Early Commencement of Oral Intake and Physical Function are Associated with Early Hospital Discharge with Oral Intake in Hospitalized Elderly Individuals with Pneumonia

To the Editor: Pneumonia is a common and serious disease that occurs frequently in elderly adults.1 Dysphagia is strongly associated with community-acquired pneumonia in elderly adults, independent of functionality,2 and is a risk factor for pneumonia. Dysphagia rehabilitation is important for treating pneumonia and dysphagia, but no study has explored the effect of early commencement of oral intake (EOI) in elderly adults with pneumonia. The aim of the current study was to investigate the relationships between EOI, physical function, and hospital discharge with oral intake in hospitalized elderly adult with pneumonia. This was a retrospective cohort study of 370 individuals aged 65 and older consecutively admitted to the hospital for treatment of acute pneumonia between April 2011 and March 2014. Attending physicians diagnosed pneumonia according to the presence of two or more of four findings (leukocytosis (white blood cell count >9,000/dL, fever (body temperature >37.5°C), purulent sputum, high plasma C-reactive protein (CRP)) plus a new abnormal shadow on chest X-ray or computed tomography.3 Pneumonia severity was assessed using the Japanese version of the CURB-65 severity score4, 5 (confusion, urea >7 mmol/L, respiratory rate ≥30/min, low systolic (<90 mmHg) or diastolic (<60 mmHg) blood pressure, aged ≥65). Physical function was evaluated using an independence scale that the Ministry of Health, Labor, and Welfare introduced in Japan in 1992. Disturbances in consciousness were evaluated using the Japanese coma scale.6 The study aimed to investigate the effect of EOI and physical function. This involved comparison of the EOI group (subjects who started to eat food orally within 2 days after admission) with the non-EOI group and comparison of the bedridden group with the nonbedridden group. The primary outcome measure was days until discharge with oral intake, assessed as subjects who were able to eat food by mouth without enteral nutrition at discharge. Participants were divided into two groups according to the number of days from admission to commencement of oral intake (EOI group, 201 subjects) and bedridden status (bedridden group, 164 subjects, Table 1). The proportion of participants discharged from the hospital with oral intake was greater in the EOI group (95.0%) than in the non-EOI group (81.1%) (P < .001) and in the nonbedridden group (94.2%) than in the bedridden group (81.7%) (P = .003). Median duration of hospital stay was shorter in the EOI group (13 days) than in the non-EOI group (18 days) (P < .001) and in the nonbedridden group (14 days than in the bedridden group (18 days) (P < .001). Cox proportional hazards regression analysis showed that EOI (adjusted hazard ratio (aHR)=0.632, 95% confidence interval (CI) = 0.495–0.808, P < .001), bedridden status (aHR=1.473, 95% CI = 1.151–1.887, P = .002), and CRP level (aHR=1.019, 95% CI = 1.001–1.037, P = .04) were independent determinants of length of stay until discharge with oral intake after adjustment for sex, age, pneumonia severity, premorbid living situation, consciousness disturbance, and albumin. EOI in elderly adults with pneumonia shortened the length of hospital stay and improved oral intake status. The hospital provided multidisciplinary medical care for individuals with pneumonia that included oral care, postural adjustments, stretching and massage of facial muscles, and lingual exercises. This care may have promoted maintenance of orofacial and pharyngeal sensory function, swallowing muscle function, and cognitive function. Although hospitalized elderly adults with pneumonia are normally encouraged not to eat after admission, the current study suggests that eating earlier improves clinical outcomes in individuals with pneumonia. A systematic approach including risk management for aspiration and comprehensive care may be necessary to increase the number of people able to have oral intake and to shorten the length of hospital stay. Participants who were bedridden before their hospitalization had longer hospitalizations and impaired swallowing ability. Poor physical activity and function are known to be associated with malnutrition and sarcopenia.7 Sarcopenic dysphagia,8 which refers to swallowing difficulties due to a generalized reduction in the mass and strength of skeletal muscles, including swallowing muscles, can lead to aspiration pneumonia.9 Sarcopenic dysphagia may be partially interpreted as sarcopenia and causal factors for sarcopenia.10 Premorbid decline in physical function associated with sarcopenic dysphagia is therefore likely to result in further decline in swallowing ability. In conclusion, EOI and physical function are associated with early hospital discharge with oral intake in hospitalized elderly adults with pneumonia. Eating at the time of admission and avoiding deconditioning should be encouraged in elderly individuals with pneumonia. The authors thank Iwao Yamashita for his support to the swallowing support team and for developing the concept of the study. Conflict of Interest: Wakabayashi was supported by a research Grant-in-Aid for Scientific Research (25350611) from the Ministry of Education, Science, Culture, Sports, Science, and Technology of Japan. The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Koyama: concept and design, data acquisition and interpretation, drafting the manuscript. Maeda, Shamoto, Wakabayashi: concept and design, data analysis and interpretation, drafting the manuscript. Anzai and Koganei: data acquisition and interpretation, critical revision of manuscript. All authors revised the manuscript critically for important intellectual content and approved the final version. Sponsor's Role: None.