older people. It contained three levels of structure including area, sub-area and strategy recommendation. The first-level entry consisted of five sections, namely screening, assessment, training, intervention and administration (Tables 2–6). The importance of the strategy recommendation was rated using the Likert 5-point scoring method “5” for “extremely important”, “4” for “very important”, “3” for moderately important, “2” for “slightly important” and finally “1” for “unimportant”. The operability was also evaluated by the same method with different statements: “extremely operable”; “very operable” and so on. In addition, enough space was given in each section in the questionnaire for experts to express their own opinions on the strategies. The information in the expert section included the basic information of the expert, the basis for judgement with degree of influence and self-assessment for their familiarity with the subject.

TABLE 2 Final strategies–assessment (8 items)

Assessment
Timing of dysphagia assessment	A-1 screening for swallowing disorder in all older inpatients. Monitoring swallowing function in dysphagia patients in 24 h, 72 h, and 1 week after admission. Standardized bedside swallowing assessment and volume–consistency assessment can be performed in dysphagia patients before starting oral intake.	4.72 ± 0.67	0.14	4.67 ± 1.16	0.25	5.00 ± 0.00	0.00	4.67 ± 0.72	0.16
Accompanying symptoms of swallowing disorders assessment	A-2 assessing accompanying problems such as aspiration pneumonia, malnutrition, weight loss, dehydration, depression and other psychological problems.	4.78 ± 0.55	0.11	4.78 ± 1.10	0.23	5.00 ± 0.00	0.00	4.80 ± 0.41	0.09
The cause of swallowing disorders assessment	A-3 evaluation of factors related to swallowing disorders: Neurological conditions such as stroke, brain damage and dementia; muscular disorders such as amyotrophic lateral sclerosis and muscular dystrophies; head and neck tumour; respiratory conditions such as chronic obstructive pulmonary disease, tracheostomy; other conditions such as gastro-oesophageal reflux disorder, certain psychiatric conditions, polypharmacy, critical illness and general debility, autoimmune disorders.	4.50 ± 1.15	0.26	4.72 ± 1.34	0.28	5.00 ± 0.00	0.00	4.93 ± 0.26	0.05
Imaging evaluation assessment	A-4 Videofluoroscopic swallowing study (VFSS) procedure or fiberoptic endoscopic evaluation of swallowing (FEES) is used to assess swallowing disorders.	4.89 ± 0.32	0.07	4.33 ± 1.23	0.28	4.87 ± 0.35	0.07	3.93 ± 0.96	0.24
Aspiration risk assessment	A-5 A monitored sip test in identifying aspiration risk in older adult postoperative patients by monitoring oxygen saturation before and after swallowing 10 ml of water.	4.06 ± 1.16	0.29	4.33 ± 1.40	0.32	3.80 ± 1.37	0.36	3.87 ± 1.36	0.35
	A-6 10 metal test forms of different shapes are placed in the patient's mouth. The patient is asked to recognize the shape of the test form with his tongue. Recognition rate lower than 50% means a high risk for aspiration.	2.83 ± 1.42	0.50	3.06 ± 1.43	0.47
	A-7 risk assessment of aspiration by reduced conscious level, wet and hoarse voice, weak voluntary cough, and any indication of reduced laryngeal function.	4.22 ± 1.11	0.26	4.39 ± 1.33	0.30	4.87 ± 0.52	0.11	4.60 ± 0.51	0.11
	A-8 risk factors for aspiration pneumonia include digestive problems (e.g., gastroesophageal reflux disease, the use of gastric acid suppressant medication, decreased or absent gag reflex), respiratory problems (e.g., tracheal intubation, COPD, malpositioned nasogastric feeding tube), nervous problems (e.g., stroke, dementia, seizures, aphasia, coma, Parkinson disease, head trauma, brain tumour), circulatory problems (e.g., severe hypotension, cardiac arrest), bad living habits (e.g., poor oral hygiene, excessive alcohol consumption, smoking), others (e.g., obesity, the use of sedative drugs or anaesthesia, drug overdose, metabolic disorders.	4.67 ± 1.03	0.22	4.71 ± 1.33	0.28	5.00 ± 0.00	0.00	4.67 ± 0.49	0.10

TABLE 3 Final strategies–training (5 items)

Training
Nursing staff training	T-1 all staff who are involved in the dysphagia management should accept professional training which includes: Risk factors for swallowing disorder, early signs of swallowing disorder, swallowing dysfunction screening, feeding technology, the identification of aspiration and first aid of choking.	4.83 ± 0.51	0.11	4.72 ± 1.13	0.24	5.00 ± 0.00	0.00	4.80 ± 0.56	0.12
Healthcare assistant training	T-2 the staff in nursing home should accept the special training for swallowing disorder care.	4.94 ± 0.24	0.05	4.44 ± 1.20	0.27	4.93 ± 0.26	0.05	4.14 ± 0.77	0.19
Patients and caregivers training	T-3 make sure that elderly dysphagia patient and his caregiver be given health guidance on oral health care, choking management, food form adjustment, dining environment, utensils and compensatory methods including posture and technique in order to ensure enough nutrition, heat and liquid.	5.00 ± 0.00	0.00	4.72 ± 1.18	0.25	5.00 ± 0.00	0.00	4.53 ± 0.52	0.11
Training methods	T-4 inform the dysphagia patient and his family health education information in some ways such as video, seminar, sheets.	4.72 ± 0.67	0.14	4.61 ± 1.18	0.26	5.00 ± 0.00	0.00	4.33 ± 0.90	0.21
Evaluation of training effect	T-5 dysphagia patients and their carers should grasp knowledge about dining environment, appliance, adjustment of food form and posture.	4.94 ± 0.24	0.05	4.67 ± 1.20	0.26	5.00 ± 0.00	0.00	4.60 ± 0.51	0.11

TABLE 4 Final strategies–intervention (41 items)

[Table omitted. See PDF]

TABLE 5 Final strategies–management (9 items)

Management
Management model	M-1 implementing the PDSA (plan, do, study, act) protocol to manage older people will reduce the incidence of aspiration.	4.67 ± 0.59	0.13	4.33 ± 1.14	0.26	4.80 ± 0.41	0.09	4.47 ± 0.74	0.17
The multidisciplinary team management	M-2 professional team should consist of doctors, nurses, dentists, speech therapists, occupational therapists, and nutritionists with aim to manage dysphagia patients comprehensively including the swallowing disorder screening, oral health care, dental care, swallowing rehabilitation, nutrition management, respiratory management, feeding instructions, and caregivers consulting, etc.	4.94 ± 0.24	0.05	4.39 ± 1.20	0.27	5.00 ± 0.00	0.00	4.13 ± 0.92	0.22
Social support system participation management	M-3 the social factors in addition to doctors or nurses should be given full consideration with encouraging family members or close friends to take part in multidisciplinary assessment and management of swallowing disorder.	5.00 ± 0.00	0.00	4.56 ± 1.19	0.26	4.87 ± 0.35	0.07	4.53 ± 0.74	0.16
Standardized management process	M-4 standardized identification and management process should be supplied for dysphagia patients including not only aspiration risk assessment for all the older people but also early warning model startup, functional assessment, fasting, and speech therapist consultation processed for the patients with high risk of aspiration.	4.89 ± 0.47	0.10	4.53 ± 1.19	0.26	5.00 ± 0.00	0.00	4.73 ± 0.46	0.10
Risk notification and informed consent management	M-5 informed consent form should be signed for patients with high risk of aspiration.	4.89 ± 0.32	0.07	4.89 ± 1.12	0.23	4.93 ± 0.26	0.05	4.93 ± 0.26	0.05
Risk alert	M-6 warning signs of dysphagia should be added beside the beds.	4.78 ± 0.65	0.14	4.94 ± 1.12	0.23	4.93 ± 0.26	0.05	4.93 ± 0.26	0.05
Doctor-patient communication	M-7 A special team should be set up to deal with the situation that dysphagia patients could not follow the diet adjustment suggestion. The members of this team will let the patient and his family know the risk level and develop individualized strategies to deal with the swallowing disorder after discussing it with them.	4.89 ± 0.47	0.10	4.67 ± 1.18	0.25	4.93 ± 0.26	0.05	4.73 ± 0.59	0.13
Doctor-nurse communication	M-8 nurses should communicate with doctors about the swallowing information in time and effectively.	4.89 ± 0.32	0.07	4.94 ± 1.09	0.22	4.87 ± 0.35	0.07	4.87 ± 0.35	0.07
Effect management	M-9 using videofluoroscopic swallowing study (VFSS) procedure to evaluate the effect of comprehensive treatment for swallowing disorder.	4.61 ± 1.04	0.22	4.11 ± 1.33	0.32	4.93 ± 0.26	0.05	4.27 ± 0.88	0.21

TABLE 6 Kendall coordination coefficient

		Importance			Probility
		W	χ 2	p	W	χ 2	p
First round	items	0.332	395.343	0.000	0.308	335.23	0.000
Second round	items	0.170	118.885	0.000	0.196	125.951	0.000

Selection of the panellists

Convenience sampling was used to recruit panellists from a dysphagia communication group with more than 400 medical staff who were engaged in dysphagia work in China. The inclusion criteria were as follows: bachelor degree or above, being engaged in work related to dysphagia for more than 10 years, being familiar with the study content and able to assist in completing at least two rounds of expert correspondence. Finally, 21 panellists were recruited from 12 cities of nine provinces in China.

Data collection

A total of two rounds of expert consultations were conducted in this study. All of these inquiry questionnaires were issued by email, and the second round of correspondence was based on the consistency of the results of the first round of inquiry. In addition, experts whose familiarity with the survey content was rated as average, not too familiar or unfamiliar were excluded in the letter inquiry group members. If more than 5% of the total items were unanswered, the questionnaire would be deemed invalid and the expert would be excluded from the second round. The interval between two rounds of consultations was two months. After the first round of expert correspondence, the entries were screened based on expert opinions and statistical results. Items were deleted or modified if its mean was less than 4 or CV was greater than 0.30. Amendments, deletions, and additions were made to form the second round of expert letter inquiry volumes, which were reissued to the correspondence experts in the same way. Based on two rounds of letters and consultations from experts, the evaluation system was modified to form a standard management strategy for older people with dysphagia.

Data analysis

The double-entry method was used to enter the collected data. The mean, standard deviation, positive coefficient of experts, coefficient of variation and Kendall coordination coefficient were calculated with Statistical Package for the Social Sciences version 21.0 for Windows (SPSS Inc.). The degree of coordination of expert opinions was assessed through the coefficient of variation (CV) and the coefficient of coordination (W) of the items in this study. CV is the ratio of standard deviation to mean. The positive coefficient of experts is generally expressed in relation to questionnaire recovery rates, while the Kendall coordination coefficient is used to measure the consistency level of scoring data which ranged between 0 and 1. A higher value indicates better consistency.

Ethics

This study did not involve direct medical concerns; therefore, no medical ethics approval was required.

RESULTS Basic information of the panellists

The expert panel consists of six doctors, 12 nurse managers and three speech therapists. As three experts did not respond, we had 18 panellists participated in this study. Among them, 95.24% came from tertiary hospitals. The mean age of the panellists was 42.28 years old, ranging from 30 to 59 years old. For the educational level, one had a doctoral degree (5.55%), four master's degrees (22.22%) and 13 bachelor degrees (72.22%). The length of being engaged in dysphagia research or care of older people varied from 5 to 28 years with mean of 14.27.

Round 1

The effective recovery rate of expert consultation questionnaire was used to express the active coefficient of experts. In the first round, the active coefficient of experts was 85.71%, as 18 of 21 questionnaires were recovered. The questionnaire of the first round was composed of 74 items on dysphagia strategy for older people. The result of the first round of inquiry (Tables 2–6) showed the coefficient of variation of the importance of each item was 0.00–0.52, and the coefficient of variation of operability was 0.27–0.32. According to the comments of the panellists and then research team discussion in the first round, two new items “identifying swallowing disorder by a complete medical history assessment” (S-5) and “placing intermittent oro-esophageal tube” (I-41) were added, and 22 items (S-2, S-6 to11, A-6, I-3, I-5, I-6, I-8, I-20, I-21, I-25, I-26, I-29 to 34) were deleted. The coefficient of variation of I-18, I-19 was greater than 0.3, however, these extremely important items were retained after discussion with the research team despite the inconsistency for operability occurs among the panellists. Consequently, the first round of consultation resulted in 54 items remaining in the questionnaires.

Round 2

In the second round, 18 questionnaires were distributed and 15 valid questionnaires and one invalid questionnaire were recovered, with a recovery rate of 83.33%. In the questionnaire of the second consultation, two items “surface electromyography biofeedback (I-18)” and “induction electric movement method (I-19)” were both unanimously approved with a mean score more than 4 and CV less than 0.30. The results of the second round of inquiry (Tables 1–5) showed that the CV of the importance of each item was 0.00–0.36 and the CV of operability was 0.05–0.35 as well. Finally, the item on monitored sip test in identifying aspiration risk (A-5) was excluded on account of the coefficient of variation being greater than 0.3.

Final consensus

A total of 53 items were involved in the final strategies. These items were organized into the following five sections which was widely accepted by experts: (1) screening with six items; (2) assessment with six items; (3) training with five items; (4) interventions with 27 items; and (5) management or administration with nine items. The first letters of the five sections made up the “SATIA” model. The screening part included swallowing dysfunction, aspiration risk, psychological status and malnutrition screening. The assessment part included timing of dysphagia, accompanying symptoms of swallowing disorders, cause of swallowing disorders, imaging evaluation and aspiration risk. The training part included trainee, selection of training method, effect evaluation. The intervention part included compensatory strategies, position, sensory stimulation, rehabilitation training, oral hygiene, diet control and nutritional support. The management part included model, multidisciplinary management team, social support system, standardized process, risk notification and informed consent, risk alert, doctor–patient–nurse communication and effect evaluation. The CV of importance for all items was 0.00–0.24, and the CV of operability for those was 0.05–0.28, respectively. (Tables 2–5). The coordination coefficient W and significance tests of the expert opinions in the two rounds of consultation are shown in Table 6.

DISCUSSION

With the increase of average life expectancy and the continuous decline of fertility rate, China has stepped into an aging society, and the medical treatment costs for older people will have a negative impact on social development. Dysphagia has been deemed as a geriatric syndrome due to its high prevalence and numerous complications for older people (Ortega et al., 2017). Dysphagia contributes to a variety of negative health changes, most notably, increased risk of malnutrition, aspiration and resultant pneumonia (Cabré et al., 2014; Poisson et al., 2016). Older adults with dysphagia tend to have decreased functional status, slower recovery, and subsequently, longer hospital stays (Kaizer et al., 2012). One study showed that dysphagia is associated with a threefold increase in the risk of chest infections, which increases to elevenfold in those with definite aspiration (Kimura et al., 2005).

This study constructed a systematic and comprehensive standard strategy for older people with swallowing disorders in line with China's national conditions and gave a theoretical basis for older patients' nursing. It described the whole process of dysphagia management in great detail, including the discovery of dysphagia, screening of complications such as aspiration, screening of the causes of dysphagia, education and training of the caregivers of dysphagia, intervention methods of dysphagia, rehabilitation treatment and management process. The recovery rate of the two rounds in this study was greater than 70%, indicating quite a high expert participation. The experts included in this research were authoritative in the management of older people with dysphagia nationwide and had high academic attainments in this field, supported by the high authoritative coefficient (≥0.70). The high authoritative coefficient indicated high level of reliability of the consulting results. The demographic data of the panellists including age, working years, and so on showed a good representation of the professionals in this area. After two rounds of consultation, the coefficients of variation were all less than 0.3 except A-5, indicating that the consensus was reached and the strategies were reliable to implement. In the end, through team discussion, we used the acronym of the initial letter of each section- “SATIA” to name the newly developed strategies for dysphagia management.

S-Screening

To deal with dysphagia in older people effectively, the first thing was to identify swallowing problems in older people. In the present study, we kept six items for screening strategies: screening for swallowing dysfunction, psychologist status and malnutrition screening. Numerous dysphagia screening tools are available nowadays, but in the first round, we selected four screening tools, namely, standardized swallowing assessment (SSA), eating assessment tool-10 (EAT-10) score, swallowing stage cervical auscultation with tongue function assessment and automated integrated impedance manometry (Kaindlstorfer & Pointner, 2016) due to their good sensitivity, specificity and being non-invasive for older people. The EAT-10 is a self-reported questionnaire-based standard screening tool (Rofes et al., 2014; Tsang et al., 2020), which has been widely used in community-dwelling older adults. Many other tools were developed based on EAT-10, such as a simple screening tool named 4QT with high sensitivity and moderate specificity (Tsang et al., 2020). A microphone was used to capture swallowing sounds, since the stethoscope had low sensitivity and low specificity for the diagnosis of dysphagia (Taveira et al., 2018). The tool “automated integrated impedance manometry” was removed after the first round due to its weak feasibility. One expert insisted on adding “comprehensive medical history assessment” to the screening part in the first round, and this was accepted by other experts in the second round.

A-Assessment

After simple screening for dysphagia, mental state and malnutrition, we need to further assess patients for concomitances, causes, aspiration risk and diagnostic radiological imaging for dysphagia. Assessment aimed to identify aspiration risk, severity and prognosis of dysphagia (Rommel & Hamdy, 2016). The section on assessment included five sub-sections. Assessment for swallowing disorder should be conducted with all older inpatients. The first sub-section involved timing of dysphagia assessment, including the initial assessment in 24 h after admission and followed by reassessment in 72 h and 1 week once an older adult was diagnosed dysphagia. Standardized bedside swallowing assessment and volume-viscosity swallow test should be performed in people with dysphagia before oral intake (Baijens et al., 2016). And the second sub-section focused on the assessment of accompanying symptoms of swallowing disorders. (Fırat Ozer et al., 2021) suggested the assessment of the accompanying problems, such as aspiration pneumonia, malnutrition, weight loss, dehydration, depression and other psychological problems. The third sub-section was about the assessment of the aetiology of swallowing disorders, which included the assessment of neurological conditions such as stroke, brain damage and dementia; muscular disorders such as muscular dystrophies and amyotrophic lateral sclerosis that is a progressive degenerative disorder of the motor neurons with weakness and wasting of swallowing muscles (Salvioni et al., 2021); head and neck tumour; respiratory conditions, for example, chronic obstructive pulmonary disease, tracheostomy; and other conditions such as gastro-oesophageal reflux disorder, certain psychiatric conditions, polypharmacy, critical illness, general debility and autoimmune disorders. The fourth sub-section included invasive evaluations such as Video Fluoroscopic Swallow Study (VFSS) and Flexible Endoscopic Evaluation of Swallowing (FEES). Finally, the fifth sub-section referred to the assessment of aspiration risks. In this section, the patient was asked to recognize the different shapes in a set of models in the oral cavity (Kolb & Bröker, 2009), which had been removed since it did not reach a consensus due to its low operability in the first Delphi round.

T-training

T items recommended the different types of trainees, training methods and evaluation methods for training outcomes. All nursing staffs involved in the dysphagia management are to receive professional training on risk factors for swallowing disorder, early signs of swallowing disorder, swallowing dysfunction screening, feeding technology, the identification of aspiration and first aid for choking (Andersen Fortes et al., 2019). In addition, healthcare assistants in nursing home are recommended to receive standardized training in swallowing disorder care (Sharma et al., 2012). Some studies also suggested that older people with dysphagia and their caregivers receive health guidance on oral care, choking management, food form adjustment, dining environment, utensils and compensatory methods including posture and technique to ensure adequate nutrition, calories and liquids (Ballesteros-Pomar et al., 2020; Di Pede et al., 2016). Training methods and tools such as seminar, video and brochures were recommended in this section. People with dysphagia and their caregivers were encouraged to learn how to promote dining environment, use the appliances and adjust food form and posture. In future, nurses should play an increasingly important role in training patients and careers for home care management including dysphagia management in China.

I-intervention

Intervention for dysphagia has become a research hotspot. In the present study, we recommended the interventions including compensatory strategies, sensory stimulation, rehabilitation training, oral hygiene, feeding position, feeding management and nutritional support. Compensatory strategies included the adjustment of swallowing behaviour, swallow posture and the technology of swallowing (Di Pede et al., 2016). Effect of intervention was confirmed by Video Fluoroscopic Swallow Study (VFSS) procedure or Flexible Endoscopic Evaluation of Swallowing (FEES).

A variety of sensory stimulations has been used to improve swallowing function (Di Pede et al., 2016), such as taste estimation and gas pulse stimulation. However, several methods have not been approved by the experts for their low operability or feasibility such as music therapy (Cohen et al., 2020; Kim, 2010), inhalation of volatile black pepper oil or menthol (Ebihara et al., 2006), oral intake combining stimulation of transient receptor potential and olfactory stimulation and thermal-tactile stimulation. Other sensory stimulations were widely approved by the experts as shown in Table 5.

Rehabilitation training played an important role in dysphagia management, which included breathing training techniques, tongue muscle training, shaker training method, airway protection, neuromuscular electrical stimulation, surface electromyography biofeedback, induction electric movement method and acupuncture. However, experts have not reached an agreement on the cerebral cortex and transcranial magnetic stimulation treatment as an intervention for older people with dysphagia.

For frail older people, oral hygiene care was given, including inspecting the oral cavity, removing plaque, maintaining oral tissue moisture, cleansing the oral tissues, decontaminating the oral cavity and using fluoride products (Coker et al., 2013).

Appropriate assistance with eating was necessary to prevent aspiration pneumonia in older people with dysphagia, and the strategies should involve taboo foods, food viscosity and a safe eating environment (Ballesteros-Pomar et al., 2020). Several diet control strategies were accepted such as avoiding foods that affect swallowing, adding thickener to the liquid diet and providing a safe eating environment. As to feeding position, the bed should be adjusted into a sitting position when people with dysphagia were feeding food or drinking water. However, some other feeding methods were excluded in the first Delphi round such as increasing carbonated liquids, using surface electromyography to make swallow easily and taking some medicines, including medicine promoting glandular secretion, mosapride preventing pneumonia, α2-adrenergic receptor agonist coordinating respiration and swallowing and botulinum toxin or angiotensin-converting enzyme inhibitors reducing pneumonia incidence (Kumazawa et al., 2019).

Nutritional support is a vital component for older people with dysphagia, since dysphagia can easily give rise to malnutrition. Different nutrition support methods are chosen for people with dysphagia in different circumstances. A nutritionist is consulted for patients whose nutrition score (NRS-2002) is more than 3. For people with mild swallowing disorders–no obvious aspiration and no large amount of food residue, appropriately processed foods and oral nutrition can be chosen to get nutrition support. For people with severe swallowing disorders, safe and effective food intake is significantly threatened. Percutaneous endoscopic gastrostomy feeding can be considered to give nutritional support for subsequent conditions such as weight loss and malnutrition in people with dysphagia (Umemoto & Furuya, 2020). One expert put forward that older people with dysphagia should be placed with intermittent oro-oesophageal tube instead of percutaneous endoscopic gastrostomy tube to reduce the risk of aspiration and regurgitation. This opinion was approved by other experts in the second consulting round in our study.

A-administration

This section consisted of nine sub-sections as shown in Table 5. Studies have shown that implementing Plan-Do-Study-Act (PDSA) protocol and standardized management process to manage older people can reduce the incidence of aspiration (Hansjee, 2018). Dysphagia management needs a multidisciplinary team collaboration, which is consisted of doctors, nurses, dentists, speech therapists, occupational therapists, nutritionists and social workers or family members. For people with high risk of aspiration, informed consent is signed, and warning signs of dysphagia are placed at the bedside. Besides, the communication between medical staff and patients is very critical; therefore, a special team involving professional nurses and nutritionists is set up to deal with people with dysphagia who are unable to follow the diet adjust suggestion. Likewise, the primary nurses need to keep a close connect with doctors about swallowing information in time. The last step for dysphagia administration was to evaluate the effect of comprehensive treatments by Video Fluoroscopic Swallow Study (VFSS), Flexible Endoscopic Evaluation of Swallowing (FEES) or other assessing methods.

Strength and limitations

To our knowledge, this is the first study reporting systematic and prioritized strategies for managing swallowing problems for older people by using a Delphi process in China. The study was rigorously designed, including the use of standardized evidence-based processes and Delphi techniques. The construction of the “SATIA” strategies may give theoretical support for the management of swallowing disorders in older people. The application and promotion of the “SATIA” strategies might help to identify the occurrence of swallowing disorders early, take effective intervention measures, reduce the incidence of aspiration in older people effectively and the burden of family care. Nonetheless, it had several limitations. First, the positive coefficient of experts was not so high, the number of selected experts was not enough. Second, people with dysphagia or their caregivers were not included in the Delphi survey, since they did not meet the inclusion criteria of panellists. Thus, we did not gain their perspectives on effective management, and further research including their perspectives is expected in the future. In addition, the constructed strategies have not yet been used and verified in several older people to manage dysphagia, thus further studies are required.

CONCLUSIONS

Generating systematic developed strategies for older people with swallowing disorders in China is of great significance for the prognosis of dysphagia. This study gave a hitherto previously absent expert consensus on dysphagia care strategies named “SATIA”, which was developed with scientific evidence from literature and experts' opinions. The construction of the strategies may give theoretical support for the management of swallowing disorders in older people. It can also give guidance for older people rehabilitation institutions to evaluate the improvement of dysphagia in older people. Further study to verify its clinical value is expected in the future. Further study to verify its clinical value is expected in the future.

AUTHOR CONTRIBUTIONS

Huafang ZHANG: conceptualization, formal analysis, investigation, data curation, writing—original draft, supervision, project administration; Li ZHENG: conceptualization, formal analysis, investigation, data curation; Mengling TANG: validation; writing—review & editing; Fanjia GUO: writing—review & editing; Suxiang LIU: investigation, data curation; Jinyun WANG: investigation, data curation; Jie CHEN: investigation, data curation; Chenxi YE: investigation, data curation; Yajun SHI: investigation, data curation; Sihan LI: investigation, data curation; Wenfeng XUE: investigation, data curation; Jie SU: investigation, data curation.

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]:

• Substantial contributions to conception and design, acquisition of data or analysis and interpretation of data;
• Drafting the article or revising it critically for important intellectual content.

ACKNOWLEDGEMENTS

The authors would like to express our gratitude to all of the experts who agreed to participate in the Delphi study.

FUNDING INFORMATION

This study was supported by “The construction and evaluation of dysphagia risk prediction model in the elderly” LGF21G010005 Public Welfare Projects of Zhejiang Provincial Department of Science and Technology in China.

CONFLICT OF INTEREST

The authors declare that they have no conflict of interest.

ETHICS STATEMENT

This study did not involve direct medical concerns; therefore, no medical review was required.

PATIENT CONSENT STATEMENT

This study did not require patient consent.