Association between dysphagia and social isolation in community-dwelling older people

doi:10.21203/rs.3.rs-5009508/v1

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Association between dysphagia and social isolation in community-dwelling older people

https://doi.org/10.21203/rs.3.rs-5009508/v1

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Purpose

This study aimed to clarify the relationship between dysphagia and social isolation among community-dwelling older people.

Methods

The participants in this cross-sectional observation study were 238 community-dwelling older people (168 women, mean age, 74.0 ± 5.2 years). Swallowing function was assessed using the Eating Assessment Tool-10, with a score of ≥ 3 defined as dysphagia. Tongue pressure and oral diadochokinesis (ODK) were also assessed as swallowing-related functions. Social isolation was assessed using the 6-item Lubben Social Network Scale. Physical function, cognitive function, body mass index, presence of comorbidities, depressive symptoms, and functional capacity were also investigated as confounding factors. The relationship between social isolation and dysphagia was examined by logistic regression analysis with social isolation as the dependent variable and oral function as the independent variable, adjusted for confounding factors.

Results

In total, 21% of the participants were defined as being socially isolated (social isolation group). The social isolation group had a significantly higher percentage of patients with dysphagia than the nonsocial isolation group (p < 0.01). No significant association was found between social isolation and either tongue pressure or ODK. Dysphagia was significantly associated with social isolation (odds ratio: 2.8, 95% confidence interval: 1.1–7.0), even after adjusting for confounders in logistic regression analysis.

Conclusion

Dysphagia may be an independent risk factor for social isolation in community-dwelling older people. These findings suggest that swallowing function should be assessed in community-dwelling older people at risk of social isolation.

Community-dwelling older people

Dysphagia

Social isolation

Swallowing function

Social network

Aim: This study investigated the association of dysphagia with social isolation in community-dwelling older people.

Findings: Dysphagia was significantly associated with social isolation, even after adjusting for physical function, cognitive function, and confounding factors.

Message: Dysphagia should be evaluated in community-dwelling older people at risk of social isolation.

Globally, it is estimated that by 2050, 20% of the total population will be elderly [1]. In developed countries, the aging population is growing rapidly; for example, the older population in Japan is estimated to exceed 30% of the population by 2025, and 39.9% by 2060 [2]. Therefore, extending the healthy life expectancy of older people is of great concern for the sustainability of the social security system. In addition, the prevention of disability in older people is an important issue that urgently needs to be addressed by health-care professionals.

With regard to the prevention of disability in older people, various factors, such as physical, psychological, cognitive, oral, and social factors, have been reported to have an effect on the promotion of disability-free life expectancy [3–6]. In particular, social factors are widely recognized as health-related factors that need to be addressed in health promotion for older people. For example, it has been reported that a decline in social function occurs before a decline in physical function [7]. Social factors have also been reported to be associated with depression, cognitive function, and oral function [8–10]. With regard to social factors in particular, social isolation has been reported to lead to adverse health outcomes, such as early mortality and the development of conditions requiring long-term care, in community-dwelling older people [11, 12]. Globally, social isolation has been highlighted as a risk factor for adverse health outcomes in community-dwelling older people [13]. It is therefore important to identify the factors that lead to social isolation and to develop appropriate preventive interventions.

Recently, an association between social isolation and oral frailty has also been reported [14]. Furthermore, dysphagia in community-dwelling older people has been suggested to be associated with not only social isolation, but also depression and quality of life [15]. However, that study did not assess dysphagia using validated or standardized methods such as the Eating Assessment Tool-10 (EAT-10) [16]. Therefore, it could be said that the relationship between social isolation and dysphagia has not been sufficiently clarified. If social isolation were found to be associated with dysphagia in older people, a new strategy to prevent social isolation could be developed. Therefore, the purpose of this study was to clarify the relationship between social isolation and dysphagia in community-dwelling older people.

Participants

The study participants were community-dwelling older people who had participated in a health check-up for geriatric syndrome in Sagamihara city, Kanagawa Prefecture, Japan, which has a population of approximately 700,000 and a relatively well-developed public transportation system. The participants were recruited through a community newspaper in Sagamihara city. The inclusion criteria were as follows: (i) ≥ 65 years of age, (ii) living in the community, and (iii) not certified by the Japanese long-term care insurance system as needs care level or support level. The exclusion criteria were as follows: (i) residing in a nursing home or other long-term care facility, (ii) a history of cerebrovascular disease, or (iii) suspected of having cognitive dysfunction. The inclusion and exclusion criteria were confirmed by trained investigators. This study was approved by the Kitasato University School of Medicine and Health Sciences Institutional Review Board (approval No. : 2018-008B-2), and written informed consent was obtained from all participants before the study began.

Study design

This study employed a cross-sectional observational design.

Social isolation

In this study, social isolation was assessed using the 6-item Lubben Social Network Scale (LSNS-6) [17]. The reliability and validity of the Japanese-translated version of LSNS-6 have been verified [18]. The LSNS-6 is a survey instrument that assesses the size of a close network of family and friends with whom one can have a conversation and ask for help. The LSNS-6 is composed of six items in a self-rating questionnaire, with each item rated on a scale of 0 to 5 depending on the participant’s subjective network size. The total score is an equally weighted sum of these six questionnaire items, with scores ranging from 0 to 30, and a higher total score indicating a greater social network. Based on previous studies, participants scoring < 12 points were defined as being socially isolated [17].

Swallowing and swallowing-related function

Swallowing function was assessed the EAT-10 [16], a questionnaire with a total score ranging between 0 and 40 points. In this study, a score of ≥ 3 points was defined as “dysphagia” in accordance with the criteria of a previous study. The EAT-10 has been validated for reliability and validity in Japan [19].

Regarding swallowing-related function, tongue pressure and oral diadochokinesis (ODK) were also assessed. Maximum voluntary tongue pressure was measured using a probe inserted into the oral cavity and a manometer (JM-TPM01; JMS, Hiroshima, Japan). After the participants were seated in a chair, a probe was inserted into the oral cavity and placed on the front of the tongue. The participants pressed the probe on their tongue with maximum effort for 7 seconds. Measurements were taken three times with an adequate interval, the mean of which was used for further statistical analyses. Based on a previous study, we defined decreased tongue pressure as a maximum tongue pressure < 30 kPa [20].

ODK was assessed as a function of tongue and lip motor function. Using a digital counter (Kenko-kun Handy; T.K.K. 3351, Takei Scientific Instruments, Niigata, Japan), the number of times the “pa” syllable was repeated in the sitting position was obtained as the number of articulations in 5 seconds, and the average number of articulations per second was calculated. The number of articulations per second was also calculated for the “ta” and “ka” syllables in the same manner. In the ODK test, we defined a loss of tongue and lip motor function as fewer than 6.0 articulations per second of “pa”, “ta”, or “ka” [20]. Both oral function assessments were measured by speech therapists.

Physical function

Cognitive function

The Japanese versions of the Trail Making Test Parts A (TMT-A) and B (TMT-B) were administered to assess cognitive function using a tablet PC (Dell Inspiron11 3000, Dell Technologies Japan Inc., Tokyo, Japan) [23]. The validity of cognitive function tests such as the TMT-A using a tablet has been verified [24], and the tablet method was also used in this study. The TMT-A was used to measure the time required to touch all numbers 1–25 displayed on the screen of a tablet PC in order. The TMT-B was used to measure the time required to touch the numbers and letters alternately (1-a-2-i-12-shi).

Basic attributes

The participants’ age, sex, height, weight, body mass index (BMI), medical history, number of medications, functional capacity, and physical activity were collected as basic attributes. Regarding comorbidities, the presence or absence of diagnoses by a physician for heart disease, respiratory disease, hypertension, dyslipidemia, diabetes, liver disease, and renal disease was investigated. Functional capacity was assessed using the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC) [25]. Instrumental activities of daily living (IADL) were assessed using a subscale of the TMIG-IC, with a full score (5 points) defined as independence in IADL. To assess physical activity, the participants were asked whether they regularly engaged in “20 to 30 minutes of exercise two to three times a week”. Depressive symptoms were measured using the 5-item version of the Geriatric Depression Scale (GDS-5) [26]. Scores on the GDS-5 range from 0 to 5 points, with scores of ≥ 2 indicating the presence of depressive symptoms.

To evaluate sarcopenia, appendicular skeletal muscle mass was measured using a bioelectrical impedance analysis device (Inbody 470; Inbody Japan, Tokyo, Japan). Skeletal muscle mass was evaluated using the skeletal muscle index, which is calculated as the appendicular skeletal muscle mass divided by the square of the height. In this study, the presence of sarcopenia was determined according to the Asian Working Group for Sarcopenia (AWGS-2019) criteria [27]. Participants who met the criteria for both low grip strength and/or low gait speed and low muscle mass were considered to have sarcopenia.

Statistical analysis

Comparisons between groups with and without social isolation were examined using the Mann–Whitney U test or the chi-square test. To examine the relationship between social isolation and dysphagia, logistic regression analysis was performed with social isolation as the dependent variable, dysphagia as the independent variable, and physical function, cognitive function, and basic attributes as the adjustment variables. In addition, the relationship between swallowing function and social networks was investigated by multiple regression analysis. The level of statistical significance was set at 5%, and EZR (version 1.62) [28] was used for all statistical analyses.

A total of 238 participants (71 men and 167 women; mean age, 73.9 ± 5.2 years) were included in the analysis after confirming the inclusion and exclusion criteria, among whom, 50 (21%) were defined as having social isolation, nine (4%) as having sarcopenia, and 231 (97%) as being independent in IADL. Comparisons of physical function, cognitive function, and confounding factors among all subjects and groups with and without social isolation are shown in Table 1. Significant differences were found for sex, BMI, and TMIG-IC, but not for age, physical function, or cognitive function.

Table 1

Participants’ characteristics
		Total (N = 238)		Social isolation group (n = 50)		Nonsocial isolation group (n = 189)		P value
SCWS	(m/s)	1.45	(1.33–1.59)	1.42	(1.29–1.56)	1.45	(1.35–1.61)	0.23
TUGT	(s)	5.37	(4.86–5.91)	5.38	(4.82–6.01)	5.37	(4.87–5.89)	0.77
Grip	(kg)	25.25	(22.00–30.78)	26.45	(22.98–33.65)	24.95	(21.80–30.00)	0.10
5-CST	(s)	5.48	(4.68–6.35)	5.50	(4.82–6.15)	5.48	(4.68–6.38)	0.98
TMT-A	(s)	52.10	(42.49–63.16)	54.75	(45.06–68.59)	50.99	(41.53–62.04)	0.08
TMT-B	(s)	86.77	(70.72–112.42)	87.38	(70.79–111.03)	84.56	(70.77–113.21)	0.76
Age	(years)	73	(70–77)	72	(69–76)	74	(70–77)	0.08
BMI	(kg/m²)	21.92	(20.08–24.49)	22.54	(20.91–25.11)	21.73	(19.93–24.27)	0.04
Number of medications	(type)	1	(0–3)	2	(1–3)	1	(0–2)	0.07
TMIG-IC	(points)	12	(11–13)	11	(10–12)	12	(12–13)	< 0.01
Independence in IADL	(yes)	231	(97)	49	(98)	183	(97)	1.00
Sex	(woman)	167	(70)	27	(54)	140	(74)	< 0.01
Depressive symptoms	(yes)	42	(18)	11	(22)	31	(16)	0.41
Sarcopenia	(yes)	9	(4)	2	(4)	7	(4)	1.00
Values are expressed as the median (interquartile range) or n (%). SCWS: self-selected comfortable walking speed, TMT-A: Trail Making Test Part A, TMT-B: Trail Making Test Part B, BMI; body mass index, TMIG-IC: Tokyo Metropolitan Institute of Gerontology Index of Competence, IADL: instrumental activities of daily living, TUGT: Timed Up and Go test, 5-CST: 5-chair stand test.

Table 2 shows the results of comparisons of dysphagia, swallowing-related function (tongue pressure, ODK) between the groups with and without social isolation. No significant differences were found for tongue pressure or ODK. However, EAT-10 scores and dysphagia significantly differed by social isolation. The results of the logistic regression analysis regarding the relationship between dysphagia and social isolation are shown in Table 3. In all regression analysis models, dysphagia was significantly associated with social isolation independent of age, functional capacity, depressive symptoms, physical function, and cognitive function.

Table 2

Participants’ swallowing function
		Total (N = 238)		Social isolation group (n = 50)		Nonsocial isolation group (n = 189)		P value
EAT-10	(points)	1	(0–2)	2	(0–3)	1	(0–1)	< 0.01
Dysphagia	(yes)	31	(13)	13	(26)	18	(10)	< 0.01
Tongue pressure	(kPa)	34.4	(28.4–38.5)	35.0	(30.2–41.4)	34.2	(28.1–38.3)	0.33
Decreased tongue pressure	(yes)	75	(32)	12	(24)	63	(34)	0.30
Decreased lip and tongue motor function	(yes)	102	(43)	22	(44)	80	(43)	0.87
Values are expressed as the median (interquartile range) or n (%). EAT-10: Eating Assessment Tool-10.

Table 3

Association between dysphagia and social isolation in multivariate logistic regression analysis
	Model	Odds ratio	95% confidence interval	P value	C statistic
Dysphagia (yes)	Crude	3.32	1.50–7.36	< 0.01	0.58
	Model 1	3.18	1.38–7.33	< 0.01	0.70
	Model 2	2.60	1.08–6.23	0.03	0.80
	Model 3	2.85	1.15–7.02	0.02	0.80
	Model 4	2.76	1.11–6.88	0.03	0.80
Dependent factor: social isolation (LSNS-6 < 12 points). Model 1: age, sex, and BMI, Model 2: Model 1 + TMIG-IC, Model 3: Model 2 + depressive symptoms, Model 4: Model 3 + SCWS, TMT-A, LSNS-6: the 6-item Lubben Social Network Scale, BMI: body mass index, SCWS: self-selected comfortable walking speed, TMT-A: Trail Making Test Part A, TMIG-IC: Tokyo Metropolitan Institute of Gerontology Index of Competence.

The results of the multiple regression analysis regarding the relationship between LSNS-6 scores and swallowing function performed as a sensitivity analysis are shown in Table 4. The dependent variable was the LSNS-6 score, treated as a continuous variable, and the independent variable was the EAT-10 score, treated as a continuous variable. All models were adjusted for age, sex, BMI, functional capacity, depressive symptoms, number of medications, physical function, and cognitive function as adjustment variables. In all models, no significant association was found between EAT-10 and LSNS-6 scores independent of age, functional capacity, depressive symptoms, physical function, and cognitive function.

Table 4

Association between swallowing function and social networks in multiple regression analysis
	Model	Unstandardized coefficient	95% confidence interval	P value	R²
EAT-10 score (points)	Crude	–0.95	–1.38 to − 0.51	< 0.01	0.07
	Model 1	–0.89	–1.31 to − 0.47	< 0.01	0.13
	Model 2	–0.71	–1.11 to − 0.32	< 0.01	0.24
	Model 3	–0.68	–1.08 to − 0.28	< 0.01	0.24
	Model 4	–0.68	–1.08 to − 0.27	< 0.01	0.24
Dependent factor: LSNS-6 score (points), Model 1: age, sex, and BMI, Model 2: Model 1 + TMIG-IC, Model 3: Model 2 + depressive symptoms, Model 4: Model 3 + SCWS, TMT-A, LSNS-6: the 6-item Lubben Social Network Scale, BMI: body mass index, SCWS: self-selected comfortable walking speed, TMT-A: Trail Making Test Part A, TMIG-IC: Tokyo Metropolitan Institute of Gerontology Index of Competence.

This cross-sectional observational study examined the relationship between dysphagia and social isolation in community-dwelling older people. The prevalence of sarcopenia in this study was 4%, which was slightly lower than that reported in previous studies [29], and the physical function of the population tended to be higher than the average for Japanese older people in the same region [30, 31]. Overall, 97% of the participants were independent in IADL. Therefore, it is likely that the participants in this study had better than average physical function and functional capacity.

Although there are various measures of social networks, such as social isolation, a systematic review and meta-analysis of social isolation in community-dwelling older people found that only 13 of 42 studies reported using the LSNS-6 to assess social isolation [32]. The LSNS-6 is an internationally used measure that has been validated for reliability and validity in Japan [17]. It has also been used in many studies of social isolation among Japanese community-dwelling older people [7, 14]. The EAT-10 is a questionnaire-based index of subjective deterioration in swallowing function. It is used internationally and has been validated for reliability and validity in a variety of subjects with dysphagia [18, 19], and been used in previous studies to assess swallowing function in community-dwelling older people [33]. The EAT-10 can be used to assess swallowing function in community-dwelling older people with good physical function. Thus, an association between dysphagia and social isolation was found using a validated assessment measure.

Dysphagia in community-dwelling older adults was independently associated with social isolation, IADL, physical function, and depressive symptoms. It has been reported that patients with dysphagia avoid eating with non-family members and stop eating out or with friends because of their isolation [34]. Increased dysphagia has been reported to affect social participation and quality of life adversely in patients with head and neck cancer with dysphagia [35]. We wonder whether this may lead to a narrowing of their social network as they worry about swallowing during meals because of their dysphagia.

Previous studies have reported that depressive symptoms in community-dwelling older people are associated with subjective assessments of oral function and social isolation [36, 37]. However, in the present study, using depressive symptoms as an adjustment variable in the multivariate analysis, we found that a subjective decline in swallowing function was independently associated with social isolation. It has also been reported that social isolation varies from country to country because of differences in cultures and values [38]. Therefore, it was suggested that the association between social isolation and dysphagia found in this study may also occur in the Asian older population.

By contrast, neither tongue pressure nor tongue and lip motor function was associated with social isolation. A previous study reported that oral function such as tongue pressure and tongue and lip motor function was not related to the social networks of community-dwelling older people [39]. Tongue pressure and ODK are mainly used to assess oral function such as tongue movement, which is one aspect of swallowing-related function, whereas the EAT-10 is mainly used to screen for dysphagia. Although these are assessments of feeding and swallowing, the subjective symptoms of dysphagia may be more strongly related to social isolation than assessments of a subset of swallowing function.

This study has some limitations. First, because this was a cross-sectional study, the causal relationship between social isolation and swallowing function could not be clarified. In the hypothetical model stage, we considered that social isolation may be caused by the deterioration of oral function, but the causal relationship needs to be verified in a future longitudinal study. Second, in this study, we focused on swallowing function, but we did not investigate the number of remaining teeth or occlusal force. It has been reported that tongue pressure is related to the number of remaining teeth, and that the effect of denture type on tongue pressure differs [40]. Oral status may have had an influence, but because the number of remaining teeth, denture type, and degree of fit were not examined in this study, this remains an issue for future research. Third, subgroup analyses could not be performed because of the sample size. The Strobe Statement also recommends subgroup analysis in observational studies. Subgroup analysis should include age, gender, and depressive symptoms, all of which may affect swallowing function and social isolation. However, subgroup analysis was not feasible with the sample size of the present study because of the high likelihood of a type II error. It may be necessary to collect more samples in the future.

In conclusion, the results of this study suggest that dysphagia is associated with social isolation independent of functional capacity, physical function, and depressive symptoms in community-dwelling older people.

Conflict of Interest

The authors have no conflicts of interest to disclose.

Funding/Support Statement

This study was supported by the Japan Society for the Promotion of Science KAKENHI (Grant No.: 19K11394). The funders played no role in the design, methods, subject recruitment, data collection, analysis, or preparation of the paper.

Data availability The datasets generated and analyzed during the cur- rent study are available from the corresponding author upon reasonable request.

Acknowledgements The authors would like to thank Dr. Haruhiko Sato for their substantial aid in data collection.

Ethics approval All procedures that involved human participants in this study were performed in accordance with the ethical standards of the Institutional Review Board of the School of Allied Health Sciences at Kitasato University (Approval Nos. 2018-008B and 2021-031) and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent Written, informed consent was obtained from all participants.

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Editorial decision: Minor revisions
08 Nov, 2024
Reviewers agreed at journal
16 Sep, 2024
Reviewers invited by journal
04 Sep, 2024
Editor assigned by journal
02 Sep, 2024
First submitted to journal
31 Aug, 2024

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Association between dysphagia and social isolation in community-dwelling older people

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Abstract

Key summary points

Background

Methods

Participants

Study design

Social isolation

Swallowing and swallowing-related function

Physical function

Cognitive function

Basic attributes

Statistical analysis

Results

Discussion

Declarations

References

Status:

Version 1