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This is to certify that the

dissertation entitled

THE EFFECTS OF AGING 0N SELECTED PARAMETERS
0F OROPHARYNGEAL SNALLONING

presented by

Debra Catherine LaPrad Gleeson

has been accepted towards fulfillment
of the requirements for

Ph.D. degmin Audiology and Speech Science

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’____—-—-————

THE EFFECTS OF AGING ON SELECTED PARAMETERS
OF OROPHARYNGEAL SWALLOWING

BY

Debra Catherine LaPrad Gleeson

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Audiology and Speech Science

1 996

ABSTRACT
THE EFFECTS OF AGING ON SELECTED PARAMETERS
or: OROPHARYNGEAL SWALLOWING
By

Debra Catherine LaPrad Gleeson

To understand the normal swallow process across the adult life span, this
cross-sectional descriptive research was designed to identify and quantify
systematic differences in oropharyngeal swallowing physiology among normal
nondysphagic older adults. The aging characteristics of deglutition were
systematically quantified to determine the extent to which gradual morphological and
physiological changes in the upper aerodigestive tract predicted deviations in
oropharyngeal swallowing.

This study consisted of 30 adult men, divided into three age groups (50-55,
60—65, 70-75). The subjects demonstrated normal oropharyngeal swallowing history
as determined by completion of a health history questionnaire which ruled out the
presence of dysphagia and medical conditions associated with dysphagia.

Completion of a dysphagia screening further ruled out the presence of swallowing

difficulty.

Debra Catherine LaPrad Gleeson

. Subjects participated in a videofluoroscopic swallow study designed to

measure five oropharyngeal swallowing duration measures: oral transit duration,

pharyngeal transit duration, total oropharyngeal swallowing duration, stage transition

duration, and hyo-Iaryngeal response duration. Two additional measures were
obtained: oral bolus position and stage transition pattern.

Subjects completed three swallows of liquid barium (5 cc) and three swallows
of a barium-paste-coated cookie. Analysis of variance revealed no significant
differences among age groups in temporo-spatial duration measures for both liquid
and barium-paste-coated cookie swallows.

, Chi-square analysis revealed a significant difference between the youngest
and oldest group in oral bolus position for liquids before initiation of the swallow, but
not for solid swallows. Significant differences were found between the youngest
group and the two older groups in stage transition pattern for both liquids and solids.
Subjects in the younger group were more likely to demonstrate a continuous pattern
of bolus flow between the oral and pharyngeal stages of swallowing. Subjects in the
two older groups were more likelyto demonstrate an interrupted pattern of bolus flow
between stages. Both intrajudge and interjudge reliability exceeded 90%.

it appears that the swallow is a relatively stable and highly synchronous
process in adult men between ages 50 and 75; a continuum of decline in
or0pharyngeal swallow function does not appear to be the standard in the group of

healthy, nondysphagic adult men sampled in this study.

Copyright by
DEBRA CATHERINE LaPRAD GLEESON
1996

ACKNOWLEDGMENTS

This study was approved by the University Committee on Research Involving
Human Subjects (UCRIHS #93-354) at Michigan State University, and the
Subcommittee on Human Studies of the Department of Veterans Affairs Medical
Center in Battle Creek, Michigan.

Support for this study was granted by the Department of Veterans Affairs
Medical Center in Battle Creek, Michigan. lwish to thank the professionals at the
Veterans Administration Medical Center for their administrative and financial support:
Amy Grayson, Ph. D., former Chief, Audiology and Speech Pathology Service, for her
acceptance of my proposal, use of office space and videorecording equipment, and
access to the patient database; 8. Shah, MD, Chief, Radiology Service, for the use
of the videofluoroscopy suite and videofluoroscopy equipment; Rebecca Busby,
Ph.D., Chief, Psychology Service, for the Research and Development Committee’s
approval; David Hallegua, MD, for his support in subject selection; and Mary
Wretzke, M.A., speech-language pathologist, whose dedication and commitment
toward my research never faltered.

Last, I am forever thankful for my parents, husband, and daughter. My love

and gratitude will always remain.

TABLE OF CONTENTS

LIST OF TABLES ............................................... viii
LIST OF FIGURES ............................................... ix
Chapter
I. INTRODUCTION ...................................... 1
Normal Swallowing .................................... 1
Measurement of Swallowing ............................. 2
Swallowing Disorders in the Aging Population ............... 3
Purpose of the Study ................................... 8
ll. REVIEW OF THE LITERATURE ......................... 11
Normal Swallowing ....... . ............................ 11
Oral Preparatory Stage .............................. 12
Oral Stage ........................................ 12
Pharyngeal Stage ................................... 14
ESOphageal Stage .................................. 17
Neural Control Mechanisms ........................... 18
Age-Related Changes ................................. 21
General Characteristics .............................. 21
Oropharyngeal Swallowing Characteristics ............... 25
Esophageal Stage Characteristics ...................... 34
Rationale for the Study ................................ 35
Ill. METHOD ........................................... 36
Participants ......................................... 36
Consent for Participation ............................... 37
Health History Questionnaire ........................... 38
Dysphagia Screening ................................. 39
Phases of Development .............................. 39
Dysphagia Screening Instrument ....................... 40
Equipment and Materials .............................. 41
Videofluoroscopic Swallow Study ........................ 42
Videofluoroscopic Analysis ............................. 44
Swallowing Duration Measures ........................ 44
Morpho-physiologiml Measures ....................... 45

vi

Training Procedure .................................. 46

Reliability ........................................... 47

Intrajudge Reliability ................................. 47

lnterjudge Reliability ................................. 48

Statistical Analysis .................................... 48

IV. RESULTS .......................................... 50

Oropharyngeal Swallowing Measures ..................... 51

Liquid Barium Swallows .............................. 51

Solid Barium Swallows ............................... 57

Intrajudge Reliability .................................. 66

lnterjudge Reliability .................................. 67

Qualitative Observations ............................... 67

V. DISCUSSION ....................................... 71

Summary of Results .................................. 71

Oropharyngeal Swallowing Measures ................... 72

Qualitative Observations ............................. 77

Clinical and Research Implications ....................... 79

Potential Limitations in Aging and Swallowing Research ..... 79

Swallowing Measures ............................... 83

Subject Selection ................................... 84

Identification and Assessment ......................... 85

Clinical Management ................................ 85

APPENDICES

A. VA Research Consent Form 10-1086 ..................... 88

8. Health History Questionnaire ........................... 92
C. Structural and Physiologic Dysphagia Screening

Components ................ w ........................ 95

D. Dysphagia Screening Instrument ........................ 96

E. Videofluoroscopy Procedure ............................ 97

LIST OF REFERENCES .......................................... 99

vii

LIST OF TABLES

Central Tendency and Variability Data for 5 cc Liquid
Barium Oropharyngeal Swallowing Durations in Adults of
Different Ages ............................................ 51

Analysis of Variance for 5 cc Liquid Barium Swallowing
Duration Measures in Adults of Different Ages ................... 54

Oral Bolus Position for 5 cc Liquid Barium Swallows in
Adults of Different Ages ..................................... 54

Stage Transition Pattern for 5 cc Liquid Barium Swallows
in Adults of Different Ages ................................... 56

Central Tendency and Variability Data for Oropharyngeal
Swallowing Durations of Barium-Paste-Coated Cookie Swallows
in Adults of Different Ages ................................... 59

Analysis of Variance for Barium-Paste-Coated Cookie
Swallowing Duration Measures in Adults of Different Ages .......... 61

Oral Bolus Position for Barium-Paste-Coated Cookie Swallows
in Adults of Different Ages ................................... 62

Stage Transition Pattern for Barium-Paste-Coated Cookie
Swallows in Adults of Different Ages ........................... 64

Frequency of Qualitative Oropharyngeal Swallowing Events
Observed During Liquid and Solid Swallows in Adults of
Different Ages ............................................ 68

viii

LIST OF FIGURES

Mean Oropharyngeal Swallowing Durations for 5 cc Liquid
Barium Swallows for Three Age Groups ........................ 53

Oral Bolus Position at Onset of 5 cc Liquid Barium Swallows
for Three Age Groups ...................................... 55

Stage Transition Pattern for 5 cc Liquid Barium Swallows for
Three Age Groups ......................................... 58

Mean Oropharyngeal Swallowing Durations for Barium-Paste-
Coated Cookie Swallows for Three Age Groups .................. 60

Oral Bolus Position at Onset of Barium-Paste-Coated Cookie
Swallows for Three Age Groups .............................. 63

Stage Transition Pattern for Barium-Paste-Coated Cookie
Swallows for Three Age Groups .............................. 65

Frequency of Qualitative Oropharyngeal Swallowing Observa-
tions for 5 cc Liquid Barium Swallows for Three Age Groups ........ 69

Frequency of Qualitative Oropharyngeal Swallowing Observa-
tions for Barium-Paste-Coated Cookie Swallows for Three
Age Groups .............................................. 7O

CHAPTER I

INTRODUCTION

Normalflaflsming

In normal swallowing, oral intake of liquids and solids--necessary to sustain
human life—is accomplished through a precisely timed, highly coordinated
physiologic process that enables liquids and solids to pass without incident from the
oral cavity to the stomach (Dodds, 1989; Miller, 1986). Researchers have studied
normal swallowing events in adults in order to better understand the intricate
neuromuscular control that allows for successful and uneventful swallowing
physiology (Logemann, 1988).

Quantitative measurement of normal oropharyngeal swallowing events allows
for detailed knowledge of anatomical, neuroanatomical, and physiological events.
A variety of swallowing events have been studied: bolus clearance (Cook et al.,
1994), effects of bolus temperature (Bisch, Logemann, Rademaker, Kahrilas, &
Lazarus, 1994; Ren et al., 1993), impact of bolus volume on swallowing (Bisch et al.,
1994; Lazarus et al., 1993; Ren et al., 1993; Tracy et al., 1989),
pharyngoesophageal pressure (Fqu et al., 1990; Wilson, Pryde, Macintyre, Maran,
& Heading, 1990), sequences of movement in the oropharyngeal swallow

(Hrycyshyn & Basmajian, 1972; Shawker et al., 1983; Stone & Shawker, 1986),

1

2
swallow safety (Langmore et al., 1988; Langmore, Schatz, & Olson, 1991),
oropharyngeal swallowing efficiency (Rademaker, Pauloski, Logemann, &
Shanahan, 1994), oropharyngeal residue (Hamlet et al., 1996), and timing and
duration of oropharyngeal swallowing events (Borgstrom & Ekberg, 1988; Cook et
al., 1989; Curtis, Cruess, Dachman, 8. M330, 1984; Shawker, Sonies, Hall, & Baum,

1984; Sonies, Parent, Morrish, & Baum, 1988).

WEEDS}

The normal swallow process has been studied by means of ultrasonography
(Shawker, Sonies, & Stone, 1984; Shawker, Sonies, Stone, 8. Baum, 1983),
manometry (Fulp, Dalton, Castell, & Castell, 1990; Mendelsohn & McConneI, 1987),
electromyography (Basmajian & Dutta, 1961; Doty & Bosma, 1956; Elidan,
Chochina, Gonen, & Gay, 1990), scintigraphy (Cook et al., 1994; Hamlet etal., 1996;
Muz, Mathog, Miller, Rosen, & Borrero, 1987; Silver, VanNostrand, Kuhlemeier, &
Siebens, 1991 ), and endoscopy (Bastian, 1991; Langmore, Schatz, & Olson, 1988).
Manometry has been combined with electromyography, fluoroscopy, endoscopy,
and other imaging techniques to quantify temporal relationships among
oropharyngeal swallowing (Dejaeger, Pelemans, Bibau, & Ponette, 1994; Shaker,
Dodds, Dantas, Hogan, & Arndorfer, 1990).

Videofluoroscopy is a widely used research, diagnostic, and clinical tool for
quantifying normal and disordered swallowing (Dodds, Logemann, & Stewart, 1990;
Dodds, Stewart, & Logemann, 1990; Donner, 1986; Ekberg & Feinberg, 1991 ; Elliott,

1988; Logemann, 1993). This radiographic assessment tool defines structural and

3
physiological components of the oral, pharyngeal, and esophageal stages of
swallOwing; evaluates timing and movement patterns; and identifies type and nature
of swallowing difficulty. Videofluoroscopy allows for assessment of the critical
physiologic elements of the oropharyngeal swallow (Langmore & Logemann, 1991):
(a) duration of bolus transit, (b) nature and pattern of tongue movement during oral
transit, (0) range of tongue base retraction, (d) timing and onset of the pharyngeal
swallow response, (9) range of pharyngeal wall contraction, (f) timing and duration
of laryngeal closure, (9) range of laryngeal excursion, and (h) duration of upper

es0phageal sphincter (UES) opening.

In addition to normal swallowing, researchers have focused on understanding
the nature of dysphagia—a difficulty or discomfort in swallowing—which occurs when
the process of deglutition is disrupted at any stage (Miller, 1986). Dysphagia is a
symptom of one or more underlying pathologies, not a disease in and of itself
(Kuhlemeier, 1994).

Dysphagia is a common but often unrecognized symptom of a variety of
neurologic, pathologic, and non pathologic conditions which may be acute or chronic
(Sonies, 1987). Oropharyngeal dysphagia has been associated with various
degenerative disorders, metabolic diseases, infectious diseases, toxic diseases,
cranial nerve neuropathies, autoimmune disorders. and dementing diseases. Two

of the three most common medical diagnoses for hospitalized patients with

4
dysphagia (Kuhlemeier, 1994) were diseases of the circulatory system (primarily
stroke) and respiratory system (primarily pneumonia).

Dysphagia is frequently associated with older people and the process of aging
(Ekberg 8 Feinberg, 1991; Feinberg 8 Ekberg, 1991; Sheth 8 Diner, 1988; Ward et
al., 1989). Swallowing difficulty often affects older people as a direct result of
disease states that occur with increased frequency in the older population (Baum 8
Bodner, 1983).

Dysphagia has been well documented in cerebral vascular accident (Homer
8 Massey, 1988; Johnson, McKenzie, Rosenquist, Lieberman, 8 Sievers, 1992;
Meadows, 1973; Robbins 8 Levine, 1988; Veis 8 Logemann, 1985), traumatic brain
injury (Lazarus 8 Logemann, 1987), and Parkinson’s disease (Logemann, Blonsky,
8 Boshes, 1975; Robbins, Logemann, 8 Kirchner, 1988; Stroudley 8 Walsh, 1991).
Head and neck cancer is a frequent cause of swallowing difficulty among older
individuals (Fleming, Weaver, 8 Brown, 1977; Logemann, 1985; Logemann 8 Bytell,
1979; McConnel, Mendelsohn, 8 Logemann, 1986). Feinberg and Ekberg (1991)
examined 50 old adults-ranging in age from 79 to 94 years—who were referred for
videofluoroscopic swallowing assessment. Etiology of dysphagia was attributed to
dementia (42%), stroke (30%), deconditioning (12%), and Parkinson's disease
(10%).

According to Sheth and Diner (1988), hypertrophic spurs, osteophytes,
rheumatoid arthritis, myasthenia gravis, polymyositis, oculopharyngeal muscular

dystrophy, hyperthyroidism, and cricopharyneal indentation all have a negative

5
impact on the integrity and synchrony of the swallow process in the older patient.
Structural and motility disorders commonly associated with esophageal dysphagia
in older individuals include neoplasm, peptic stricture, diverticula, vascular
compression, achalasia, diffuse esophageal spasm, and scleroderma (Ergun 8
Miskovitz, 1992).

In a study by Bloem et al. (1990), 16% of a group living at home (aged 87
years or more) reported dysphagia symptoms. The prevalence of swallowing
complaints in 476 adults from the general population aged 50 to 79 years was
investigated by Lindgren and Janzon (1991). The most frequent complaints were
gastroesophageal reflux and globus sensation (20%). Other reported complaints
were bolus obstruction (3%) and frequent choking during meals (5%).

Tibbling and Gustafsson (1991) examined the presence of dysphagia in a
random sample of 796 adults from the ages of 60 to 99. Dysphagia was regarded
as present if the subject reported a ”feeling of sticking” in the throat (hypo-
pharyngeal) or in the chest (esophageal) when eating. Symptoms of dysphagia
were reported by 62 subjects (8%). Hypopharyngeal dysphagia alone (1 %) was less
frequent than combined hypopharyngeal and esophageal dysphagia (3%). Those
with symptoms of hypopharyngeal dysphagia all reported a feeling of anxiety at
mealtime, and all preferred not to eat alone.

The institutionalized adult is at increased risk for development of oral feeding
and swallowing problems. Those institutionalized are at increased risk for

malnutrition, dehydration, and infection because of problems associated with

6

chewing and swallowing. It is not surprising that dysphagia has been found to be
prevalent in 59% of nursing home residents (T rupe, Siebens, 8 Siebens, 1984).

A study of 740 residents in two nursing facilities, mean age 72.9 years,
revealed that 31% were on mechanically altered diets (Groher 8 McKaig, 1995).
The most frequent diagnoses included dementia (53%), stroke not producing
dementia (26%), and progressive neurological disease (8%). Of those on
mechanically altered diets, 87% were at the level of either pureed or tube feeding;
choking was the primary reason for the diet modification.

A study focusing on identification of clinical indicators for unintentional weight
loss and pressure ulcers (Gilmore, Robinson, Posthauer, 8 Raymond, 1995)
examined 290 older residents living in nursing homes. The authors found that
chewing problems accounted for more than half of the clinical indicators. Swallowing
problems were indicated in 30% of those residents with a combination of
unintentional weight loss and intake less than 50%. In addition, swallowing
problems occurred with 47% frequency in residents with unintentional weight loss
and pressure ulcers.

In the Feinberg and Ekberg (1991) study of 50 old adults referred for
videofluoroscopy, 46% of the subjects were diagnosed with oral stage dysfunction,
34% with combined oral-pharyngeal dysfunction, and 20% with pharyngeal stage

dysfunction. In all subjects, oral stage dysfunction was the most common cause of

bolus misdirection.

7

Objective measures of normal swallowing have recently been applied to the
study of the effects of aging on normal swallowing physiology (Cook et al., 1994;
Ren et al., 1993; Robbins, Hamilton, Lof, 8 Kempster, 1992; Sonies, Parent,
Morrish, 8 Baum, 1988). According to Robbins et al., the speed of swallowing
begins a gradual slowing after age 45. The authors concluded that at 70 years of
age, the swallow process is significantly slower in time than in individuals under 45
years of age.

It has been suggested that older adults demonstrate an increase in multiple
lingual gestures to complete an oral swallow (Sonies et al., 1988), a different lingual
pattern in swallow initiation (Dodds et al., 1989), oral sensorimotor incoordination
(Ekberg 8 Feinberg, 1991), and altered tongue posture and masticatory function
(Baum 8 Bodner, 1983). Findings in studies focusing on age effects have reported
longer oral transit durations in older people (Cook et al., 1994; Shaw et al., 1990),
increased delay in onset of the pharyngeal swallow (Robbins et al., 1992; Tracy et
al., 1989), increased pharyngeal transit durations for liquids (Cook et al., 1994),
increased delay in upper es0phageal relaxation (Fulp et al., 1990; Robbins et al.,
1992; Shaw et al., 1990; Tracy et al., 1989), increased total swallowing time
(Robbins et al., 1992; Sonies et al., 1988; Tracy et al., 1989), and increased

pharyngeal post-swallow residuals and pharyngeal clearance time (Cook et al.,

1994).

8
WM!

It is still not clear how aging affects swallowing in any or all of the three
primary systems: afferent system responsible for sensory input, central control
system located in the brainstem swallowing centers, or efferent system responsible
for motor activation. The question of whether older adults develop compensatory
swallowing strategies as a result of normal degeneration of neural and muscular
tissue has yet to be answered.

Normal swallowing is essential to the maintenance of healthy states and
management of disease in the older population. The normal swallow process in
older adults is still relatively poorly understood. Incomplete knowledge of its
physiological mechanisms raises problems of definition further complicated by the
aging process. Because there are few specific studies of swallowing across the
adult life span, researchers remain unclear in their ability to distinguish pathologic
from nonpathologic age-related changes in the swallow process.

The aging characteristics of deglutition must be quantified to determine the
extent to which gradual morphological and physiological changes in the
aerodigestive tract associated with older individuals can predict pathological from
nonpathological deviations in oropharyngeal swallowing. Further studies are needed
to determine whether aging alters the synchrony, symmetry, and integrity of the
oropharyngeal swallowing process.

Researchers have begun to investigate the structure and function of both the

oral and pharyngeal stages of the aging swallowing mechanism with increased

9

detail. However, there remains both scientific and clinical need for additional
investigations based on the observations that (a) minimal research has focused on
oropharyngeal swallowing of solids, (b) discrepancies exist among researchers in
reports of age effects in bolus duration measures, (c) no studies have examined the
pattern of stage transition between the oral and pharyngeal stages of swallowing in
detail, (d) a continuum of decline in oropharyngeal swallowing after age 50 has not
been reported, and (e) it is not clear whether the swallowing patterns observed after
age 50 represent a natural compensatory mechanism of the aging swallow
mechanism.

To further understand the normal swallow process across the adult life span,
this cross-sectional descriptive research was designed to identify and quantify the
presence or absence of systematic differences in oropharyngeal swallowing
physiology among competent, nondysphagic old adults using videofluoroscopy.
Specifically, this investigation attempted to examine the continuum of decline
reported by Robbins et al. (1992) to determine whether significant differences in age-
related swallow function exist in the population of adults over age 50. The following

questions were posed:

1. Is there a significant age effect in oral transit duration during the
swallow?
2. lsthere a significant age effect in pharyngeal transit duration during the

swallow?

1O

3. Is there a significant age effect in total oropharyngeal swallowing
duration?

4. Is there a significant age effect in stage transition duration during the
swallow?

5. Is there a significant age effect in hyo-Iaryngeal response duration

during the swallow?

6. Is there a significant age effect in oral bolus position prior to initiation

of the swallow?

7. Is there a significant age effect in the stage transition pattern during the

swallow?

CHAPTER II

REVIEW OF THE LITERATURE

NermaLSwallmuing

Traditionally, the act of swallowing, or deglutition, is described as a highly
coordinated process involving four stages: oral preparatory stage, oral stage,
pharyngeal stage, and esophageal stage. Although the stages allow for a more
organized study of the swallow process, normal swallowing is considered a rapid,
dynamic process involving a functionally integrated system (Robbins et al., 1992).
Swallowing as a physiological phenomenon is a coordinated sequence of intricate
motor and sensory events that may be initiated as a conscious volitional act.
However, the majority of swallows occur subconsciously without cerebral
involvement.

In adults, saliva production occurs at a rate of approximately 0.5 mllmin,
resulting in a swallow rate of one swallow/min in alert states (Dodds, Stewart, 8
Logemann, 1990). Swallowing and salivation nearly cease during sleep states
(Lichter 8 Muir, 1975). In the normal adult, this equates to approximately 1,000

swallows per day, the majority of which occur involuntarily in response to salivation.

11

12
We

During the oral preparatory stage, the bolus is mixed with saliva, shaped, and
positioned on the tongue in a cohesive bolus in preparation for the swallow. It
involves voluntary control in the coordination of lip closure, jaw motion, buccal tone,
and tongue motion (Logemann, 1988) to collect the bolus.

Chewing involves rotary, lateral motion of the tongue and mandible
(Logemann, 1993), motions critical for mixing the bolus with saliva and placing it on
the teeth. The oral preparatory and oral stages of swallowing are linked closely
together and are, therefore, often difficult to distinguish. Peripheral and central

recognition of food in the mouth and motor programming are essential components

in initiating the oral swallow.

QLaLSIaQe

In the oral stage of swallowing, the primary action involves propulsion of the
bolus from the oral cavity into the oropharynx. Bolus preparation and bolus
movement are under voluntary control, yet they are often performed without
conscious effort.

The oral stage of swallowing is initiated by the onset of a leading complex of
four closely related events (Cook et al., 1989): (a) the onset of tongue tip
movement; (b) tongue base movement, (c) vertical hyoid movement, and (d)
submental electromyographic activity. Two’distinct types of oral stage tongue tip
movement initiate the normal liquid swallow (Cook et al., 1989; Dodds et al., 1989).

The tipper-type swallow begins with the bolus located on the superior surface of the

13
tongue with the tongue tip pressed against the upper incisors and alveolar ridge. In
the dipper-type swallow, the bolus is positioned in front of or inferior to the tongue
tip, which is then scooped to a supralingual location. Although type of oral stage
tongue-tip movement differs among and within subjects, Dodds et al. concluded that
the tipper-type swallow pattern is dominant for all age groups.

Forward and upward phases of tongue blade movement are initially prevalent
in the oral stage of the normal swallow (Stone 8 Shawker, 1986) and are highly
synchronous with movement of the hyoid bone, which serves as a supporting
structure for the larynx and platform for the tongue. The tongue tip moves forward
with the tip and sides making contact with the alveolar ridge, followed by anterior to
posterior tongue elevation. Subsequently, the tongue applies pressure to the bolus
tail and pushes the bolus posteriorly into the oropharynx in a groove on the lingual
dorsum.

Descent of the soft palate and elevation of the tongue dorsum form a
Iinguavelar valve that prevents the bolus from entering the pharynx prematurely. As
the tongue propels the bolus posteriorly into the oropharynx, the soft palate then
elevates, meeting the upper part of the posterior pharyngeal wall and closing off the
nasopharynx.

The mean duration of tongue movement required to swallow a 5 cc water
bolus from initiation to termination was reported as 1.54 s (Shawker et al., 1983).
Oral transit duration, also referred to as oral transit time, is always under 1.5 s in

normal swallowing and is usually less than 1.0 s (Logemann, 1993). Oral transit

14
duration (OTD) is defined as the time it takes the bolus head to begin posterior
movement on the tongue, until the bolus head reaches thejuxtaposition ofthe ramus

of the mandible and the base of the tongue on videofluoroscopy.

EhanmgeaLSjage

The oral and pharyngeal stages of swallowing are closely coupled in the
normal swallow. The pharyngeal stage is the third stage in the swallow sequence,
involving a series ofinvoluntary, highly coordinated neuromuscular events that occur
to draw the pharyngeal wall upward over the bolus and propel the bolus through the
hypopharynx for entry into the esophagus.

According to Robbins (1988), the pharyngeal stage is typically initiated as the
bolus head reaches the ramus of the mandible at the junction of the tongue base,
as observed on videofluoroscopy. Robbins further stated that the pharyngeal stage
is governed in its entirety by velopharyngeal, laryngeal, and cricopharyngeal valving
action. First, the velopharyngeal valve functions to prevent entrance of material into
the nasal cavity. Second, the actions of the laryngeal valve responsible for
protection of the airway during the normal swallow include sphincteric closure of the
aryepiglottic folds, false vocal folds, and true vocal folds. Third, the cricopharyngeal
valve remains in a state of tonic contraction and relaxes to allow bolus transport into
the esophagus.

The principal neuromuscular events in the pharyngeal swallow involve
velopharyngeal closure, glottic closure, superior/anterior movement ofthe hyoid and

larynx, epiglottic descent, tongue base retraction, pharyngeal contraction, and upper

15
esophageal sphincter (UES) relaxation (Logemann, 1993). Glottic closure appears
to be the initial event in the swallow sequence, and coordination of laryngeal kinetics
with bolus transport prevents laryngeal penetration from occurring.

Swallow-induced vocal cord adduction, essential to the normal swallow
process, precedes the onset of hyo-laryngeal elevation and pharyngeal peristaltic
action (Shaker et al., 1990). Adduction of the vocal cords occurs first. In the
majority of subjects studied, vocal cord adduction occurred 0.22 s before initiation
of laryngeal elevation. Following vocal fold closure, horizontal then vertical
approximation of the arytenoids occurs. Anterior tilting and contact of the arytenoid
cartilages to the base of the epiglottis is a significant feature in airway closure
(Logemann, 1993).

The next principal event in the pharyngeal swallow involves hyoid
displacement and laryngeal ascent. In a study involving a single subject swallowing
a 5 ml liquid bolus (Logemann, Kahrilas, Begelman, Dodds, 8 Pauloski, 1989),
superior hyoid displacement was approximately 9 mm and anterior displacement
was 11 mm. This was similar to the results reported by Jacob, Kahrilas, Logemann,
Shah, and Ha (1989). In their study of eight subjects swallowing 1 ml liquid boluses,
mean superior hyoid excursion was 8 mm and mean anterior excursion was 11 mm.
The entire hyo-laryngeal complex elevated approximately 2 cm in normal subjects
(Jacob et al., 1989; Kahrilas, Logemann, Krugler, 8 Flanagan, 1991).

Following bye-laryngeal displacement, inferior movement of the epiglottis to

horizontal position overthe laryngeal aditus is a principal element in airway closure.

16

This movement is closely correlated with hyoid elevation (Ekberg 8 Sigurjonsson,
1982). The duration of laryngeal vestibule closure is approximately 0.6 to 0.7 s in
normal swallowing.

As the bolus head enters the hypopharynx and the tail approaches the base
of the tongue, the contracted lateral and pharyngeal walls meet the base of the
tongue, which moves about two-thirds of the distance posteriorly (Kahrilas,
Logemann, Lin, 8 Ergun, 1992). This action creates the major pressure-generating
force required to transport the bolus through the hypopharynx (Logemann, 1993).
Caudal-to-rostral contraction of the pharyngeal constrictors produces a downward
”stripping wave" action of the posterior pharyngeal wall to propel the bolus into the
esophagus. The intricate actions involved in pharyngeal transit duration (PTD), also
referred to as pharyngeal transit time, normally take place in 0.3 to 1.0 s (Logemann,
1990). Speed of the peristaltic wave in the pharyngeal constrictors is approximately
10.8 cmls (Baum 8 Bodner, 1983; Borgstrom 8 Ekberg, 1988).

As the bolus reaches the contracted pharyngoesophageal segment (PE
segment), bolus force contributes to upper esophageal sphincter (UES) opening.
Dodds et al. (1990) proposed four essential elements to normal UES opening: (a)
relaxation of the contracted UES (0.5 s), (b) low compliance of the relaxed UES, (c)
hyoid traction and anterior cricoid cartilage movement on the relaxed UES, and (d)
distention of the relaxed UES due to radial pressure forces of the bolus. In normal

swallowing, arytenoid contact to base of epiglottis generally occurs within 3.0.06 3 of

17
UES opening, with no bolus hesitation in the pyriform sinus prior to opening
(Logemann et al., 1992).

Establishment of a pressure gradient for bolus passage contributes to the
completion of the pharyngeal stage (McConnel, Cerenko, 8 Mendelsohn, 1988).
Propulsive pressure is generated by the tongue and pharyngeal walls in the
oropharynx. Negative pressure generated by the pharyngoesophageal (PE)
segment in the hypopharynx establishes the bolus gradient. The pharyngeal stage
is completed when the bolus tail flows through the PE segment into the esophagus.

The timing of events in the swallow sequence is directly related to the volume
and viscosity of the bolus swallowed. Timing of hyoid movement, laryngeal
elevation, upper esophageal sphincter (UES) relaxation, and transsphincteric flow
have been reported to be volume dependent (Cook et al., 1989). Increases in bolus
volume cause events in the swallow sequence to occur earlier in time. Larger
boluses enter the pharynx and arrive at the UES earlier than smaller boluses.
Dantas, Dodds, Massey, and Kern (1989) reported significant differences in timing
and magnitude of swallowing events which were due to variations in density and
viscosity of the barium preparation swallowed. High-density barium resulted in
significantly longer oral and pharyngeal transit durations, delayed UES opening, and

greater duration of UES opening.

Escubagealfitage
During the final esophageal stage, the bolus is propelled the length of the

esophagus into the stomach. The esophageal stage of the swallow involves active

18

peristalsis under involuntary neural control (Logemann, 1988). The esophageal
stage involves (a) relaxation of the upper esophageal sphincter (U ES) allowing for
passage of the bolus into the esophagus, (b) descent of the hyoid bone and larynx
to the resting position, (0) cessation of contraction of the posterior pharyngeal wall,
(d) opening of the nasopharyngeal passage, and (e) relaxation of the lower
esophageal sphincter at the base of the esophagus to allow passage of food into the
stomach.

Esophageal transit duration (ETD) is defined as the time it takes the bolus
head to travel from the entrance of the upper esophageal sphincter until the tail
passes through the lower esophageal sphincter. ETD has been reported to range

from 3 to 9 s (Janssens, cited in Miller, 1986) and 8 to 20 s (Mandelstam 8 Lieber,

1970) in adults.

NeuLaILQmLQLMecbanisms

Two major theories exist that describe the neural control mechanism of the
oropharyngeal swallow: reflex chain and central pattern generator hypotheses
(Miller, 1982). In the first, a bolus stimulates sensory receptor fields in the
oropharynx, an action that sequentially triggers the next step in the swallowing
sequence. Swallowing therefore proceeds as a reflex chain, with each step
stimulating the next.

In the second hypothesis, Doty (1968) proposed that the central swallowing
pathway consisted of a group of interneurons within the central nervous system that

controlled a complex motor response, a “central pattern generator.“ Once the

19

pattern generator was triggered, it would activate motor neurons in a systematic
order, with each swallow being a programmed sequence of events governed by the
medullary region of the brainstem, independent of sensory feedback.

The primary sensory stimuli for swallowing originate from sensory receptor
fields in the oral and pharyngeal cavity. However, the precise nature of the stimuli
responsible for eliciting the pharyngeal swallow remains in question. Miller and
Sherrington (1916) first recognized that electrical stimulation of regions of the central
nervous system including selected areas of the cortex and portions of the brainstem
elicited a pharyngeal swallow. Pommerenke (1982) identified the anterior faucial
arches as the most sensitive site for eliciting the swallow reflex, followed in
sensitivity by the posterior pharynx and pillars. However, Pommerenke concluded
that no single area was solely responsible for elicitation of the swallowing reflex.

Doty (1951) stimulated selected patterns of peripheral nerve input with
electrical pulses and found that the central swallowing pathway was triggered by
these patterns. Doty and Bosma (1956) showed that swallowing was a sequenced
pattern of muscle activation involving the tongue, floor of the mouth, pharyngeal
constrictors, suprahyoid and infrahyoid muscles, and upper esophageal constrictor.
They concluded that the motor response could be preserved in the presence of
impaired peripheral feedback.

In a later study, Miller (1982) reported that the faucial pillars, pro-epiglottic
sinus, glottis, and base of epiglottis were the sensory receptor regions most

successful in eliciting the pharyngeal swallow response. Linden, Tippett, Johnston,

20

Siebens, and French (1989) examined the bolus position at pharyngeal onset and
found that a significant proportion of the swallows were elicited after the bolus head
passed the faucial pillars. Their summations lent further support to Miller’s (1982)
conclusion that a broad zone in the pharynx is responsible for elicitation of the
pharyngeal swallow.

Two medullary regions exist for the central control of the swallow response
(Miller, 1993). The dorsal region consists of areas around the nucleus tractus
solitarius and reticular formation. The dorsal region receives the initial peripheral
sensory descending cortical inputs that effect the swallowing response. The ventral
region, which surrounds the nucleus ambiguus and reticular formation, functions to
organize the sequential activation of motor nuclei group and modify the motor output
during swallowing. Conceptually, the dorsal region contains "master neurons“ that
activate the swallowing process, and the ventral region contains "switching neurons"
that transmit the timed output to the proper motor neuron pools.

According to Dodds (1989), sensory fields activate the central paired
brainstem swallowing centers in the nucleus tractus solitarius and medullary reticular
formation in a coded manner. Each swallow center consists of an elaborate array
of interneurons that process sensory input, generate a preprogrammed stereotypical
swallowing response, and distribute signals to cranial nerve motor nuclei to activate
striated muscle peristaltic contraction in the pharyngeal and esophageal stages of

swallowing. The swallowing center ensures the accuracy of bilateral motor activity

21
and the proper sequencing of muscular action necessary for swallowing to occur
without incident.
In the older adult, swallowing probably depends on stimulation of sensory
receptors that in turn modulate the programmed swallowing sequence. Swallowing
likely reflects a relatively stable and unvarying sequence of motor activity in the

presence of a system that adjusts to widely varying factors (Kennedy 8 Kent, 1988).

W
G I CI I . l'

Aging--the result of complex changes occurring at molecular, cellular, and
organ levels-—results in a progressive decline in the body’s ability to respond to
homeostatic equilibrium disruptions (Chodzko-Zajko 8 Ringel, 1987), thereby
producing afunctional decline in human performance. The structural and behavioral
consequences ofaging appear relatively consistent across allphysiological systems.

Characteristics of aging include atrophy, dystrophy, and edema--precursors
to gross morphological changes such as decreased elasticity and demyelinization
(Chodzko-Zajko 8 Ringel, 1987). From an anatomical and physiological perspective,
aging organ systems are usually slower and exhibit decreased strength, stability,
coordination, and endurance.

One of the most reliable observations from research on aging is the general
slowing of behavior with increased age. As age increases, behavioral speed
decreases (Salthouse, 1985). Behavioral slowing of motor responses is

characterized by a decline in reaction time, the time necessary for transmission of

22

sensory information, decision making, and motor execution. According to Salthouse,
cognitive decline in the normal elderly is associated with decreased psychomotor
speed; slowing of central cognitive processes; and decline in somatosensory,
auditory, and visual sensory acuity.

Age-dependent alterations in oral morphology (Logemann, 1990) include
increased fatty and connective tissue changes in the tongue. The mucosa, bony
framework, and salivary glands show gradual but significant changes with age
(Heeneman 8 Brown, 1986), resulting in atrophy of the alveolar margin and
reduction in quality and quantity of saliva. Lingual activity plays a major role in
oropharyngeal swallowing, and isometric maximum tongue blade pressure has been
found to decline with age (Robbins, Levine, Wood, Roecker, 8 Luschei, 1995).

The most common age-related sensory changes affecting communication in
the elderly are perceptual deficits in hearing and vision. The chemical senses—taste,
smell, and trigeminal sensation-show age-related changes; however, the character
and degree of alteration appear unique to each system (Murphy, 1992). Marked
decline in older individuals has been reported in oral form discrimination (Ostreicher
8 Hawk, 1982) and taste (Moeller, 1989). According to Murphy (1992), flavor
preference shifts more in older individuals, who perceive greater concentrations of
sugar and salt as more pleasant. Taste sensitivity at threshold and suprathreshold
taste intensity perception both decline in aging. However, the magnitude of the
decline, the degree to which various taste qualities are affected, and the impact on

swallowing are not clearly understood.

23

In normal aging, general agreement exists that decline in the chemosensory
perception of smell (Doty et al., 1984; Moeller, 1987)-including degeneration of the
olfactory nerve and olfactory mucosa-is inevitable (Cain 8 Stevens, 1989).
According to Murphy (1992), olfactory loss demonstrates significant impairment with
age in studies assessing threshold sensitivity, suprathreshold intensity,
suprathreshold identification, and odor memory. Older individuals’ difficulty with
identification of blended foods is attributed more to olfactory loss than to taste loss.

No evidence has been found to support the common generalizations that
edentulous states (Chauncey, Feldman, 8 Wayler, 1983) and decreased saliva
production (Baum, 1981) affect swallowing in older individuals. Neither decreased
gustatory function (Moeller, 1987; Weiffenbach, 1984) nor decreased taste (Moeller,
1987) shows significant decrements negatively affecting swallowing ability with age.

Hollien (1987) summarized available physiologic and aerodynamic data
supporting the hypothesis that respiratory function declines significantly with
advancing age, thereby affecting the communication acts of the older individual.
Age-related changes in the respiratory system include a decrease in diaphragmatic
action, vital capacity, maximum breathing capacity (Wantz 8 Gay, 1981), and loss
of elasticity in the lungs (T urner, Mead, 8 Wohl, 1968). Although the impact of
respiratory alterations in speech and voice is not clear, the question of a correlation
between respiratory decline and alterations in the normal swallow process cannot

be overlooked.

24

The qualitative and quantitative characteristics of age-dependent alterations
in the laryngeal structures underlying the normal swallow process have not been
fully realized. As early as 1941, Bach, Lederer, and Dinolt documented age-related
degenerative and atrophic changes in the laryngeal muscles. -Kahane (1987)
summarized reports in the aging literature that substantiated specific structural and
physiological changes that occurred at the laryngeal level.

Michel et al. (1987) reported a lowering of the laryngeal position to the level
of cervical vertebrae six-seven. This lowering was due to age-related cervical spine
changes as well as increased dilation of the pharynx subsequent to decreased
muscle tonus. The hyaline cartilages of the larynx have been found to undergo
ossification with increasing age, occurring earlier and to a greater extent in males.
This ossification results in decreased flexibility and increased stiffness (Kahane,
1980). Kahn and Kahane (1986) reported age-related changes in the articular
surfaces of the cricoarytenoid joint, impacting on the smoothness of cartilage
movement and vocal fold approximation.

The senescent voice undoubtedly relates to the manner and extent of
structural and physiological changes in the tissues of the larynx (Kahane, 1987).
Identifying characteristics of the nonpathologic aging voice may, in turn, aid in the
identification of specific characteristics of the nonpathologic aging swallow process.

Considerable research has focused on vocal fold changes associated with
aging. In the layers of the lamina propria, decreased density of collagenous and

elastic fibers, thinning of elastic tissues, and thickening of collagenous fibers have

25
been reported (Hirano, Kurita, 8 Nakashima, 1983; Kahane, 1983). Atrophy of the
vocal folds and vocal edema (Honjo 8 lsshiki, 1980) has also been identified.

Age—related changes in connective tissues of the vocal folds may result in
irregularities in vocal fold vibration and changes in pitch level (Hollien 8 Shipp, 1972;
Mysak, 1959). Investigations into fundamental frequency identified a tendency
toward increased fundamental frequency in aging male voices (Hollien 8 Shipp,
1972; Mueller, Sweeney, 8 Baribeau, 1984; Mysak, 1959). Pitch changes in elderly
males have been attributed to fibrosis of the vocal ligament and muscle atrophy. A
slight decrease in fundamental frequency in aging female voices has been reported
(Heeneman 8 Brown, 1986; Mueller et al., 1984), and laryngeal edema consistently
has been associated with pitch changes among elderly females.

Perceptual characteristics of the aging voice included altered pitch,
breathiness, weakness, and hoarseness (Kent 8 Burkard, 1981 ). According to Ryan
and Burk (1974), vocal fry contributed to vocal tremor, increased breathiness, and
the perceptual characteristics of roughness in older voices. An age-related increase
in maximum phonation duration and generalized slowing in temporal factors of
speech production rate were also reported (Ryan, 1972; Ryan 8 Burk, 1974).

Evidence for vocal intensity changes was inconclusive.

Q l I E II . GI l . I'
In recent years, research efforts have been directed toward delineating
changes in the stages of the normal swallow process associated with advanced age

(Cook et al., 1994; Robbins et al., 1992; Sonies et al., 1988). It becomes apparent

26

that the problem of defining the parameters of normal aging constitutes a
fundamental difficulty in the measurement of the aging swallow process.
Identification of the qualitative characteristics of age-dependent swallowing decline
is made difficult by the obscurity of the normal swallow process and prevalence of
disease states impacting on the swallow process. As such, there remains to be an
accepted definition of exactly what features of the aging swallowing mechanism are
normal.

Several investigators have attempted to qualify their general observations of
normal swallowing behavior in older individuals. Baum and Bodner (1983) examined
aging and oral motor function in 257 healthy subjects (range 23 to 88 years) through
physical examination. Significant differences between the oldest group (> 80 years)
and the youngest group (< 39 years) were found, demonstrating a significant
progression in altered lip posture, tongue postural function, and masticatory muscle
function with increased age.

To delineate between dipper— and tipper-type swallow patterns, Dodds et al.
(1989) examined normal patterns of oral phase onset in 160 subjects with normal
pharyngoesophageal structure and function using videofluoroscopy. Forty-two
subjects (age > 60 years) performing three swallows of liquid barium (10 ml) were
compared to 118 younger subjects (mean age 47 years).

In the Dodds et al. (1989) study, the tipper—tipper pattern accounted for 72%
of the swallow patterns for all age groups combined. Chi-square analysis indicated

that the dipper-dipper swallow pattern occurred significantly more often in the older

27
group (31 %), a finding that may contribute to increased oral phase duration of up to
0.5 s as reported by Cook et al. (1989).

Using videofluoroscopy, Ekberg and Feinberg (1991) evaluated deglutition
in 56 asymptomatic older subjects ranging in age'from 72 to 93 years (M = 83
years). Thirty-one of the subjects had no history of neurologic disease. However,
the remaining subjects reported a positive history of dementia, stroke, or Parkinson’s
disease. The subjects performed a minimum of four swallows of liquid barium.
Bolus size was not controlled.

Results in the Ekberg and Feinberg (1991) study indicated the presence of
synchronous and symmetric swallowing function in only 16% of the subjects. Oral
stage dysfunction, specifically oral sensorimotor incoordination (32%) and
dissociation between the oral and pharyngeal stages (48%), was the most prevalent
finding in the neurologically impaired group. However, in the nonneurologically
impaired group, oral sensorimotor incoordination and dissociation occurred in only
3% and 26% of the group, respectively.

The effect of lingual pressure generation during isometrics and swallowing
was studied in healthy young and healthy old adults (Robbins et al., 1995), using the
Iowa Oral Performance Instrument. In the young group, maximum tongue blade
isometric pressures were greater than for the older group. Neither tongue dorsum
nor tongue tip isometric pressures were significantly greater in the young group.
There were no statistically significant differences between age groups for peak

lingual swallowing pressures. The authors concluded that although swallow

28

pressure did not decline with age, the difference between maximum isometric and
swalI0w pressure (pressure reserve) declined with age, suggesting that “as
individuals grow older they may be working harder to maintain the critical pressures
necessary for safe and effective bolus passage through the oropharynx“ (p. M261 ).

The major finding among the few studies of oropharyngeal swallowing in old
adults is that swallowing slows with age (Robbins et al., 1992; Shaw et al., 1990;
Sonies et al.,1988; Tracy et al., 1989). Shaw et al. (1990) reported the influence of
age on oral-pharyngeal bolus duration measures in normal swallowing in 14
nondysphagic subjects (age range 52-84 years) and 1 1 healthy young controls (age
range 18-24 years) using manofluoroscopy. The authors found a significant
increase in oral transit duration for the aged group (M = 0.67 s) for all volumes of
liquid barium when compared to the young group (M = 0.47 s). In contrast to
increased oral stage duration identified by Shaw et al., no differences in pharyngeal
transit duration were found between older subjects (M = 0.44 s) and younger
subjects (M = 0.37 s).

In a more recent study using manofluoroscopy, Robbins et al. (1992)
evaluated the effect of normal aging on pressure and temporospatial parameters of
oropharyngeal movement and bolus transit during swallowing in 80 normal
volunteers. The subjects were divided into four different age groups: mean age 24,
44, 65, and 72 years.

Nine duration measures of structure or bolus movement were obtained in the

Robbins et al. (1992) study. The authors reported significantly longer durations for

29
the oldest subject group (> 70 years) in stage transition, pharyngeal transit duration,
upper esophageal sphincter opening, and total swallowing duration. Longer
durations with increased age were primarily accounted for by delayed initiation of
maximal hyolaryngeal excursion. However, Robbins et al. failed to find an age effect
for oral transit duration.

Using ultrasonography, Sonies et al. (1988) examined the effects of normal
aging on the oropharyngeal phase of swallowing in 47 adults. The authors
examined initiation and termination of tongue/hyoid activity in defining the oral-
pharyngeal phase of swallowing. They examined three age groups: young-age
(range 18-34 years), middle-age (range 35-54 years), and old-age (range 55-74
years, n = 19). Subjects completed three single dry swallows, continuous dry
swallows for 10 s, and three 10-ml water swallows.

Sonies et al. (1988) found that total time of hyoid activity for dry and wet
swallows increased significantly with age. For the women, the total time for dry
swallows (3.41 s) and wet swallows (2.43 3) increased significantly with age. The
number of consecutive dry swallows completed in 10 s (M = 1.89) in the old-age
group was significantly less than that of the young-age group (M = 2.87). Duration
of hyoid movement from rest to maximum anterior displacement during wet swallows
was significantly longer for the old-age group (M = 1.24 s) than for the young-age
group (M = 0.59 s).

For males, Sonies et al. (1988) reported no significant difference in the

number of continuous dry swallows between the old-age group (M = 3.13) and the

30
young-age group (M = 3.14). The older males demonstrated significantly longertotal
swallowing durations for wet swallows (M = 2.47 s) than the young-age group (M =
1.39 s) and the middle-age group (M = 1.49 s).

In the Sonies et al. (1988) study, there was a significant increase in multiple
lingual gestures required to complete an oral swallow for both older men and older
women. Eighty percent of the old-age group required double ortriple hyoid gestures
to complete the swallow, in contrast to 0% of the middle-age subjects.

The impact of bolus volume on temporal measures of oropharyngeal
swallowing in 24 normal subjects using combined manometry and videofluoroscopy
was studied by Tracy et al. (1989). The study consisted of three groups of subjects:
Group 1 (< 30 years), Group 2 (30-59 years), and Group 3 (60-79 years). The oldest
group included six subjects. The subjects performed three liquid barium swallows
each in the following amounts: 1 ml, 5 ml, 10 ml, and 20 ml. Measures of oral transit
duration, pharyngeal swallow delay, pharyngeal swallow response, duration of
closure of laryngeal vestibule, pharyngeal peristaltic velocity, and pharyngeal
peristaltic amplitude were obtained.

In the Tracy et al. (1989) study, the authors found that pharyngeal swallow
delay—the interval between arrival of the bolus at the ramus and onset of purposeful
laryngeal elevationnwas significantly longer in the oldest group (M = 0.4 8). One
other measure was systematically affected by age. Pharyngeal swallow response—
the duration from onset of laryngeal elevation to upper esophageal sphincter

closureuwas significantly shorter in the oldest group (range 0.5-0.6 s). The authors

31

concluded that the physiological changes accompanying age include "a weakening
of the coupling between the oral and pharyngeal phases of swallowing" (p. 94).

Results of the Tracy et al. (1989) study revealed no significant differences
across bolus volumes or age groups in oral transit duration (OTD), mean duration
of laryngeal closure, mean velocity of pharyngeal peristaltic wave (12-14 cmls), or
mean amplitude of pharyngeal peristaltic wave (120—150 mmHg). Mean OTD for all
subjects over age 30 was < 0.3 s.

Lof and Robbins (1990) studied test-retest reliability in nine durational aspects
of normal oropharyngeal swallowing using videofluoroscopy in 16 subjects divided
into a middle-aged group (mean age 45 years) and an old-aged group (mean age
65 years). The subjects performed three swallows each of liquid barium (2 ml) and
semisolid barium (2 ml). A repeat study was performed at least three months later.

In the Lof and Robbins (1990) study, there were no effects found for age or
gender. The potential range of normal within-subject variability for swallow durations
was highly variable for some subjects and minimally variable for others. No
significant differences were found in test-retest durations of middle-aged and old-
aged subjects. For all subjects combined, mean oral transit duration was 0.50 s
(liquid) and 1.11 s (semisolid); mean pharyngeal transit duration was 0.51 8 (liquid)
and 0.66 s (semisolid). Stage transition duration averaged -0.22 s (liquid) and
-0.033 s (semisolid). Pharyngeal response duration averaged 1.14 3 (liquid) and

1.13 s (semisolid).

32

Levine, Robbins, and Maser (1992) examined nondysphagic neurologically
normal individuals aged 43 to 79 years through videofluoroscopy and cranial
magnetic resonance imaging (MRI) exams. Results found slower oral swallowing
durations and total swallowing durations as MRI score increased.

Using manofluorography, Dejaeger et al. (1994) examined oropharyngeal
swallowing of a 10 cc liquid bolus in 16 subjects aged 75 to 85 years. They
compared their performance with that of subjects aged 20 to 36 years. They
examined (a) pharyngeal driving forces, (b) bolus transit time, (c) bolus velocity, and
(d) amplitude of pharyngeal contraction. Results showed no significant differences
in bolus transit times, bolus velocities, or amplitude of pharyngeal contraction
between the two groups, although greater variability was evident in the older group.
Two of three pharyngeal driving forces were also not significant: tongue driving
force and oropharyngeal propulsion pump.

In the Dejaeger et al. (1994) study, qualitative differences between age
groups in residue post swallow were identified. Stasis in the valleculae and piriforrn
recesses was observed post swallow in 50% of the older group and in only 15% of
the younger group. Interestingly, significantly higher tongue driving forces and
pharyngeal contraction amplitudes were identified in the nonstasis group.

Further studies of pharyngeal and upper esophageal sphincter (UES)
dynamics revealed significantly lower mean resting UES pressures (Fulp et al.,
1990; Pelemans 8 Vantrappen, 1985; Wilson et al., 1990) and delayed UES

relaxation (Fulp et al., 1990; Shaw et al., 1990) in older subjects. These studies

33
suggested aging was associated with increased resistance to flow across the UES
because of decreased UES compliance.

Cineradiography was used to study the influence of age on speed of
peristalsis in the pharyngeal constrictor musculature (Borgstrom 8 Ekberg, 1988) in
70 subjects divided into three age groups: < 40 years, 50 to 60 years, and > 75
years. The old group (> 75 years) included 20 subjects with dysphagia in the
presence of a grossly normal pharyngeal swallow. The authors failed to find
significant age-related differences in speed of pharyngeal peristalsis and concluded
that speed of peristalsis was fairly constant in the grossly normal pharynx,
irrespective of dysphagia or aging. In the old group, speed of pharyngeal peristalsis
ranged from 7.7 to 21.3 cm/s (M = 10.2 cmls). Nondysphagic younger subjects
obtained a mean peristaltic speed of 10.8 cmls.

The findings of Borgstrom and Ekberg (1988) were further supported by both
Tracy et al. (1989) and Wilson et al. (1990), who failed to find an age effect for
pharyngeal peristalsis. Although there were no significant differences between age
groups in the Borgstrom and Ekberg (1988) study, intrasubject variation reportedly
increased with age. ~ More than 50% of the subjects had variations in speed > 1
cmls.

In a recent publication, scintigraphy was the technique used to examine the
effect of age on bolus transit, pharyngeal clearance, and regional residue (Cook et
al., 1994). Twenty-one healthy subjects with a mean age of 68 years (range 55-83

years) were compared with nine healthy subjects with a mean age of 28 years

34
(range 19—37 years). Of significance was the finding that oral and pharyngeal transit
durations were prolonged in the older subjects, in addition to prolonged pharyngeal
clearance and pharyngeal post-swallow residual counts.

The effect of age on the coordination of the glottis and upper esophageal
sphincter (UES) during swallowing was examined in 10 young-age (M = 23 years)
and 10 old-age (M = 73 years) healthy adults. Through combined videoendoscopy
and manometry, vocal cord adduction preceded the onset of UES relaxation for all
water volumes (5-20 ml), for both age groups. Furthermore, duration of deglutitive
vocal cord adduction (range 1.40 s to 3.47 3) did not differ significantly between
groups. The authors concluded that coordination between deglutitive glottal closure
and UES relaxation is preserved in the elderly, as well as the duration of deglutitive

vocal cord adduction.

E I I SI III I . I'

In a review of the eSOphageal stage of swallowing, Ergun and Miskovitz
(1992) reported only minor changes in the structure and function of the esophagus
associated with aging. Hollis and Castell (1974), as cited by the authors, found only
a decrease in peristaltic amplitude in subjects over 80.

Additional studies of esophageal transit concluded that esophageal function
deteriorates more significantly after age 70 (Mandelstam 8 Lieber, 1970).
Individuals over age 70 showed increased esophageal transit duration and slower
esophageal clearance. Ekberg and Feinberg (1991) found the presence of

esophageal abnormalities in 36% of the 56 subjects studied (M = 83 years).

35
BatiQnaIiLQLIhLStudx

Most of the information that exists about the older swallow has been extracted
from studies of dysphagic adults, increasing our understanding of the pathogenesis
of swallowing. The few studies that have attempted to quantify normal
oropharyngeal swallowing, particularly in the older population, have presented some
interesting and often conflicting results. Systematic, quantitative techniques must
be applied to samples of the normal population of older persons to delineate a
continuum of subclinical changes in oropharyngeal swallowing. Using
videofluoroscopy, the coordinated sequence of intricate motor and sensory events
in swallowing can be examined to determine the nature of differences in age-related
swallow function and the extent to which such differences exist.

The purpose of this study was to investigate age effects in oropharyngeal
swallowing among three groups of nondysphagic adult men over age 50.
Specifically, the study was designed to determine whether significant differences in
temporo-spatial and morpho-physiological oropharyngeal swallowing events occur
as a function of age and whether the differences reflect a continuum of change

associated with age.

CHAPTER III

METHOD

E I. . I

Participants in this study consisted of 30 competent, nondysphagic adult men
ranging in age from 50.4 years to 75.3 years, grouped into three age categories:
Group 1 included 10 men aged 50.4 to 54.7 years (M = 52.8, SD = 1.55); Group 2
consisted of 10 men ranging in age from 60.8 to 64.8 years (M = 62.9, SD = 1.52);
and Group 3 consisted of 10 men aged 70.2 to 75.3 years (M = 72.8, SD = 1.9).
Although postmenopausal and surgically sterile women were not excluded from
participation, no women met the criteria for inclusion.

Participants were recruited from competent inpatients and outpatients at the
Veterans Affairs (VA) Medical Center in Battle Creek, Michigan. Outpatients were
registered in the Audiology and Speech Pathology Service (126), and inpatients
were recruited from the Medical Rehabilitation Ward (82-2) and the Post Traumatic
Stress Disorder Ward (12). Incompetent subjects were excluded from this study.

Competence was determined and documented by the consenting physician on VA

Standard Form 513.

36

37

This study was approved by the University Committee on Research Involving
Human Subjects (UCRIHS #93-354) at Michigan State University and the
Subcommittee on Human Studies of the Department of Veterans Affairs Medical
Center in Battle Creek, Michigan. Participants were provided with a verbal and
written description of the research by the principal investigator and gave their
informed consent by signing the VA Research Consent Form #10-1086 (Appendix
A). The consent form apprised participants of the (a) purpose of the study; (b)
description of the study and procedures; (c) discomforts, potential reactions, and
risks associated with ingestion of barium sulfate and exposure to radiation from the
videofluoroscopy x-ray procedure; (d) benefits of participation; and (e) rights
associated with participation.

Physicians” consent was documented for all participants prior to participation
in the study on VA Standard Form 513. The physician verified and documented (a)
absence of allergy history that would interfere with ingestion of the barium sulfate,
(b) absence of medication use that could pose any risk associated with the
videofluoroscopy x-ray procedure, and (c) competency. For all subjects accepted
into the study, a progress note was written by the principal investigator on the
medical chart, stating (a) the VA Research Consent Form #10-1086 was discussed
with the subject, (b) the subject was mentally competent, and (c) the subject

understood and agreed to participate in the study.

38
II "III! E] I' .

All participants recruited for the study completed a Health History
Questionnaire (HHQ) administered by the principal investigator (Appendix 8).
Medical charts were reviewed, and physician contact was made when verification
of medical status was required. Specifically, the questionnaire obtained information
from the subject on 68 health conditions organized into five categories: medical,
surgical, speech, voice, and swallowing. Subjects with a reported or documented
history in any one of these 68 health conditions that were judged by the principal
investigator to interfere with the normal swallow process or with the videofluoroscopy
x-ray procedure were eliminated from the study.

Because of the risks associated with swallowing barium sulfate in the
presence of certain preexisting conditions, subjects were not allowed to participate
in this study if they had (a) a known obstruction of the colon; (b) suspected or
impending gastrointestinal perforation; (c) hypersensitivity to barium sulfate
products; (d) bronchial asthma; (e) history of multiple (greater than three) food or
drug allergies; (f) a history of allergies as evidenced by hayfever and eczema; or (9)
used medications that contained a topical anesthetic agent like those in
mouthwashes (e.g., Listerine), sore throat products (e.g., Cepacol, Vicks, Cepastat,
and Chloraseptic), cough medicines, or products for tooth or gum pain (e.g., Orajel,
Orabase, Anebesol) within one to two hours prior to participation in the

videofluoroscopy x-ray procedure.

39
D I . S .
Subjects receiving a passing score on the Health History Questionnaire were
administered the Dysphagia Screening Instrument (DSI) by the principal investigator.
The DSI was administered to rule out the presence of swallowing difficulty and

determine eligibility for further participation in the study.

EbasescLDevelcpmem

In the first phase of development, 10 certified speech-language pathologists
(SLPs) completed an open-item questionnaire designed to elicit specific components
included in a dysphagia screening. Five areas were probed: respiration, phonation,
resonation, articulation, and nonspeech. They were asked to generate a list of tasks
that they would perform during a swallowing screening. From this questionnaire, a
total of42 different structural and physiologic dysphagia screening components were
identified by the responding SLPs (see Table Ci, Appendix C).

A 42-item swallowing questionnaire was then developed from the responses
generated in the first phase. Twelve SLPs with dysphagia experience ranging from
1 to 19 years (M = 6.75 years) participated in the second phase of the DSI
development. The SLPs were required to rate each of the 42 items individually by
determining whether the key item would be an effective indicator of oropharyngeal
dysphagia in the elderly population.

The SLPs were asked to answer yes or no to the following question (no
operational definitions for the terms "abnormal,” “oropharyngeal dysphagia,” or

'elderiy" were provided):

40

If this parameter was abnormal, would it be an effective indicator of
oropharyngeal dysphagia in the elderly population?

Of the original 42 items, 15 target areas were identified to be effective
predictors of oropharyngeal dysphagia in the elderly population by receiving a
positive predictive score by at least 66% (n = 8) of the respondents. The 15 target
areas were (a) labial seal, (b) lingual sensation, (c) lingual elevation, (d) lingual
Iateralization, (e) lingual strength, (f) lingual symmetry, (9) posterior tongue
diadochokinetic rate, (h) voluntary cough, (i) reflexive cough, (j) involuntary swallow,
(k) voluntary dry swallow, (I) voluntary liquid swallow, (m) laryngeal elevation, (n)
vocal quality, and (o) saliva control.

In the final phase of development, 10 of the 12 original respondents further
rated each of the 15 target areas, using a five-point rating scale. They completed
a questionnaire that required a rating of how effective each parameter would be in
predicting oropharyngeal dysphagia in the elderly ifthat parameter was abnormal.
Scores ranged from a rating of 1 (extremely ineffective) to a rating of 5 (extremely
effective). Again, no operational definitions of abnormal, oropharyngeal, dysphagia,
or elderly were provided. Each of the 15 target areas received a rating score of
either 4 (effective) or 5 (extremely effective) in their predicting ability. No area was

judged to be an ineffective predictor by any of the respondents.

D I . S . I I I
The final format for the Dysphagic Screening Instrument (DSI) was

constructed from these 15 target areas (Appendix D). The DSI consisted of 15

41

screening task items. Eight oral-motor tasks to screen motor and sensory
capabilities of the swallowing mechanism were adapted from Love and Webb
(1992): lingual sensation, lingual strength, tonguetip elevation, lingual Iateralization,
lingual symmetry, labial seal, reflexive cough, and saliva control. The remaining
seven DSI screening tasks involved assessment of alternate motion rate (Fletcher,
1972), vocal quality and voluntary cough (Aronson, 1990), involuntary swallow
(Dodds et al., 1990), voluntary dry swallow (Sonies et al., 1988), and voluntary liquid
swallow and laryngeal elevation (Logemann, 1983).

Subjects who passed the Health History Questionnaire and qualified for
further participation completed the Dysphagia Screening Instrument (DSI). Each
task on the DSI was administered to the subjects by the principal investigator in the
order outlined on the DSI. Functional performance for each of the 15 tasks was
subjectively scored by the examiner as 1 (accurate, immediate, and without cues)
or 0 (inaccurate, delayed, or with verbal/tactile cues). The total score possible was
15. Subjects scoring less than 15 were excluded from the study. Subjects
successfully passing the DSI completed a Videofluoroscopic Swallow Study (VF SS)
of oropharyngeal swallow structure and function. The delay between completion of

the DSI and participation in the VFSS averaged 11.03 days (range 0-30 days).

E . I I I I I . I
The videofluoroscopy swallow study (VFSS) recordings were obtained from
a General Electric Prestilix (Model #1690s) using a six-inch image magnifier. Data

from the fluoroscopic image were recorded on a JVC Super VHS Player/Recorder

42

(#BR 861 1 U), with a 3M Master Broadcast Anti-Stat Super VHS Videocassette 3/4“
tape run at 30 frames/s. Data were viewed on a 13—in Panasonic Color S-Video
Monitor (#CT 1383 Y). The tape recorder was coupled to a Panasonic Time/Date
Generator (#WJ-810), allowing frame-by-frame analysis of duration measures in ms
for each swallow. Data analysis was performed using the same videocassette tape
recorder and color monitor.

VFSS recordings of the oral cavity and pharynx were obtained at 70 to 80
KeV. Fluoroscopic exposure was limited to < 10 s for each test bolus. If the swallow
duration exceeded 10 s, fluoroscopy was deactivated. Total exposure ranged from
41 to 144 sin duration per subject. Average exposure was 76 s.

The test materials consisted of E2 Paste Barium Sulfate Cream (120%
wt/vol), coated onto a hard cookie (Lorna Doone), and EZPAQUE liquid barium (95%
wt/vol). The liquid barium test boluses were prepared 15 minutes before the VFSS
procedure, then shaken for 10 seconds immediately prior to the swallow. The liquid
barium test boluses were presented in 5.0 ml volumes. For the solid test boluses,

2.0 ml of barium paste was coated onto a 1.0 oz cookie test bolus.

I I' I I] . 5 II SI I

The protocol for completion of the Videofluoroscopy Swallow Study (VFSS)
for each subject remained constant (Appendix E). The VFSS was conducted by the
principal investigator and the Chief of Radiology at the Veterans Affairs Medical
Center in Battle Creek, Michigan, with assistance provided by a radiological

technician at the discretion of the Chief, Radiology Service.

43

Each subject was examined while seated upright on a bench attached to the
General Electric Prestlix table in the fluoroscopy suite. The distance between the
fluoroscopy table and tube remained constant (< 3 feet) for each subject. Subjects
were viewed in the lateral plane, allowing for visibility of the lips‘, teeth, tongue,
palate, velum, mandible, pharyngeal wall, cervical vertebrae, hyoid bone, larynx, and
upper esophageal sphincter. The margins in focus included the lips anteriorly, the
pharyngeal wall posteriorly, the hard palate superiorly, and the seventh cervical
vertebra inferiorly.

The test boluses were administered by the principal investigator. The liquid
barium was swallowed first, being self—administered by the subject. The subject was
instructed to hold the liquid test bolus in the mouth until the command to swallow
was given and then to swallow naturally and normally. Fluoroscopy was activated
just before the command to swallow and deactivated alter the bolus tail passed
through the upper esophageal sphincter.

The barium-paste-coated cookie test trials were completed after the liquid
trials. The subject was instructed to chew the barium-paste-coated cookie, signal
to the principal investigator when he was ready to swallow, then swallow naturally
and normally. Fluoroscopy was activated just before the command to swallow and
deactivated after the bolus tail passed through the upper esophageal sphincter.

Each subject participated in one testing session, during which a total of six
swallows were performed and recorded: three swallows of liquid barium followed by

three swallows of a barium-paste-coated cookie. Presentation of test boluses were

44

not counterbalanced. The liquid barium was presented first for all subjects to

eliminate the likelihood that residue from solid swallows would interfere with imaging.

1 C' I [I . g I .
Seven swallowing events were determined for each swallow for each subject:
five tempera-spatial events and two morpho-physiologic events. Seven dependent

variables were then calculated from these swallowing events.

5 II . D I' I I

Timing of five tempera-spatial swallowing events was determined by reading
the digital clock (in ms) recorded on each frame of the videotape for each swallow,
for each subject. The five temporo-spatial swallowing events were identified by (a)
time at which posterior bolus head movement in the oral cavity began, (b) time at
which the head of the bolus first reached the ramus of the mandible, (c) time at
which the hyoid began maximal vertical excursion, (d) time at which the bolus tail
passed through the upper esophageal sphincter, and (e) time at which the hyoid
returned to rest.

Five dependent variables—oropharyngeal swallowing duration measures-
were then calculated from these tem pom-spatial swallowing events for each swallow
for each subject following the protocol outlined by Lof and Robbins (1990): three
bolus duration measures and two temporo-spatial duration measures. The five
dependent variables (in ms) were (a) oral transit duration (OTD)—time at which

posterior bolus movement in the oral cavity began until the head of the bolus entered

45
the pharynx, i.e., first reached the ramus of the mandible, (b) pharyngeal transit
duration (PTD)-—time at which the head of the bolus first reached the ramus of the
mandible until the bolus tail passed through the upper esophageal sphincter, (c) total
swallowing duration (T SD)—time at which the bolus began to move posteriorly until
the tail of the bolus passed through the UES, (d) stage transition duration (STD)—
time at which the bolus head reached the ramus of the mandible until the hyoid
began maximal upward excursion, and (e) hyo-Iaryngeal response duration (HLD)-—

time at which the hyoid began maximal upward excursion until the hyoid returned to

rest.

I I I _ I . I . I I I

Two of the remaining seven swallowing events were identified through
videofluoroscopic analysis for each swallow for each subject. The two morpho-
physiologic dependent variables were oral bolus position (OB P) and stage transition
pattern (STP). OBP was defined as the antero-postero position of the bolus head
on the superior surface of the tongue prior to posterior bolus movement during the
oral stage of the swallow. OBP was identified as anterior, mid, or posterior; i.e., the
bolus head was visible on the anterior 1/3 of the tongue, middle 1/3 of the tongue,
or posterior 1/3 of the tongue surface prior to swallow initiation. Antero-postero
demarcations included the lips anteriorly and the ramus of the mandible posteriorly.

Stage transition pattern (STP) was defined as the presence of a continuous
stage transition pattern (CSTP) or an interrupted stage transition pattern (ISTP) of

bolus movement through the oral and pharyngeal stage of the swallow. A CSTP

46

was characterized by continuous movement ofthe test bolus through the oropharynx
without visible hesitation between the oral and pharyngeal stages of swallowing. An
ISTP was characterized by interrupted movement of the test bolus through the

oropharynx with visible hesitation of the bolus between the oral and pharyngeal

stages of swallowing.

I . . E I

Each swallow was examined on the videocassette tape recorder in normal
speed, slow motion, and frame-by-frame by the principal investigator. Frame-by-
frame analysis was utilized for data collection and analysis.

Two additional judges, speech-language pathologists with experience
interpreting videofluoroscopic evaluations of dysphagia, participated in the
videofluoroscopy swallow study (VFSS) analysis following completion of a training
session by the principal investigator.

In the training session, three VFSS samples of normal adult subjects
swallowing a 5 cc liquid barium bolus were reviewed on videotape by each of the
judges. The judges received instruction on identification of video frames
corresponding to five temporo—spatial swallowing events. Definitions and examples
of each swallowing event were provided. The judges were then required to identify
the video frame corresponding to five temporo-spatial swallowing events by noting
and recording the time (in ms) at which the event occurred. If inter-judge differences

exceeded 0.1 3, continued instruction on the same swallow samples was provided

47

until interjudge differences averaged less than 0.1 s for each of the five temporo-
spatial swallowing events for each of the three sample swallows.

The judges received instruction on identification of the two morpho-
physiologic swallowing events: oral bolus position and stage transition pattern.
Definitions and examples of each swallowing event were provided. Thejudges were
then required to make observations on the two morpho-physiologic swallowing
events for each of the three sample swallows. If inter-judge agreement was less
than 90%, continued instruction was provided until all three judges reached 100%
agreement on both oral bolus position and stage transition pattern for each of the

three sample swallows.

B I'I'I'I
II 'I BI'I'I'I

Intrajudge reliability in identification of the seven swallowing events was
assessed by having each of the three judges repeat their analysis of two randomly
selected video-fluoroscopic taped samples from each age group. For each of the
five temporo—spatial oropharyngeal swallowing events, average intrajudge
differences in scoring between the first and second analysis of 0.1 s or less were
considered a priori as reliable. For the two morpho-physiologic events, 90%

agreement between the first and second analysis was required.

48

II 'I BI'I'I'I

lnterjudge reliability in identification of the seven swallowing events was
determined a priori by requiring two of three judges to obtain agreement within 0.1 s
for each of the five temporo-spatial sWaIlowing events on one randomly selected
videofluoroscopic taped sample from each age group. For the two morpho-
physiologic swallowing events, 90% agreement between two of three examiners
was required. After completion of the VFSS analysis, judges were required to rate
their level of confidence in data collection and analysis for each subject on a scale

ranging from 1 (not confident) to 5 (very confident).

Statistical analysis of five dependent variables-oropharyngeal swallowing
duration measures—was completed using the mean values ofthe three swallows by
each subject for each texture, to obtain the group mean. A one-way simple factorial
analysis of variance (ANOVA) using the computer program SPSS (Statistical Data
Analysis, 1989) was completed for each of the five durational dependent variables
using a p < .05 level of significance: (a) oral transit duration, (b) pharyngeal transit
duration, (c) total oropharyngeal swallowing duration, (d) stage transition duration,
and (e) hyo-Iaryngeal response duration.

Chi-square analysis (p < .05) was performed on the two morpho-physiological
dependent variables to determine whether age-related differences existed in oral

bolus position and stage transition pattern. Intrajudge and interjudge reliabilities

49

were determined by performing a Pearson product-moment correlation coefficient

and index of determination.

CHAPTER IV

RESULTS

To understand the normal swallow process across the adult life span, this
research was designed to identify systematic differences in oropharyngeal
swallowing physiology among normal nondysphagic older adults. This study
consisted of 30 adult male veterans, divided into three age groups: Group 1 (50-55
years), Group 2 (60-65 years), and Group 3 (70-75 years).

A Health History Questionnaire (HHQ) was administered to the subjects to
rule out the presence of dysphagia or medical conditions associated with dysphagia.
No subjects reported a history of speech, voice, or swallowing problems preceding
the Videofluoroscopy Swallow Study. Medical and surgical history were negative for
the presence of conditions, disease states, or medication use that has been
associated with swallowing difficulty.

The Dysphagia Screening Instrument (DSI) was then completed for each
subject to further rule out the presence of swallowing difficulty. Subjects receiving
a passing score of 15 participated in the videofluoroscopy x-ray procedure.

The Videofluoroscopy Swallow Study (VFSS) measured seven dependent

variables. Five durational dependent variables were calculated: oral transit duration

50

51
(OTD), pharyngeal transit duration (PTD), total oropharyngeal swallowing duration
(T OSD), stage transition duration (STD), and hyo-laryngeal response duration
(HLD). Two morpho-physiological dependent variables were measured: oral bolus

position (OBP) and stage transition pattern (STP).

Q I I 5 II . II
I . . I B . S II

No participants reported a subjective difficulty swallowing any of the three
liquid test boluses during the Videofluoroscopy Swallow Study. Central tendency
and variability data were calculated and summarized for five oropharyngeal
swallowing durations of a 5 cc liquid barium bolus (Table 1).

Table 1: Central tendency and variability data for 5 cc liquid barium oropharyngeal
swallowing durations (in seconds) in adults of different ages.

 

Swallowing Durations

 

Group Measure

 

 

 

OTD PTD TOSD STD HLD

M 0.27 0.61 0.88 -0.30 1.41

50-55 SD 0.17 0.16 0.22 0.11 0.30
Range 0.07 - 0.64 0.46 - 1.01 0.65 - 1.25 -0.16 - -0.50 1.12 - 1.90

M 0.28 0.70 1.00 -0.20 1.32

60-65 SD 0.11 0.15 0.20 0.23 0.33
Range 0.13 - 0.42 0.47 - 0.95 0.66 - 1.27 -0.55 - 0.14 0.80 - 1.84

M 0.27 0.67 0.94 -0.21 1.35

70-75 512 0.10 0.09 0.12 0.17 0.26

Range 0.13 - 0.44 0.56 - 0.79 0.82 - 1.16 -0.43 - 0.07 1.03 - 1.80

 

 

 

 

 

 

 

 

 

Note. M (mean), SD (standard deviation), OTD (oral transit duration), PTD
(pharyngeal transit duration), TOSD (total oropharyngeal swallowing duration),
STD (stage transition duration), HLD (hyo-laryngeal response duration).

52

The mean liquid swallowing durations for each age group were compared
(Figure 1). The mean oral transit duration for all groups was less than 0.30 s. Mean
pharyngeal transit duration for all age groups ranged between 0.61 s and 0.7 s. The
mean total oropharyngeal swallowing duration (TOSD) did not exceed 1.0 s for any
of the age groups. The mean value for stage transition duration was negative for all
groups; i.e., the hyoid began maximal vertical excursion prior to the bolus head
reaching the ramus. Hyo-laryngeal response duration exceeded TOSD for all age
groups and was the longest measured event for liquid swallows.

Analysis of variance (ANOVA) revealed no significant differences among the
three age groups in oropharyngeal swallowing duration measures for a 5 cc liquid
barium bolus (Table 2). An E ratio of 3.37 was required for significance at p < .05.

Oral bolus position data for 5 cc liquid barium swallows for each of the three
age groups were summarized (Table 3). Eighty-four swallows were analyzed. A
determination could not be made on six swallows, three of each in Groups 1 and 3.
For liquid swallows, mid placement occurred in 59.3% of the youngest group, 53.3%
of the middle-age group, and only 29.6% of the oldest group (Figure 2). Posterior

placement was observed in only 14.8% of the youngest group as compared to

48.1% of the oldest group.

53

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Table 2: Analysis of variance for 5 cc liquid barium swallowing duration measures
in adults of different ages.

 

 

 

 

 

 

Source d! 55 MS E
OTD
Between (age) . 2 .001 .000 .024
Within 27 .447 .017
PTD
Between (age) 2 .039 .019 1 .037
Within 27 .504 .019
TOSD
Between (age) , 2 .074 .037 1.082
Within 27 .929 .034
STD
Between (age) 2 .059 .030 .967
Within 27 .829 .031
HLD
Between (age) 2 .048 .024 .271
Within 27 2.378 .088

 

 

 

 

 

 

 

Note. An E ratio of 3.37 was required for significance at p < .05. OTD (oral transit
duration), PTD (pharyngeal transit duration), TOSD (total oropharyngeal swallowing
duration), STD (stage transition duration), HLD (hyo—laryngeal response duration).

Table 3: Oral bolus position (OBP) for 5 cc liquid barium swallows in adults of
different ages.

 

 

 

 

 

 

. . Age Group
Posrtion
50-55 60-65 70-75
ANT 7 6 6
MID 16 16 8
POST 4 8 13

 

 

 

 

 

Note. OBP (oral bolus position = antero-postero position of the bolus head on the
superior surface of the tongue prior to posterior bolus movement during the oral
stage of the swallow), ANT (anterior = bolus head positioned on the anterior 1/3 of
the tongue), MID (middle = bolus head positioned on the middle 1/3 of the tongue),
POST (posterior = bolus head positioned on the posterior 1/3 of the tongue).

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There were no statistically significant differences among the three age groups
in oral bolus position for liquid swallows based on the Pearson chi-square statistic
(x2 = 8.2225, df = 4, n = 84, p s .05). A chi-square value of 9.488 was required for
significance at the p < .05 level. The contingency coefficient was .29860.

Differences among the three age groups were significant at p < .08376, based
on the Pearson chi-square statistic. Age effects in oral bolus position were observed
between Groups 1 and 3 (x2 = 7.50830, :11 = 1, n = 54, p s .05). Age effects were not
observed between Groups 1 and 2 (x2 = 1.25584, d1: 1, n = 57, p s .05) or between
Groups 2 and 3 (x2 = 3.70952, at = 1, n = 57, p 3.05). For 1 or, a chi-square value
of 3.841 was required for significance at the p < .05 level.

Stage transition pattern (STP) data for liquid swallows for the three age
groups were calculated (Table 4). A total of 84 swallows were analyzed. STP for
six swallows could not be determined: three each in Groups 1 and 3.

Table 4: Stage transition pattern (STP) for 5 cc liquid barium swallows in adults
of different ages.

 

 

 

 

 

 

 

 

Age Group
Pattern
50-55 60-65 70—75
CSTP 22 1 3 8
ISTP 5 17 19

 

 

Note. STP (stage transition pattern), CSTP (continuous stage transition pattern =
continuous movement of the test bolus through the oropharynx without visible
hesitation between the oral and pharyngeal stages of swallowing), ISTP (interrupted
stage transition pattern = interrupted movement of the test bolus through the
oropharynx with visible hesitation of the bolus between the oral and pharyngeal
stages of swallowing).

57

A continuous stage transition pattern (CSTP) was observed more frequently
in the 50 to 55 year age group (Figure 3). A CSTP was observed in 81.5% (Group
1), 43.3% (Group 2), and 29.6% (Group 3) of the liquid swallows. In contrast, an
interrupted stage transition pattern (ISTP) for liquid swallows was observed more
often in the 60 to 65 and 70 to 75 year age groups. An ISTP for liquid swallows was
observed in only 18.5% of the youngest group as compared to 56.7% and 70.4% of
the two oldest groups.

Stagetransition pattern for liquids reached statistical significance forthethree
age groups based on the Pearson chi-square statistic (x2 = 15.67979, df = 2, n = 84,
p < .05). A chi-square value of 5.991 was required for significance at the .05 level.
The contingency coefficient was .39661.

Further analysis revealed significant differences in stage transition pattern
(STP) between Groups 1 and 2 (x2 = 8.72602, or = 1, n = 57, p < .05) and Groups
1 and 3 (x2 = 14.70000, :11 = 1, n = 54, p < .05). There were no significant
differences in STP for liquid swallows between the two oldest groups (x2 = 1.14687,

d1 = 1, n = 57, p < .05). For 1 sit, a chi-square value of 3.841 was required for

significance at the .05 level.

S l' | B . S H
No subjects reported a difficulty swallowing any of the three solid test boluses
during the Videofiuoroscopy Swallow Study. Aspiration was not observed in any

subject. Central tendency and variability data were calculated and summarized for

58

Stage Transition Pattern for Liquid Swallows

If

80% -~
70% .l..
60% ‘r
50% --
40% -~

Percent

IISTP ‘
IGSTP,

 

30% T ,~ ~ . q .
10% i 7‘52?“T:.'§}':'_._.:ii.13‘§‘}.

 

 

 

 

0%

 

 

50—55 60-65

Age Group

Figure 3: Stage transition pattern (STP) for 5 cc liquid barium swallows for three
age groups. CSTP (continuous movement of the test bolus through
the oropharynx without visible hesitation between the oral and
pharyngeal stages of swallowing, ISTP (interrupted movement of the
test bolus through the oropharynx with visible hesitation between the
oral and pharyngeal stages of swallowing).

59

five oropharyngeal swallowing durations of a 2 cc barium-paste-coated cookie

(Table 5).

Table 5: Central tendency and variability data for oropharyngeal swallowing

durations (in seconds) of barium-paste-coated cookie swallows in adults

of different ages.

 

 

 

 

 

 

 

 

 

 

 

 

Swallowing Durations
Group Measure
OTD PTD TOSD STD HLD
M 0.41 0.81 1.22 -0.10 1.41
50-55 512 0.26 0.41 0.48 0.27 0.38
Range 0.16 - 0.81 0.41 - 1.83 0.71 - 2.16 -0.42 - -0.48 0.97 - 2.03
M 0.54 0.86 1.41 0.03 1.43
60-65 SD 0.25 0.23 0.39 0.26 0.39
Range 0.16 - 0.94 0.54 - 1.30 0.76 - 2.06 -0.34 - 0.50 1.04 - 2.14
M 0.54 0.78 1.32 -0.05 1.28
70-75 SD 0.25 0.20 0.42 0.36 0.32
Range 0.28 - 0.96 0.48 - 1.29 0.76 - 2.25 -0.66 - 0.63 0.96 - 2.01

 

[1913. M (mean), SD (standard deviation), OTD (oral transit duration), PTD
(pharyngeal transit duration), TOSD (total oropharyngeal swallowing duration),
STD (stage transition duration), HLD (hyo-Iaryngeal response duration).

The mean durations for solid swallows in each age group were compared

(Figure 4). The mean oral transit duration for all age groups approximated one-half

second, and the mean pharyngeal transit duration ranged from 0.78 s to 0.86 s. The

mean total oropharyngeal swallowing duration (T OSD) for all age groups was

greater than 1.0 3. Mean hyo-laryngeal response duration (HLD) ranged from

1.28 s to 1.43 s. In addition, the mean HLD was longer than TOSD for the two

youngest groups and shorter than TOSD in the oldest group.

 

60

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61
Analysis of variance (ANOVA) revealed no significant differences among the
three age groups in oropharyngeal swallowing duration measures for barium-paste-
coated cookie swallows (Table 6). An E ratio of 3.37 was required for significance

at p < .05.

Table 6: Analysis of variance (ANOVA) for barium-paste-coated cookie swallowing
duration measures in adults of different ages.

 

 

 

 

 

 

Source at 5.8 MS E
OTD
Between (age) 2 .1 13 .056 .970
Within 27 1 .570 .058
PTD
Between (age) 2 .037 .018 .186
Within 27 2.660 .099
TOSD
Between (age) 2 .071 .086 .463
Within 27 4.991 .185
STD
Between (age) 2 .095 .047 .525
Within 27 2.434 .090
HLD
Between (age) 2 .124 .062 .465
Within 27 3.609 .134

 

 

 

 

 

 

 

Note. An E ratio of 3.37 was required for significance at p < .05. OTD (oral transit
duration), PTD (pharyngeal transit duration), TOSD (total oropharyngeal swallowing
duration), STD (stage transition duration), HLD (hyo-laryngeal response duration).

Oral bolus position (OBP) data for solid barium swallows were summarized
(Table 7). A determination of OBP could not be made on 10 swallows: four (Group

1), one (Group 2), and five (Group 3).

62

Table 7: Oral bolus position (OBP) for barium-paste-coated cookie swallows in
adults of different ages.

 

 

 

 

 

Age Group
Pattern
50—55 60-65 70-75
ANT 12 7 6
MID 11 18 17
POST 3 4 2

 

 

 

 

 

 

Note. OBP (oral bolus position = antero-postero position of the bolus head on the
superior surface of the tongue prior to posterior bolus movement during the oral
stage of the swallow), ANT (anterior = bolus head positioned on the anterior 1/3 of
the tongue), MID (middle = bolus head positioned on the middle 1/3 of the tongue),
POST (posterior = bolus head positioned on the posterior 1/3 of the tongue).

For all swallows combined, mid OBP was the most frequently observed
placement (57.5%), followed in turn by anterior (31.3%) and posterior (11.3%)
placement (Figure 5). For oral bolus position, anterior placement occurred in 46.2%
(Group 1), 24.1% (Group 2), and 24% (Group 3) of the solid swallows. Mid
placement occurred in 42.3% (Group 1), 62.1% (Group 2), and 68.0% (Group 3) of
the solid swallows. Posterior placement prior to initiation of the swallow was
observed in 11.5% (Group 1), 13.8% (Group 2), and 8.0% (Group 3) of the solid
swallows.

There was no effect due to age in oral bolus position for solid swallows based
on the Pearson chi-square statistic (x2 = 4.76961, df = 4, n = 80, p s .05). A chi-

square value of 9.488 was required for significance at the .05 level. The contingency

coefficient was .23720.

63

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64

Data for stage transition pattern (STP) were summarized (Table 8). A total
of 78 swallows were analyzed. Twelve swallows could not be analyzed for STP:
five in the youngest group, one in the middle-aged group, and six in the oldest group.
Group 1 was more likely to display a continuous stage transition pattern (64%) for
solid swallows, as compared to 10% and 17% for Groups 2 and 3, respectively
(Figure 6). An interrupted stage transition pattern for solids predominated for
Group 2 (90%) and Group 3 (83%).

Table 8: Stage transition pattern (STP) for barium-paste-coated cookie swallows
in adults of different ages.

 

 

 

 

Age Group
Pattern
5055 60-65 70-75
CSTP 16 3 4
ISTP 9 26 20

 

 

 

 

 

 

Note. STP (stage transition pattern), CSTP (continuous stage transition pattern =
continuous movement of the test bolus through the oropharynx without visible
hesitation between the oral and pharyngeal stages of swallowing), ISTP (interrupted
stage transition pattern = interrupted movement of the test bolus through the

oropharynx with visible hesitation of the bolus between the oral and pharyngeal
stages of swallowing).

A Pearson chi-square statistic revealed significant differences among the
three age groups in stage transition pattern for solid swallows (x2 = 21.32988, 51! =
2, n = 78, p s .05). For 2 at, a chi-square of 5.991 was required for significance at

the .05 level. The contingency coefficient was .46340.

65

Stage Transition Pattern for Solid Swallows

100% T

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20°/. I I
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50-55 60-65 70-75

Age Group

Figure 6: Stage transition pattern (STP) for barium-paste—coated cookie
swallows for three age groups. CSTP (continuous movement of the
test bolus through the oropharynx without visible hesitation between
the oral and pharyngeal stages of swallowing), ISTP (interrupted
movement of the test bolus through the oropharynx with visible
hesitation of the bolus between the oral and pharyngeal stages of
swallowing).

66
Further analysis revealed significant differences in stage transition pattem
(STP) between Groups 1 and 2 (x2 = 16.94858, d1: 1, n = 54, p s .05) and Groups
1 and 3 (x2 = 11.35674, or = 1, n = 49, p _<. .05). There were no significant
differences in STP for solid swallows between the two oldest groups (3:,2 = 0.45784,

df = 1, n = 53, p _<. .05). For 1 df, a chi-square value of 3.841 was required for

significance at the .05 level.

Il'l Bl'l'l'l

Intrajudge reliability in identification ofthe seven swallowing events during the
initial and repeat data analysis was high for liquid ([ = 0.93) and solid swallowing
measurements (1: = 0.99). The coefficient of determination was 0.86. For oral bolus
position, 100% agreement between the first and second analysis was obtained for
each of the threejudges. For stage transition pattern, 100% agreement between the
first and second analysis was obtained for two of the three judges. For the third
judge, agreement between the first and second analysis was 89%.

For the five temporo-spatial swallowing events, the average intrajudge
difference in scoring between the first and second analysis was 0.1 s or less in 94%
of the swallows. Differences greater than 0.1 s were observed in the two nonbolus
events: hyoid begins maximum excursion (M = 0.39 s) and hyoid returns to rest
(M = 0.13 3). Complete agreement between the first and second analysis was
observed for each of the three judges forthe three bolus events: (a) posterior bolus

movement begins, (b) head of bolus reaches ramus, and (c) bolus tail passes

through the UES.

67
ll . I Bl'l'l'l

lnterjudge reliability in identification of the seven swallowing events was high
for comparison 'of liquid (1: = 0.97) and solid ([ = 0.99) swallowing measurements.
The second analysis was used to determine interjudge scoring reliability. For the
two morpho-physiologic variables, 100% agreement was obtained among the three
judges in oral bolus position before swallow initiation and pattern of stage transition.
For the five temporo-spatial oropharyngeal swallowing events, 92% agreement
(0.1 s or less) was obtained among the three judges.

lnterjudge disagreement (> 0.1 s) was observed for two nonbolus durations:
hyoid begins maximum excursion (M = 0.15 s) and hyoid returns to rest (M = 0.13 s).
Disagreement was also observed for one bolus duration: bolus begins posterior
movement (M = 0.13 s). Scoring differences greater than 0.1 s were not observed
for two of the remaining three bolus durations: head of bolus reaches ramus and
bolus tail passes through the upper esophageal sphincter.

For the first analysis, the average level of confidence in data collection for the
three judges was 3.8, on a scale ranging from 1 (not confident) to 5 (very confident).

For the repeat analysis, the average level of confidence in data collection for the

three judges was 4.4.

0 I'I I' [ll I'

General qualitative observations were made for each subject in five different
areas: (a) premature bolus spillage, (b) bolus residue in hypopharynx or valleculae
post swallow, (c) penetration-entry of the test bolus into the laryngeal vestibule

above the level of the true vocal folds, (d) aspiration—entry of the test bolus into the

68

trachea below the level of the true vocal folds, and (9) multiple swallows required to
clear the bolus from the oropharyngeal channel. Frequencies of qualitative
observations noted during at least one of three swallow events for liquid and solid
textures were tabulated (Table 9) and illustrated (Figures 7 and 8). With data from
the groups combined, trace residue in the hypopharynx or valleculae post swallow
was the most frequent observation for both liquids (73%) and solids (73%).
Premature spillage was observed in 40% of liquid swallows but only 6% of solid
swallows. Bolus penetration was more likely to occur in liquid swallows (27%) than
solid swallows (6%). Percentage of multiple swallows was 50% (solids) and 37%
(liquids).

Table 9: Frequency of qualitative oropharyngeal swallowing events observed
during liquid and solid swallows in adults of different ages.

 

 

 

 

 

 

 

 

Age Group
Event
50-55 60—65 70-75

Premature spillage

Liquids 4 4 4

Solids 2 0 0
Trace residue

Liquids 8 7 7

Solids 7 8 7
Penetration

Liquids 1 4 3

Solids 0 1 3
Aspiration

Liquids 0 0 0

Solids 0 0 0
Multiple swallows

Liquids 4 2 5

Solids 4 4 7

 

 

 

 

 

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CHAPTER V

DISCUSSION

We

This cross-sectional descriptive study sought normative data for investigating
systematic differences in oropharyngeal swallow function in adult men over age 50.
Thirty healthy adults, age 50 to 75, completed a Health History Questionnaire
(HHQ), Dysphagia Screening Instrument (DSI), and \frdeofluorosoopy Swallow Study
(VFSS)to determine whether significant differences in age-related swallow function
exist.

Videofluoroscopy—the primary instrumental procedure used by speech-
language pathologists providing clinical services to individuals with swallowing
disorders—was the diagnostic tool of choice. The use of videofluoroscopy in this
study allowed for assessment of discriminating elements of the oropharyngeal
swallow: duration of bolus transit, pattern of tongue movement during oral transit,
pattern of bolus positioning, pattern and duration of stage transition, and duration of
hyoid movement. In the Videofiuoroscopy Swallow Study, participants completed
three liquid barium swallows and three barium-paste-coated cookie swallows.
Measures of oropharyngeal swallowing durations and events were obtained and

analyzed to determine whether differences existed among the three age groups.

71

72

There were no statistically significant differences among the three groups in
the five oropharyngeal swallowing duration measures examined in this study. The
findings applied to both textures: liquid barium and barium-paste-coated cookie
swallows.

When the coupling between the oral and pharyngeal stages of swallowing ~
was investigated, statistically significant differences were found between the
youngest group and the two older groups in stage transition pattern for both liquid
and solid swallows. Differences were also found between the youngest and oldest

group in oral bolus position for liquid swallows but not for solid swallows.

anbamngealjwallmingflaasum

The mean bolus durations—oral transit duration, pharyngeal transit duration,
and total oropharyngeal swallowing duration—for liquid swallows were similar in the
three age groups. There were no statistically significant differences among the three
groups.

There was no effect due to age in oral transit duration, similar to the findings
of Dejaeger et al. (1994), Robbins et al. (1992), and Tracy et al. (1989). Peripheral
and central recognition of food in the mouth and the primary motoric action of bolus
propulsion into the oropharynx appeared to reflect a stable process of fonNard and
upward phases of tongue base and vertical hyoid movement. The oral bolus
propulsive forces appeared to get the support of the labial and velopharyngeal

valves necessary for development of a positive pressure gradient for timely oral

stage events.

73

Dejaeger et al. (1994) reported that neither the tongue-driving force generated
in the oropharynx by the tongue and pharyngeal walls nor the oropharyngeal
propulsion pump was significantly different in the older subjects studied, aged 75 to
85. Thus, one would argue that oral transit duration for simple liquids and solids is
constant across age groups in men over 50, based on the stability of oral propulsive
forces and the concept that bolus propulsion occurs as a result of a stable
synergistic action of tongue thrust and hypopharyngeal negative pressure
(McConnel, 1988).

Aging oral swallowing events do not appear slower or less coordinated, and
sensori-motor integration would likely be adequate for timely oral bolus transit in men
between the ages of 50 and 75 with normal swallowing. This agrees with the
findings of Ekberg and Feinberg (1991), who reported oral sensori-motor
incoordination in only 3% of adults aged 72 to 93 years. Furthermore, age-
dependent alterations in oral morphology, saliva production, and chemosensory
perception do not appear to impact on oral stage bolus duration measures.

Forthe oral bolus position observations, the oldest group in this study initiated
liquid swallows with the bolus head placed posteriorly on the tongue blade
significantly more often (48%) than the youngest group (22%). Oral bolus position
for solid swallows did not reach statistical significance. The observation of a more
posterior bolus 'hold" position was also made in an earlier study (Tracy et al., 1989).

Bolus position prior to initiation of the oral stage may have had an impact on

oral transit duration (OTD). In this study, OTD was measured from the beginning of

74

posterior bolus head movement on the tongue; therefore, OTD for liquids would be
expected to be shorter when the bolus is carried posteriorly, as compared with bolus
carriage more anteriorly in the oral cavity. In contrast, OTD was not statistically
different among the three age groups.

Perhaps oral transit duration does increase with age, as suggested by Shaw
et al. (1990); but because the bolus had less distance to travel in the oral cavity with
posterior placement for the oldest subjects in this study, the increased duration was
not observed. This would lead one to question the presence of slower aging oral
systems in nondysphagic men over age 70.

Oral bolus position for solids failed to show an age effect. Solid boluses were
more often carried mid-tongue prior to initiation of the oral stage and less often
carried on the posterior tongue surface. The oral stage was initiated with the bolus
on the superior surface of the tongue for all swallows for all subjects, characteristic
of the "tipper-type" swallow described by Dodds et al. (1989).

For pharyngeal bolus duration measures, pharyngeal transit duration (PTD)
was not influenced by age in this study, similar to the findings of Dejaeger et al.
(1994), Lof and Robbins (1990), and Shaw et al. (1990). Findings were similar for
both liquid barium and barium-paste-coated cookie swallows. Although Robbins et
al. (1992) found significantly longer PTDs and total swallowing durations in subjects
over age 70 when smaller liquid bolus volumes were swallowed, the continuum of

swallowing decline predicted to occur in subjects over age 45 was not observed in

this study.

75

Stagetransition duration-the interval between arrival of the bolus head at the
ramus and initiation of maximal hyoid excursion-was not significantly different
among the three age groups, similar to the findings of Lof and Robbins (1990). In
contrast, other studies have found increased stage transition delay (Robbins et al.,
1992) and pharyngeal delay (Tracy et al., 1989) among older groups.

Mean stagetransition duration (STD) values forliquid swallows were negative
for all groups, suggesting that hyoid excursion begins prior to arrival of the bolus at
the base of the tongue. Mean STD values for solid swallows were negative for
Groups 1 and 3 but positive for Group 2 (M = 0.03 s). For Group 2, mean STD was
one videoframe away from simultaneous arrival of the bolus head at the ramus and
initiation of maximal hyoid excursion.

From these findings, one might expect pharyngeal response—as measured
by hyoid activity—to remain timely in the population of healthy, nondysphagic adult
men over age 50. This is further supported by the findings associated with hyo-
laryngeal response duration (HLD): no differences among age groups were found.
HLD was the longest event for liquid swallows, exceeding all bolus duration
measures. For solid swallows, HLD approximated total oropharyngeal swallowing
duration for the two youngest groups. In the oldest group, total swallowing duration
exceeded HLD.

Some investigators have defined the entire oropharyngeal phase of
swallowing by the motions of the hyoid bone (Ekberg, 1986; Sonies et al., 1988).

The Sonies et al. study used ultrasonography to examine 10 cc liquid swallows.

76

Mean hyoid activity for subjects aged 54 or less (M = 1.43 3 women, 1.49 3 men)
was similar to the values for hyo-laryngeal response duration in this study. However,
duration of hyoid activity for subjects over age 55 in the Sonies et al. study exceeded
hyo-laryngeal response duration values obtained in this study by 1.0+ s.

The findings of this study suggest that the sequence of intricate
neuromuscular events associated with bolus transport through the pharynx reflects
a coordinated sensori-motor effortthat remains relatively intact in adult men between
the ages of 50 and 75. In turn, one might hypothesize that the central swallowing
pathway-the dorsal region of the medulla that activates the process of swallowing
and the ventral region that transmits the motor response-performs in a relatively
stable and unheralded fashion when speed of swallowing is investigated.

In discussing these results, one must consider the statement by Ergun and
Miskovitz (1992) that ”aging itself does not cause any clinically evident dysphagia,
however, age-related changes may aggravate pre-existing swallowing problems” (p.
58). It would appear that age-related changes reported by researchers in previous
swallowing studies may be a product of increased vulnerability of sensori-motor
systems in the presence of subtle disease states or medically compromised
conditions that were previously undetected.

When stage transition pattern was investigated, a continuous pattern of stage
transition was observed more frequently in the youngest group for both liquid and
solid boluses. An interrupted stage transition pattern of bolus flow was more

prevalent in the two older groups. This suggests that the transition between the oral

77

and pharyngeal stages of swallowing may be qualitatively judged as uniquely
demarcated, perhaps not so closely coupled in the normal swallow of adult men over
age 60. When durations were not the focus of study, the. sequence of involuntary,
highly coordinated neuromuscular events that occurred to draw the pharyngeal wall
upward over the bolus appeared to do so later in older individuals, a coordination
that likely represents a natural compensatory mechanism of the aging swallow
mechanism to adjust to the incoming bolus.

In clinical practice, increases in stage transition duration (STD) have been
equated with (a) delayed onset of pharyngeal dynamics, (b) delayed triggering of the
swallow reflex, and (c) pharyngeal swallow delay. Qualitative judgments of swallow
delay or ”stage transition pattern" may not be the best indicator of actual delay in the
onset of the pharyngeal swallow, as observed by the mean STD values obtained on
the Videofluoroscopy Swallow Study. There were no significant differences among
groups in STD in this study. Observations of stage transition pattern might
correspond more closely with STD when measured at the onset ofanterior excursion

in future studies.

0 II |' GI I'

The videofluoroscopy results in the clinical sample suggest that duration
measures for liquids and solids are fairly constant in men between the ages of 50
and 75. In this study, several qualitative oropharyngeal swallowing observations
were made; some of these events would be judged by many professionals as

abnormal activity (e.g., penetration, residue). Other researchers have made similar

78

nondurational observations. Ekberg (1982) observed swallowing aberrations in 17%
of nondysphagic individuals of all ages, with penetration present in 6% of the
subjects. Liquid penetration was observed in 27% of the subjects in this study, only
10% of which occurred in the youngest group. Vallecular and diffuse
hypopharyngeal residue post swallow was subjectively rated as present in 73% of
the subjects. Although residue could not be quantified using videofluoroscopy in this
study, Cook et al. (1994) found that pharyngeal post-swallow residual counts
increased significantly with age.

Pharyngeal contraction has a significant function in pharyngeal clearing, with
residue minimized when adequate tongue-driving forces and pharyngeal shortening
exist. Kahrilas (1993) summarized two important components of deglutive
pharyngeal contraction: longitudinal shortening and propagated horizontal
contraction. Pharyngeal shortening has the effect of approximating the upper
esophageal sphincter to the tongue base. Adequate pharyngeal shortening
obliterates the laryngeal vestibular pyriform recesses, thus minimizing post-swallow
residue. In contrast, horizontal contraction coincides with clearance of the bolus tail
through the pharynx, acting as a pharyngeal clearance mechanism.

Observations on the pharyngeal clearing mechanism in this study suggest
that bolus clearance may not be as efficient as that of younger subjects. In addition,
the occurrence of multiple swallows for liquids (n = 11) and solids (n = 12) is not
surprising. This observation, coupled with the presence of liquid penetration by eight

subjects, might suggest that the pharyngeal clearance mechanisms of longitudinal

79

and horizontal contraction might be compromised in the older subject; and increased
pharyngeal residue is a characteristic swallowing feature in nondysphagic men over

age 50.

Cl"l IB II l'l'

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Identification of normal swallowers is a difficult task in research on aging and
deglutition. Most researchers of aging and swallowing eliminate subjects from their
study who have compromising medical conditions or diseases known to influence
deglutition (Dejaeger et al., 1994; Lof & Robbins, 1990: Sonies et al., 1988; Tracy
et al., 1989). Others eliminated subjects who were asymptomatic for dysphagia
(Ekberg 8r Feinberg, 1991) regardless of medical history.

In this study, detailed efforts were made to determine the presence of
compromising medical conditions to eliminate threats to internal validity. No
participants had a documented medical, surgicalgor medication history found to
interfere with oropharyngeal swallowing. This information was confirmed by the
attending physician on the medical chart. The Health History Questionnaire further
ruled out the presence of compromising conditions as reported by the subjects
themselves. Speech and voice difficulties were also not a factor in any of the
subjects.

However, one must consider the fact that the medical history of the subjects

may not have been thoroughly representative of all possible conditions that could

80
potentially influence normal swallowing. Knowledge of dysphagia and conditions
associated with deglutition problems are continuously expanding. There is always
the possibility that subtle conditions associated with swallowing performance went
undetected.

Furthermore, the subject’s self-knowledge of medical conditions may have
been a limiting factor. The participants (a) may not have been aware of previously
diagnosed conditions, (b) may have been confused about the definition or
description of a medical condition, or (c) may have been unsure of the presence or
absence of a condition, therefore stating ”no” to the investigator’s health history
questions when in fact they might have responded "yes.”

Even though there may have been conditions that went undetected, it is
thought that the male participants in this study represented a population of healthy
adults. Furthermore, the participants in this study likely represented men between
the ages of 50 and 75 whose swallowing would be considered normal. Future
studies of aging and normal swallowing will need to include specific and detailed
procedures aimed at ruling out potential medical conditions as well as
pharmacological effects that might interfere with the normal swallowing process.

To identify normal swallowers, researchers of aging and swallowing should
implement use of a reliable and valid swallowing screening tool to further support the
notion of normal swallowing. In this study the sensori-motor tasks on the Dysphagia
Screening Instrument (DSI) focused on the presence of normal structure and

function in lingual, labial, and laryngeal systems.

81

In one prior study, researchers of aging and swallowing used an oral-motor
evaluation and swallowing screening to rule out subjects with deglutition problems
(Sonies et al., 1988). A surprising number of researchers did not describe the
oropharyngeal sensori-motor exam used (Lof & Robbins, 1990) or failed to include
a clinical screening tool to rule out the presence of dysphagia in their subjects
(Dejaeger et al., 1994; Ekberg 8 Feinberg, 1991; Tracy et al., 1989; Wilson et al.,
1990). Rather, they simply reported the fact that no subjects had a history of
dysphagia.

In one study comparing clinical signs of dysphagia with videofluoroscopy
findings of aspiration (Linden, Kihlemeier, 8 Patterson, 1993), nine clinical signs
were associated with subglottic penetration, all of which were associated with
laryngeal functioning. The authors found that the probability of correctly predicting
subglottic penetration from clinical observations was approximately 66%.

The Dysphagia Screening Instrument used in this study contained seven task
items associated with laryngeal functioning. Four tasks were similar to those
described by Linden et al. (1993): voluntary cough (spontaneous cough quality),
laryngeal elevation (laryngeal elevation), vocal quality (wet phonation), and saliva
control (swallowing of secretions). There is the possibility that this screening
instrument failed to detect or predict subtle swallowing deviations involving the
pharyngeal stage. This is especially important considering the presence of

penetration in eight (27%) of the subjects in this study.

82

The Dysphagia Screening Instrument contained six items sensitive to lingual
functioning. Considering the nature of the investigation which addressed both
durational and nondurational measures of oral stage swallowing, these items
appeared critical to the study at hand. If one considers McConnel’s (1988)‘model
of swallowing as a two-pump system, tongue compression against the pharyngeal
wall is essential in the development of positive pressure applied to the bolus. The
peripheral and central recognition of food in the mouth and the lingual motor
response are key elements in successful initiation of the swallow, and any screening
tool that fails to address primary lingual control would be inadequate.

The Dysphagia Screening Instrument was administered to each subject by
the principal investigator only once. No otherjudges were involved in the screening
process. To eliminate threats to internal validity and establish reliability data, a
repeat analysis by the principal investigator and a separate analysis by an additional
judge would be warranted in future studies.

Considering the importance of the screening process in studies of normal
swallowing, the Dysphagia Screening Instrument developed for use in this study
appeared sensitive enough to identify potential swallowing alterations in the
participants in this study. No significant differences among age groups were found
across six factors.

Delay from completion of the Dysphagia Screening Instrument (DSI) to
completion of the Videofluoroscopy Swallow Study (VFSS) averaged 11 days. The

screening process averaged 20 minutes for each subject. The VFSS procedure,

83

including waiting time and videotape review, averaged 30 minutes. There is the
possibility that history confounded the effects of the oropharyngeal swallowing
variables on the VFSS in some of the subjects. A change in the subjects’ swallowing
status may have occurred between the administration of the DSI and the VFSS. Or
changes in psychological and physiological status may have confounded the effects.
In future studies, the shorter the interval between the screening and the actual

swallow study, the lesser the likelihood that history will serve to contaminate the

results.

SuallsminlMfiasuLes

From this study, several important swallowing measures have been identified
that can be used in clinical practice. First, it is reasonable to assume that duration
values for small liquid and solid boluses remain relatively constant in the population
of adult men between age 50 and 75. As a baseline, the clinician would expect
healthy adults to (a) transport a 5 cc liquid bolus through the oropharynx in 1.0 s or
less on average; (b) transport a small solid bolus through the oropharynx in 1.30 s
or less on average; (c) demonstrate hyoid durations of 1.3 s on average for liquid
and solid bolus swallows; (d) be less likely to demonstrate a smooth and continuous
transition pattern between the oral and pharyngeal stages of swallowing with
advanced age; (e) occasionally demonstrate premature spillage, residue post
swallow, and penetration of liquids as a normal condition of swallowing; and (f)

occasionally demonstrate multiple swallows and hypopharyngeal residue post

swallow for masticated boluses.

84

Future studies of oral stage events should Involve detailed investigation of
barium-impregnated and masticated foods. Specifically, studies involving larger
bolus volumes, "bolus sectioning," and oral preparatory maneuvers would provide
insight into timing and patterns of bolus management in the oral'cavity.

To further understand the pharyngeal stage, additional studies need to focus
on refining measurement of stage transition duration or ”pharyngeal delay,“ delineate
the role of pharyngeal contraction in individuals with poor vallecular clearing, and
determine the nature of qualitative differences in pharyngeal clearing that may exist
in asymptomatic older individuals. Research on aging and normal swallowing should
also examine the ability to perform dynamic swallowing maneuvers frequently

utilized by practicing clinicians.

S l . | S I l'

The writer acknowledges that "normal“ in this clinical sample is defined solely
by the group of normal male controls selected and does not imply a normal pattern
of swallowing among all asymptomatic individuals over age 50. It does suggest,
however, that the range of normalcy is perhaps broader than expected; and judges
may mistake ”normal" swallowing events in older individuals as abnormal swallowing
events. The 30 participants in this study likely represented men between the ages
of 50 and 75 whose swallowing would be considered normal. However, larger
sample sizes would be warranted in future studies of normal swallowing.

All participants in this study were men. Although women were not excluded

from this study, few women in the age range specified were identified, and no

85

women in the age range of 50 to 75 years met the criteria for inclusion. Further
investigations may want to include women to measure gender differences in

oropharyngeal swallowing events.

IdentificationjniAssessment

Further refinement of screening tools and noninstrumental evaluation
techniques would be warranted in future studies of normal and disordered
swallowing. Researchers of aging and swallowing should implement a screening
tool similar to the Dysphagia Screening Instrument to further support the notion of
normal swallowing. Quantitative and qualitative measures of normal oropharyngeal
swallowing must be systematically studied in older individuals to strengthen the
clinician’s skills in differentiating between normal and abnormal swallowing.

A heightened awareness of normal swallowing by practitioners may result in
early identification of symptoms or warning signs, which in turn may prevent decline
in swallowing among older institutionalized individuals. Specifically, enhanced
knowledge may eliminate the risk for developing swallowing disorders often
associated with specific disabilities affecting many older adults: incontinence,
immobility, malnutrition, dehydration, intellectual impairment, instability, or

generalized debility.

CI' . | I I l
Knowledge ofvideofluoroscopy findings in asymptomatic, normal swallowers

will enable practicing clinicians to use this diagnostic technique to more effectively

86

manage patients who aspirate or have primary clinical conditions of oropharyngeal
dysphagia. Clinical advances associated with heightened knowledge of
neuromuscular function and sensori-motor integration in the normal swallow would
include improved application of diagnostic and therapeutic principles to individuals
with a broad spectrum of dysphagic characteristics. Clinical advances should be
realized in identification of risk factors, establishment of therapeutic protocols (e.g.,
neuromuscular facilitation, compensatory strategies, swallowing maneuvers), and
evaluation of clinical outcomes.

In working with adults with oropharyngeal dysphagia, practicing clinicians are
obligated to advance their techniques beyond simple diet modifications and
positioning recommendations. The application of systematic yet person-centered
approaches should enhance clinical outcomes.

Clinical outcomes of institutionalized older adults with dysphagia are not
promising. In a study of 12-month outcomes on 22 nursing home residents with
aspiration identified on videofluoroscopy (Croghan, Burke, Caplan, & Denman,
1966), 68% required feeding tube placement, 82% were rehospitalized, 50%
developed pneumonia, and 50% expired. The residents who underwent
videofluoroscopy had poor clinical outcomes at 12 months, regardless oftest results.
The clinical practitioner cannot ignore these findings or sidestep the challenge they
impose.

Prevention of swallowing decline in older individuals entails adaptation of a

"quality-of-life" standard. To improve quality of life for institutionalized adults,

87
practicing clinicians would be trained to (a) reference normative data on the timing
and duration of oropharyngeal swallowing events in clinical practice, (b) identify risk
factors associated with dysphagia, (c) utilize technically advanced diagnostic
methods and specific protocols for assessment of swallowing performance, (d)
design environments conducive to optimal oral intake, (0) educate caregivers and
professionals working with older adults in a knowledge base consistent with an
understanding ofthefundamentals of normal swallowing, and (f) maximize functional

independence in all aspects of eating and swallowing.

APPENDICES

APPENDIX A

VA RESEARCH CONSENT FORM 10-1086

88

 

QB Department of Veterans Affairs VA RESEARCH CONSENT FORM

 

Subject Name: Date

 

Title of Study; The Effects of Aging on Selected Parameters of Oropharyngeal SwalloiiLing

Principal Investigator: Debra Gleeson, M.A., CCC-SLP VAMC: W

Ph.D. Candidatei MSU I—

DESCRIPTION OF RESEARCH BY INVESTIGATOR

Purpose of study and how long It will last:

Description of the study including procedures to be used:

Description of any procedures that may result in discomfort or lnconvenience:
Expected risks of study:

Expected benefits of study:

Other treatment available:

Use of research results:

Special circumstances:

989999”?

PURPOSE OF STUDY: There has been minimal research on the functions of the swallowing
mechanism in adults over age 50. We do not know for sure if swallowing becomes more
difficult or slows down with age, or if, in fact, the process of swallowing remains

normal into old age. As a result, this study is designed to examine the effects of

aging on the ability to swallow in 45 normal, healthy adults ranging in age from 50 to

75 years. By learning about the normal aspects of swallowing in the older population,
knowledge of normal and abnormal swallowing may be further realized, allowing for effec-
tive medical and therapeutic management of persons with disorders of swallowing (dysphagia).

DESCRIPTION OF STUDY AND PROCEDURES: This study involves completion of three distinct
steps. STEP 1, completion of a Health History Questionnaire, requires you to answer ques-
tions about your medical, surgical, speech, voice and swallowing history. STEP 2, the
Dysphagia Screening Protocol, will be completed to examine your swallowing mechanism and
rule out the presence of swallowing difficulty. It involves an examination of your tongue,
lips, mouth, and throat. You will be asked to perform simple tasks, such as cough, swallow,
and move your tongue back and forth. STEP 3 involves completion of a Videofluoroscopy X-ray
(radiation) Procedure to examine your swallowing mechanism. You will be required to swallow
small amounts of liquid barium and a barium-coated cookie. The Chief of Radiology will take
videofluoroscopy x-ray pictures of your oral cavity and throat. The principal investigator
and two additional certified speech-language pathologists trained in analyzing fluoroscopy

x-ray pictures will then examine the video pictures to take measurements of your swallowing
pattern.

SWECT'S IDENTIFCAT'ON (1.0. plus or give name-Inst. first. middle)

 

 

 

 

 

33330 1 0-1086

89

 

Q2) Department of Veterans Affairs VA RESEARCH CONSENAI) FORM

(Continuation Page

 

 

Subject Name: Date

 

Title of Study: The Effects of Aging on Selected Parameters of Oropharyngeal Swallowing

Principal Investigator: Debra Gleeson, M.A., CCC-SLP VAMC: Battle Creek, MI
Ph.D. Candidate, MSU

 

DISCOMFORTS/RISKS: Participation in this study is not expected to cause psychological or
physical discomforts; however, some people may find the questions or procedures unpleasant

or inconvenient. Specifically, you may find the taste of the barium to be unpleasant.
Adverse reactions and/0r allergic reactions after ingestion of the barium are infrequent and
usually mild. Mild allergic reactions include rash and itching. Rare severe reactions

(1 in 500,000) include shortness of breath (bronchospasm), low blood pressure (hypotension),
and swelling of the throat (laryngeal edema). Death (1 in 2,000,000) has been reported.
Other side effects to the barium may include constipation, cramping, or diarrhea. Because
the amount of barium you swallow will be very small (i. e. , 2 tablespoons), the likelihood

of inhaling the barium substance into your lungs (aspiration) or experiencing adverse reac-

tions is rare. Upon completion of this procedure, there will be no restrictions on normal
activities.

As a precautionary measure, you will not be allowed to participate in this study if you have
(1) a known obstruction of the colon, (2) a suspected or impendin gastrointestinal perfora-
tion, (3) a known hypersensitivity to barium sulfate products, (4) bronchial asthma, (5) a
history of multiple (greater than three) food or drug allergies, (6) a history of allergies
as evidenced by hayfever and eczema, or (7) used medications that contain a topical anes-
thetic agent like those in mouthwashes (i. e. , Listerine), sore throat products (i. e. ,
Cepacol, Vicks, Cepastat and Chloraseptic), cough medicines, or products for tooth or gum

pain (i. e. ,Orajel, Orabase, Anebesol) within one to two hours prior to participation in
the videofluoroscopy x-ray procedure.

High doses of’ radiation and long-term radiation exposure have been associated with the
development of some malignancies and contribute to overall lifetime cancer risk. According
to the Chief of Radiology, there are no immediate complications or conceived risk of long-
term complications associated with radiation exposure from the videofluoroscopy x-ray
procedure. The radiation exposure will be significantly less than that obtained from a
common chest x-ray. Total duration of radiation exposure from the videofluoroscopy x-ray
procedure will not exceed five minutes and will most likely be less than two minutes.

BENEFITS: Identification of the aging characteristics of swallowing may not directly
benefit you, but may benefit health professionals working with older adults. Through the
knowledge gained from understanding the aging swallow, guidelines for assessment, treat-

ment and management of adults with swallowing disorders can be developed, strengthened,
and implemented.

 

 

:L'r:o1 0’ 1 o 8 6 0 u s GPO 1991-052204020503 Page

 

90

 

\‘i‘ Department of Veterans Affairs VAEREEZErfiifluEth gagegEN-l) FORM

 

Subject Name: Date

 

Title of Study: The Effects of Aqinq on Selected Parameters of Orooharvngeal Swallowing

Principal Investigator: Debra 519950”, M.A., CCC'SLP VAMC: Battle Creek, MI
Ph.D. Candidate, MSU

PARTICIPATION/RIGHTS: Physician's consent will be obtained prior to your participation in
this study. Participation in this study can be completed in one or two sessions. The total

amount of time required for participation in the study is estimated to be 45 minutes to one
hour.

I am aware that participation in this study is voluntary, and I may withdraw from partici-
pation at any time. I will not be paid for participation in this study, nor will I be
responsible for the costs associatd with the study. I am aware that all results will be
treated with strict confidence. Video pictures presented to outside judges will not be
identified by subject. I will remain anonymous in any report of research findings, and

I will not be associatd with any specific respnses or other data. At my request, research
findings may be made available to me.

If you sustain any injury related to your participation in this study, you are entitled to
any necessary care and treatment. Compensation may also be payable pursuant to Federal

Law under Title 38 U.S. Code, Section 1151, or in some circumstances under the Federal
Tort Claims Act.

If I have any questions regarding my rights as a research subject, Tina Maloney, Pharm.D.,

Chairperson of the Subcommittee on Human Studies, can be contacted at (616) 966-5600,
Ext. 4001.

 

 

30,3911 0'1 0 8 6 .u s GPO 1991-052200120503 hp

91

 

a Department of Veterans Affairs VA RESEARCH CONSENT FORM

(Continuation Page LOIL)

 

Subject Name: Date

 

Title of Study: The Effects of Aging on Selected Parameters of Oropharyngeal Swallowing

Principal Investigator; Debra GleesonJ M.A., CCC-SLP VAMC: Battle Creek, MI
Ph.D. Candidate, MSU

 

 

RESEARCH SUBJ ECTS' RIGHTS: I have read or have had read to me all of the above.
Debra Gleeson, M-A has explained the study to me and answered all of my questions. I have been told

of the risks or discomforts and possible benefits of the study. I have been told of other choices of treatment
available to me. ‘

I understand that i do not have to take part in this study. and my refusal to participate will involve
no penalty or loss of rights to which I am entitled. I may withdraw from this study at any time
without penalty or loss of VA or other benefits to which I am entitled.

The results of this study may be published, but my records will not be revealed unless required by law.

the Medical Officer of the Day
In case there are medical problems or questions. I have been told I can call (MOD ) at $616) 966'5600 :
Ext. 0 (Operator) during the day and the MOD at same number after hours.
If any medical problems occur in connection with this study the VA will provide emergency care.

I understand my rights as a research subject, and I voluntarily consent to participate in this study. I understand
what the study is about and how and why it is being done. I will receive a signed copy of this consent form.

 

 

 

 

 

 

Sub ject’s Signature Date
Signature of Subject’s Representative‘ Subject's Representatives
Signature of Witness Witness (print)

 

Signature of Investigator

‘Oniy required if subject not competent.

 

iF MORE THAN ONE PAGE IS USED. EACH PAGE IVAF IO-IOBGAI MUST BE CONSECUTIVELY NUMBERED AND SIGNED.

::N‘Io::010-1086 . Page 3

 

 

APPENDIX B

HEALTH HISTORY QUESTIONNAIRE

SUBJECT:
BIRTHDATE:

Ill'll llllE"|ll'l:

92

HEALTH HISTORY QUESTIONNAIRE

 

 

 

SEX:

“I am going to ask you some questions about your health history. I will read each
question carefully to you and you are to answer each question with a YES or M).
If you do not know, I will check with your physician and your medical records to
determine the correct answer. If you do not understand the question or need me to
repeat or explain the question, be sure to let me know. Do you have any questions?

Let’s begin."

A.

599°F‘9’9‘99’Nr‘

Alzheimer’s disease
Amyotrophic lateral sclerosis
Aspiration pneumonia
Bronchial asthma

Cancer of the mouth, throat, or esophagus

Cerebral palsy

Cervical spur

Cleft lip or palate

Colon obstruction
Dermatomyositis

IDDM or NIDDM

Dysphagia (difficulty swallowing)
Encephalitis

Esophageal reflux, rings, webs, or
eSOphagitis

Food or drug allergy (more than 3)
Friedreich’s ataxia
Gastrointestinal perforation
Guillain-Barre syndrome

Head trauma (or TBI)

Heart attack

Hiatal hernia

Huntington’s chorea
Hypersensitivity to barium sulfate
Inflammation of the epiglottis
Lupus

Meningitis

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Regarding your medical history, do you presently or have you ever had...

No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No

93

27. Multiple sclerosis Yes No__
28. Muscular dystrophy Yes No—
29. Myasthenia gravis Yes No__
30. Parkinson’s disease Yes No__
31. Poliomyelitis Yes No_
32. Polymyositis Yes No__
33. Scleroderma Yes No_
34. Sjogren’s syndrome Yes No

35. Spinal cord injury Yes No__
36. Stroke (cerebral vascular accident) Yes No__
37. Thyroid hypofunction Yes No—
38. TIA (transient ischemic attack) Yes No_
39. Tumor of the head, neck or mouth Yes No—
40. Wilson’s disease Yes No—
41. Xerostomia (dry mouth) Yes No___
42. Zenker’s diverticulum Yes No—
Other —

 

Regarding your surgical history, have you ever had surgery involving your...

1. Brain Yes No—
2. Esophagus Yes No

3. Face or head Yes No—
4. Heart Yes No—
5. Mouth Yes No

6. Stomach Yes No—
7. Throat, larynx, or neck Yes No__
Other

 

Regarding your speech, do you presently or have you ever had...

1. Difficulty pronouncing sounds Yes_ No__
2. Difficulty expressing ideas Yes_ No__
3. Numbness or tingling in the face Yes No—
4. Slurred speech Yes_ No__
5. Weakness in the facial area Yes_ No__
Other

 

Regarding your voice, do you presently or have you ever had...

1. Extremely breathy voice Yes_ No—
2. Extremely hoarse or harsh voice Yes_ No___
3. Pain in your throat Yes_ No—
4. Periods of voice loss Yes_ No__
5. Wet/gurgly voice quality Yes_ No—
Other

 

94

E. Regarding your swallowing, do you presently or have you ever had...

1. Choking episodes when swallowing Yes_ No_
2. Coughing episodes when swallowing Yes_ No__
3. Difficulty controlling saliva Yes_ No_
4. Difficulty swallowing liquids Yes_ No_
5. Difficulty swallowing solids Yes_ No—
6. Food leakage from mouth or nose Yes_ No—
7. Pain while swallowing Yes_ No—
Other

 

F. In addition, Do you...

1.

SUMMARY:

PASS

Frequently use medications that contain a topical anesthetic agent like
those in mouthwashes (Listerine), sore throat products (Cepacol,
Vicks, Cepastat and Chloraseptic), cough medicines, or products for
tooth or gum pain (Orajel, Orabase, Anebesol)?

Yes No

Have any other conditions or concerns you feel I should know about?
Yes No

 

 

 

Number of E5 responses l68
Number of NO responses [68

FAIL

APPENDIX C

STRUCTURAL AND PHYSIOLOGIC DYSPHAGIA SCREENING COMPONENTS

95

Table C1: Structural and physiologic dysphagia screening components.

 

Category

Dysphagia Screening Component

 

Mandible

Elevation, depression
Lateralization, protrusion

 

Lips

Sensation

Retraction, protrusion
Symmetry

Seal, strength

 

Tongue

Sensation

Protrusion, retraction
Elevation, depression
Lateralization
Anterior tongue DDK
Posterior tongue DDK
Strength, symmetry

 

Palate

Sensation, symmetry
Velar elevation
Gag reflex

 

Larynx

Voluntary cough, reflexive cough, throat clearing
Involuntary swallow

Voluntary dry swallow

Voluntary liquid swallow

Laryngeal elevation

 

Voice

Quality

Pitch

Intensity

Sustained phonation

 

Speech

Intelligibility
Rate
Articulation

 

Respiration/other

 

 

Breathing pattern
Rate

Saliva control
Posture

 

 

 

APPENDIX D

DYSPHAGIA SCREENING INSTRUMENT

96
DYSPHAGIA SCREENING INSTRUMENT

SUBJECT: DATE:
BIRTHDATE: AGE: SEX:

 

Smn'ngfltecflons: For each task completed correctly, immediately and without
cues, assign a score of '1." For each task completed incorrectly, with significant
delay or with verbal/tactile cues, assign a score of '0.” Total possible score is 15.
Passing score is 15.

SCQBEIASIS

1. Lingual sensation-Detect light touch applied with cotton-
tipped swab to anterior 2/3 and posterior 1/3 of tongue.

2. Lingual strength-Actively resist moderate anterior tongue tip
pressure applied with tongue depressor.

3. Lingual elevationuTouch tongue tip to upper lip and alveolar
ndge.

4. Lingual Iateralization—Demonstrate full range of tongue tip

movement from one corner of the mouth to the other corner.

5. Posterior tongue movement—Elevate back of tongue to
articulate /k/ 10 times in 5 seconds.

6. Lingual symmetry--Tongue symmetrical at rest and when
protruded past lips.

7. Labial seal-Close lips tightly and hold 5 cc of water in mouth
with no observable leakage.

8. Voluntary cough—Initiate and demonstrate sharp cough and

sharp glottal attack on the vowel la].

9. Involuntary swallow-Observable swallow on 2 occasions
within 2 minutes.

10. Voluntary dry swallow—Initiate 3 consecutive dry swallows
within 10 seconds.

11. Voluntary liquid swallow—Demonstrate swallow of 5 cc of
water within 5 seconds.

12. Laryngeal elevation-Elevation of larynx observed and
palpated during dry or liquid swallow.

13. Reflexive cough—Absence of reflexive cough after swallowing
5 cc of water.

14. Vocal quality-Absence of wet/gurgly voice quality during
phonation of la/ after swallowing 5 cc of water.

15. Saliva control-No observable drool or dribble.

= TOTAL SCORE PASS___ FAIL___

 

APPENDIX E

VIDEOFLUOROSCOPY PROCEDURE

‘k-Wfl

97
VIDEOFLUOROSCOPY PROCEDURE

PRINCIPAL INVESTIGATOR (PI): Debra Gleeson

RADIOLOGIST (R): Dr. Shah

EQUIPMENT REQUIRED.

1. General Electric Prestilix (Model #16903)

2. JVC Super VHS Player/Recorder (#BR8611U)

3. Panasonic Color S—Video Monitor (#CT1383Y)

4. Panasonic Time/Date Generator (#WJ-810)

5. Rehab Tech Videofluoro Swallow Study Chair

6. Super VHS Master Broadcast Videocassette tapes
MATERIALS REQUIRED:

1. E2 paste barium sulfate cream (120% vaol)

2. EZPAQUE liquid barium (95% vaol)

3. Lorna Doone cookies

4. Plastic medicine cups

VIDEOFLUOROSCOPY RECORDINGS:
1. 70-80 KeV

2. Exposure will be limited to < 10 seconds for each test bolus and < 300
seconds for each subject
3. Distance between fluoroscopy table and tube will remain constant (<
3 feet) for each subject
FOCUS:
1. Subjects are viewed in the lateral plane
2. Visible structures include the lips, teeth, tongue, palate. velum,
mandible, hyoid bone, larynx, and UES
3. Anterior margin—lips
4. Posterior margin-pharyngeal wall
5. Superior margin—hard palate
6. Inferior margin-seventh cervical vertebra
PREPARATION:
1. Pl will prepare fluoroscopy materials prior to subject’s arrival

2 PI will be sure recording equipment is in proper working condition and
ready for recording

3. R will be sure fluoroscopy equipment is in proper working condition

4 Prior to recording, PI will code video tapes by subject number (01-15)
and group membership (1 = 50-55 years; 2 = 6065 years; 3 = 70-75
years)

 

98

LIQUID BARIUM PROCEDURES:

1.
2.

9° New

Subjects will stand or sit in Rehab Tech Videofluoro swallow study
chair if physical limitations prohibit standing

Subjects will be asked if they used medications that contain a topical
anesthetic agent like those in mouthwashes (i.e., Listerine), sore throat
products (i.e., Cepacol, VICkS. Cepastat, and Chloraseptic), cough
medicines, or products for tooth or gum pain (i.e., Orajel, Orabase,
Anebesol) during the last 2 hours

PI will give 5 ml liquid barium in plastic medicine cup to subject

Pl will instruct subject, ”Put the barium in your mouth and hold it until
I say swallow. When I say swallow, I want you to swallow all of the
barium as normally and naturally as possible. Be sure to wait until I
say swallow"

R will activate fluoroscopy at Pl’s command, Ready

Pl will give the command to swallow

R will deactivate fluoroscopy when the bolus tail passes through the
UES and at Pl’s command to stop

Above procedure will be repeated two more times for a total of three
swallows of liquid barium

BARIUM COOKIE PROCEDURE:

1.
2.

9’ 9‘9.“

Pl will give subject 1/2 of a Lorna Doone cookie with 2 ml of barium
paste coated on top

PI will instruct subject, “Put the cookie in your mouth and chew it up.
When you are ready to swallow it, raise your hand. When I say
swallow, go ahead and swallow the cookie as naturally and normally
as possible. Be sure to wait until I say swallow"

R will activate fluoroscopy at Pl’s command, Ready

PI will give subject command to swallow

R will deactivate fluoroscopy when the bolus tail passes through the
UES and at Pl’s command to stop

The above procedure will be repeated two more times for a total of
three swallows of barium-paste-coated cookie

LIST OF REFERENCES

“P-.. [HWY

 

M

LIST OF REFERENCES

Aronson. A- E. (1990). Won
(3rd ed.). New York: Thieme.

Bach, A. Lederer, F., &D.,inolt R. (1941). Senile changes In the laryngeal

Basmajian, J. V., 8. Dutta, C. R. (1961). Electromyography of the pharyngeal
constrictors and levator palatini' In man. Anatommaecom, 139, 561-563.

Bastian, R. W. (1991). Videoendoscopic evaluation of patients with dysphagia:

An adjunct to the modified barium swallow. Qtolaryngologyfieaiand
Neckfiumenc 1MB). 339-350.

Baum, B. J. (1981). Evaluation of stimulated parotid saliva flow rates in different
age QVOUPS- JoumaLoIDentaLBesearch. 60. 1292-1296.

Baum, B. J., & Bodner, L. (1983). Aging and oral motor function: Evidence for

altered performance among older persons. JoumamLQentaLBeseamh,
62(1). 2-6.

Bisch, E. M.. Logemann, J. A., Rademaker, A. W., Kahrilas, P. J., & Lazarus, C.
L. (1994). Pharyngeal effects of bolus volume, viscosity, and temperature
in patients with dysphagia resulting from neurologic impairment and' In

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