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212 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
A Look at the Chapter
The aging population is projected to take up a
significant caseload in swallowing clinics in the
near future. This chapter describes the changes
to swallowing-related functions in healthy aging.
Current clinical guidelines for the management
of swallowing problems associated with individuals with dementia are presented. The ethics
involved in managing nutrition in dysphagia are
also addressed in this chapter. When a speechlanguage pathologist or other team member
recommends a change in diet, especially to a
nonoral diet, the patients and their family may
not agree with the recommendations. Ethical
dilemmas relating to diet changes are discussed
especially in relation to patients with dementia or
at end of life.
AGING PROCESS RELATED TO SWALLOWING
Presbyphagia is used to describe the continuous
and degenerative changes in swallowing functions
in healthy aging. When swallowing functions deteriorate to a level that is not tolerated or compensated
for by the older adult, dysphagia will then occur.
Up to 84% of older adults may develop changes in
swallowing functions that would be considered as
“abnormal” in younger healthy adults.
2
Swallowing
problems with advancing age are a major health
problem in older adults as well as for hospitalized
individuals and nursing home residents.
Studies estimated that 30% to 68% of nursing
home residents have signs of swallowing
disorders.
3–6
Physical Changes
INTRODUCTION
The world population is aging. It is projected by the
United Nations that 1 in 6 people in the world will
be 65 years of age or over by 2050.
vidual may experience changes in cognitive status,
physical health, emotional health, as well as changes
in financial status, daily activities dependence, and
home environment. This chapter focuses on changes
that have significant impacts on swallowing and
mealtime experiences. Readers are encouraged to
refer to other references to gain a comprehensive
understanding of the aging process to better prepare care plans for aging individuals.
It is important to remember that the assessment
and management procedures described in earlier
chapters are applicable to the aging population.
This chapter highlights additional issues that clinicians should consider when working with an aging
patient. The ethical considerations at the end of the
chapter are also relevant to patients at end of life,
such as those with terminal illnesses.
1
An aging indi-
Cortical changes have been identified in older adults
when compared with younger adults. Studies have
found that older adults have different activation patterns (in terms of activation areas and levels of activities) in the cortex, suggesting that more cognitive
resources are needed to control voluntary movements
and trigger involuntary reflexes during swallowing.
Always remember to ask older patients if they
have more trouble swallowing when watching
television or when talking with friends. Distractions often lead to coughing, choking, or just “it
went down the wrong way.”
7–9
Sarcopenia is defined as a syndrome characterized by progressive and generalized loss of skeletal
muscle mass and strength and/or physical performance.
10
A number of swallowing-related muscles
have been found to reduce in size with age, such
as jaw muscles and suprahyoid muscles and tongue
9. SWALLOWING IN THE AGING POPULATION 213
muscles.
11–13
Studies have found a decrease in jaw
bite force, suprahyoid muscle strength during jaw
opening, and maximum isometric lingual pressure
with age.
14–17
Some studies have found that the previously named muscle strength is better reserved in
females than males.
16,18,19
A decline in muscle strength does not mean
there must be swallowing problems.
The prevalence of chronic diseases is higher in
older adults than in young adults, and older adults
tend to have more than one chronic disease. Common chronic diseases include diabetes, hypertension, stroke, Parkinson disease, metabolic disorders,
chronic pain, cardiovascular disease, reduced vision
and hearing, depression, cancer, and dementia.
20
In
order to control the chronic diseases, older adults are
often prescribed a number of medications. Polypharmacy is defined as regular use of at least five medications. Polypharmacy is identified as one of the factors
associated with increased risk of aspiration, dysphagia, and malnutrition.
21,22
Frailty occurs when there
is significant reduced muscle strength and impaired
physical function, which limits the older adult’s activities of daily living and independence.
Cognitive Changes
Past studies investigating cognitive changes in adults
found that memory and cognitive speed deteriorate
with age. However, there are individual variations
on how much and when such changes begin. Low
education level and poor health are two common
risk factors identified in past studies to be associated with cognitive decline.
23
Oral Stage
A system review found that sensitivity to taste
degrades with age, and the level of decline varies
across taste modalities.
24
Dental issues, such as tooth
loss and use of dentures, are common in the aging
population and may have an impact on chewing and
malnutrition.
25,26
Longer oral transit time, mastication time, and more time needed to reach maximal
lingual pressure have been reported in older adults
when compared with younger adults.
15,27,28
There is
also a trend in increasing amount and frequency of
oral residue with age.
27,29
Pharyngeal Stage
Slower triggering of the swallowing reflex with
age has been reported in a number of studies.
Some studies have also found that a larger bolus is
required to trigger the reflex in older adults than in
younger adults.
33,34
A number of associated factors
for reduced airway closure with aging have been
reported, including a reduction in amplitude of
hyolaryngeal elevation and excursion,
35,36
space between hyoid bone and the mandible,
more inferior placement of the larynx.
38
Increased
pharyngeal transit time, less powerful pharyngeal
constriction, and larger time lag between maximum pharyngeal constriction and swallow onset
have been reported in aging adults, especially in
27,39,40
males.
With the above previously mentioned
reduction in pharyngeal constriction amplitude, it is
expected that there is also more residue identified in
older adults than younger adults.
8,41
Together with
the reported reduction in sensitivity of the pharyngeal and laryngeal sinuses with age,
42–44
an increased risk of aspiration with aging. Finally,
a reduction in duration and range of opening of
the upper esophageal sphincter (UES) has been
reported in aging adults.
45,46
30–32
increased
37
and
there is
CHANGES IN SWALLOWING
The following changes in swallowing functions are
identified from studies that included healthy aging
adults in the community.
Note that the presence of aspiration does
not mean there is dysphagia or aspiration
pneumonia.
214 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Esophageal Stage
A less secured closure of the UES at rest in older
adults than in younger adults has been reported.
Lower amplitudes in peristaltic movement and
reduced sensory perception of pressure and pain in
the esophagus with aging have been reported.
The study also found that there was an increased
cross-sectional area and increased stiffness of the
esophagus with age.
47,48
49–51
NUTRITION IN THE AGING POPULATION
In the aging population, nutrition and eating play an
important part of life, whether to maintain physical
and mental health or to aid in recovery from disease or sickness.
intakes for older adults approximates 2500 kcal and
2100 kcal for males and females, respectively.
European Society for Swallowing Disorders and the
European Union Geriatric Medicine Society released
a joint position document on dysphagia in older
adults.
54
The guidelines recommended the daily
energy intake for older adults should be around
27 to 30 kcal/kg of body weight. Protein is one of
the key nutrients for older adults. Inadequate protein intake has been shown to relate to muscle loss,
sarcopenia, and other chronic diseases. The Food
and Nutrition Board of the National Academies of
Science, Engineering, and Medicine recommended
10% to 35% of daily energy intake should come
from protein, and experts have recommended that
the protein intake for older adults should be 1.2 to
2.0g/kg/day or higher.
especially those with frailty and dysphagia, may
consume a smaller amount of food in each meal,
careful planning of high-quality protein meals is
important to prevent malnutrition.
Because of the importance of eating, no diet
should be recommended simply on the basis of a
diagnosis or on the basis of an instrumental test.
This is especially true in older adults, including
those restricted to nursing home care or those individuals with other comorbidities. In both groups,
the diet should be as liberal as swallowing safety
52
The recommended daily energy
53
The
55
Given that older adults,
allows. The dysphagic older adult may face many
problems affecting nutrition, such as poor eyesight,
eating alone, and limited hand mobility. All of these
problems have a bearing not only on what the
patient may or may not eat but also on the patient’s
quality of life. The importance of qualified dietitians
overseeing the content of meals for older adults
should not be overlooked in the rehabilitation process. However, the dietitian should not undertake
the management of nutrition in older adults as their
responsibility solely.
Multidisciplinary management is crucial in
managing nutritional needs in older adults.
The SLP must work together with the dietitian,
the physical therapist, the pharmacist, and the
attending physician to make sure that nutritional
needs are met within the framework of the
medical conditions present, the physical abilities
and limitations of the patient, and the quality of
life that apply to each particular patient.
In some patients, a more liberalized diet can
enhance quality of life; in others, restrictions in certain food groups or viscosities may be necessary.
DEMENTIA
Dementia is an increasingly prevalent condition
globally, especially in the aging population.
nutrition and dehydration are common concerns for
individuals with different stages of dementia. Studies have reported up to 93% of patients with dementia may have some level of swallowing difficulties.
The prevalence of dysphagia and types of swallowing difficulties (sensory, motor, behavioral) vary for
different types and stages of dementia. The causes
may include an inability to recognize food; loss of
appetite; difficulties in coordinating head, hands,
and arms movements; and in cases of advanced
dementia, difficulty with swallowing. Common
observable signs of swallowing difficulties include
pocketing of food in the mouth for extended period,
57
Mal-
56
54
9. SWALLOWING IN THE AGING POPULATION 215
choking and coughing while eating, and needing
reminders to swallow. Regular clinical swallowing evaluation, with instrumental evaluation when
appropriate, should be arranged to closely monitor
the progress of dementia on swallowing functions.
A swallowing and mealtime management plan need
to be regularly updated and communicated with all
members of the multidisciplinary team.
Individuals with dementia are often on a modified diet and/or require feeding assistance to ensure
swallow safety. Studies have found that the nutritional and moisture levels of modified texture food
varied greatly with different methods of preparation, and this may have a significant impact on the
nutrition and hydration levels of the patients.
Speech-language pathologists should work
closely with dietitians and caregivers to ensure
that patients with dementia have adequate
nutrition and hydration. This includes calorie
counts and proper mix of protein, fats, and
carbohydrates.
51,58,59
Studies have found that providing training to
caregivers who are responsible for providing feeding assistance to dysphagic patients may help to
improve the patients’ amount of food intake and
reduce feeding difficulties.
60–62
There is moderate
evidence in support of using nutritional supplements to improve the nutritional status of patients
with dementia.
63,64
Behavioral and Psychological
Symptoms of Dementia
Behavioral and psychological symptoms of dementia (BPSD) refer to neuropsychiatric disturbances
that are commonly seen in individuals with dementia and have significant impact on their daily living, prognosis, and management of dementia. BPSD
are clinically classified into five domains: cognitive/
perceptual, motor, verbal, emotional, and vegeta-
65
tive.
Examples include delusions, pacing, physical
aggression, yelling, repetitive speech, depression,
anxiety, and disturbances in sleep and appetite. It
is common for these symptoms to occur more frequently in late afternoons and evenings, known as
“sundowning.” BPSD will affect the patients’ mealtime experience and swallowing functions, and likewise, the nutritional status and mealtime experience
may also contribute to BPSD. It is important that
the SLPs are aware of the symptoms experienced
by the patients and take these into consideration
when making swallowing management and mealtime plans.
The patient with dementia is often monitored
for wandering away, leaving lights on, or leaving
fires burning. It is equally important to make sure
the patient with dementia is getting enough to
eat. In advanced stages, this usually does not
happen without a caregiver.
Environmental modifications can be used to
improve the mealtime experience and reduce BPSD.
Limited evidence is available, and most studies are
small-scale studies.
66
However, a positive impact is
generally found for the following recommendations:
n Play relaxing music during mealtimes.
n Increase light intensity in the dining area.
n Increase visual contrast in table settings,
including placemats, plates, and glasses.
n Provide more food choices during mealtimes.
n Create family-style meals (serving in bulk and
passing the dish around instead of having
individually served meals).
n Create a social environment (eat with
others) and encourage conversations during
mealtimes.
Tube Feeding
A Cochrane systematic review on the use of tube
feeding in older adults with advanced dementia
concluded that there is not enough strong evidence
to support the use of tube feeding in this popula-
67
tion.
Only 7 observational controlled studies were
216 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
identified in the literature, and they found that tube
feeding neither prolonged life nor improved nutritional status, when compared with assisted feeding.
Recently, a large-scale retrospective cohort study
was conducted to compare the effect of nasogastric
tube feeding (NGF) and careful hand feeding (CHF)
outcomes in hospitalized patients with advanced
dementia.
68
The study found that there was no difference in survival for patients in the 2 groups, and
patients who were on NGF were associated with
higher pneumonia risk.
The American Geriatrics Society and The
National Institute for Health and Care Excellence
(NICE) from the United Kingdom issued statements and recommendations in relation to the use
of feeding tubes for individuals with advanced
TABLE 9–1. Steps to Comfort Feeding
1. Interview family
members, patient,
and/or surrogate
decision-maker
• Review if an Advanced Directive or Advanced
Care Plan is in place.
• What is the patient’s preference? What does the
family think the patient would want?
dementia.
69,70
Both papers do not recommend the
use of feeding tubes for older adults with advanced
dementia and that careful hand-feeding should be
offered instead. It was highlighted that mealtime
should be a time for socialization and not a task that
needs to be completed as soon as possible. This is a
very important attitude that should be educated to
all caregivers of patients with dementia. This is especially important to the managers of nursing homes
and policymakers when assigning or planning
resources for mealtime assistance. The statement
recommends institutions should promote informed
decision-making on feeding options using decision aids for this population.
71–73
Table 9–1 shows
the suggested steps for recommending comfort
feeding.
2. Pros and cons
of oral and tube
feeding
3. Reach a decision • Give enough time for the family to make a
4. Documentation • Different countries and institutions may have
5. Implementation • Family and caregivers should be trained on
• Explain the evidence, potential benefits, and
associated risks for oral feeding and tube
feeding.
decision.
• Clinicians should remain as unbiased as
possible and avoid casting guilty feelings to
family, no matter what decision is made.
different legal requirements on how to document
medical decisions.
• Usually the document is signed off by more
than one clinician and physician. It may not be
necessary for the family to sign this document.
careful hand-feeding strategies.
• All members of the care team (eg, nurses,
physicians, speech-language pathologists)
should be aware of the feeding arrangement.
• Maintain good oral hygiene.
• Create a comforting, distraction-free environment
for mealtimes.
9. SWALLOWING IN THE AGING POPULATION 217
A decision aid for tube feeding published by NICE
can be downloaded from their website.
SLPs need to carefully balance the benefits and
risks of diet modifications and enteral feeding
and fully involve the patients and surrogate
decision-maker in the decision-making process.
Comfort feeding or careful hand-feeding refers to
a series of feeding assistance and swallowing strategies, such as frequent reminders to swallow, multiple
swallows, encouraging gentle coughs after each swallow, teaspoon feeding, and thickened liquids. The
patient should be seated upright during feeding. The
caregivers should be trained to identify signs of swallowing distress and should pay full attention to the
patient during feeding. A least restrictive diet should
be recommended as far as possible to allow patients
to enjoy their favorite dishes and drinks, which helps
to increase their appetite and quality of life.
Support pillows for the back, neck, or head may
be necessary to keep the patient in a position
that maximizes their swallow and the ability to
cough after the swallow.
FEEDING ASSISTANCE
All older adults should be encouraged to feed themselves as long as possible to facilitate mealtime
engagement and enjoyment, independence, and
dignity. However, it is not uncommon that feeding
assistance is needed for those who are frail, have a
disability, have dementia, or have severe dysphagia.
Studies have found that feeding assistance can help
to improve the nutritional and hydration status in
older adults.
At the initial stage or for milder cases, feeding
assistance can be in the form of providing verbal
prompts to encourage swallowing, self-feeding, or
61,74,75
pacing of swallows. When more assistance is needed,
caregivers may need to start hand-holding to initiate
feeding or completely take over the feeding process.
An important role of the SLP is to educate caregivers in the skills of feeding assistance and arrange
regular monitoring or review of the feeding skills.
Table 9–2 shows some tips for feeding assistance.
Case Vignette
Ralph, a 66-year-old male, had a mild cerebrovascular accident but then had an infection that
required him to stay in the hospital for 4 more
weeks. He went home with significant weight
loss. His primary doctor was surprised since he
was told that Ralph was given 3 meals a day
and appeared to eat most of his food. Ralph
told the doctor he did not like the food, so he
offered much of it to one of the night cleaning
people. He told his doctor that he would try to
eat better. When Ralph returned to the doctor’s
office 4 weeks later, he gained 5 pounds. The
doctor asked how his wife’s cooking was. He
said, “same as usual but I was able to drink two
bottles of beer a day to help digest it!”
Table 9–3 summarizes the major points to consider when preparing diets for older adults. The SLP
and dietitian must take all of these into consideration, along with the nutritional requirements of
each individual. These considerations are important
because it is not always possible to do the proper
tests or complete tests in older adults. Thus, the
choice of food consistencies and the viscosities and
combinations of viscosities may be more subjective
than objective. There is a need to talk to the families, if available, other caregivers such as nurses and
attendants, and roommates or neighbors to get a
feel for what the older patient’s needs are when the
patient themself cannot or does not express those
needs. In all older patients, no diet should be so
restrictive that it discourages oral intake. The Academy of Nutrition and Dietetics advocates a liberal
policy when considering diets for older adults.
76
218 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
TABLE 9–2. Clinical Tips for Feeding Assistance
Before mealtime • Prepare appropriate feeding utensils.
• Prepare appropriate foods and liquids according to
speech-language pathologist’s suggestions.
Before feeding • Assist the patient to sit upright, head looking
forward (not tilted up), may need cushions or other
supporting devices to maintain good head and
sitting postures.
• Check the oral cavity for any residue and buildup of
secretions.
• (If denture is needed) Check denture position.
• Greet and chat with the patient to make sure the
patient is awake and alert. Let the patient know it is
mealtime.
During feeding • Seating arrangement: sit at a similar height level as
the patient and not directly in front of the patient.
• Create a warm, comfortable, and distraction-free
environment.
• Let the patient know what is included in the meal
(especially if it is pureed).
• Ensure the patient swallows with the recommended
posture (if available).
• Monitor pace and volume of feeding.
• Allow enough time for the patient to swallow each
bolus before feeding the next one.
• Where possible, provide choices for the patient
during mealtime. It could be simply asking if the
client would like to drink some water first before
eating.
After mealtime • Check the oral cavity for residues.
• Encourage the patient to remain seated for 30 to
45minutes after meals.
• Maintain oral hygiene.
The Academy of Nutrition and Dietetics encourages health care professionals to carefully
balance the benefits and risks associated
with “therapeutic diets” (including modified
diets). Older patients should be involved in the
decision-making as far as possible to increase
the desire to eat and quality of life.
ETHICAL CONSIDERATIONS
Ethical dilemmas may occur when considering
whether to recommend nonoral feeding or highly
restrictive modified diets to older adults or to
patients who are at the end-of-life stage. SLPs may
have identified high aspiration risks or inadequate
nutritional and hydration intakes, warranting a med-
9. SWALLOWING IN THE AGING POPULATION 219
TABLE 9–3. Considerations When Planning a Nutritional
Rehabilitation Program for the Older Adult Patient
Body Structures and Functions
Swallow safety
Dentition
Physical disabilities and limitations
Cognitive functions
Motivation and appetite
Communication ability
Emotional functions
Nutritional needs — weight maintenance, weight gain,
weight reduction
Activities and Participation
Social interactions at mealtime
Religious preferences
Ethnic food preferences
Environmental Factors
Living situation
Family or friends support
Available community diet services
Meal delivery systems
made repeated comments to the treatment team
that she feels stressed and lost, wondering if this
is how her mother wishes her life to end.
There is no straightforward recommendation
that can be applied to all similar cases as the one
presented. A number of clinical settings have published decision-making algorithms or guidelines to
aid health care providers to make decisions on diet
modifications or tube feeding.
77–80
A number of common themes to these guidelines are as follows:
1. Accurately identify the current progress and
prognosis of the patient.
2. Educate the patient and family members of the
risks and benefits of the dysphagia management recommendations.
3. Involve the patient and family in the decision
making.
4. Encourage regular follow-up after a decision
has been made.
These guidelines can help to ease the burden on
health care providers and the patient’s family.
ical need to modify the oral diet and/or the use of
enteral feeding. However, the situation may become
more complicated and ethically challenging when
the patient has an advance directive or a living
will, or when the patient or the surrogate decision-
maker does not agree with the recommendations.
The following case is a hypothetical situation that
may be seen in rehabilitation hospitals:
Mrs P is a 69-year-old woman who had a severe
stroke a month ago, resulting in severe global
aphasia and dysphagia. She had a PEG tube
placed a week ago. Mrs P’s swallowing functions are slightly and slowly improving over the
last week. Mrs P’s daughter produced Mrs P’s
advance directive (AD) to the physicians and
demanded Mrs P’s feeding tube be removed,
as Mrs P indicated in her AD that she does not
want to live on tube feeding. Mrs P’s daughter
Biomedical Ethics Principles
Beauchamp and Childress proposed four ethical principles that could be used to guide ethical
decisions
n respect for autonomy
n beneficence
n nonmaleficence
n justice
that each competent individual should have the right
to decide how one is medically managed. Beneficence means clinicians should take positive action
to do good for patients and act to prevent or remove
harm. Nonmaleficence means that clinicians should
not cause any deliberate harm to a patient. Finally,
justice means patients’ needs should be addressed
in a fair and equitable manner.
81
:
Respect for autonomy refers to the principle
220 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
SUMMARY
This chapter presented how swallowing functions
may change with age. Presbyphagia is a continuum
of swallowing changes that occur in healthy aging.
Clinicians should be aware that such changes may
not lead to dysphagia.
And remember, older adults have their “likes and
dislikes” just as everyone else. Learn what they
are for each patient as they relate to food and
drink, and pay attention to their experiences with
foods and liquids that they do not like.
Special clinical guidelines have been developed
for managing nutritional and hydration needs for
individuals with dementia. Family members and
patients should be involved in making an informed
decision on how swallowing should be managed
for this population. It is important to remember that
eating (swallowing) is not just a means to obtain
nutrition, but it is also an occasion for social interaction and enjoyment of life. Clinicians should adopt
a least-restrictive diet and independent feeding as
much as possible when working with older patients.
Four biomedical ethics principles should guide all
clinical decision-making: respect for autonomy,
beneficence, nonmaleficence, and justice.
A. Loss of muscle mass and strength
B. Reduction in suprahyoid muscle strength
C. Reduction in laryngeal elevation and
excursion
D. Reduced sensation in pharyngeal and
laryngeal sinuses
E. All of the above
2. Which of the following is not a feature of
careful hand-feeding?
A. Verbal prompts to swallow
B. Talk while swallowing
C. Gentle coughs after each swallow
D. Teaspoon feeding
E. Focus on one patient during the entire
mealtime
3. The meaning of respect for autonomy is
A. Clinicians should make clinical decisions
on behalf of the patients.
B. Clinicians should do no harm.
C. Clinicians should act to the benefit of the
patients.
D. Clinicians should respect that patients
have the right to make decisions for their
medical care.
E. All of the above
REFERENCES
DISCUSSION QUESTION
1. Discuss how clinical ethics can be applied to
the management of swallowing in older adults.
Would you consider a prescription of nonoral
feeding for an individual with advanced dementia as “an action to do good” or “a harmful act”?
STUDY QUESTIONS
1. Which of the following are changes that occur
in healthy aging?
1. United Nations, Department of Economic and Social
Affairs, Population Division. World Population Ageing
2019; Highlights (ST/ESA/SER.A/430); 2019.
2. Ekberg O, Feinberg MJ. Altered swallowing function in
elderly patients without dysphagia: radiologic findings
in 56 cases. Am J Roentgenol. 1991;156(6):1181–1184.
3. Maeda K, Akagi J. Sarcopenia is an independent risk
factor of dysphagia in hospitalized older people. Geriatr
Gerontol Int. 2016;16(4):515–521.
4. Nogueira D, Reis E. Swallowing disorders in nursing
home residents: how can the problem be explained? Clin
Interv Aging. 2013;8:221–227.
5. Steele MC, Greenwood C, Ens I, Robertson C, SeidmanCarlson R. Mealtime difficulties in a home for the aged:
not just ysphagia. Dysphagia.12(1):43–50.
6. Park Y-H, Han H-R, Oh B-M, et al. Prevalence and associated factors of dysphagia in nursing home residents.
Geriatr Nurs. 2013;34(3):212–217.
9. SWALLOWING IN THE AGING POPULATION 221
7. Windel AS, Mihai PG, Lotze M. Neural representation of
swallowing is retained with age: a functional neuroimaging study validated by classical and Bayesian inference.
Behav Brain Res. 2015;286:308–317.
8. Humbert IA, Fitzgerald ME, McLaren DG, et al. Neurophysiology of swallowing: effects of age and bolus type.
Neuroimage. 2009;44(3):982–991.
9. Onozuka M, Fujita M, Watanabe K, et al. Age-related
changes in brain regional activity during chewing: a
functional magnetic resonance imaging study. J Dent Res.
2003;82(8):657–660.
10. Dionyssiotis Y. Sarcopenia in the elderly. Eur Endocrinol.
2019;15(1):13–14.
11. Newton J, Yemm R, Abel R, Menhinick S. Changes in
human jaw muscles with age and dental state. Gerodon-
tology. 1993;10(1):16–22.
12. Feng X, Todd T, Lintzenich CR, et al. Aging-related geniohyoid muscle atrophy is related to aspiration status in
healthy older adults. J Gerontol A Biol Sci Med Sci. 2013;
68(7):853–860.
13. Sonies BC, Baum BJ, Shawker TH. Tongue motion in
elderly adults: initial in situ observations. J Gerontol.
1984; 39(3):279–283.
14. Oh D-H, Park J-S, Jo Y-M, Chang M. Differences in maximal isometric tongue strength and endurance of healthy
young vs. older adults. J Phys Ther Sci. 2016;28(3): 854–
856.
15. Vanderwegen J, Guns C, Van Nuffelen G, Elen R, De
Bodt M. The influence of age, sex, bulb position, visual
feedback, and the order of testing on maximum anterior
and posterior tongue strength and endurance in healthy
Belgian adults. Dysphagia. 2013;28(2):159–166.
16. Palinkas M, Nassar MSP, Cecílio FA, et al. Age and gender
influence on maximal bite force and masticatory muscles
thickness. Arch Oral Biol. 2010;55(10):797–802.
17. Iida T, Tohara H, Wada S, Nakane A, Sanpei R, Ueda
K. Aging decreases the strength of suprahyoid muscles
involved in swallowing movements. Tohoku J Exp Med.
2013; 231(3):223–228.
18. Jeong D-M, Shin Y-J, Lee N-R, et al. Maximal strength
and endurance scores of the tongue, lip, and cheek in
healthy, normal Koreans. J Korean Assoc Oral Maxillofac
Surg. 2017;43(4):221.
19. Machida N, Tohara H, Hara K, et al. Effects of aging and
sarcopenia on tongue pressure and jaw‐opening force.
Geriatr Gerontol Int. 2017;17(2):295–301.
20. Schäfer I, von Leitner EC, Schön G, et al. Multimorbidity
patterns in the elderly: a new approach of disease clustering identifies complex interrelations between chronic
conditions. PLoS One. 2010;5(12):e15941.
21. Pu D, Wong MCH, Yiu EML, Chan KMK. Profiles of polypharmacy in older adults and medication associations
with signs of aspiration. Expert Rev Clin Pharmacol.
2021; 14(5):643–649.
22. Matsumoto A, Yoshimura Y, Nagano F, et al. Polypharmacy and its association with dysphagia and malnutri-
tion among stroke patients with sarcopenia. Nutrients.
2022; 14(20):4251.
23. Christensen H. What cognitive changes can be expected
with normal ageing? Aust N Z J Psychiatry. 2001;35(6):
768–775.
24. Methven L, Allen VJ, Withers CA, Gosney MA. Ageing and
taste. Proc Nutr Soc. 2012;71(4):556–565.
25. Sheiham A, Steele J. Does the condition of the mouth
and teeth affect the ability to eat certain foods, nutrient
and dietary intake and nutritional status amongst older
people? Public Health Nutr. 2001;4(03):797–803.
26. Sahyoun NR, Lin C-L, Krall E. Nutritional status of the
older adult is associated with dentition status. J Am Diet
Assoc. 2003;103(1):61–66.
27. Yoshikawa M, Yoshida M, Nagasaki T, et al. Aspects of swallowing in healthy dentate elderly persons older than 80
years. J Gerontol A Biol Sci Med Sci. 2005;60(4):506–509.
28. Fujii W, Kondo I, Baba M, et al. Examination of chew
swallow in healthy elderly persons: does the position of
the leading edge of the bolus in the pharynx change with
increasing age? Jpn J Compr Rehabil Sci. 2011;2:48–53.
29. Ono T, Kumakura I, Arimoto M, et al. Influence of bite
force and tongue pressure on oro‐pharyngeal residue in
the elderly. Gerodontology. 2007;24(3):143–150.
30. Martin R, Barr A, MacIntosh B, et al. Cerebral cortical
processing of swallowing in older adults. Exp Brain Res.
2007;176(1):12–22.
31. Wang CM, Chen JY, Chuang CC, Tseng WC, Wong AM,
Pei YC. Aging‐related changes in swallowing, and in the
coordination of swallowing and respiration determined
by novel non‐invasive measurement techniques. Geriatr
Gerontol Int. 2015;15(6):736–744.
32. Yokoyama M, Mitomi N, Tetsuka K, Tayama N, Niimi S.
Role of laryngeal movement and effect of aging on swallowing pressure in the pharynx and upper esophageal
sphincter. Laryngoscope. 2000;110(3):434–439.
33. Shaker R, Ren J, Bardan E, et al. Pharyngoglottal closure reflex: characterization in healthy young, elderly
and dysphagic patients with predeglutitive aspiration.
Gerontology. 2003;49(1):12–20.
34. Ren J, Xie P, Lang IM, Bardan E, Sui Z, Shaker R. Deterioration of the pharyngo‐UES contractile reflex in the
elderly. Laryngoscope. 2000;110(9):1563–1566.
35. Kim Y, McCullough GH. Maximum hyoid displacement
in normal swallowing. Dysphagia. 2008;23(3):274–279.
36. Leonard R, Kendall KA, McKenzie S. Structural displacements affecting pharyngeal constriction in nondysphagic
elderly and nonelderly adults. Dysphagia. 2004;19(2):
133–141.
37. Feng X, Todd T, Hu Y, et al. Age‐related changes of hyoid
bone position in healthy older adults with aspiration.
Laryngoscope. 2014;124(6):E231–E236.
38. Logemann JA, Pauloski BR, Rademaker AW, Colangelo
LA, Kahrilas PJ, Smith CH. Temporal and biomechanical
characteristics of oropharyngeal swallow in younger and
older men. J Speech Lang Hear Res. 2000;43(5):1264–1274.