medicina
ArticleThe Association between Party Horn Use and Respiratory
Function in Patients with Dementia: An Experimental Study
Misako Higashijima 1 , Hisako Hayashi 2 , Tomotaka Ueda 1 , Yuko Hirano 3 , Hiroyasu Shiozu 4
and Moemi Matsuo 1, *
1
2

3

4

*

Citation: Higashijima, M.; Hayashi,H.; Ueda, T.; Hirano, Y.; Shiozu, H.;
Matsuo, M. The Association between
Party Horn Use and Respiratory
Function in Patients with Dementia:

Faculty of Rehabilitation Sciences, Nishi Kyushu University, 4490-9 Ozaki, Kanzaki 842-8585, Japan
Kankikai Healthcare Corporation Tsuji Surgeon Rehabilitation Hospital, 3-24 Ikutamamaemachi,
Tennoji Ward, Osaka 543-0072, Japan
Unit of Medical Science, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto,Nagasaki 852-8520, Japan
Department of Occupational Therapy, Chubu University, 1200 Matsumotocho, Kasugai 487-8501, Japan
Correspondence: matsuomo@nisikyu-u.ac.jp; Tel.: +81-8056090223

Abstract: Background and Objectives: Respiratory diseases account for 55.5% and 33.1% of all mortality rates in patients with Alzheimer’s disease and vascular dementia, respectively. However, thewidespread use of spirometers is often difficult due to challenges in performing the procedure. Therefore, the use of spirometers is usually unfeasible in patients with dementia and hinders the provisionof preventive measures for aspiration pneumonia. The party horn is a common toy in many countries
and can potentially be used as a novel tool. This study was conducted to analyze the usefulness ofthe party horn as an assessment tool for respiratory function, and to detect eating-related behavioral
problems in patients with dementia. Materials and Methods: A total of 62 inpatient participants withdementia (34 males, 28 females; age, mean ± SD, 80.4 ± 7.59 years) were included in the study. The
respiratory functions of patients were assessed using a party horn and a spirometer. Assessment
items pertaining to cognitive function, mental and behavioral disorders, eating-related behavioral
problems, and the required dietary modifications were evaluated to compare between patient groups
stratified by respiratory function. Results: Significant differences between groups were noted inlength of hospital stay, cognitive functions, mental and behavioral disorders, eating-related behavioral problems, and dietary modifications. Forced expiratory volume in 1 s, peak expiratory flow,
and eating-related behavioral problems were significantly associated with the party-horn-integrated
value (p < 0.05). Conclusions: Party-horn-based evaluation can facilitate the screening and evaluationof older dementia patients for eating-related behavioral problems and aspiration risk.

An Experimental Study. Medicina
2023, 59, 134. https://doi.org/
10.3390/medicina59010134

Keywords: dementia; party horn; respiratory function; dietary modification; deglutition; Alzheimer’s
disease; vascular dementia; rehabilitation; spirometer; aspiration pneumonia

Academic Editor: Vida Demarin
Received: 27 November 2022
Revised: 5 January 2023
Accepted: 7 January 2023
Published: 10 January 2023

Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms andconditions of the Creative Commons
Attribution (CC BY) license (https://creativecommons.org/licenses/by/

1. Introduction
Population aging continues to increase rapidly worldwide and is accompanied by aconcomitant increase in associated conditions, such as dementia, which has been particularly evident in Japan. Respiratory diseases account for 55.5% and 33.1% of all mortality
rates in patients with Alzheimer’s disease and vascular dementia, respectively [1]. Nursing
home residents with dementia have a 50% risk of experiencing at least one episode of
respiratory disease, such as pneumonia or bronchitis, and an 85.8% chance of eating-related
behavioral problems [2]. A previous study on 412 inpatients with dementia in hospitalwards reported that 73.2% experienced at least one episode of eating-related problems
across the four stages (anticipatory, preparatory, oral, and pharyngeal) of deglutition [3].
Although the elastic recoil of the lungs tends to decrease with age, both deglutitionand cough reflexes remain unimpaired in otherwise healthy older individuals [4]. In

4.0/).

Medicina 2023, 59, 134. https://doi.org/10.3390/medicina59010134

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contrast, older individuals with neurological disorders are highly likely to have impaired
swallowing due to which they can develop aspiration pneumonia [4].
The prevention of aspiration pneumonia requires effective expectoration of foreign
substances and sputum, which largely depends on the ability to maintain a sufficient
expiratory flow rate and forced vital capacity (FVC). However, the widespread use of
spirometers for measuring these respiratory functions is unavailable because reliable dataacquisition with a spirometer requires sufficient training and experience. Furthermore, it
is often difficult to perform this procedure, even in healthy older individuals [5], as it isessential that the examinees comprehend the procedure and fully comply with relevant instructions. Therefore, the use of spirometers is usually unfeasible in patients with dementia
and hinders the provision of preventive measures for aspiration pneumonia. To ensure safe
eating in patients with dementia, a simple and easy-to-use alternative to the spirometer isrequired for assessing respiratory function.
The party horn is a common toy in many countries, including Japan, and can potentially be used as a novel tool [6]. A previous study showed a significant difference inthe ability to blow the party horn to its full length between patients who used thickening
liquids/texture-modifying foods, and those who did not [7]. Another study found a significant correlation between FVC and the duration of party horn extension in patients withdementia [8]. Nonetheless, it is difficult to objectively assess the sustained safe-eating activity of patients with dementia, and no previous study has evaluated the use of alternative
assessment tools for respiratory function in this population.
This study was conducted with the aim to analyze the usefulness of the party hornas an assessment tool for respiratory function and detecting eating-related behavioral
problems in patients with dementia.
2. Materials and Methods
The patients or their family members provided written informed consent, and all
methods were performed per the relevant guidelines and regulations.
Study design: the protocol of this experimental prevalence study was approved by
the Institutional Ethics Committee of Nagasaki University (approval no. 10072294) andcomplied with the Declaration of Helsinki (World Medical Association).
2.1. Participants
Among the 68 inpatients in the dementia-specialized ward of a psychiatric hospitalin Japan who were screened for inclusion in this study, 6 who did not understand how
to use the tool or blow the party horn more than 10 cm were excluded. Patients thatagreed to participate in this study and could blow the party horn more than 10 cm in the
pre-experimental setting were included. Thus, 62 inpatients for whom all required data
were available were enrolled in this study (Table 1).
Table 1. Comparison of various factors associated with respiratory function between the two groups.

Items

Age (years)
Length of hospital stay (days)
Cognitive functions (points)
Mental and behavioral disorders (points)
FVC (L)%VC (%)
FEV1 (L)Respiratory Function
with a Party Horn
High Group(n = 27)

Low Group(n = 35)

78.7 ± 7.6
117.6 ± 143.5
14.9 ± 3.0
24.1 ± 3.1
2.39 ± 0.5
89.7 ± 18.9
1.89 ± 0.4

81.6 ± 7.1
235.5 ± 226.0
8.5 ± 4.2
21.7 ± 3.9
1.23 ± 0.5
51.9 ± 20.9
0.98 ± 0.4

p-Value

0.15
0.04 *
0.001 **
0.01 *
0.001 **
0.002 **
0.001 **

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Table 1. Cont.

Items

FEV1% (%)
PEF (L/s)
FET (s)Eating-related behavioral problems (points)
Dietary modifications (points)

Respiratory Function
with a Party Horn
High Group(n = 27)

Low Group(n = 35)

78.5 ± 11.4
3.03 ± 1.5
5.5 ± 2.6
35.0 ± 3.8
2.7 ± 1.3

81.0 ± 16.5
1.66 ± 0.7
6.0 ± 4.4
30.2 ± 6.9
1.4 ± 1.3

p-Value

0.42
0.001 **
0.91
0.006 **
0.001 **

* p < 0.05 ** p < 0.01 by the Mann–Whitney U test. Abbreviations: FVC: forced vital capacity; VC: vital capacity; FEV1 : forced expiratory volume in 1 s; FEV1% : FEV1 as a percentage of FVC; PEF: peak expiratory flow;
FET: forced expiratory time.

2.2. Evaluation Tool
We used a party horn with a maximum length of 90 cm (Figure 1a: Party Horn
Entertainment Village, Hyogo, Japan) and a HI-801 spirometer (Figure 1b: Chest M.I.,
Tokyo, Japan). Before the experiment, an examiner completely unrolled the new party
horns three times to minimize unequal resistance inside the 90 cm duct line. The end of
the paper tube was then marked with a sticker to easily determine whether the tube had
been completely unrolled. Each party horn had a disposable mouthpiece (Tsutsumi Co.,Tokyo, Japan). To ensure that the mouthpiece of the party horn had the same diameteras the spirometer, we used customized bullhorn-shaped, black rubber adaptors (Kanae
Medicina 2023, 59, x FOR PEER REVIEWProsthesis Manufacture, Nagasaki, Japan). The larger end of the adaptor was attached
4 of 8 tothe spirometer, and the smaller end was connected to the disposable mouthpiece.

Figure1. (a)
Photographof anindividual
blowing
a 90
cmcm
party
horn,
and
(b)(b)
HI-801
spirometer
Figure1. (a)
Photographof anindividual
blowing
a 90
party
horn,
and
HI-801
spirometer(ChestM.I.,
Tokyo,
Japan).
(Chest M.I., Tokyo, Japan).

2.3. Experimental Protocol
The study was conducted as an experimental design. For each patient, a standard
examination procedure was followed. Patients were assessed in a private room on days
when their condition was stable. First, patients were instructed to blow into their own
party horn when seated on a chair or in a wheelchair; this assessment was performed
twice with a 3 min rest interval between each respiratory test. Patients were then asked toMedicina 2023, 59, 134

4 of 72.3. Experimental Protocol
The study was conducted as an experimental design. For each patient, a standard
examination procedure was followed. Patients were assessed in a private room on days
when their condition was stable. First, patients were instructed to blow into their own
party horn when seated on a chair or in a wheelchair; this assessment was performed
twice with a 3 min rest interval between each respiratory test. Patients were then asked
to blow the party horn swiftly and for as long as possible. The maximum length of theparty horn was measured by using a 1 cm inter-spatial scale on a table. The time durationfrom complete unrolling to the point at which the party horn started to resume its coiled
form was measured using an HS-80TW stopwatch (Casio, Tokyo, Japan). The “maximum
length × party horn extension duration” (the party-horn-integrated value in cm s−1 ) was
calculated, and the larger value was used in the analysis.
Next, using a spirometer on another day, the following parameters of respiratory
function were examined twice via the vital capacity (VC) test at the point of maximum
FVC, which was caused by the opening of the nasal cavity: FVC, percent VC (%VC), forced
expiratory volume in 1 s (FEV1 ), FEV1 as a percentage of FVC (FEV1% ), peak expiratory flow(PEF), and forced expiratory time (FET). These data were measured with patients sitting in achair, using a nose clip to prevent air from coming out of their noses. Data on demographics(e.g., age and sex) and clinical characteristics (e.g., length of hospital stay) were obtained
from the medical records. Moreover, cognitive functions, mental and behavioral disorders,eating-related behavioral problems, and dietary modifications were assessed.
Assessment items pertaining to cognitive function (9 items) and mental and behavioral
disorders (14 items) were evaluated (Supplementary Tables S1 and S2) in accordance with
the instructions provided in the textbook of the nursing certification investigator [9]. Each
item was scored according to the following responses: “can” or “no” (2 points); “sometimes”(1 point); and “cannot” or “yes” (0 points). In addition, the assessment form used forthe documentation of eating-related behavioral problems (18 items) and required dietarymodifications (4 items) is shown in Tables S3 and S4. The assessment form for eating-related
behavioral problems was evaluated according to two responses: “Yes” = 0 points and “No”
= 2 points. The assessment form for the required dietary modifications was evaluatedusing five responses: “not applicable” = 4 points, “1 item concerned” = 3 points, “2 items
concerned” = 2 points, “3 items concerned” = 1 point, and “all items concerned” = 0 points.
2.4. Statistical Analysis
To verify the factors that affected respiratory function among older patients, theparticipants were divided into two groups depending on whether they could blow the party
horn to its full length; participants with an integrated value > 2000 cm s−1 or FVC > 2 L
were assigned to the high group, and the remaining patients were allocated to the lowgroup. The Mann–Whitney U test was used to compare the following factors between thetwo groups: age, the length of hospital stay, cognitive functions, mental and behavioral
disorders, party-horn-integrated value, FVC, %VC, FEV1 , FEV1% , PEF, FET, eating-related
behavioral problems, and dietary modifications. Furthermore, multiple linear regression
analysis with backward stepwise selection was performed to model the effects of age,cognitive functions, mental and behavioral disorders, eating-related behavioral problems,
dietary modifications, FVC, %VC, FEV1 , FEV1% , and PEF (independent variables) on
the party-horn-integrated value as the dependent outcome. The corresponding p-values,
standard regression coefficients (SRCs), and T-values were also calculated. Data wereanalyzed in SPSS Version 24.0 (IBM, Tokyo, Japan). A p-value < 0.05 was set to indicate
statistical significance.
3. Results
Of the 68 inpatients (36 men, 32 women; age, mean ± SD, 80.8 ± 7.46 years) who werescreened for inclusion, 62 (34 men, 28 women; age, mean ± SD, 80.4 ± 7.59 years) wereenrolled in this study. Among them, 27 and 35 patients were included in the high and low

Medicina 2023, 59, 134

5 of 7groups, respectively. There were significant intergroup differences in the length of hospital stay, cognitive functions, mental and behavioral disorders, eating-related behavioral
problems, dietary modifications, party-horn-integrated value, FVC, %VC, FEV1 , and PEF(Table 1).
Multiple linear regression analysis identified three factors that were significantly
associated with the party-horn-integrated value: FEV1 (SRC −0.325, T 2.949, p = 0.005), PEF(SRC 0.283, T 3.912, p = 0.005), and eating-related behavioral problems (SRC 0.251, T 2.255,
p = 0.028) (Table 2).
Table 2. Factors associated with the party-horn-integrated value.

FEV1
PEF
Less severe eating-related behavioral problems

SRC

T-Valuep-Value−0.325
0.283
0.251

2.949
3.912
2.255

0.005 **
0.005 **
0.028 *

* p < 0.05, ** p < 0.01, by the multiple linear regression analysis with backward stepwise selection. Excluded
items = age, length of hospital stay, cognitive functions, mental and behavioral disorders, %VC, FEV1% , FET,
and dietary modifications. Abbreviations: FEV1 : forced expiratory volume in 1 s; PEF: peak expiratory
flow; SRC: standard regression coefficient; %VC: percent vital capacity; FEV1% : FEV1 as a percentage of FVC;
FET: forced expiratory time.

4. Discussion
We found that participants in the low group had a longer hospital stay and lowered
cognitive function as compared to those in the high group, which concurs with the findingsof previous studies [10]. Similarly, eating-related behavioral problems differed significantly
between the groups, implying that eating-related behavior is associated with respiratory
function. Restrictive ventilatory impairments were associated with a high risk of aspiration
due to the lack of a deglutition apneic period, which is replaced by shallow respiration andtachypnea [11]. Disuse muscle atrophy affects respiration muscles and intercostal muscles,
which may lead to restrictive ventilatory impairments [10]. Thus, it is necessary to maintainlung function to ensure safe eating.
However, patients with dementia are often administered antipsychotics to treat disquiet or aggressive symptoms, especially in the early phase of hospitalization. These
medications are associated with various side effects, including disuse muscle atrophy
secondary to low activity [12]. Previous research suggested that party horns are useful for
improving intra-oral pressure [13]. This study showed that party horns could be used as
an evaluation tool for the prediction of FEV1 and PEF. Our results indicate that FEV1 andthe party-horn-integrated value have an inversely proportional relationship, whereas PEF
and the party-horn-integrated value have a linear proportional relationship. Therefore,
the abovementioned findings indicate that the party horn may enable the evaluation of
maximum exhalation flow with the longest possible duration. Moreover, we found robust correlations between the integration expiratory pressure and FEV1 , which have beenpreviously reported [6].
The PEF is proportional to the intention to cough; therefore, party horns can be used asa tool to evaluate eating-associated problems, including aspiration and diminished force of
expectoration [14]. The advantage of using party horns is that the evaluation of respiratory
function in patients with dementia can be performed more easily, which addresses thechallenges caused by limited comprehension ability in patients with dementia to enable theprovision of instructions pertaining to deglutition rehabilitation and nutritional guidance.
This is pertinent, as pneumonia is a major cause of mortality in patients with advanced
dementia [15].
As such, some studies have reported correlations between deglutition and aspiration.
The evaluation of respiratory functions with party horns in early-stage dementia may
facilitate treatment planning and the provision of individual- or group-level rehabilitativeinterventions. Such rehabilitation plays an important role in maintaining deglutition andMedicina 2023, 59, 134

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aspiration functions in hospitalized elderly patients [16]. Furthermore, such an assessment
can be extended to healthy older adults to ensure safe eating [17].
The limitations of this study include the low reproducibility of data and the lack of atrusting relationship with the examiner due to cognitive impairments of the patients. Thus,
whether the results can be generalized to dementia patients with any degree of cognitive
impairment remains unclear. Most of these above-discussed issues may be resolved ifparty horns are incorporated into daily training practices. Additional studies with a big
sample size are required to estimate the sensitivity, specificity, and validity of the party horn
evaluation system. Furthermore, a power analysis should be used for the determination of
the sample size. To investigate the efficacy of respiratory training for patients with dementia,
the correlation between time-course changes in respiratory function and eating-related
behavioral problems are also should be examined.
5. Conclusions
The results of this study support the usefulness of party horns for the evaluation of
respiratory functions, such as FEV1 and PEF, as well as eating-related behavioral problems.
This novel assessment tool may be used to screen and evaluate aspiration risk and eatingrelated behavioral problems of older patients in the early stages of dementia.
Supplementary Materials: The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/medicina59010134/s1, Table S1: Assessment of cognitive function;
Table S2: Assessment of mental and behavioral disorders; Table S3: Assessment of eating-related
behavioral problems; Table S4: Assessment of dietary modifications.
Author Contributions: M.H. contributed to literature search, manuscript preparation, manuscript
editing, and manuscript review. H.H. contributed to the research concept, design, and data acquisition.
T.U. and Y.H. contributed to the research concept, design, and definition of intellectual content.
H.S. contributed to the data analysis and statistical analysis. M.M. contributed to the manuscript
preparation, manuscript editing, and manuscript review. All authors have read and agreed to the
published version of the manuscript.
Funding: The authors received no financial support for the research, authorship, and/or publicationof this article.
Institutional Review Board Statement: This study was approved by the Institutional Ethics Committee of Nagasaki University (approval no. 10072294).
Informed Consent Statement: Written informed consent was provided by either the patient or theirfamily member.
Data Availability Statement: The datasets generated and analyzed during the current study are notpublicly available due to a lack of participants’ agreement to put the data in public, but are available
from the corresponding author on reasonable request.
Acknowledgments: The authors would like to express their appreciation to the participants of thisstudy, their families, and the hospital staff of Deguchi Hospital in Nagasaki, Japan.
Conflicts of Interest: The authors declare no competing interest.

References
1.
2.
3.
4.
5.

Ashley, F.; Kannel, W.B.; Sorlie, P.D.; Masson, R. Pulmonary Function: Relation to Aging, Cigarette Habit, and Mortality.
Ann. Intern. Med. 1975, 82, 739–745. [CrossRef]
Brunnström, H.R.; Englund, E.M. Cause of Death in Patients with Dementia Disorders. Eur. J. Neurol. 2009, 16, 488–492. [CrossRef][PubMed]Gavazzi, G.; Krause, K.H. Ageing and Infection. Lancet Infect. Dis. 2002, 2, 659–666. [CrossRef] [PubMed]
Higashijima, M. Evaluation of Cooperation Between Swallowing and Respiration in a Case of Multiple Cerebral Infarctions Using
Non-invasive Swallowing Function Methods. Jpn Occup. Ther. Res. 2008, 27, 290–294.
Higashijima, M. Relationship Between Swallowing Dysfunction and Decreased Respiratory Function in Dementia Patients.
J. Phys. Ther. Sci. 2013, 25, 941–942. [CrossRef] [PubMed]

Medicina 2023, 59, 134

6.
7.
8.
9.
10.
11.
12.

13.
14.

15.
16.
17.

7 of 7

Higashijima, M.; Miyagawa, Y. Study on Actual Conditions of Eating and Swallowing in Senile Dementia Care Wards. J. Jpn Soc.
Dement. Care 2009, 8, 428–432.
Higashijima, M.; Shiozu, H. Using Party Horns to Test Respiratory Function in Patients with Dementia. Am. J. Alzheimers Dis.
Other Demen. 2015, 30, 326–329. [CrossRef] [PubMed]
Higashijima, M.; Shiozu, H.; Ueda, T.; Kurozumi, C. Utility of a Simple Expiratory Pressure Measurement Device in the Evaluationof Pulmonary Function. Int. J. Gerontol. 2018, 12, 208–211. [CrossRef]
Higashijima, M.; Tanaka, A.; Higashi, J.; Sakai, T.; Shiozu, H. The Efficacy of Intervention for the Prevention of Aspiration
Pneumonitis in Recipients of Non-oral Nutrition. Int. J. Phys. Med. Rehabil. 2017, 05, 1000442. [CrossRef]
Kaneko, H.; Suzuki, A.; Horie, J. Relationship of Cough Strength to Respiratory Function, Physical Performance, and Physical
Activity in Older Adults. Respir. Care. 2019, 64, 828–834. [CrossRef] [PubMed]
Katsumata, U.; Sekizawa, K.; Ebihara, T.; Sasaki, H. Aging Effects on Cough Reflex. Chest 1995, 107, 290–291. [CrossRef] [PubMed]
Ministry of Health, Labour and Welfare. The Textbook of the Nursing Certification Investigator. Tokyo, Japan, Revised Version.
Volume 2009. 2009. Available online: https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/hukushi_kaigo/kaigo_koureisha/nintei/nintei_text.html (accessed on 25 March 2022).
Mitchell, S.L.; Teno, J.M.; Kiely, D.K.; Shaffer, M.L.; Jones, R.N.; Prigerson, H.G.; Volicer, L.; Givens, J.L.; Hamel, M.B. The ClinicalCourse of Advanced Dementia. N. Engl. J. Med. 2009, 361, 1529–1538. [CrossRef] [PubMed]
Pathan, S.S.; Gottesman, R.F.; Mosley, T.H.; Knopman, D.S.; Sharrett, A.R.; Alonso, A. Association of Lung Function with
Cognitive Decline and Dementia: The Atherosclerosis Risk in Communities (ARIC) Study. Eur. J. Neurol. 2011, 18, 888–898.
[CrossRef] [PubMed]
Sasao, Y.; Tachimura, T.; Nohara, K.; Wada, T. Inconsistent Reliability of Evaluation of Velopharyngeal Function Using Carnival
Blowers. Jpn J. Logoped. Phoniatr. 2006, 47, 166–170. [CrossRef]
Shaker, R.; Ren, J.; Bardan, E.; Easterling, C.; Dua, K.; Xie, P.; Kern, M. Pharyngoglottal Closure Reflex: Characterization in
Healthy Young, Elderly and Dysphagic Patients with Predeglutitive Aspiration. Gerontology 2003, 49, 12–20. [CrossRef] [PubMed]
Sokoloff, L.G.; Pavlakovic, R. Neuroleptic-Induced Dysphagia. Dysphagia 1997, 12, 177–179. [CrossRef] [PubMed]

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