Jean Kyung Paik

doi:10.5720/kjcn.2025.00290

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Evaluation and standardized dietary strategies for dysphagia in older adults: a narrative review: Jean Kyung Paik^†; Korean Journal of Community Nutrition 2025;30(5):323-330.
DOI: https://doi.org/10.5720/kjcn.2025.00290
Published online: October 31, 2025

Professor, Department of Food and Nutrition, Eulji University, Seongnam, Korea

†Corresponding author: Jean Kyung Paik Department of Food and Nutrition, Eulji University, 553 Sanseong-daero, Sujeong-gu, Seongnam 13135, Korea Tel: +82-31-740-7141 Fax: +82-31-740-7370 Email: jkpaik@eulji.ac.kr

• Received: October 10, 2025 • Revised: October 21, 2025 • Accepted: October 21, 2025

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
METHODS
OVERVIEW OF DYSPHAGIA
MECHANISMS AND CHARACTERISTICS OF PRESBYPHAGIA
ASSESSMENT AND DIAGNOSIS OF DYSPHAGIA
DIETARY MANAGEMENT AND STANDARDIZATION SYSTEMS FOR DYSPHAGIA
CONCLUSIONS
NOTES
REFERENCES

Abstract

Objectives
This review aimed to elucidate the characteristics of dysphagia and age-related swallowing changes (presbyphagia) in older adults and to comprehensively examine assessment tools and standardized meal management strategies applicable in community settings to propose effective meal management strategies for healthy longevity.
Methods
Domestic and international literatures were analyzed regarding the definition and causes of dysphagia, physiological and structural characteristics and clinical impacts of presbyphagia, assessment and diagnostic tools Korea version of EAT-10 (K-EAT-10) and Korea version of Dysphagia Risk Assessment for the Community-dwelling Elderly (K-DRACE), and the International Dysphagia Diet Standardization Initiative (IDDSI).
Results
Dysphagia compromises safe swallowing and nutritional intake in older adults, leading to serious complications, such as aspiration pneumonia, dehydration, malnutrition, sarcopenia, and reduced quality of life. The K-EAT-10 and K-DRACE proved effective for rapid screening of dysphagia risk in community-dwelling older adults. Moreover, texture-modified meals and viscosity adjustments based on the IDDSI standards are useful for reducing the risk of aspiration and improving nutrient intake. Meals can be classified as liquidized, minced, chopped, or regular, allowing for individualized management.
Conclusion
Presbyphagia is a multidimensional problem, and the integrated use of assessment tools and standardized meals is crucial. Community-based dysphagia management programs and collaboration among dietitians and healthcare professionals are needed to improve the nutritional status and quality of life of older adults.
Keywords: deglutition disorders; aged; nutritional assessment; diet therapy

INTRODUCTION

South Korea is experiencing the most rapid global increase in the proportion of older adults. The United Nations classifies societies into three categories based on the proportion of the population aged ≥ 65 years: aging societies (≥ 7%), aged societies (≥ 14%), and super-aged societies (≥ 20%) [1]. According to data from Statistics Korea, the proportion of the population aged ≥ 65 years has continuously increased from 7.2% in 2000 to 10.8% in 2010 and 15.7% in 2020. As of 2025, the population aged ≥ 65 years comprises 20.3% of the total population, representing 10.514 million individuals, indicating that South Korea has already become a super-aged society. By age group, 7.1% are aged 65–69 years, 4.9% are aged 70–74 years, and 8.3% are aged ≥ 75 years. Currently, the population aged 65–74 years (6.216 million) exceeds that of those aged ≥ 75 years (4.298 million); however, this proportion will reverse from 2038.

Demographic changes will accelerate in the future. According to long-term population projections by Statistics Korea, the population aged ≥ 65 years will exceed 30% of the total population by 2036 and 40% by 2050, and reach 47.5% by 2070 [2]. Rapid aging has significant implications for socioeconomic structures and healthcare systems. As of 2023, the remaining life expectancy is 21.5 years at age 65 years and 13.2 years at age 75 years, representing increases of 0.7 years and 0.6 years, respectively, compared to the previous year. Women's life expectancy (23.6 years at age 65 years, 14.7 years at age 75 years) exceeds that of men (19.2 years at age 65 years, 11.6 years at age 75 years) by 4.3 years and 3.1 years, respectively, surpassing the average of the Organization for Economic Co-operation and Development [2]. However, despite the increase in the average lifespan, the period during which individuals can maintain healthy living remains limited. Therefore, extending healthy life expectancy, preventing chronic diseases and functional decline, and establishing comprehensive health management systems remain a critical challenge in terms of long-term quality of life and health management of older adults [3].

Health problems in older adults are characterized by complex aging processes that involve physical, psychological, and social functions. Physical aging is defined as changes in body organs, structures, and functions over time [3]. As aging progresses, physiological functions, such as digestive function, respiratory function, metabolism, blood circulation, sleep, and urinary function decline, accompanied by the onset of chronic diseases and weakening of musculoskeletal function [4]. These changes result in reduced physical activity capacity and difficulties in performing activities of daily living, ultimately impairing the health and quality of life of older adults [5].

According to the 2023 Survey of Older Adults by the Ministry of Health and Welfare, 31.5% of individuals aged ≥ 65 years reported difficulties with chewing, suggesting challenges in food intake [6]. Common issues in the older adult population, such as tooth loss, chewing difficulties, decreased saliva production, reduced digestive enzyme secretion, and impaired taste and smell, can lead to nutritional imbalances and indigestion [7]. Furthermore, oral function limitations became more pronounced with increasing age, with 35.9% of men and 36.2% of women in their 60s, and 50.3% of men and 51.8% of women aged ≥ 70 years experiencing oral function restrictions. Thus, the high likelihood that a decline in chewing function leads to impaired swallowing function with advancing age [8]. According to data from the Health Insurance Review and Assessment Service, the number of patients treated for dysphagia has steadily increased from 10,930 in 2015 to 19,114 in 2020 and 29,503 in 2023. As of 2023, the age distribution shows that individuals aged ≥ 70 years account for 72.7% of all patients, with 13.1% in their 60s and 5.63% in their 50s, demonstrating that age-related dysphagia has become a major health concern among older adults [9].

Owing to rapid aging and decline in physical function, problems of reduced swallowing ability and nutritional imbalance in older adults are intensifying, leading to various health issues such as aspiration pneumonia, sarcopenia, and reduced quality of life [10]. Therefore, presbyphagia should be recognized as a clinical problem that requires active assessment and management, and not merely as a natural aging phenomenon. This review examines the mechanisms and characteristics of presbyphagia and presents evaluation and diagnostic methods for dysphagia and International Dysphagia Diet Standardization Initiative (IDDSI)-based dietary management strategies aiming to contribute to safe nutritional intake and improved quality of life for older adults.

METHODS

Ethics statement

As this study is a narrative review, it did not require institutional review board approval or individual consent.

Study design

This study was conducted as a narrative review. To ensure transparency in literature selection, international databases such as PubMed and Web of Science, as well as domestic databases such as Korean studies Information Service System and DBpia, were utilized. Search terms included “dysphagia,” “elderly,” “nutrition,” and “IDDSI,” with no restrictions on publication year, and both Korean and English literature were included.

OVERVIEW OF DYSPHAGIA

Dysphagia is defined as a condition in which a part of the swallowing function is impaired, resulting in difficulty in moving food or liquids from the oral cavity to the gastrointestinal tract [11]. Swallowing consists of the oral preparatory, oral, pharyngeal, and esophageal phases, and physiological abnormalities at each stage can lead to dysphagia [12]. The term dysphagia originates from the Greek words dys (impairment) and phago (eating) [13]. The World Health Organization’s 2025 International Classification of Diseases defines it as “difficulty in swallowing that may be caused by neuromuscular disorders or mechanical obstruction,” and distinguishes between oropharyngeal and esophageal dysphagia [14]. Dysphagia arises from various causes, including neurological, musculoskeletal, and structural abnormalities, with approximately 75% of all cases associated with neurological conditions, such as stroke, Parkinson's disease, and dementia [13, 15]. Other major causes include Alzheimer’s disease, motor neuron disease, and gastroesophageal reflux disease, and anatomical abnormalities or mechanical obstructions in the oral cavity can also induce or exacerbate dysphagia [16]. Declining swallowing function can occur during the natural aging process, and is referred to as presbyphagia. Age-related changes such as tooth loss, xerostomia, and reduced sensorimotor abilities are associated with declining swallowing function [12, 15].

MECHANISMS AND CHARACTERISTICS OF PRESBYPHAGIA

Physiological and structural features associated with aging

Aging induces structural and functional changes in multiple body systems that affect swallowing function. Aging causes the degeneration of neural structures and functions in the nervous system, leading to decreased nerve conduction velocity, autonomic nervous responses, and sensory discrimination abilities, impairing the regulation and response speed of the swallowing process [15, 17]. Skeletal changes also affect swallowing function; decreased cartilage elasticity and degenerative changes in the cervical spine weaken airway protection mechanisms, inducing coughing and choking during swallowing and compromising swallowing safety [15, 18]. Loss of muscle mass and strength is a major factor in age-related swallowing decline, with total muscle mass decreasing by 0.5%–1.0% annually and cumulative loss reaching 30%–50% by the age of 80 years [19]. In particular, atrophy of the tongue and perioral muscles prevents complete lip closure and causes food to spread and remain in the oral cavity for prolonged periods, reducing swallowing efficiency [15, 20, 21]. Additionally, changes in the oral structure, decreased saliva production, and xerostomia impede food movement and increase pharyngeal residue, compromising swallowing safety [15, 22]. Finally, age-related reductions in lung volume and elasticity weaken respiratory function, impair coordination between swallowing and respiration, prolong apnea during swallowing, weaken airway protection, and increase the risk [7, 15, 23]. Thus, age-related changes in the nervous system, musculoskeletal system, muscles, oral structures, and respiratory function interact organically, causing various clinical problems associated with declining swallowing function in older adults.

Clinical impact and complications

Presbyphagia directly affects nutritional intake and safety of swallowing, resulting in various clinical complications. The most serious complication is aspiration pneumonia, which occurs when food or saliva is aspirated into the airway, and is a leading cause of death in older adults [24]. Dysphagia reduces meal volume and dietary variety; as individuals shift toward consuming predominantly soft foods, their nutritional density decreases. These changes accelerate weight and muscle loss, exacerbate sarcopenia, and lead to an increased risk of falls, delayed recovery, and reduced quality of life [25]. Furthermore, declining swallowing function extends beyond simple swallowing problems to cause insufficient intake of energy, proteins, and micronutrients, triggering a vicious cycle of decreased immunity, increased infection risk, dehydration, and increased dependence on tube feeding. In particular, deficiencies in iron, zinc, and vitamin B12 negatively affect mucosal recovery and immune function [7, 25].

Clinically, symptoms such as food spillage from the mouth, piecemeal swallowing, nasal regurgitation, and postmeal voice changes may occur. Particularly in patients with stroke or dementia, dysphagia should be suspected if unexplained pneumonia or weight loss recurs [11]. Sarcopenic dysphagia is distinguished by two core manifestations: loss of swallowing safety leading to choking and aspiration, and a high risk of aspiration pneumonia owing to silent aspiration. Aspiration pneumonia occurs in approximately 50% of older adults residing in long-term care facilities, with 45% of the cases resulting in death [13]. Moreover, reduced swallowing efficiency leads to dehydration and malnutrition, with nutritional deficiency exacerbating sarcopenia, leading to functional decline, increased fall risk, prolonged hospitalization, and increased mortality. Thus, presbyphagia should be recognized not simply as a swallowing problem, but as a multidimensional health issue involving interactions among nutritional, immune, and functional aspects [13].

ASSESSMENT AND DIAGNOSIS OF DYSPHAGIA

Older adults often perceive dysphagia as a normal part of the aging process and frequently do not receive appropriate assessment or treatment, even when symptoms are present. This lack of awareness results in diagnosis occurring only after serious complications, such as aspiration pneumonia, develop and missing opportunities for early intervention [26]. Therefore, early screening for dysphagia is the starting point for preventing complications and establishing systematic management plans. The use of simple yet reliable assessment tools is essential. Representative assessment tools include the Eating Assessment Tool-10 (EAT-10) and the Dysphagia Risk Assessment for the Community-dwelling Elderly (DRACE), which are designed to rapidly and objectively assess declining swallowing function in older adults and play an important role in early risk group identification and personalized management planning.

Korean version of the Eating Assessment Tool-10 (K-EAT-10)

The EAT-10 is a self-administered assessment tool developed by Belafsky et al. [27] to evaluate the severity of dysphagia and monitor treatment efficacy. It consists of 10 items (Table 1) [26, 28], with each item rated on a 5-point scale from 0 (no problem) to 4 (severe problem). A total score of ≥ 3 is considered indicative of possible dysphagia [28]. The EAT-10 is simple and rapid for screening, has been translated into multiple languages, and is widely used internationally [28]. The Korea version of EAT-10 (K-EAT-10) was standardized by Noh et al. [28] and is used in various settings, including hospitals, long-term care facilities, and community settings [27, 28]. The key items included weight loss, avoidance of eating out, difficulty in swallowing solids and liquids, swallowing discomfort, coughing during meals, and reduced pleasure in eating. Score interpretation categorizes scores of ≤ 2 as normal, 3–7 as potential risk, and ≥ 8 as high risk. Thus, the K-EAT-10 is a reliable tool that can conveniently assess declining swallowing function in older adults and can be utilized for risk group screening and treatment planning.

Korean version of the Dysphagia Risk Assessment for the Community-dwelling Elderly (K-DRACE)

DRACE was developed to screen for dysphagia risk in community-dwelling older adults and is designed to assess each stage of swallowing with a functional focus [26, 29]. This tool encompasses the entire swallowing process, from the oral preparatory phase to the esophageal phase, and assesses dysphagia-related symptoms, including fever, meal duration, difficulty chewing and swallowing, food spillage, choking, nasal and esophageal regurgitation, voice changes, discomfort during and after swallowing, and increased sputum production [30]. It includes an item on chewing ability that is not covered by other tools, offering the advantage of more broadly identifying the early risks of declining swallowing function [26]. The DRACE consists of 12 items (Table 1) [26, 28], with each item rated on a 3-point scale (never = 0, sometimes = 1, and often = 2) based on the frequency of symptoms experienced in the past year. Higher total scores indicate higher risk, and a score of ≥ 4 warrants a detailed assessment [30, 31]. The Korean version, the K-DRACE, is an adaptation and validation of the DRACE originally developed in Japan, tailored to the Korean context, and applied to Korean community-dwelling older adults [31]. The 12 items were classified according to the swallowing stage: oral preparatory and oral phases (items 2, 4, and 5), pharyngeal phase (items 1, 3, and 6–10), and esophageal phase (items 11, 12). The assessment used a 3-point scale, yielding a total score of 0–24 points. Higher total scores indicated a higher risk of dysphagia, with scores of ≥ 4 classifying individuals as at risk for dysphagia. Thus, the K-DRACE can assess dysphagia risk in community-dwelling older adults in detail by stage and can be practically utilized for early risk group screening, preventive approaches, and rehabilitation intervention planning.

DIETARY MANAGEMENT AND STANDARDIZATION SYSTEMS FOR DYSPHAGIA

Dietary management for older adults with dysphagia should aim to prevent aspiration and create a safe eating environment, while ensuring weight maintenance and adequate nutritional status. This requires a personalized approach that considers age, level of physical function, and individual preferences, with an emphasis on increasing appetite and food intake. In particular, to reduce aspiration risk, it is important to consume small amounts and avoid dry or highly viscous foods and foods that crumble easily, while selecting moist foods with a uniform texture [32]. To address these needs, the IDDSI was developed, providing common terminology and definitions that can be universally applied regardless of age, culture, or environment [16, 33-37]. The IDDSI classifies foods and drinks into eight levels from 0 to 7, with levels 0–4 corresponding to drinks and levels 3–7 to solid foods [34-37]. Each level was defined as follows: level 0: thin; level 1: slightly thick; level 2: mildly thick; level 3: liquidized/moderately thick; level 4: pureed/extremely thick; level 5: minced and moist; level 6: soft and bite-sized; and level 7: regular/easy-to-chew. Levels 3 and 4 are presented separately for solid foods and drinks to distinguish between texture and viscosity (Fig. 1) [35-37]. In clinical practice, these are categorized as liquid diets (levels 0–2), pureed diets (levels 3 and 4), minced diets (levels 5 and 6), and regular diets (level 7), and by utilizing thickening agents as needed, detailed dietary adjustments are possible, simultaneously promoting safe swallowing and adequate nutritional intake [34].

CONCLUSIONS

As South Korea has become a super-aged society, the problem of dysphagia in older adults has progressively intensified. Dysphagia extends beyond a simple decline in swallowing function to induce complications, such as malnutrition, dehydration, and aspiration pneumonia, ultimately accelerating physical and social functional decline in older adults. In this context, early detection and preventive management of declining swallowing function are emerging as core tasks for promoting older adult health.

This review comprehensively examined the definition and causes of dysphagia, physiological characteristics of presbyphagia, clinical impacts, and complications and presents the characteristics and applicability of the K-EAT-10 and K-DRACE as screening tools available for use in community settings. Both tools are convenient and reliable assessment instruments, and K-DRACE is particularly useful for assessing older adults in the community, as it can comprehensively evaluate function at each swallowing stage and chewing ability.

Furthermore, the IDDSI serves as an essential foundation for providing safe meals and improving the nutritional status of older adults with dysphagia and should be consistently applied in clinical and welfare settings. Such standardization will prevent nutritional imbalances and reduce swallowing-related complications.

Moving forward, an integrated management system that links early screening for dysphagia with personalized nutritional and dietary interventions is required. If a continuous management model of prevention, assessment, and intervention is established through a multidisciplinary approach involving collaboration among medical, nutritional, and rehabilitation professionals, it will greatly contribute to extending healthy life expectancy and improving the quality of life in an aging society.

NOTES

CONFLICT OF INTEREST

There are no financial or other issues that might lead to conflicts of interest.

FUNDING

None.

DATA AVAILABILITY

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Fig. 1.

International Dysphagia Diet Standardization Initiative (IDDSI) framework. Reprinted from IDDSI, 2019. Permitted by the Creative Commons Attribution-Non-Commercial 4.0 International License (https://www.iddsi.org/standards/framework?utm_source=chatgpt.com, accessed on 1 Oct 2025) [37].

Table 1.

Items of the dysphagia risk assessment tool

	EAT-10	DRACE
Items	1. My swallowing problem has caused me to lose weight	1. Do you sometimes have a fever?
	2. My swallowing problem interferes with my ability to go out for meals	2. Do you feel as though having a meal is more time-consuming than before?
	3. Swallowing liquids takes extra effort	3. Do you sometimes feel as though swallowing is difficult?
	4. Swallowing solids takes extra effort	4. Do you sometimes feel as though it is difficult to eat something hard?
	5. Swallowing pills takes extra effort	5. Does food sometimes spill out of your mouth?
	6. Swallowing is painful	6. Do you sometimes choke during your meals?
	7. The pleasure of eating is affected by my swallowing	7. Do you sometimes choke when you drink liquid, such as tea?
	8. When I swallow, food sticks in my throat	8. Are there times when the things you swallowed flow back into your nose?
	9. I cough when I eat	9. Does your voice sometimes change after eating or drinking?
	10. Swallowing is stressful	10. Does sputum form in your throat during meals or after eating or drinking?
		11. Do you sometimes feel as though food gets stuck in your chest?
		12. Are there times when food or a sour fluid flows back from your stomach toward your throat?

Adapted from Kim et al. (Korean J Occup Ther 2024; 32(4): 39-51) [26].

Adapted from Noh et al. (Commun Sci Disord 2022; 27(4): 830-843) [28].

EAT-10, Eating Assessment Tool-10; DRACE, Dysphagia Risk Assessment for the Community-dwelling Elderly.

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Evaluation and standardized dietary strategies for dysphagia in older adults: a narrative review

Korean J Community Nutr. 2025;30(5):323-330. Published online October 31, 2025

DOI: https://doi.org/10.5720/kjcn.2025.00290

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Evaluation and standardized dietary strategies for dysphagia in older adults: a narrative review

Fig. 1. International Dysphagia Diet Standardization Initiative (IDDSI) framework. Reprinted from IDDSI, 2019. Permitted by the Creative Commons Attribution-Non-Commercial 4.0 International License (https://www.iddsi.org/standards/framework?utm_source=chatgpt.com, accessed on 1 Oct 2025) [37].

Fig. 1.

Evaluation and standardized dietary strategies for dysphagia in older adults: a narrative review

	EAT-10	DRACE
Items	1. My swallowing problem has caused me to lose weight	1. Do you sometimes have a fever?
	2. My swallowing problem interferes with my ability to go out for meals	2. Do you feel as though having a meal is more time-consuming than before?
	3. Swallowing liquids takes extra effort	3. Do you sometimes feel as though swallowing is difficult?
	4. Swallowing solids takes extra effort	4. Do you sometimes feel as though it is difficult to eat something hard?
	5. Swallowing pills takes extra effort	5. Does food sometimes spill out of your mouth?
	6. Swallowing is painful	6. Do you sometimes choke during your meals?
	7. The pleasure of eating is affected by my swallowing	7. Do you sometimes choke when you drink liquid, such as tea?
	8. When I swallow, food sticks in my throat	8. Are there times when the things you swallowed flow back into your nose?
	9. I cough when I eat	9. Does your voice sometimes change after eating or drinking?
	10. Swallowing is stressful	10. Does sputum form in your throat during meals or after eating or drinking?
		11. Do you sometimes feel as though food gets stuck in your chest?
		12. Are there times when food or a sour fluid flows back from your stomach toward your throat?

Table 1. Items of the dysphagia risk assessment tool

Adapted from Kim et al. (Korean J Occup Ther 2024; 32(4): 39-51) [26].

Adapted from Noh et al. (Commun Sci Disord 2022; 27(4): 830-843) [28].

EAT-10, Eating Assessment Tool-10; DRACE, Dysphagia Risk Assessment for the Community-dwelling Elderly.