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Implementation of Oral Frailty Diet for Elderly Patients on Emergengy Admission: A Quality Improvement Initiative

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19 October 2026

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20 October 2026

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Abstract
Aim: The Oral Frailty Diet (OF Diet) has been implemented since 2022 as a safe initial meal option for elderly patients on emergency admission, addressing risks of malnutrition,dysphagia, choking, and aspiration. However, the prevalence of oral frailty and dysphagia among elderly emergency admissions is unclear, and the suitability of the OF Diet against patients’ actual swallowing abilities has not been systematically assessed. Therefore, we aimed to evaluate the impact the OF Diet on swallowing function and dietary intake in elderly patients (≥70 years) on emergency admission. Methods: This retrospective study included 478 patients aged ≥70 years on emergency admission between October 2022 and December 2024. Patients were divided into OF Diet (n=108) and non-OF Diet (n=370) groups. Assessments included meal texture at admission and after modification, swallowing function (Seirei Swallowing Questionnaire), and dietary intake. Results: Initial meal provision comprised 53% regular diet and 23% OF Diet. The OF Diet group had a higher rate of suspected dysphagia on admission (p<0.0001). While the non-OF Diet group showed significant deterioration in meal texture from admission to modification (p<0.0001), the OF Diet group showed stable textures. A linear mixed model revealed significant main effects of the OF Diet (F=19.71, p<0.0001) on swallowing scores. The OF Diet group also demonstrated significantly lower dietary intake <30% (12.0% vs. 21.4%, p=0.0308). Conclusions: Implementation of the OF Diet enables safe initial meal provision for elderly patients on emergency admission who are at high risk of dysphagia, thereby improving dietary intake without negatively affecting swallowing function.
Keywords: 
oral frailty diet
;  
elderly
;  
emergency admission
;  
dysphagia
;  
swallowing assessment
;  
dietary intake
Subject: 
Medicine and Pharmacology  -   Dietetics and Nutrition

Introduction

Oral frailty is a concept first proposed in Japan in 2014, representing an intermediate state between normal oral function and established oral dysfunction.[1,2] It describes age-related decline across multiple oral domains, including mastication, swallowing, articulation, and oral hygiene.[3,4] Its significance was formally recognized in 2024 through a landmark consensus statement jointly issued by three major Japanese academic societies: the Japan Geriatrics Society, the Japanese Society for Oral Health in Gerodontology, and the Japanese Association on Sarcopenia and Frailty.[5] The prevalence of oral frailty among community-dwelling older adults varies considerably, ranging from 8.1% to 53.2%, with pre-frailty states affecting 33.7%–75.6% of this population.[6] Data from our institution suggest a prevalence of approximately 11.7% among hospitalized older adults over a one-year period.
The clinical significance of oral frailty extends beyond oral health alone. Oral dysfunction directly contributes to malnutrition, sarcopenia, and systemic inflammation, creating a vicious cycle that accelerates overall functional decline in older adults.[7,8] Furthermore, impaired oropharyngeal function, a central feature of oral frailty, has been identified as a risk factor for pneumonia, and oral frailty has been reported to negatively impact healthy life expectancy.[9,10] Preventing the progression of oral frailty is therefore essential not only for preventing aspiration pneumonia but also for maintaining physical function and preventing physical frailty in the aging population.[11]
Assessment and management of eating and swallowing function in hospitalized elderly patients is critical for safety.[12] While aspiration and choking can be prevented by optimizing diet texture to match swallowing function, the timing and methodology of such assessment remain challenging in emergency admission settings.[13,14] Several screening tools have been developed to evaluate dysphagia risk in hospitalized elderly patients. The Eating Assessment Tool (EAT-10) is a widely used, self-administered, symptom-specific questionnaire with reliability and validity across multiple languages and populations.[15,16] In Japan, Seirei Hamamatsu Hospital has developed a scoring system that integrates existing dysphagia screening questionnaires with oral frailty assessments, demonstrating practical clinical utility.[17,18]
Emergency admissions present unique challenges for swallowing assessment, owing to acute medical instability, time constraints, competing clinical priorities, and limited availability of specialized dysphagia assessment services.[19,20] There is also considerable variation in institutional approaches to initial diet management for elderly emergency admissions, and standardized protocols have not been widely established.[21,22] The optimal balance between safety and nutrition in the acute phase remains debated, as overly restrictive diet modifications may inadvertently compromise nutritional intake and quality of life.[23,24]
At our institution, we implemented a protocol in which elderly patients on emergency admission commence oral intake with a standardized diet—the “Oral Frailty Diet (OF Diet)”. This preventive approach was designed to provide a universally safe initial diet for high-risk patients while allowing time for comprehensive swallowing and nutritional assessments. However, the actual prevalence of oral frailty and dysphagia among this population remains unknown, and the appropriateness of our standardized initial diet in relation to patients’ actual swallowing capabilities has not been systematically evaluated. Therefore, we conducted this study to examine (1) the prevalence of oral frailty and swallowing dysfunction among elderly patients admitted through our emergency department, (2) the appropriateness of diet texture provided under our institutional protocol, and (3) whether optimal diet texture matching to swallowing function was being achieved. Understanding these issues is critical for optimizing care pathways for hospitalized elderly patients and may provide insights for institutions seeking to develop evidence-based protocols for managing dysphagia risk in emergency admissions.[25]

Methods

Study Design and Participants

This retrospective cohort study was conducted at the University of Ryukyus Hospital between October 2022 and December 2024. Inclusion criteria were (1) age ≥70 years and (2) emergency admission. Exclusion criteria were (1) nil per os (NPO) or tube feeding at admission, (2) missing evaluation data, (3) initial assessment not conducted within 5 days, (4) absence of both initial and second assessments, or (5) second assessment conducted >1 month after the first assessment. Of 2,271 patients screened, 478 were included in the final analysis (OF Diet group: 108 patients; non-OF Diet group: 370 patients)(Supplementary Figure S1). The age threshold of ≥70 years was determined based on institutional practice, taking into account both the increased risk of dysphagia in older adults and the operational feasibility of providing standardized modified diets in the acute care setting. Patients in the “fasting group” (NPO) were excluded because the timing for resuming oral intake depends on the attending physician’s judgment, and no standardized resumption criteria exist. Cases were also excluded when assessment results were incomplete, when patients could not be followed up for more than 5 days after admission, or when the interval between the first and second assessments exceeded one month, as these factors precluded accurate evaluation of changes from the time of admission.
Main dishes were classified as regular rice, soft rice, rice porridge, and others (dysphagia-adjusted foods such as liquid foods), while side dishes were classified as regular food, soft food, finely chopped thickened foods, and others (jelly and liquid foods). Texture levels were defined with reference to the 2021 Classification of Dysphagia-adjusted Foods (regular, Level 4, Level 3, and Level 2 or below).[26]The OF Diet consisted of soft rice porridge (zenkayu) with a finely minced, thickened dish (gokukizami-toromi-tsuki).Because this classification system is based on food texture rather than particle size, finely minced diets are not defined as a specific category. Therefore, the OF Diet could not be directly classified; however, based on its textural properties, it was operationally defined as falling between Level 3 and Level 4. At our hospital, this diet is the standardized initial meal for all patients aged 70 years and older on emergency admission. While the attending physician initiates the order, nurses are empowered to adjust or transition patients to the OF Diet upon clinical assessment. Preliminary observations suggest that this proactive protocol effectively prevents severe choking incidents requiring emergency intervention.

Data Collection and Assessment

Data on demographic characteristics (age, sex, height, weight, body mass index [BMI]), admission department, and admission diagnosis were collected from medical records. Meal texture at admission and after modification was classified for both main (rice/porridge) and side (regular/minced) dishes. Swallowing function was assessed using the Seirei Swallowing Questionnaire (SSQ),[27] categorizing patients as having normal swallowing function (scores ≤3), suspected oral frailty (scores 4–7), or suspected dysphagia (scores ≥8)(Supplementary Table S1). Nutritional status was evaluated using the modified Controlling Nutritional Status (mCONUT) score, based on laboratory data obtained from the first blood test performed at admission. The mCONUT score is calculated using three parameters: serum albumin level, peripheral lymphocyte count, and hemoglobin level.[28,29] Higher scores indicate poorer nutritional status. Dietary intake after meal modification was calculated as the percentage of three meals consumed, estimated by nursing staff and dichotomized as <30% or ≥30%.

Statistical Analysis

Continuous variables were compared using t-tests, categorical variables using χ² tests, and paired comparisons using Wilcoxon signed-rank tests.
Swallowing function was assessed using the SSQ, and changes in swallowing function were analyzed using a linear mixed model (LMM). The model included group (OF group vs. non-OF group), time point (upon admission vs. post-modification), and the interaction between group and time (group × time) as fixed effects. Baseline characteristics, including age, BMI, disease, department, and mCONUT score, were included as covariates.
Subject ID was included as a random effect to account for repeated measurements within individuals. Parameter estimates for the fixed effects were obtained using the restricted maximum likelihood (REML) method. Degrees of freedom were estimated using the Satterthwaite approximation.
All statistical analyses were performed using JMP Student Edition 18 (SAS Institute Inc., Cary, NC, USA). A two-sided p value < 0.05 was considered statistically significant.

Results

Patient Characteristics

The mean age was 80 years (range 70–99), and 53% were male. Initial meal provision patterns were as follows: regular diet, 53%; OF Diet, 23%; and other modified diets, 24%. The most common admission departments were Internal Medicine (40%), Urology (13%), and Surgery (11%). The most frequent admission diagnoses were malignant neoplasms (25%), infectious diseases (12%), and cardiovascular diseases (11%). The overall prevalence of oral frailty and dysphagia was 9.4% (4.8% oral frailty, 4.6% dysphagia). (Table 1 and Table 2)

Meal Texture Changes and Swallowing Function

In the non-OF Diet group, both main and side dish textures showed significant deterioration from admission to modification (p<0.0001), indicating that initial meal provision exceeded swallowing capacity. In contrast, textures were maintained with fewer meal omissions in the OF Diet group (Figure 1). The proportion of patients whose diet level was downgraded was higher in the non-OF Diet group (18.9% vs. 1.7%).
On admission, suspected dysphagia or oral frailty was significantly more common in the OF Diet group (p<0.0001)(Figure 2).
Linear mixed model analysis of changes in swallowing function showed a significant main effect of group (F(1, 928.4) = 19.71, p < 0.0001), indicating that SSQ scores differed significantly between groups. The main effect of time was not statistically significant (F(1, 928.0) = 2.88, p = 0.090), nor was the group and time interaction (F(1, 928.0) = 0.89, p = 0.346), suggesting that changes in SSQ scores over time did not differ between groups. Parameter estimates showed that the OF Diet group had significantly higher SSQ scores (β = 1.07, 95% CI 0.24–1.89, p = 0.0116), indicating poorer swallowing function.

Dietary Intake

After meal modification, the proportion of patients with dietary intake <30% was significantly lower in the OF Diet group than in the non-OF Diet group (12.0% vs. 21.4%, p=0.0308). (Figure 3)

Safety Outcomes

Between 2019 and 2022, the hospital’s Patient Safety Office reported four choking-related incidents of severity level 3b or higher and six incidents of level 3a or lower.

Discussion

This study demonstrates that implementation of the OF Diet as a standardized initial meal option for elderly patients on emergency admission enables safe meal provision without adversely affecting swallowing function while improving dietary intake. The significant downgrading of meal texture in the non-OF Diet group suggests that the traditional practice of providing a regular diet without prior swallowing assessment poses a safety risk.

Impact of the OF Diet on Dietary Intake and Safety

Our findings revealed that patients in the OF Diet group achieved significantly higher dietary intake compared with the non-OF Diet group. In particular, the proportion of patients with dietary intake <30% was significantly lower in the OF Diet group. This improvement in nutritional intake is particularly important given the well-established relationship between malnutrition and adverse clinical outcomes in hospitalized elderly patients.[14,30] Avoiding meal withholding represents a key advantage of the OF Diet protocol, as previous studies have shown that prolonged fasting periods can exacerbate nutritional decline and delay functional recovery in older adults.[31,32]
The safety profile of the OF Diet was confirmed by the absence of adverse swallowing events requiring emergency texture modifications. Between 2019 and 2022, our hospital’s Patient Safety Office reported four reported choking-related incidents of severity level 3b or higher and six incidents of level 3a or lower. In contrast, following the implementation of preventive measures in 2022, the number of reported incidents decreased substantially, with only two level 3a or lower incidents recorded between 2022 and 2024. This finding aligns with that of previous research showing that appropriately designed texture-modified diets can reduce aspiration risk while maintaining adequate nutritional intake.[23,33] Furthermore, the significantly reduced rate of meal texture downgrading observed in the OF Diet group (1.7% vs. 18.9%) suggests that the intermediate texture characteristics of the OF Diet provide an appropriate balance between safety and palatability for most elderly patients on emergency admission.

Systemic Conditions and Swallowing Function

One critical aspect that warrants further investigation is the extent to which acute systemic conditions influence swallowing function at the time of emergency admission. Previous studies have established that swallowing capacity can be significantly compromised by various factors, including acute illness severity, dehydration, polypharmacy, and metabolic disturbances.[30,34,35] Baijens et al. conceptualized oropharyngeal dysphagia in older adults as a geriatric syndrome, emphasizing the multifactorial nature of swallowing impairment in this population, in which aging physiology intersects with acute and chronic disease processes.[36]
During acute hospitalization, the interplay between systemic inflammatory response, altered consciousness, medication effects, and reduced oral intake creates a complex environment that may transiently affect swallowing mechanics beyond baseline functional capacity.[37,38] This dynamic nature underscores the importance of implementing conservative dietary approaches until comprehensive swallowing assessment can be performed. Future prospective studies incorporating standardized measures of illness severity, biomarkers of systemic inflammation, and longitudinal swallowing assessments are needed to quantify the relationship between general medical condition and swallowing dysfunction in emergency admissions.

International Perspectives on Hospital Food and Nutrition

The importance of healthcare food quality and availability has gained increasing recognition across European healthcare systems as a fundamental component of malnutrition prevention strategies.[39,40] Recent European consensus statements emphasize that nutritional care should be regarded as an integral part of patient-centered medical care, particularly ensuring adequate food intake within the first 48 hours of hospitalization.[40,41] Studies in European acute care settings have shown that early nutritional intervention, facilitated by prompt swallowing assessment and appropriate meal provision, can reduce hospital length of stay and improve clinical outcomes.[42,43]
However, the implementation of standardized dietary protocols must account for cultural differences in food preferences and eating behaviors across populations.[44,45] Although the IDDSI framework provides internationally standardized texture levels, specific food items, flavoring, and presentation styles must be adapted to local food cultures to optimize patient acceptance and intake.[46] In our Japanese hospital setting, the OF Diet was designed to incorporate familiar food textures and flavors while maintaining appropriate safety characteristics, which may have contributed to the observed positive acceptance rates. Cross-cultural studies would provide valuable insights into optimal strategies for implementing intermediate-texture diets globally.

Future Applications of the OF Diet Beyond Emergency Admissions

Although this study was focused on emergency admissions, the potential applications of the OF Diet may extend to other clinical scenarios. Our institution is currently exploring the use of the OF Diet as an interim dietary option for general ward patients experiencing acute deterioration or resuming oral intake after short-term fasting (e.g., post-procedural or post-operative states).[47,48] The concept of a “bridging diet” that provides a safe intermediate step between complete meal withholding and provision of a regular texture diet may have particular relevance for patients with fluctuating swallowing capacity or those in transitional stages of recovery.
Previous studies have shown that patients resuming oral intake after prolonged fasting or critical illness benefit from graduated dietary advancement protocols that allow physiological adaptation of swallowing mechanisms.[49,50] The OF Diet approach aligns with these principles by providing a standardized starting point that minimizes aspiration risk while avoiding unnecessary dietary restrictions. Furthermore, the finding that only a small proportion of patients had dietary intake below 30% suggests that, compared with complete meal withholding, the OF Diet may facilitate safe oral intake and contribute to improved nutritional status, while also potentially accommodating patients who have difficulty consuming regular diets.

Limitations and Considerations

Several limitations should be acknowledged. First, as a retrospective single-center cohort study, it is subject to selection bias, variations in data quality, and unmeasured confounding factors inherent to observational research designs.[51] The absence of randomization means that differences between groups may reflect not only the intervention effect but also temporal trends in clinical practice or patient population characteristics during the different study periods. Second, we did not systematically evaluate outcomes for patients who had meals withheld upon admission, representing an important gap in understanding the full impact of the OF Diet protocol. Future studies should involve prospective follow-up of all patients, including those initially kept NPO, to determine the timing and safety of meal reinitiation and the need for additional swallowing function assessments. Third, dietary intake analysis included patients who required meal texture modifications during the observation period, which may have influenced the overall intake measurements. Although texture changes were documented, the specific impact of these modifications on subsequent intake patterns was not analyzed separately. Additionally, the study did not capture qualitative data on patient satisfaction, palatability ratings, or specific reasons for meal rejection, which would provide valuable context for interpreting intake patterns. Fourth, the relatively short observation period (initial 7 days of admission) may not fully capture long-term outcomes, such as nutritional status changes, incidence of aspiration pneumonia, or overall hospital length of stay. Extended follow-up studies incorporating these endpoints would strengthen the evidence base for OF Diet implementation. Finally, generalizability to other healthcare settings may be limited by differences in staffing patterns, availability of dysphagia specialists, baseline patient characteristics, and local food culture. Multicenter studies across diverse geographical and cultural contexts would help establish the broader applicability of this approach. In addition, the age threshold of 70 years was determined based on institutional practice rather than a strictly evidence-based cutoff. In our clinical setting, a lower threshold (e.g., ≥65 years) was considered; however, it was not feasible to provide the OF Diet to all eligible patients due to resource limitations in meal preparation. Therefore, the threshold of ≥70 years was pragmatically adopted. Future studies are needed to determine the optimal age cutoff based on clinical outcomes.

Clinical Implications

Despite these limitations, our findings have important clinical implications for acute care of elderly patients. The OF Diet protocol represents a pragmatic approach to balancing safety and nutrition in the vulnerable period immediately following emergency admission, when formal swallowing assessment may not be immediately available. The reduction in meal texture downgrading and avoidance of unnecessary meal withholding suggest that this approach may help optimize nutritional intake without compromising safety.
Implementation of such protocols requires multidisciplinary collaboration among physicians, nurses, dietitians, and speech-language pathologists to ensure appropriate patient selection, monitoring, and timely escalation when concerns arise.[52,53] Educational initiatives to increase awareness of swallowing risks in elderly patients and the rationale for intermediate-texture diets are essential for successful adoption of these protocols.

Conclusions

Implementation of the OF Diet as a standardized initial meal option for elderly emergency admissions improved dietary intake while maintaining safety, as evidenced by reduced rates of meal texture downgrading compared with traditional regular diet provision. This approach addresses the critical need for early nutritional support in acutely ill older adults awaiting comprehensive swallowing function assessment. Avoidance of unnecessary meal withholding and provision of an appropriately textured intermediate diet are important strategies for optimizing nutritional care in this vulnerable population.
Future research should focus on (1) elucidating the relationship between acute systemic conditions and swallowing function to better predict which patients require dietary modification; (2) conducting multicenter prospective studies to validate these findings across diverse healthcare settings and cultural contexts; (3) evaluating long-term outcomes, including nutritional status, aspiration pneumonia incidence, and functional recovery; and (4) exploring expanded applications of intermediate-texture diets for hospitalized patients experiencing acute medical deterioration or transitioning back to oral intake after fasting periods. Such investigations will help refine evidence-based dietary protocols that balance safety and nutritional adequacy in hospitalized older patients.

Patient and Public Involvement

Patients and/or members of the public were not involved in the design,conduct, reporting, or dissemination plans of this study. The study wasa retrospective audit of routinely collected clinical data fromhospital records of patients aged ≥70 years admitted through the emergency department between October 2022 and December 2024. Because the analysis used only existing anonymised data and did not involve any direct contact with patients, recruitment of participants, or implementation of new interventions, patient and public involvement was not applicable. We recognise this as a limitation and consider involving patients and their families in future prospective implementation studies of the Oral Frailty Diet in order to incorporate their perspectives on acceptability, palatability, and the mealtime experience of texture-modified meals.

Supplementary Materials

The following supporting information can be downloaded at the website of this paper posted on Preprints.org.

Author Contributions

T.N. conceived and designed the study. T.N. and T.K. collected the data. T.N. analyzed the data and drafted the manuscript. J.N., G.T., N.Y., and K.K. critically reviewed the manuscript. All authors approved the final version of the manuscript.

Funding

The authors declare that no funds, grants, or other support was received during the preparation of this manuscript.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Ethics approval statement: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University of the Ryukyus (Date: 24/07/2025/No. 25-2501).
Patient consent statement: The requirement for informed consent was waived by the Ethics Committee of University of the Ryukyus due to the retrospective nature of the study, and an opt-out method was implemented on the hospital website.

Acknowledgments

The authors would like to thank Swallowing Support Team Staff and Working Group on Oral Frailty in Ryukyu University Hospital for their support in data collection and patient care.

Conflicts of Interest

The authors have no relevant financial or non-financial interests to disclose.

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Table 1. Baseline characteristics.
Table 1. Baseline characteristics.
n=478
Age, year 80 [73-86]
Male, % (n) 52.7 (252)
BMI*, kg/m²　n (SD) 23 (± 4.8)
mCONUT**, n[IQR] 4.3 [2-6]
Initial meal, % (n) regular diet 52.7 (252)
Oral Frailty Diet*** 22.6 (108)
other modified diets 24.7 (118)
Admission swallowing assessment 　
SSQ****, n[IQR] 0[0-1]
normal function, % (n) 90.6 (433)
suspected oral frailty, % (n) 4.8 (23)
suspected dysphagia ,% (n) 4.6 (22)
Initial main dish regular rice ,% (n) 57.7 (276)
soft rice, % (n) 5.2 (25)
rice porridge, % (n) 32.6 (156)
other modified rice, % (n) 4.4 (21)
Initial side dish regular diet, % (n) 65.3 (312)
soft diet, % (n) 9.2 (44)
finely minced with thickened diet, % (n) 23.6 (113)
other modified diet, % (n) 1.9 (9)
*Body Mass Index :BMI
**modified Controlling Nutrition Status: mCONUT
***Soft rice porridge and finely minced with thickened diet: Oral Frailty Diet
****Seirei Swallowing Questionnaire
Table 2. OF Diet group vs. the non-OF Diet group.
Table 2. OF Diet group vs. the non-OF Diet group.
OF Diet group n=108 non-OF Diet group n=370 p
%,mean, median n,(SD),[IQR] %,mean, median n,(SD),[IQR]
age, year 81 [74-86.75] 76 [73-81.25] <0.0001
Male 50% 54 54% 198 0.5199
BMI*, kg/m² 22.3 (0.46) 23.2 (0.25) 0.0861
Department Internal Medicine 51.9% 56 36.8% 136 0.0012
Urology 10.2% 11 13.2% 49
Surgery 5.6% 6 13.0% 48
Orthopedic Surgery 7.4% 8 7.3% 27
Obstetrics and Gynecology 4.6% 5 7.8% 29
Neurosurgery 7.4% 8 4.3% 16
Dermatology 6.9% 7 4.3% 16
Emergency Medicine 4.6% 5 0.8% 3
Other 1.9% 2 12.2% 45
Diseases Neoplasms(C00-D48) 17.6% 19 27.0% 100 <0.0001
(ICD-10)** Infectious and parasitic diseases(A00-B99) 19.4% 21 9.5% 35 　
Diseases of the circulatory system(I00-I99) 15.7% 17 10.0% 37 　
Diseases of the respiratory system(J00-J99) 9.9% 11 6.8% 25 　
Diseases of the nervous system(G00-G99) 9.3% 10 1.4% 5 　
Diseases of the genitourinary system(N00-N99) 7.4% 8 10.8% 40 　
Injury, poisoning and certain other consequences of external causes(S00-T98) 5.6% 6 8.1% 30 　
Diseases of the musculoskeletal system and connective tissue(M00-M99) 5.6% 6 3.5% 13 　
Other 9.3% 10 22.7% 84 　
Days until dietary texture modification , day 1 [1-1] 1 1,2
*Body Mass Index. **International Statistical Classification of Diseases and Related Health Problem-10.
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