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Aging and disease    2017, Vol. 8 Issue (4) : 420-433     DOI: 10.14336/AD.2017.0102
Original Article |
Evaluation of the Mann Assessment of Swallowing Ability in Elderly Patients with Pneumonia
Chojin Yasuo1, Kato Tatsuji1, Rikihisa Mariko2, Omori Masami2, Noguchi Shingo3,4, Akata Kentaro3, Ogoshi Takaaki3, Yatera Kazuhiro3,*, Mukae Hiroshi3,5
1Department of Respiratory Medicine, Tobata Kyoritsu Hospital
2Department of Rehabilitation, Tobata Kyoritsu Hospital
3Department of Respiratory Medicine, University of Occupational and Environmental Health, Japan
4Department of Respiratory Medicine, Wakamatsu Hospital of the University of Occupational and Environmental Health, Japan
5Department of Respiratory Medicine, Unit of Translational Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
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Elderly pneumonia patients have various underlying diseases and social backgrounds, and it is difficult to predict their mortality using the current severity assessment tools. However, aspiration is a risk factor for mortality in pneumonia patients. In the evaluation of aspiration, endoscopic and video fluoroscopic methods are reliable but cannot be performed in all pneumonia patients. We evaluated the significance of the Mann Assessment of Swallowing Ability (MASA) in these patients. This study was prospectively performed between December 2014 and June 2015, and all adult hospitalized patients with pneumonia were consecutively enrolled. The MASA score was evaluated soon after admission. The outcome measures were in-hospital mortality, a recurrence of pneumonia within 30 days, 6-month mortality, and the detection of antibiotic-resistant bacteria. A total of 153 patients were ultimately included. The proportion of in-hospital mortality was greater among the severe MASA score patients than normal score patients (p < 0.01), as was the proportion of recurrence of pneumonia (p < 0.01) and 6-month mortality (p < 0.01). In addition, patients with a moderate MASA score more often experienced recurrence of pneumonia than normal score patients (p < 0.05). Furthermore, patients with a mild MASA score more often experienced recurrence of pneumonia (p < 0.01) and 6-month mortality (p < 0.05) than normal score patients. The areas under the curve were 0.74 (95% confidence interval [CI], 0.67-0.82) for in-hospital mortality, 0.75 (95% CI, 0.68-0.82) for recurrence of pneumonia, 0.72 (95% Cl, 0.64-0.81) for 6-month mortality, and 0.60 (95% CI, 0.46-0.73) for detection of antibiotic-resistant bacteria. A multivariate analysis showed an abnormal MASA score to be an independent risk factor for the recurrence of pneumonia (p = 0.001) and 6-month mortality (p = 0.005). The MASA is useful for predicting the mortality and recurrence of pneumonia in elderly patients.

Keywords mann assessment of swallowing ability      elderly      aspiration risk      pneumonia      mortality      recurrence of pneumonia     
Corresponding Authors: Yatera Kazuhiro   
About author:

these authors equally contributed to this work

Issue Date: 01 August 2017
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Chojin Yasuo
Kato Tatsuji
Rikihisa Mariko
Omori Masami
Noguchi Shingo
Akata Kentaro
Ogoshi Takaaki
Yatera Kazuhiro
Mukae Hiroshi
Cite this article:   
Chojin Yasuo,Kato Tatsuji,Rikihisa Mariko, et al. Evaluation of the Mann Assessment of Swallowing Ability in Elderly Patients with Pneumonia[J]. Aging and disease, 2017, 8(4): 420-433.
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Figure 1.  Flow chart.
Age (years), mean ± SD85.4 ± 9.9
Female sex; n (%)96 (62.7)
Performance status ≥3; n (%)138 (90.2)
HCAP; n (%)100 (65.4)
Comorbidity; n (%)
 Malignancy38 (24.8)
 Cerebrovascular disease87 (56.9)
 Laryngopharynx disorder26 (17.0)
 Chronic cardiovascular disease69 (45.1)
 Chronic respiratory disease58 (37.9)
 Chronic liver disease6 (3.9)
 Chronic kidney disease8 (5.2)
 Diabetes mellitus23 (15.0)
 Dementia131 (85.6)
Clinical parameters; n (%)
 Orientation disturbance (confusion)9 (5.9)
 Respiratory failure90 (58.8)
 Systolic BP <90 mmHg or diastolic BP ≤60 mmHg3 (2.0)
 Body temperature ≤35 or ≥40 °C8 (5.2)
 Pulse rate ≥125 beats/min17 (11.1)
Laboratory findings
 BUN ≥10.7 mmol/L76 (49.7)
 Glucose ≥13.9 mmol/L7 (4.6)
 Hematocrit <30%23 (15.0)
 Albumin <3.0 g/dl52 (34.0)
PSI score; n (%)
 I-III20 (13.1)
 VI65 (42.5)
 V68 (44.4)
Gastrogavage5 (3.3)
ICU admission13 (8.5)
Length of hospital stay (days)19.1 ± 11.9
In-hospital mortality; n (%)14 (9.2)
Recurrence of pneumonia within 30 days; n (%)†147 (32.4)
6-month mortality †229 (22.8)
Table 1  Characteristics of 153 patients with pneumonia.
Clinical assessment itemsNumber of abnormality
Auditory comprehension119(77.8)
Respiratory rate for swallowing121(79.1)
Lip Seal95(62.1)
Tongue movement105(68.6)
Tongue strength122(79.7)
Tongue coordination131(85.6)
Oral preparation86(56.2)
Bolus clearance85(55.6)
Oral transit133(86.9)
Cough reflex109(71.2)
Voluntary cough101(66.0)
Pharyngeal phase103(67.3)
Pharyngeal response27(17.6)
Table 2  Number of abnormality of the clinical assessment items of the Mann Assessment of Swallowing Ability.
Staphylococcus aureus11(13.4)
Staphylococcus epidermidis1(1.2)
Streptococcus pneumoniae12(14.6)
Enterococcus spp.1(1.2)
Moraxella catarrhalis3(3.7)
Haemophilus influenzae11(13.4)
Escherichia coli11(13.4)
Klebsiella pneumoniae7(8.5)
Pseudomonas aeruginosa5(6.1)
Enterobacter spp.2(2.4)
Acinetobacter spp.1(1.2)
Legionella pneumophila1(1.2)
Anaerobic bacteria4(4.9)
Oral bacteria65(79.3)
Detected antibiotic-resistant bacteria16(19.5)
Table 3  Microbes identified in patients with pneumonia.
Figure 2.  Prediction of each parameter according to the MASA score

A) In-hospital mortality, B) Recurrence of pneumonia within 30 days, C) 6-month mortality, D) Detection of antibiotic-resistant bacteria.

Figure 3.  The receiver operating characteristics curve for each parameter according to the MASA score

A) In-hospital mortality, B) Recurrence of pneumonia within 30 days, C) 6-month mortality, D) Detection of antibiotic-resistant bacteria.

Figure 4.  The revised oral assessment guide according to MASA
A. In-hospital mortality
Odds ratio95% Confidence intervalp value
Cerebrovascular disease7.481.31-42.840.024
Orientation disturbance11.041.46-83.660.020
Hematocrit <30%3.640.93-14.180.063
Albumin <3.0 g/dl2.670.77-9.240.121
B. Recurrence of pneumonia within 30 days
Odds ratio95% Confidence intervalp value
MASA score ≤16936.204.17-314.670.001
Cerebrovascular disease1.930.84-4.400.119
Inappropriate initial antibiotics2.400.98-5.860.055
Albumin <3.0 g/dl2.090.90-4.840.085
C. Six-month mortality
Odds ratio95% Confidence intervalp value
MASA score =16921.292.49-182.220.005
Chronic liver disease10.490.94-117.070.056
Inappropriate initial antibiotics3.251.07-9.860.037
Albumin <3.0 g/dl5.832.02-16.870.001
Table 4  Multivariate analysis of risk factors for each outcome
Odds ratio95% Confidence intervalp value
Age ≥ 75 years1.460.18-11.980.727
Age ≥ 85 years2.470.66-9.270.179
Female sex0.770.25-2.350.650
MASA score ≤ 1691.00
Performance status ≥ 31.00
MMSE ≤ 260.980.29-3.290.967
Neoplastic disease0.810.21-3.070.757
Cerebrovascular disease5.121.10-23.730.037
Gastroesophageal disorder0.800.17-3.800.778
Chronic heart disease1.240.41-3.730.699
Chronic respiratory disease0.630.19-2.110.453
Chronic liver disease1.00
Chronic kidney disease1.450.17-12.720.737
Collagen disease10.610.63-179.800.102
Diabetes mellitus0.940.20-4.490.935
Sleeping medications2.410.75-7.810.141
ACE inhibitor drugs2.410.47-12.440.294
Inhaled corticosteroid1.00
Orientation disturbance6.051.33-27.540.020
BUN ≥ 21 mg/dl1.930.62-6.060.258
Respiratory rate ≥ 30 breaths/min2.020.58-6.990.268
Systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg1.00
Body temperature ≥ 40 or ≤ 35 °C1.450.17-12.70.737
Pulse rate ≥ 125 beats/min1.380.28-6.760.693
SpO2 ≤ 90%, PaO2 ≤ 60 mmHg1.840.55-6.170.321
Pleural effusion1.920.63-5.900.253
Detected history of antibiotic-resistant bacteria1.960.50-7.730.338
Inappropriate initial antibiotics2.150.70-6.610.183
Antibiotic-resistant bacteria2.140.48-9.490.315
Hematocrit < 30%3.731.12-12.400.031
Albumin < 3.0 g/dl4.021.27-12.700.018
Na < 130 mEq/ml1.450.17-12.720.737
Glucose ≥ 250 mg/dl4.470.78-25.520.092
Suppmental Table 1  A univariate analysis of the in-hospital mortality
Odds ratio95% Confidence intervalp value
Age ≥ 75 years1.850.49-7.000.362
Age ≥ 85 years1.340.65-2.760.434
Female sex0.580.28-1.170.129
MASA score ≤ 16933.094.38-249.780.001
Performance status ≥ 31.00
MMSE ≤ 260.990.46-2.160.989
Neoplastic disease1.250.56-2.750.585
Cerebrovascular disease2.221.07-4.610.032
Gastroesophageal disorder0.650.24-1.760.398
Chronic heart disease0.520.25-1.060.072
Chronic respiratory disease0.930.45-1.920.853
Chronic liver disease4.470.79-25.310.091
Chronic kidney disease2.950.63-13.730.169
Collagen disease2.110.13-34.470.601
Diabetes mellitus1.230.48-3.180.668
Sleeping medications1.460.62-3.420.389
ACE inhibitor drugs0.890.22-3.590.866
Inhaled corticosteroid1.00
Orientation disturbance1.270.29-5.550.752
BUN ≥ 21 mg/dl0.840.42-1.700.635
Respiratory rate ≥ 30 breaths/min0.780.30-2.020.705
Systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg1.040.092-11.810.973
Body temperature ≥ 40 or ≤ 35 °C0.330.039-2.850.316
Pulse rate ≥ 125 beats/min0.850.28-2.580.779
SpO2 ≤ 90%, PaO2 ≤ 60 mmHg1.440.70-2.940.320
Pleural effusion1.170.54-2.530.681
Detected history of antibiotic-resistant bacteria1.380.50-3.830.532
Inappropriate initial antibiotics2.281.06-4.870.034
Antibiotic-resistant bacteria0.990.77-1.250.904
Hematocrit < 30%1.930.77-4.880.161
Albumin < 3.0 g/dl2.311.12-4.770.023
Na < 130 mEq/ml2.190.52-9.150.284
Glucose ≥ 250 mg/dl1.00
Suppmental Table 2  A univariate analysis of recurrence of pneumonia within 30 days of admission
Odds ratio95% Confidence intervalp value
Age ≥ 75 years0.880.22-3.480.851
Age ≥ 85 years2.050.83-5.080.120
Female sex0.390.17-0.920.031
MASA score ≤ 16916.982.22-130.100.006
Performance status ≥ 31.00
MMSE ≤ 260.850.34-2.080.715
Neoplastic disease0.930.35-2.440.881
Cerebrovascular disease2.050.85-4.940.111
Gastroesophageal disorder0.350.08-1.630.182
Chronic heart disease0.560.24-1.320.185
Chronic respiratory disease1.220.52-2.830.651
Chronic liver disease7.681.33-44.350.023
Chronic kidney disease2.710.57-12.890.210
Collagen disease1.00
Diabetes mellitus0.760.23-2.480.652
Sleeping medications1.410.52-3.810.494
ACE inhibitor drugs0.400.05-3.350.400
Inhaled corticosteroid0.590.12-2.810.504
Orientation disturbance1.00
BUN ≥ 21 mg/dl0.550.23-1.300.172
Respiratory rate ≥ 30 breaths/min0.820.25-2.680.742
Systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg1.00
Body temperature ≥ 40 or ≤ 35 °C1.00
Pulse rate ≥ 125 beats/min1.00
SpO2 ≤ 90%, PaO2 ≤ 60 mmHg0.850.37-1.960.701
Pleural effusion1.690.71-4.060.238
Detected history of antibiotic-resistant bacteria1.650.52-5.200.395
Inappropriate initial antibiotics3.611.48-8.820.005
Antibiotic-resistant bacteria3.410.88-13.250.077
Hematocrit < 30%2.800.96-8.190.060
Albumin < 3.0 g/dl4.892.03-11.78≤0.001
Na < 130 mEq/ml2.710.57-12.890.210
Glucose ≥ 250 mg/dl0.840.09-7.820.878
Suppmental Table 3  A univariate analysis of six-month mortality
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