mama

.
a

 

 

 

, . 5|
. 3a 13% . ‘
Al I. XI. ' C A
. It. {\tbnwhuptflulfli.tanu.
. A $61.“... :1.

IA h“ F .
r. ; ii n.
if... (13%;. .
a. 33!... El: .
H1 a. 5.3...“ vatmfiklfw
fit ti ,. ft 1!; «
.Jfi_\..l..1.v.?lu:a 9!! I! gun—t
tum]?! 31.25%!
ohtsvouhpf\:viu 37!. 4 l
45.!!hv..,,i&
{a 3.. .
‘71 t v“
axfluwu...

I!
1! 7

1... turuun‘...
:2 iv. 2r
3 ,ll .. ,

131...?
‘ A .3thpxzn
a. 51. r.
3.3.5.3.» 1.3....
’31v‘vt“.

A Y

. .
‘ 1..de
.51).. :4» x...

 

WEE-am
lo 0 7

This is to certify that the
dissertation entitled

THE EFFECTS OF AGING ON OROPHARYNGEAL
SWALLOW DURATION IN NONDYSPHAGIC WOMEN

presented by
' RUTH RENEE HANNIBAL

has been accepted towards fulfillment
of the requirements for the

PH.D. degree in COMMUNICATIVE SCIENCES
AND DISORDERS

 

 

Pei CA;

Major Professor’s‘SignatJFe

BQCzb—cLS/t [Lil 200é

Date

MSU is an Afi‘innative Action/Equal Opportunity Institution

 

LIBRARY
Michigan State
University

 

 

 

_t-....-.-.—.-.-.-.-.--.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.—

on-.-.-.-.---.--.-c-.-o---o---.-._ _.- ._

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2/05 p:/CIRCIDaleDue.indd-p.l

 

 

THE EFFECTS OF AGING ON OROPHARYNGEAL SWALLOW DURATION IN
NONDYSPHAGIC WOMEN
By

Ruth Renee Hannibal

A DISSERTATION
Submitted to
Michigan State University

in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Communicative Sciences and Disorders

2006

ABSTRACT
THE EFFECTS OF AGING ON OROPHARYNGEAL SWALLOW DURATION IN
NONDYSPHAGIC WOMEN
By

Ruth Renee Hannibal

In order for speech-language pathologists to understand how to diagnose
and effectively treat dysphagia. it is imperative that they have a thorough
understanding of the normal swallow. This cross-sectional research study was
designed to examine whether aging influenced nondysphagic women's
swallowing status and whether nondysphagic women’s perceptions aging and
swallowing changed as people aged. In addition, this study examined whether
the use of Cervical auscultation was reliable in detecting changes in normal
swallowing sounds as women age.

Fifty-five adult women distributed in three different age groups were
participants: Group 1(20-29), Group 2(40-49), and Group 3 (60-95). The
participants completed a Medical Health Questionnaire which indicated normal
oropharyngeal swallowing history and which ruled out any conditions that would
likely contribute to dysphagia.

Chi-square analysis of the Swallowing Status Questionnaire (questions
SSQ1-SSQ7) revealed that across groups there was a significant difference
between the responses given as “rarely” compared to any of the other

responses. The vast majority of participants regardless of age, reported to have

no difficulty with chewing and swallowing skills. In addition, the response
between the three age groups on any of the seven questions indicated no
significant differences. Thus, the participants perceived their eating and drinking
skills to be normal. Regarding their perceptions of aging on swallowing, the
youngest group indicated that aging would likely affect one’s ability to chew and
swallow, while the remaining two groups reported that aging did not affect ones’
Chewing and swallowing abilities.

To determine reliability using cervical auscultation, participants completed
three trials of liquids (5cc) and three cracker trials during both the training period
and the experimental study. Results of the training period revealed inter-rater
reliability was 100%. Reliability during the study revealed the investigator judged
all 60 swallowing sounds to be normal. The raterjudged the first 24 sounds as
‘unable to detect’. While the investigator and rater did not agree on any of the
first four participants’ swallow sounds, the raters had perfect agreement with the
remaining six participants. Thus, cervical auscultation was viewed as a reliable

screening adjunct to the clinical swallowing examination.

Copyright
Ruth Renee Hannibal
2006

Thanks family and friends for your prayers and support throughout this process

ACKNOWLEDGEMENTS

This study was approved by the University Committee on Research
involving Human Subjects (UCRIHS) # 00-473 at Michigan State University and
the Institutional Review Board (IRB) # 00657-2001 at Valdosta State University in
Valdosta, Georgia. It would be unthinkable to acknowledge and thank everyone
without giving honor and reverence to my Lord and Savior Jesus Christ who is
the head of my life. Thanks to everyone in Norway, South Carolina and
especially the Norway Senior Citizens’ Club in Norway, South Carolina.
Additionally, I wish to thank the faculty, staff, and students in the Department of
Special Education and Communication Disorders at Valdosta State University,
and the women at Victory Temple Evangelistic Center for allowing me to collect
my data. I Would like to thank Dr. Leo Deal who stood as the Gate Keeper since I
first enrolled at Michigan State. He has given me his unrelenting time and
support and I thank him through all of the seasons of working towards the
doctoral degree. Thank you Dr. Michael Wieting for all of the knowledge you
have shared and for all of the telephone calls you made to make sure things
were going smoothly. I wish to also thank Dr. Ida Stockman for her support and
words of encouragement. Lastly, to Dr. Paul Cooke, when all seemed impossible,
he stepped in and picked up the pieces and got me going in the right direction.
Under his leadership the process of my dissertation has come to fruition. I thank
him for his time, patience, dedication, and passion in helping me to complete the
quest for my Ph.D.

vi

TABLE OF CONTENTS

LIST OF TABLES ................................................................................................ ix
LIST OF FIGURES ............................................................................................... x
CHAPTER I
INTRODUCTION .................................................................................................. 1
Statement of the Problem ........................................................................... 3
Purpose of the Study .................................................................................. 8
CHAPTER II
REVIEW OF THE LITERATURE .......................................................................... 9
Normal Swallow ........................................................................................ 10
Stages of Normal Swallow ............................................................ 12
Oral Preparatory Stage ................................................................. 12
Oral Stage .................................................................................... 14
Pharyngeal Stage ......................................................................... 1 5
Esophageal Stage ........................................................................ 16
The Effects of Aging on Normal Swallowing ............................................ 16
Oral Cavity Changes ..................................................................... 17
Pharyngeal Cavity Changes ......................................................... 23
Esophageal Cavity Changes ........................................................ 23
Neurogenic Swallowing Disorders ................................................... 24
The Clinical Swallowing Examination ...................................................... 29
Cervical Auscultation ................................................................................ 34
Speculations on Physiologic Cause of Swallowing ....................... 34
Cardiac and Vocal Tract Analogy Hypothesis ............................... 35
CHAPTER III
METHOD ............................................................................................................ 40
Participants ............................................................................................... 40
Data Collection ......................................................................................... 41
Medical History Questionnaire ...................................................... 41
Swallowing Status Questionnaire .................................................. 42

vii

Clinical Swallowing Examination and Cervical Auscultation ................................ 43

Structure of the Oral Cavity ................................................................................. 44

Facial Symmetry/face at Rest ....................................................... 44

Lip Closure ................................................................................... 44

Lingual Size ................................................................................... 44

Tongue at Rest .............................................................................. 44

Hard Palate ................................................................................... 44

Soft Palate at Rest ......................................................................... 45

Condition of Teeth ......................................................................... 45

Function of the Oral Structures ................................................................ 45

Labial Protrusion ........................................................................... 45

Labial Retraction ............................................................................ 45

Labial Range of Motion .................................................................. 45

Labial Strength .............................................................................. 45

Labial Seal ..................................................................................... 45

Lingual Protrusion .......................................................................... 46

Lingual Retraction .......................................................................... 46

Lingual Strength ............................................................................. 46

Lingual Elevation .......................................................................... 46

Lingual Depression ........................................................................ 46

Lingual Range of Motion/Lateralization .......................................... 46

Velar Elevation .............................................................................. 46

Jaw at Rest and During Movement ................................................ 46

Gag Reflex ..................................................................................... 47

Volitional Cough ............................................................................. 47

Trial Swallows and Cervical Auscultation ................................................. 47

Scoring of Clinical Swallowing Examination ............................................. 48

Inter-rater Reliability during Training Period ............................................. 49

Equipment and Materials .......................................................................... 49
CHAPTER IV

RESULTS ........................................................................................................... 51

Medical Health Questionnaire .................................................................. 52

Swallowing Status Questionnaire ............................................................. 52

Clinical Swallowing Examination and Cervical Auscultation ..................... 64

viii

Reliability .................................................................................................. 65

CHAPTER V

DISCUSSION ...................................................................................................... 67
Significance and Clinical Implications ................... ‘ .................................... 6 8
Limitations and Future Research ............................................................. 70
Conclusions .............................................................................................. 74

APPENDICES ..................................................................................................... 75
A. Letter to Prospective Referral Sources .......................................... 77
B. Written-Oral Script ........................................................................ 79
C. Research Consent Form ............................................................... 81
D. Medical History Questionnaire ....................................................... 84
E. Swallowing Status Questionnaire ................................................. 86
F. Clinical Swallowing Examination ................................................... 88

REFERENCES .................................................................................................... 91

LIST OF TABLES

1. Ethnicity, total number of participants and mean ages across groups ........... 54

LIST OF FIGURES

1. Group mean percentages of responses across three age groups for SSQ1
(In general, do you cough after drinking liquids?) .................................... 55

N

. Group mean percentages of responses across three age groups for $802
(In general, do you cough after swallowing foods?) ................................ 56

OD

. Group mean percentages of responses across three age groups for $803
(In general, do you cough after swallowing saliva?) ................................ 57

4. Group mean percentages of responses across three age groups for SSQ4
(In general, do you take small drinks of liquids to avoid coughing?) ........... 58

5. Group mean percentages of responses across three age groups for SSQ5
(In general, do you eat small bites of food to avoid coughing?) ............... 59

6. Group mean percentages of responses across three age groups for SSQ6
(In general, do you experience pain while swallowing?) ........................ 6O

7. Group mean percentages of responses across three age groups for SSQ7
(In general, do you experience heartburn or indigestion
following meals?) ......................................................................... 61
8. Group mean percentages of responses across three age groups for SSQ8
(Does getting older affect one’s ability to swallow?) .............................. 62

9. Group mean percentages of responses across three age groups for SSQ9
(Does getting older affect one’s ability to chew?) ................................. 63

10. Group mean percentages of responses across three age groups for
SSQ1-SSQ7 ............................................................................... 64

11. Group mean percentages of responses across three age groups for
8808-8809 ............................................................................... 65

xi

CHAPTER I
INTRODUCTION

Deglutition is defined as “the act of swallowing” (Dirckx, 2001, p. 253). It
may be initiated voluntarily or involuntarily (Murray & Carrau, 2001). Miller (1986)
specifically described deglutition as “the semiautomatic motor action of the
muscles of the respiratory and gastrointestinal tracts to propel food from the oral
cavity to the stomach” (p. 91). The study of the normal swallow is important
because of issues related to the quality of life, morbidity, and mortality (Horner &
Massey, 1988). It is also important to the natural enjoyment of foods and liquids.
When dysphagia (a swallowing disorder) occurs, the quality of life may change in
a number of ways such as aspiration (which may lead to aspiration pneumonia)
and dehydration and malnutrition (which may lead to weight loss).

The normal swallow is a complex physiologic process that results from
interacting cranial and parasympathetic nerves and skeletal and smooth muscles
(Bass, 1997; Cherney & O’Neill, 1986; Crary & Groher, 2003). Swallowing
requires over 40 pairs of muscles that must be coordinated and work smoothly
together in order to ensure a safe and efficient swallow (Bass, 1997; Perlman &
Christenen, 1997). During the normal swallow, food is propelled from the oral
cavity to the stomach safely and efficiently. The motor action of swallowing
removes secretions and particles from the upper respiratory tract and protects
the tract from aspiration (Bass, 1997; Dray, Hillel, & Miller, 1998; Miller, 1986).

The normal swallow, however, can become compromised or interrupted
because of symptoms such as reduced tongue base control, reduced pharyngeal

1

contraction, cricopharyngeal dysfunction, or esophageal diverticulum. Although
there are many symptoms and disorders of deglutition, the prevalence of
dysfunction for the entire United States (U. S.) population is unknown (Cherney,
1994; Crary & Groher, 2003; Kuhlemeir, 1994). Researchers are continually
confronted with the challenge of determining appropriate definitions and
parameters for normal deglutition. There are several reasons for this problem, as
explained by Massey and Shaker (1997). First, there are no universally accepted
criteria for defining what is normal. “There are plenty of aspects of deglutition in
which there is no gold standard for, or even overwhelming consensus about,
what is normal” (p.7). A second critical issue is the sample size of the reference
group for determining normalcy. A third issue is the “generalizability of the normal
range for a measured parameter to different study conditions" (p. 7)

The field of communication disorders has advocated for normative data on
swallowing and the inclusion of professional education and training at the
undergraduate and graduate levels. To ensure proficient diagnosis and treatment
of dysphagia, the study of deglutition should be included in the curriculum at both
the undergraduate and graduate levels (Logemann, 1997). She noted that
because 30% to 90% of a speech-language pathologist’s (SLP’s) time in health
care settings is spent working with dysphagic patients, he/she should have a
thorough understanding of the upper aerodigestive tract, respiration, and
dysphagia in order to diagnose and treat dysphagia. Serious problems such as

pneumonia and aspiration can further complicate the patient’s health status.

As the population of the United States continues to increase and to age,
and because of demographic changes, there is a need to conduct‘studies on the
effects of aging in healthy elderly adults across the adult lifespan. Rademaker,
Logemann, Pauloski & Colangelo (1998) indicated the need to establish norms of
the normal swallow across the adult lifespan in order to provide the knowledge
base needed for diagnosing and treating dysphagia. The US population is
getting increasingly older. The number of older Americans will rapidly increase
between 2010 and 2030 when the “baby boomers” reach age 65. Data since the
1930’s shows that women’s life expectancy has been longer than men. In 1991,
there were 19 million women and 12.8 million men over 65 years of age,
corresponding to a gender ratio of 148 women to every 100 men (Lueckenotte,
2000). Since women outlive men, they will require more services by numerous
health care professionals, including speech-language pathologists. Thus, the
inclusion of women in research studies is important.

Statement of the Problem

Normal swallowing is a complex process. It can, however, become
compromised secondary to a number of age-related changes such as arthritis or
cervical osteophytes, laryngeal pathology such as carcinoma, or esophageal
pathology such as Zenker’s diverticulum or esophagitis. Additionally, structural
changes due to surgery or prolonged intubation can cause swallowing disorders.

Studies have suggested that there are changes in the oral motor function
of the elderly and that older individuals take more time to chew and prepare a
bolus for a consistency that is easier to swallow (Sonies, Baum & Shawer, 1984).

3

Further, swallowing begins to slow around age 45 and is significantly slower by
age 70 (Robbins, Hamilton, Loft & Kempster, 1992). Because normative data and
changes in the oral and pharyngeal stages of swallow across the life span in
women are lacking, new studies are needed to accurately diagnosis and treat
dysphagia effectively in this population.

The speech-language pathologist should “have a large, integrated
knowledge base as well as many attributes, skills, and competencies to work
effectively and safely with a range of dysphagic patients" (Logemann, 1997).
Videofluoroscopic Swallow Study (VFSS) and Fiberoptic Endoscopic
Examination of Swallowing (FEES) are two instruments that provide imaging of
the oropharyngeal areas in swallowing and used to diagnosed dysphagia.
\fideofluoroscopy is the most frequently used instrumental procedure for
evaluating deglutition and oropharyngeal dysphagia (Logemann, 1998;
O’Donoghue & Bagnall, 1999). It is considered the “gold standard” for assessing
oropharyngeal function during swallowing because it permits the imaging of rapid
dynamic movements of swallowing (Arvedeson 8 Lefton-Grieft, 1999;
McCullough, Wettz, Rosebek, & Dinneen, 1999; Perlman, 1997; Daniels,
MCAdams, Brailey & Foundas, 1997; Ekberg & Feinberg, 1991; Dodds, Steward
& Logemann, 1990).

The clinician should become more knowledgeable about the purpose and
function of each instrument in order to choose which instrument would give the
best objective information needed in the diagnosis and treatment of swallowing
dysfunction (Logemann, 1998). Each instrument has its own strengths and

4

weaknesses (Mills, 2000). Advances in technology have given clinicians and
researchers a better understanding of complex and physiologic biomechanics of
the swallow mechanism (Perlman, 1997; Sonies & Baum, 1988; Sonies, 1997).
Logemann (1998) reported that videofluoroscopy enables visualization of (1) the
oral cavity during chewing and the oral stage of swallowing; (2) the triggering of
the pharyngeal swallow in relation to position of the bolus; and (3) the motor
aspects of the pharyngeal swallow, including movements of the larynx, hyoid,
tongue base, pharyngeal walls, and cricopharyngeal region (pp. 60-61). With
videofluoroscopy, the clinician can observe the movement of a bolus in sagittal
and antero-posterior positions. Further, VFSS allows the clinician to analyze
information frame-by-frame and follow the path of the bolus from the oral cavity
via the esophagus to the stomach. Kendall, McKenzie, & Leonard (1997)
indicated that “Objective data can also facilitate interpretations of greater
subtlety; increasing our understanding of swallow dynamics and leading to more
tailored and appropriate interventions” (p. 101).

Although videofluoroscopy is the “gold” standard for evaluating the
swallow mechanism, it is also a costly procedure. Aviv et al. (2000) conducted a
study designed to determine cost effectiveness of two instruments used to
diagnose dysphagia: the modified barium swallow (MBS) procedure and flexible
endoscopic evaluation of swallowing with sensory testing (FEEST) in 30 hospital
head and neck cancer patients. The patients ranged in ages from 50 to 80 years.
Half of the patients were diagnosed by MBS and half by F EEST. Results
revealed the MBS generated 40% more reimbursement ($451.00) than did the

S

inpatient first consult using F EEST ($321.23). Further, other cost factors must be
considered such as the number of personnel required (e.g., persons who
transport patients, radiologists, radiology technicians) and their salaries.
Additionally, equipment cost and repair, overhead, and disposal supplies such as
barium and x-ray film contribute to the overall costs of these procedures.

With the rise in health care costs, many medical facilities have sought
different avenues to provide quality services in cost effective ways. Cervical
auscultation is a noninvasive clinical process that is gaining recognition and
credibility among speech-language pathologists as a means of detectingclinical
signs of dysphagia (Cichero & Murdoch, 2002; Cichero & Murdoch, 1998;
Nilsson, Ekberg, Olsson, Kjellin & Hindfelt, 1996; Hamlet, Penny & Formolo,
1994; Takahashi, Groher & Michi, 1994a; and Takahashi, Groher & Michi,
1994b). A variety of instruments have been used (eg. accelerometer, a
sonograph with Doppler, a laryngeal microphone, and a stethoscope) placed at
specific sites (trachea or larynx) to detect acoustic data about the swallow
(Zenner, 2000). The most widely used instrument in cervical auscultation is the
stethoscope. It is inexpensive and can be performed at bedside by a health care
provider trained in listening to swallowing sounds.

The US. demographics show that women outlive men; therefore, they will
rely more on the medical profession as they age. With changes in body mass,
increased risk of osteoporosis and changes in health care policy, there is a need

to study the variability of normal swallowing of women across the life span.

Historically, women have not been included in biomedical and longitudinal
research. The Baltimore Study Longitudinal Study began in 1958 and was a
pioneer study that provided information concerning the elderly. One limitation to
that study was that the data were based on findings from a male population and
generalizations were made to women and minorities. It was not until the 19805
that women were included in the study (Ebersole & Hess, 1998). When the US.
demographics are taken into consideration, the 2000 census reported that there
were 14.4 million men and 20.6 million women who were age 65 and over putting
the male-female ratio at 0.721 (Hetzel & Smith, 2000). Overall, the male-female
ratio decreases as age increases. In the 65-to-74 age group, the male-female
ratio was 0.82:1 while in the 75-to 84 age group it was 0.65:1. For the old-old
group, 85 years and older, the male-female ratio was 0.41:1. To address the lack
of studies v'Vith women and minorities, NIH (1994) issued guidelines for including
women and minorities in clinical research. Specifically, it states that “It is
important, however, that women and minorities be included in clinical research if
scientists are to make valid inferences about health and disease in these groups
(National Institutes of Health, NIH Publication No. 97-4160, 1994, p.14). Because
normative data of the changes in the oral and pharyngeal stages of swallow
across the life span in women are lacking, new studies are needed to accurately
diagnose and effectively treat dysphagia.

With the increased number of elderly who have dysphagia and related
illnesses, cost containment is a factor in patient care. Therefore SLPs must be
innovative and knowledgeable about using noninvasive methods in addition to

7

VFSS and FEES to evaluate dysphagia. Changes in Medicare reimbursement
have prompted many facilities to be vigilant about providing quality services to
their patients in a cost effective way. In many settings such as long-term care
facilities, the use of videofluoroscopy is limited due to such factors as patient’s
medical status and/ or location of a facility. There is a growing need in the area of
dysphagia management to use noninvasive methods such as cervical
auscultation as an adjunct to the clinical swallowing examination as a means of
qualifying, quantifying, and detective clinical signs of dysphagia (Cichero &
Murdoch, 2002; Cichero & Murdoch, 1998; Nilsson, Ekberg, Olsson, Kjellin &
Hindfelt, 1996; Hamlet, Penny & Formolo, 1994; Takahashi, Groher & Michi,
1994a; and Takahashi, Groher & Michi, 1994b).
Purpose of the Study

A prerequisite to evaluating the nature and extent of dysphagia in persons
with swallowing disorders is to understand the nature of swallowing in persons
without swallowing disorders. This study addressed the following questions: (1)
Does aging change nondysphagic women’s swallowing status across the adult
age span? (2) Does aging change nondysphagic women’s perceptions of
swallowing as they age? and; (3) Is cervical auscultation a reliable screening

adjunct to the clinical swallowing examination?

CHAPTER II
REVIEW OF THE LITERATURE

This chapter provides an extensive review of literature and research
concerning deglutition. It is divided into sections that are relative to (1) normal
swallow, (2) effects of aging on normal swallow, (3) neurogenic swallowing, (4)
the Clinical Swallowing Examination, and (5) cervical auscultation. Schecthter
(1998) reported that “the act of swallowing is the most intricate neuromuscular
action carried out in the body” (p. 525). It includes “an integrated interdependent
group of complex feeding behaviors emerging from interacting cranial nerves of
the brainstem and governed by neural regulatory mechanisms of the medulla as
well as in sensorimotor and limbic cortical systems” (Bass, 1997, p.7).

To provide accurate diagnosis and appropriate treatment of pathologic
swallowing", the SLP must understand the neuromuscular controls of normal
swallow (Perlman & Christensen, 1997) and have a thorough understanding of
the normal function of the upper aerodigestive tract (Logemann, 1983; 1997;
1998). In the healthy adult, the chewing and swallowing sequence is performed
by highly intricate coordination of the muscles and cranial nerves involved in
swallowing. An individual can talk, chew, and drink liquids all at the same time
while a portion of the food is held in the mouth (Bass, 1997).

When dysphagia occurs, the individual’s quality of life may change.
Individuals may experience coughing, choking, and aspiration during meals.
When an individual has frequent episodes of aspiration and an inability to expel
foreign material, the quality of life may be diminished (Murry & Carrau, 2001).

9

Individuals may be able to cough and protect the ainNay of the aspirant. Although
the cough is one of the most important mechanisms for airway protection and
maintenance (Murray, 1999), it should be noted that it may not always be a
reliable indicator of dysphagia in those individuals with decreased sensitivity to
pharyngeal problems or those with compromised health issues.

When pulmonary infections occur because of chronic and acute aspiration
and/or resultant pneumonia, a decrease in health status occurs. Patients with
neurologic impairments often have difficulty swallowing liquids and ingesting food
safely and efficiently. When individuals do not ingest enough liquids or when they
have difficulty swallowing liquids, a negative fluid balance results (dehydration).
When a person does not safely ingest enough food for nutritional needs because
of neurologic disease or other swallowing disorders, dehydration and malnutrition
may occur which lead to weight loss and can be severe enough to cause
weakness leading to decrease in activities that are performed routinely and on a
daily basis (activities of daily living, Dirckx, 2001). Thus, continuous weight loss
may be an indication of a swallowing disorder (Murry & Carrau, 2001).

Normal Swallow

The normal swallow is a complex, physiologic action. It requires
integration and execution of neural and muscular events and intact anatomy. The
normal swallow is a continuous motor action of food being propelled from the oral '
cavity to the stomach. Accurate diagnosis and appropriate treatment of
dysphagia first requires that the SLP has an understanding of the neuromuscular
controls of the normal swallow (Perlman & Christensen, 1997).

10

The upper aerodigestive tract is “a series of tubes and valves that must
open or close at appropriate times during the swallow” (Logemann, 1997, p.
232). The upper aerodigestive tract consists of the nasal cavity, oral cavity,
pharynx, larynx, and cervical esophagus. It serves three functions: respiration,
swallowing, and speaking (Logemann, 1997). The nares, at the base of the
external nose, allow access to the nasal cavity. The nasal cavity is primarily
responsible for the passage of air. The velopharyngeal valve (the entry to the
nose from the pharynx) is normally closed during swallowing.

U The oral cavity consists of the lips anteriorly, teeth, hard and soft palates,
uvula, faucial arches, tongue, the palatine tonsils, and mandible. The lips are
responsible for keeping food and liquids in the mouth during chewing and ‘
swallowing. The teeth assist in bolus formation. The tongue, divided into oral and
pharyngeal portions, has a role in swallowing and speaking. The pharyngeal
tongue, extending from the soft palate to the hyoid bone and valleculae, applies
pressure to the food bolus and propels it posteriorly to the esophagus
(Logemann, 1998).

The larynx, trachea, bronchi, and lungs are situated superiorly to the
airway. The larynx serves three basic functions: protection, respiratory, and
phonatory (Sasaki & Isaacson, 1988). Its primary biologic function is that of
protecting the airway during swallowing. Three valves in the larynx are
responsible for closing during the swallow: the true vocal folds, the arytenoid

cartilages (with the false vocal folds and the base of the epiglottis), and the

11

epiglottis (Logemann, 1997). When the larynx is closed, it protects foreign matter
from entering the airway.

The pharynx lies at the confluence of the upper digestive and respiratory
tracts which allows for airflow during respiration and for bolus flow during
deglutition. The pharynx closes briefly during swallowing. It is located behind the
nose, mouth, and larynx (Bass, 1997) and consists of the superior, medial, and
inferior‘pharyngeal constrictors. The pharyngeal constrictors form the pyriforrn
sinuses which, along with the vallecula, are known as the pharyngeal recesses.
These recesses form the normal pathway for food to pass through the pharynx
during swallowing. During deglutition, the pharynx moves the bolus from the oral
cavity into the esophagus without allowing nasal regurgitation or aspiration into
the lungs. Normal flow of bolus is aboral and abnormal if retrograde (Siebens,

1 990).
Stages of Normal Swallow

Although normal swallow is divided into four stages (oral preparatory, oral,
pharyngeal, esoohageal), it is best understood as one integrated behavior with
four distinct components. It is a continuous motor action of food or liquids being
propelled from the oral cavity to the stomach. The normal swallow will be
discussed in the aforementioned four stages.

Oral Preparatory Stage

The oral preparatory stage, the initial stage of the swallowing process,
begins when the liquid and/or food bolus is brought to the mouth for mastication
and deglutition. If the material is for the purpose of mastication, it must be mixed

12

with saliva in preparation for bolus formation and flow. Mansson and Sanburg
(1975) indicated that there must be an adequate amount of saliva in the oral
cavity for preparation of “dry swallow" and bolus formation. Once the food is
placed in the mouth, a lip seal is formed by action of the orbiculais oris,
buccinator muscles and by placement of the tongue tip against the alveolar ridge
by the genioglossus. The orbicularis oris, buccal tone, genioglossus action and
oral cavity pressure prevent drooling and keep the bolus from falling into the
anterior and lateral sulci as the pressure in the oral cavity increases.

Logemann (1993) indicated that the action of the tongue (which is
complimented by the masseters, temporalis, and internal and external ptyergoid
muscles) collects the food onto the teeth for mastication, retrieves the bolus from
the teeth, mixes it with saliva to form a cohesive bolus, and then returns it to the
teeth. The intrinsic muscles of the tongue facilitate mastication of the bolus. The
food is chewed in a lateral rotary fashion. Lingual shaping brings the food and
liquid together on the dorsal tongue before sealing it against the hard palate.

The contraction of the palatoglossus muscles lowers the soft palate to the
tongue and forms a seal to prevent the material from prematurely spilling into the
pharynx. During this time the larynx and pharynx are at rest. Nasal breathing
continues until the voluntary swallow is initiated (Logemann, 1983). Toward the
end of the oral preparatory stage, the tongue brings the food together in a bolus.
The oral preparatory stage is under voluntary and cognitive control (Cherney,

1994; Hardy & Robinson, 1993; Lazarus, 1989; Logemann, 1993). Additionally,

13

this stage, along with the oral stage, is sensitive to abnormalities of cognition
and/orbehavior changes.
Oral Stage

The oral stage of normal swallow begins when the bolus is transported
posteriorly in the oral cavity, and triggers the pharyngeal swallow. Structures
involved in manipulation of the food bolus are the teeth, tongue, lips, jaw, soft
palate, muscles of mastication and buccal muscles. The primary muscles
involved in chewing are the masseters, temporalis, and pterygoid muscles (Bass,
1997). The major responsibility of the massester is to close the jaw while the
temporalis moves the jaw up, forward, or backward. The pterygoid muscles and
the temporalis muscles elevate the velum (Perlman & Christensen, 1997). The
lateral pterygoid muscles depress the mandible during mastication. Both sets of
pterygoid muscles work together in food mastication (Bass, 1997; Perlman &
Christensen, 1997; Corbin-Lewis, Liss, Sciortino, 2005).

Lingual mixing continues by action of the intrinsic muscles for the purpose
of bolus formation. The tongue elevates to the hard palate to move the bolus
posteriorly in an anterior-posterior rolling action. Anterior-to-posterior elevation of
the tongue squeezes the bolus toward the pharynx by contraction of the
genioglossus, geniohyoid, hyoglossus, anterior and posterior digastricus,
stylohyoid, and styloglossus muscles. Elevation of the velum by the levator veli
palatini, superior pharyngeal constrictor, and palatopharyngeus muscles, seals
the nasopharynx (Siebens, 1990). When the bolus reaches the anterior faucial
arch region, the oral stage ends and the pharyngeal stage begins. The oral

14

stage usually takes 1.0-1.5 seconds to complete (Logemann, 1998) and is under
voluntary control.
Pharyngeal Stage

Once the pharyngeal stage of swallow begins at the anterior faucial arch
region, the anterior portion of the tongue is retracted and depressed, mastication
ceases, and respiration is inhibited momentarily (Bass, 1997). This stage, which
takes approximately one second, is under involuntary control. Any abnormality in
laryngeal structures operating correctly can cause morbidity. As the bolus enters
the pharynx, the leading edge fills the vallecular space; the epiglottis begins to
tilt, and thyrohyoid movement at C1-C3 cause elevation of the hyoid bone and
larynx. “As the hyo-Iaryngeal complex elevates, the floor of the pharynx elevates
with it resulting in a shortening of the pharynx” (Murray, 1999, p. 124). Once the
swallow has been initiated, the tongue prevents food from reentering the-oral
cavity, while the soft palate contracts and elevates resulting in the closure of the
velopharynx. The airway is sealed by action of the intrinsic laryngeal muscles.
The relaxation of the cricopharyngeus muscle, together with the passive opening
of the upper esophageal sphincter, allows the bolus to pass into the esophagus.
The sphincter then closes, and the pharyngeal structures return to their original
position (Cherney, 1992, 1994; Hardy & Robinson, 1993; Palmer, Drennan &
Baba, 2000; Spieker, 2000).
Esophageal Stage

During the esophageal stage the bolus is propelled downward by a
peristaltic wave which is under involuntary neural control (Logemann, 1988). The

15

lower esophageal sphincter relaxes and allows the bolus to move through the
distal esophagus (Cherney, 1992; Cherney & O’Neill, 1986; Palmer et al., 2000;
Schnechter, 1998; Spieker, 2000). Studies show that the range of duration for
bolus travel through the lower esophagus is between eight to 20 seconds in
adults (Logemann, 1993).
Effects of Aging on Normal Swallow
' “Aging is a highly individualized process that affects each person in unique

ways” (McConnell, 1997, p.7). Normal age-related changes in the oropharyngeal
area can affect chewing and swallowing (Logemann, 1993). Aging alone does
not cause swallowing problems severe enough to interfere with functional
swallowing (Cherney 8 O’Neill, 1986); however, some age-related changes might
slow the swallowing process (Robbins, Hamilton, Lof, & Kempster, 1992).
Madison stated that “human aging is influenced by a composite of biologic,
psychologic, social, functional, and spiritual factors” (p.20). Since every
individual is different, the course of aging varies from individual to individual.

The biologic theory of aging suggests that there are physiologic changes
in the body’s structure and function that occur over the lifespan. The age-related
changes occur independently of any external or pathologic influence (Madison,
2000, p. 21). These biologic theories of aging raise questions about factors that
trigger the aging process.

Additionally, the sociologic theories tend to look at the social adaptations
individuals make as they grow older. The circumstances usually determine how
each individual will respond to societal pressures.

l6

Lueckenotte (2000) stated that while a biologic theory is concerned with
physiological processes, the psychologic theory of aging refers to how the
individual copes with the environmental and biologic changes that occur
throughout life. Such Changes might affect learning capacity, memory, feelings,
and intellectual function. The psychologic theory is influenced by both biologic
and sociologic aging factors.

While there are systemic changes that occur throughout the lifespan, there
are also localized changes that occur in the oropharynx and esophagus that may
lead to pathologic conditions. Robbins et al. (1992) contend that swallowing may
have age-related, physiologic, or iatrogenic causes.

With reference to age-related changes and nutritional status, Granieri
(1990) divided the effects of aging into primary, secondary, and tertiary types.
Primary effects occur as a result of the normal aging process, .and secondary
effects result from disease process. Tertiary effects are related to psychological,
environmental, and social factors and changes, which can impact oral intake and
place the older person at increased risk for illness and changes in swallowing
physiology. Hudson 8 Mills (2000) and Sheth 8 Diner (1988) reported that the
ability to chew is unaffected by age but is affected by poor dentition, tooth loss or
dental prosthetics, and atrophy of the alveolar ridge. I
Oral Cavity Changes

While many studies in the field of dysphagia focus on the pharyngeal
phase of swallow because of aspiration risks, few have examined the oral phase
and its effects on swallowing. The oral system is composed of flexible and rigid

l7

tissues (Hudson 8 Mills, 2000). The teeth, mandible, maxilla, temporomandibular
joint (T MJ), and hard palate comprise the rigid elements. The soft palate,
muscles of mastication and tongue comprise the flexible elements. The
increased prevalence of dysphagia in the elderly could be attributed to loss of
motor activity in the oral cavity, pharynx, and larynx. In addition, there also may
be a progressive decrease of sensory capacity in the laryngopharynx with
increasing age (Aviv et al., 1994).

Changes in tongue position and movement are sometimes altered in older
individuals. Atrophic tongue muscles can lead to decreased oral intake and may
affect ingestion and enjoyment of food (Logemann, 1990). With changes in the
tongue, persons may experience difficulty in bolus formation before propelling the
food posteriorly to initiate swallow. Labial posture and weakness can also occur
with aging and cause spillage of material from the oral cavity.

To form a bolus, material must be mixed with saliva (Logemann, 1998).
Johnson and Scott (1993) noted the seven functions of saliva: (1) protect the
teeth and gums and assist with oral hygiene, (2) lubricate food to assist with
chewing and form food into a bolus for ease of swallow, (3) lubricate the tongue
and lips during speech, (4) facilitate taste, (5) destroy micro-organisms and clear
toxic substances, (6) initiate carbohydrate digestion and, (7) regulate acidity in
the esophagus (p.1). Additionally, decreased salivary flow may lead to
xerostomia (dry mouth) and result in difficulty with mastication and swallowing

(Donner 8 Jones, 1991). Although xerostomia associated with normal aging has

18

been reported, age-related salivary dysfunction has not yet been supported by
research (Linton, 1997).

Xerostomia occurs in approximately 20% of the population at or above 65
years of age (Linton, 1997). Xerostomia can lead to many different problems in
the oral cavity including impeded bolus lubrication, mastication, bolus flow, and
decreased oral mucosal and dental health (Leonard, Kendall, Mckenzie 8
Goodrich, 1997). Because of poor bolus flow, residue can remain on the surface
of the tongue and palate and in pharyngeal crevices, placing the individual at risk
for post swallow aspiration. Further, with concomitant xerostomia oral residue
increases bolus viscosity which increases aspiration risk.

There are numerous causes of xerostomia which include (1) obstructive
nasal diseases that promote mouth breathing; (2) drugs (i.e. antidepressants,
anticholing'erics, decongestants, diuretics, antihypertensives, antineoplastics,
antipsychotics); (3) vitamin B complex deficiency; (4) diabetes; (5) dehydration;
(6) anxiety; and (7) fear (Ebersole 8 Hess, 2000; Linton, 1997; Leonard, Kendall,
McKenzie 8 Goodrich, 1997). Several of the above are the result of multiple
medications (whether prescribed or over the counter) secondary to acute and
Chronic illnesses. Ebersole and Hess (2000) further contend that other causes of
xerostomia include radiation therapy (of the head and neck for tumors), blockage
of salivary ducts, parotid gland fibrosis, primary or secondary Sjogren’s
syndrome, defective sensory receptors, and/or impaired cognition (p. 223).

In addition to xerostomia, other causes of oral cavity changes in the
elderly include temporomandibular joint pain, periodontal disease, tooth loss,

19

burning and painful tongue, oral lesions and root caries (Linton, 1997).
Individuals affected by dry mouth may experience altered taste sensation, which
can lead to poor oral intake and weight loss, increased oral pain, dysphagia, and
an inability to Clear bacteria that cause caries. Additionally, oral ulcers may
develop if the individual wears dentures and has decreased lubrication.

Oro-dental health is important for all individuals across the lifespan and is
of particular importance for the elderly (Ebersole 8 Hess, 2000). Dental health of
the elderly is often neglected because it is assumed that older individuals are
edentulous. Tooth loss, however, is not a natural part of the aging process
(Ebersole 8 Hess, 2000). In addition to oral health, it is important to look at
dental factors that can contribute to poor oral health. Poor oro-dental status can
lead to tooth loss, decreased eating pleasure, poor communication skills, and
compromised oral hygiene, which can put the elderly at risk for malnutrition.
Further, loss of teeth limits food choices (Ebersole 8 Hess, 2000).

Ebersole and Hess (2000) reported changes in the buccal cavity that *
occur during the aging process. These changes include (1) teeth becoming
brittle, drier, and of darker color; (2) loss of enamel covering which may cause
teeth to become loose (because of bone loss resorption or a breakdown of the
supporting tissue); (3) gum recession; (4) reduced gingival vascularity; (5)
periodontal tissue loss; (6) alveolar bone atrophy; (7) periodontal disease; and
(8) uneven teeth secondary to years of crushing and grinding wear. In addition to
tooth loss, an individual may find it difficult to chew certain foods because of poor
dentition, ill fitting dental prosthetics, or atrophic changes in the alveolar ridge

20

(Hudson 8 Mills, 2000; Logemann, 1990). Edentulous individuals may choose
food consistencies that are easier for them to chew and which may be deficient in
nutritive value.

Linton (1997) reported that oral cavity disorders seen in the elderly are
frequently caused by systemic, local, and physiological changes. These changes
include hypertension, nutritional deficiencies, dehydration, decreased circulation,
atrophy, decreased glandular secretions, and shortness of breath. Many elderly
individuals suffer from chronic conditions such as hypertension and osteoporosis
both of which lead to nutritional problems.

Since food and liquid are essential for sustaining life and play an important
cultural role, any decrement in gestation becomes problematic. Mealtime remains
a social and interpersonal activity time for many older individuals (Robbins et al.,
1992). Decreased enjoyment of food can also become problematic if there are
other sensory deficits. Wilson (1995) reported a 40 per cent decrement in smell
and taste in the elderly. Ebersole and Hess (2000) and Hensel (2000) reported
age-related losses in fine taste and smell, usually occurring around the sixth
decade. A decrease in smell may compromise the ability to detect food that is
spoiled. In addition, smoking accelerates this process. Brozenec (2000) indicated.
that taste bud atrophy might lead to an inability to discriminate between flavors -
(sour and salty) and cause decreased eating pleasure and poor nutrition.
Malnutrition and starvation may eventually lead to death.

Decreased ability to perform daily living activities associated with eating or
feeding can lead to malnutrition. The individual may not be able to shop for or

21

prepare food and may have decreased strength for eating. “A feeding disorder is
impairment in the process of food transport outside of the alimentary system”
(Crary 8 Groher, 2003, p.1). Decreased strength and coordination, especially of
the dominant hand, could contribute to a feeding disorder.

F ucile et al. (1998) studied the effects of aging on functional eating skills in
79 healthy older individuals ranging in ages 60-97 years and explored the
relationship between denture wearing and food avoidance. Their results revealed
that functional eating skills did not deteriorate with age; the difficulties that
occurred were related to denture use. Rademaker et al. (1998) examined
swallowing variation with age and with liquid bolus volume in women ages 20-89
and found that differences in swallowing function occurred with age. These
differences were related to altered bolus transit time, velopharyngeal closure,
criocopharyngeal opening, laryngeal elevation, and hyoid movement. Sonies et
al. (1988) used ultrasound to assess timing of the oropharngeal‘phase of the
swallow in normal subjects and discovered that, as people age; there was an
increase in swallow duration.

A study by Tracy et al. (1989) evaluated the effect of bolus volume upon
temporal measures of oropharyngeal swallow in normal volunteers in three age
groups (young, middle-aged, and older) of normal subjects. Duration of
pharyngeal swallow response, peristaltic amplitude, and peristaltic velocity
decreased, whereas duration of pharyngeal swallow delay increased across their

three age groups.

22

Pharyngeal Cavity Changes

As with normal oral cavity changes, there are also laryngeal and tracheal
changes that occur due to normal aging. Calcification can cause the cartilage of
the larynx and trachea to stiffen. Additionally, cilia lining the trachea are less
pliable and thus, less effective (Ebersole 8 Hess, 2000).

Decreased muscular tonicity can cause delayed pharyngeal clearing
especially in the pyrifonn sinuses. The pharynx is then susceptible to types of
diverticula formation (Groher, 1997), such as ZenkeI’s and Killian-Jamieson
diverticula, and dysmotility of the pharyngeal muscles. Cervical osteophytes,
tumors, and rheumatoid arthritis can also contribute to pharyngeal changes.
Zenker’s diverticulum is “a pouch that develops in the hypopharynx . . . and
typically forms at the junction of the oblique and circular fibers of the
hypopharynx (Killian’s dehiscence)” (Crary 8 Groher, 2003 p. 97). Killian-
Jamieson diverticulum is “located laterally and inferior to the insertion of the
cricopharyngeal muscle on the cricoid cartilage” (Eckberg, 1997, p.211).
Logemann (1990) indicated that in some adults over 60, maximum laryngeal
elevation lasts longer and that the larynx appears to descend more slowly.
Esophageal Cavity Changes

Although “esophageal function is essentially preserved with aging” (Linton,
1997, p.319), there has been evidence to show that problems that increase with
age (e.g. hiatial hernia, gastroesophageal reflux, and diminished strength and
tonicity in the esophagus) can cause problems with peristaltic contractions.
Muscle weakness can also cause slowing of the action of the food in the

23

esophagus. The reduced action of the food into the esophagus causes some of
the material to stay above the aortic arch (Sheth 8 Diner, 1988).

Another age-related problem is a motility disorder called achalasia.
“Achalasia is an esophageal motility disorder that is characterized by a decrease
in peristalsis of the body of the esophagus, increase resting pressure of the
cardiac sphincter, and failure of the cardiac sphincter to fully relax during
swallowing” (Brozenec, 2000, p. 552). The exact etiology of achalasia is unclear.
The incidence is said to be 1 to 2 persons in 2000 (Bronzenec, 2000). Brozenec
further stated that symptoms of achalasia include ( 1) progressive dysphagia; (2)
vomiting of food (3) nausea; and (4) weight loss (p. 522). Individuals with
achalasia report pain during eating. Progression of dysphagia from solids to
liquids and nocturnal aspiration can occur, both of which can lead to bacterial
infections. The onset of achalasia is insidious and often its diagnosis is delayed.
Severe weight loss may signify malignancy or cancer. The study also indicated
that about five percent of clients have esophageal squamous cell carcinoma.

Neurogenic Swallowing Disorders

Dysphagia has become one of the fastest growing areas in the field of
speech-language pathology (Sonies, 1997). During the past ten years, speech-
Ianguage pathologists have seen the number of referrals for dysphagia services
increase in hospitals, long-term care facilities, private practice, and clinics
(Kahrilas, Dodds, Dent, Logeman 8 Shaker, 1998; Sonies, 1997). As a result of'
neurologic diseases, neurogenic dysphagia is common (Gordon, Hewer and
Wade, 1987). Homer 8 Massey (1988) reported that the prevalence of dysphagia

24

following stroke ranges from 25% to 32%. One-third of the patients in an acute
care setting study were dysphagic (Groher 8 Bukatman’s, 1986). Additionally,
Trupe, Siebens, and Siebens (1984) reported that 50-60% of patients in an acute
care setting may be dysphagic, while Cherney (1994) reported that at least 42
per cent of the patients in inpatient rehabilitation facilities were dysphagic.

One of the myriad of problems associated with neurogenic dysphagia is
aspiration. Aspiration is the entry of material into the airway below the level of the
true vocal folds (Smith, Logemann, Colangelo, Rademaker 8 Pauloski, 1999).
Aspiration can occur before, during, or after the swallow for a number of reasons,
including but not limited to, hypoglossal nerve incompetence, unilateral paralysis,
incomplete closure of the larynx, poor tongue control of the bolus, poor
coordination of the epiglottis, or reduced anterior laryngeal movement (Batchelor
et al., 1996; Logemann, 1993). Aspiration can also cause life-threatening
pulmonary diseases. Although the pulmonary system can tolerate and clear small
amounts of aspirated material, a large build-up of aspirated material can obstruct
the bronchi and lead to complications, even death. Infiltrates can be detected if a
chest x-ray shows involvement of the lower right lobe (Blitzer, 1990). Aspiration
can be detrimental to those individuals whose medical condition is already
compromised, especially those who have had strokes, respiratory and/ or
pulmonary problems.

Daniel et al. (1998) revealed that of 55 stroke patients studied, 21 (38%)
aspirated. Seven of the 21 (33%) aspirated overtly, and 14 (67%) silently. Ding
and Logemann (2000) revealed that between 48% and 55% of stroke patients in .

25

their study aspirated. Garon, Engle, and Ormiston (1996) measured aspiration

. and silent aspiration in 1000 patients who had multiple neurological pathologies
and found that 573 (57%) patients aspirated; additionally, 276 (52%) of the 573
were silent aspirators.

Linden and Siebens (1983) showed that 11 of 15 subjects with central
nervous system damage had laryngeal penetration, and nine of 15 exhibited
pooling of liquids in the pyriforrn sinuses. Homer and Massey (1988) reported
that one-half of the patients with strokes showed aspiration, with silent aspiration
occurring in 8 of 21 patients (38%). According to Homer, Massey and Brazer
(1990), 49% of patients studied (who had bilateral strokes) aspirated secondary
to incomplete laryngeal elevation and closure and weak pharyngeal peristalsis
after the swallow during videofluoroscopy.

Horner, Buoyer, Albert, and Helms (1991) investigated the correlation of
neurologic findings with radiographic lesions; their results revealed that 15 of 23
patients exhibited aspiration. Of the 15 patients who aspirated, the majority had
bilateral strokes with multiple lesion loci. Their results also revealed significant
. statistical associations between aspiration and pharyngeal residue, cranial nerve
IX abnormality, vocal fold weakness, and severe dysarthria.

Pneumonia is associated with aspiration (aspiration pneumonia) in
patients who have had strokes or other neurologic and neuromuscular diseases
such as Alzheimer’s disease and Parkinson’s disease. According to Arms, Dines,
and Tinstman (1974), Mendelson in 1946 was the “first to describe aspiration
pneumonia as a clinical entity in obstetrical anesthesia” (p. 138). They further

26

stated that the most common symptoms of aspiration identified in their 88
patients were cough and dyspnea.

Aspiration pneumonia develops after the aspiration of colonized
oropharyngeal contents (Marik 8 Kaplan, 2003, p. 329). Marik et al. further
indicated that the incidence of pneumonia increases with age. The highest rate is
seen in those individuals 75 years and older. Additionally, those who reside in
nursing homes also had a high incidence of pneumonia. Gordon, Hewer and
Wade (1987) indicated that aspiration is thought to be a significant cause of
pneumonia in individuals who have had strokes. In a study by Hanning, Wuttage—
Hanning, Honnann and Herrmann (1989), six per cent of patients who had a
stroke died within the first year from aspiration pneumonia.

Aspiration pneumonia causes serious complications after stroke and often
results in a longer hospital stay and can cause death (Ding 8 Logemann, 2000).
Although not all pneumonias are caused by food or aspirated contents,
pneumonia is seen in about 34 per cent of all stroke-related deaths and is the
third highest cause of death the first month post stroke (Homer 8 Massey, 1988).

Reynolds, Gilbert, Good, Knappertz, et al. (1998) studied variables
associated with the development of pneumonia in patients with ischemic strokes.
Their purpose was to use the clinical swallowing examination and
videofluoroscopy to identify those individuals who were at risk for aspiration and
subsequent pneumonia and to determine hospital outcome. Their results

revealed that of the 102 patients studied, a 21% rate of pneumonia was noted.

27

Toharo et al. (2003) used the water swallowing test, food test and the x-
ray test (static radiographs of the pharynx) to predict aspiration without the use of
videofluoroscopy. Their results showed 90% sensitivity for all three non-
videofluoroscopic tests for predicting aspiration. They also concluded that
clinicians could use these three tests when VFSS is not available or feasible.
Additionally, the water test can be used as a screening procedure to determine
which dysphagic patients will need VFSS.

Kendall and Leonard (2001) determined the incidence of abnormalities in
timing and extent of pharyngeal constriction in an elderly population with
dysphagia. Seventy-three percent demonstrated incomplete pharyngeal
iconstriction relative to controls. Poor pharyngeal constriction accounted for 75%
of aspiration cases. In addition, they found that although hyoid elevation was
slow and of reduced duration in older dysphagic patients, it was appropriate for
patients’ ages. These findings may indicate that the elderly use compensatory
movements to minimize the short duration of hyoid elevation on the upper
esophageal sphincter.

In a similar study by Leonard, Kendall, McKenzie, Gonclaves, 8 Walker
(2000) on 60 adult .nonnal volunteers, dynamic Videofluoroscopic swallow studies
were performed to establish normative data for displacement of upper
aerodigestive tract structures during deglutition. They studied hyoid bone
displacement, larynx-to-hyoid bone approximation, pharyngeal constriction, and
the extent of pharyngoesophageal sphincter (PES) opening during various
volumes of liquid swallows and found that there was a direct relationship

28

between bolus size and hyoid bone displacement, PES opening, and pharyngeal
constriction. .

Deglutition is a complex process that can become compromised by subtle
changes in the ability to chew and swallow. Some Changes occur over a period of
time due to normal aging but a disease condition warrants concern and attention.
To assess these changes, a clinical swallow examination is usually performed
before radiographic studies in order to document changes in structure and
function of the oral and pharyngeal cavities. Some clinicians incorporate cervical
auscultation as an adjunct to the CSE to detect clinical changes in swallowing.
Cervical auscultation is an inexpensive, noninvasive procedure that is used to
listen to swallowing sounds. When patients cannot be transported to hospital
facility for a Videofluoroscopic swallow study or FEES, cervical auscultation is
employed to document changes in swallowing and to provide immediate
information regarding the person’s swallow.

The Clinical Swallowing Examination

“The Clinical Swallowing Examination (CSE) allows a circumscribed
exploration of a patient’s muscle function, sensation, and ainrvay protective
functions” (Murray, 1999). It is used in hospitals, long-term care, and other
clinical facilities to provide clinicians with information relevant to patients’
swallowing problems. Additionally, CSE provides the clinician with information
of the patients’ readiness to undergo further evaluation relevant to therapeutic

processes (Goodrich 8 Walker, 1997; Murray, 1999; Zenner, 2000).

29

The Clinical Swallowing Examination is used to obtain the patient’s
medical history, to acquire details about swallowing difficulty, and to assess oral-
motor function. Other names given to this procedure in the literature include
physical examination (Sonies 8 Baum, 1988), bedside dysphagia examination
(Murry 8 Carrau, 2001); clinical/bedside examination (ASHA, 2000; McCullough,
et al., 1999), and clinical examination (Perlman et al., 1991; Daniels et al.; 1997;
Miller, 1997). In this research the process will be referred to as Clinical
Swallowing Examination (Murray, 1999).

The Clinical Swallowing Examination allows the clinician to gather
pertinent information regarding the patient’s complaint or swallow-related
problem, relevant health history, and clinical observations of swallowing including
oral-motor anatomy and function and observation of swallow (Goodrich 8 Walker,
1997; Miller, 1997; Murray, 1999; Zenner, 2000; Schulze-Delrieu 8 Miller, 1997).
It is the most common method for evaluating swallow function before
performance of a Videofluoroscopic swallow study (VFSS) or when VFSS is not
available (Tohara, Saitoh, Mays, Kuhlemeier, 8 Palmer, 2003).

Zenner (2000) indicates three components of the CSE should include
history taking, meal observation, and physical examination. The case history and
the physical examination are relevant to this study. The case history is the
starting point of the Clinical swallow examination of the patient suspected of
dysphagia (Zenner, 2000). The clinician gathers information relevant to the
patient’s dyspahgia from a number of sources which include written medical
records, observations by health care professionals and family, and those of the

30

clinician. It is important that the clinician review both past and recent medical
records. Additionally, it is important that the SLP include (1) age, gender,
heredity, and ethnic background; (2) neurologic, psychiatric, systemic/metabolic,
respiratory, or esophageal disease; (3) surgery; (4) radiologic study results; and
(5) advance directives (Groher, 2000) as part of the diagnostic process. After
data collection and at the completion of the CSE, the clinician should be able to
develop a tailored management program for the patient or determine if further
instrumental assessment is warranted.

For hospital patients, the nursing staff can be invaluable in providing
information regarding the patient’s swallowing problems as they provide
information regarding food preferences or whether the patient fatigues during
meals. For those individuals who reside in the community, the family’s
descriptiori'concerning the patient’s swallowing disorder or attempts at
minimizing the disorder is of particular importance to the speech-language
pathologist. It is also important for the speech-language pathologist to note the
impact the swallowing disorder has on family members’ or caregiver’s lives. For
example, mealtime is when families get together to discuss the events of the day.
Additionally, meals are social times that bring family and friends together. It is
important for caregivers to understand the types of food that are difficulty for the
patient to chew and swallow and to make appropriate compensations.

The physical examination portion of the Clinical Swallowing Examination
assesses the patient’s oral-motor structure and function and provides the
clinician with the opportunity to verify and test the information gathered during the

31

case history and meal observation portions (Zenner, 2000). Miller (1997)
indicated that the purposes of the physical examination for the clinical
assessment of swallowing are to (1) establish a possible cause of dysphagia; (2)
assess the patient’s ability to protect the airway; (3) determine the practicality of
oral feeding and/or recommend alternative methods for nutritional management;
(4) determine the need for additional specific diagnostic tests, studies or
referrals; and (5) establish baseline clinical data that can be used to chart
changes in feeding function of patients with progressively deteriorating diseases
(pp. 153-154). During the physical examination the clinician examines motor
speech performance, oral reflexes, mobility and strength of the oral muSculature,
conducts inspection of the oral cavity and tests swallows. During trial swallows
the clinician examines mastication, oral transit of the bolus, pharyngeal and
laryngeal elevation, phase transition, and airway protection (Zenner, 2000;
Goodrich 8 Walker, 1997; Miller, 1997).

Miller (1997) indicated that the CSE should allow the clinician to (1) screen
for the presence or absence of swallowing impairments; (2) contribute
information regarding the possible etiology of the dysphagia relative to its
anatomic and physiologic basis; (3) ascertain the relative aspiration risk for
certain patients; (4) determine the need for an alternative means of nutritional
management; and (5) recommend additional tests and procedures necessary to
diagnose and/or treat dysphagia (p.169). The American Speech-Language
Hearing Association (ASHA) (2000) has also indicated that the clinical
examination might include “use of tools and techniques (such as cervical

32

auscultation and pulse oximetry) to detect and monitor clinical signs of
dysphagia” (p. 2).

The Clinical Swallowing Examination may be modified in certain
circumstances to fit the situation and individual needs of patients. The CSE does
not allow visualization of structures or function of oral, pharyngeal, and laryngeal
areas during the swallow and cannot provide etiologic information about
aspiration. Clinicians, however, rely on results of the Clinical Swallowing
Examination since it (1) is used as the first step in assessment of swallowing; (2)
incorporates more aspects of swallowing than movement of the larynx, pharynx,
and mouth; (3) provides information regarding ingestion of food and liquids for
sustaining nutrition and hydration; (4) is readily available and does not require
expensive equipment; and (5) is not invasive and has no known health risks
(Goodrich 8 Walker, 1997; Zenner, 2000).

ASHA (2000) indicated that the purposes of the clinical swallowing
examination are to enable the speech-language pathologist to (1) integrate
information from the interview/case history, review of medical/clinical records,
standardized protocols, observations from physical examination and
collaboration with physicians and other caregivers; (2) observe and assess the
integrity and function of the following structures of the upper ainrvay and digestive
tract: face, jaw, lips, oral mucosa, tongue, teeth, hard palate, soft palate during
nonspeech, speech, and swallowing tasks; (3) identify the presence and observe
the characteristics of dysphagia based on clinical signs and symptoms; this may
include identifying factors that may affect swallowing function such as bolus size,

33

consistency, and fatigue during a meal, posture, positioning, and environmental
conditions; (4) identify clinical signs and symptoms of esophageal dysphagia or
gastroesophageal reflux in order to make an appropriate referral to another
specialty; (5) determine the need for an instrumental evaluation following the
clinical examination; (6) identify and follow up with patients who may require
reevaluation, instruction, intervention, or other procedures prior to the
instrumental evaluation; (7) detennlne whether the patient is an appropriate
candidate for treatment and/or management, based on clinical examination
findings such as medical stability, cognitive status, nutritional status,
psycho-social-environmental and behavioral factors; (8) recommend, as
appropriate, the route of nutritional management (i.e., oral vs. nonoral);
(9) recommend clinical interventions (e.g. positioning, food and liquid consistency
modifications, feeding routine alterations) and other clinical strategies designed
to enhance the efficiency and safety of swallowing; and (10) provide counseling,
education, and training to the patient, health care providers, and care givers.
Cervical Auscultation

Speculations on Physiologic Cause of Swallowing Sounds

There has been speculation concerning the physiologic cause of
swallowing sounds. Cichero and Murdoch (1998) pointed out that the acoustic
signature of the swallow can be discussed in terms of (1) duration of the signal,
(2) frequency characteristics of the signal, and (3) amplitude of the waveform
(p.40). Researchers have agreed that the average duration of the swallow signal
for a liquid bolus is 500 msec. and for one third teaspoon of paste it is 250 msec.

34

Cardiac and Vocal Tract Analogy Hypothesis

Cichero and Murdoch (1998) proposed that the sounds of the heart and
vocal tract are propagated via vibration of muscles and valves. Additionally they
indicated that there may be a similarity or comparison between the generation of
heart and vocal tract sounds to swallowing sounds which they coined ‘cardiac
analogy hypothesis’. They further mentioned that there are four cardiac sounds
perceivable in humans, each with different components. The first has four
components, but only two are audible via stethoscope. The second heart sound
Is said to be caused by vibration initiated by closure of the aortic and semilunar
valves and sudden cessation of back flow of blood. There is inconsistency
surrounding the third cause of the heart sound. The fourth cause of heart sounds
seems to occur with atrial contraction as the valve separates a second time due
to increased flow across the valve (p. 42). They feel that the swallowing sounds
of a healthy nondysphagic individual are distinctive from the sounds of an
individual with dysphagia. If cervical auscultation could prove beneficial in
detecting where structure and function breakdown in physiologic swallowing
occurs, it would be a useful diagnostic tool in clinical swallowing examination.
Cichero and Murdoch (1998) point, out that cervical auscultation may have its
roots in techniques of cardiovascular and respiratory sounds analysis. In
summary, Cichero and Murdoch (1998) indicate that cardiac sounds appear to be
caused by vibration which is initiated by (1) opening or closure of valves in the
heart, (2) general disturbance of the muscles of the heart caused by vibration, or
(3) fluid flow into a confined space initiating the vibration (p. 42).

35

Similarly, when comparing the‘vocal tract to the cardiac phenomenon,
there are sites and structures within the tract that are potential vibratory sources.
In the swallowing mechanism, there are a series of valves (oropharyngeal,
laryngeal, and esophageal) and pumps (pharyngeal, esophageal, and
respiratory) that act as potential vibratory sources. The vocal tract is a vibrating
column and many speech sounds that are generated and modified are periodic.
Thus, the question is: Is there a similar pattern for swallowing sounds? Cichero
and Murdoch further state that the swallowing sounds are aperiodic in nature.
The frequency components are not related to each other and do not show a
visually repeatable pattern.

When comparing the generation of heart and swallowing sounds, heart
sounds are aperiodic although repetitive, a situation which gives more credence
to the argument that heart sounds and swallowing sounds may be generated in a
similar fashion. When examining the cardiac and vocal tract analogy hypothesis,
several things should be considered: (1) the difference in the male and female
vocal tract, (2) gender differences in the swallowing sounds, and (3) the site of
placement of the acoustic detector. Female and male vocal tract sizes and
configurations are different. Additionally, the female swallow duration is shorter
than that of the male (Takahashi et al., 1994). Considering the cardiac analogy
hypothesis, there is greater attention given to the best placement of the acoustic
detector unit on the cervical region. Takahashi et al. (1994) indicated that the
best placement for listening to swallowing sounds is over the lateral border of the
trachea, immediately inferior to the cricoid cartilage.

36

Shaw et al. (2004) conducted a study that used bronchial auscultation
(BA) paired with the clinical examination to detect dysphagia and aspiration.
Their results indicated that although there was high agreement for risk of
aspiration, specificity was low. Bronchial auscultation was highly specific in
confirming the absence of aspiration with a relativity low sensitivity to the
presence of aspiration. Bronchial auscultation is therefore thought to potentially
be a useful adjunct to the Clinical swallowing examination.

Leslie (2005) presented an overview of studies that have used cervical
auscultation. She reported that although cervical auscultation continues to be
used as a possible adjunct to the CSE, there still needs to be future research to
answer questions such as what causes changes in swallowing.

Youmans 8 Stierwalt (2005) studied several measures of duration, intensity, and
frequency of the acoustic swallowing signal. Additionally, they looked at
correlations between the variables and bolus consistencies using cervical
auscultation. Their results compared favorably with previous reports. There were
no gender specific differences among the variables studied. Leslie et al. (2004)
indicated that “cervical auscultation is experiencing a renaissance as an adjunct
to the clinical swallowing assessment” (p.231). Cervical auscultation is being
used by a number of clinicians in long-term care (LTC) facilities where the clinical
examination may be the only assessment procedure used to detect aspiration
and to make decisions concerning the resident’s diet level (Zenner, Losinski 8
Mills, 1995). Zenner et al. further revealed that, although the clinical swallowing
examination does not accurately assess the mechanics of the pharyngeal

37

swallow, CSE is an appropriate tool to use in determining a diet level in LTC
when cervical auscultation is used.

Dawson’s (1964) investigation of the use of auscultation with the
stethoscope did not use the stethoscope to detect swallowing sounds but to find
out which stethoscope was better suited for use with his patients. Abella and
Formolo (1.992) compared the acoustic properties of six popular stethoscopes. Of
the six stethoscopes tested the Littman Cardiology ll provided the best overall
performance. Hamlet, Penny and Formolo (1994) investigated stethoscope
acoustics for cervical auscultation of swallowing. The Littman Cardiology II and
the Hewlett-Packard Rappaport Sprague were found to have superior acoustical
performance as compared to those tested for use in the cervical auscultation of
swallowing sounds.

Takahasi, Groher and Michi’s (1994) investigated three different
swallowing sounds using cervical auscultation: (1) acoustic detector unit for
analyzing swallowing sounds. (2) type of adhesive suited for attachment to the
detector, and (3) best site for swallowing sound detection. Fourteen normal adult
volunteers (nine males, mean age 32.4) and five females (mean age 29.4)
served as participants. Results revealed that the optimal site for detecting
swallowing sounds was the lateral border of the trachea immediately inferior to
the cricoid cartilage. The detector of choice was an accelerometer with double-
sided paper tape wire selected because of its wide range of frequency response

and small attenuation level.

38

Cichero and Murdoch (2002) revisited the methodology used by
Takahashi et al. to study acoustic detector and placement site for listening to
swallowing sounds. It was found that the electret microphone - as opposed to
the accelerometer - - was better for recording swallowing sounds. Cichero and
Murdoch agreed on the placement site (the lateral border of the trachea
immediately inferior to the cricoid cartilage) for listening to swallowing sounds.
Additionally, they concluded “that cervical auscultation is within the reach of the

average dysphagia clinic” (p. 40).

39

CHAPTER III
METHOD
Participants

The purpose of this study was to examine aging on swallowing in
nondysphagic women across the age span, aging on nondysphagic women’s
perceptions of swallowing as people age, and whether cervical auscultation was
a reliable screening adjunct to the clinical swallowing examination. Criteria for
inclusion were women who (1) fit the age criteria; 20-29, 40-49, 60-80+; (2) were
negative for neurologic or degenerative diseases on medical history; (3) were
negative for diagnosis of dysphagia; (4) had no history of cancer of the brain, oral
cavity or the larynx; and (5) reported no illnesses to all questions on the Medical
Health Questionnaire without reported illnesses. Only those individuals who met
all of the criteria were included in the study.

This study was approved by the University Committee on Research
Involving Human Subjects (UCRIHS # 00-473). at Michigan State University and
the Institutional Review Board (IRB # -00657—2001) at Valdosta State University.
Participants were provided with verbal and written descriptions of the research by
the Principal Investigator and gave informed consent by signing the Research
Consent Form (Appendix C). The consent form provided participants with a (1)
summary of the proposed research, (2) description of procedures,

(3) statement of possible discomforts/risks involved in study participation, (4)
benefits of participation and, (5) statement concerning confidentiality of data and
personal information.

40'

Several referral sources were contacted via telephone requesting their
members’ participation in the study. A letter to prospective referral sources
(Appendix A) was given to explain the purpose of the study and criteria for
participation. Those who responded included The Norway Senior Citizens Club;
members of the Bushy Pond Baptist Church in NonNay, South Carolina; Victory
Temple Evangelistic Center Virtuous Women of Excellence Ministry; and faculty,
staff, and students from the College of Education in Valdosta, Georgia.
Individuals in the general community of Norway, South Carolina, were also
contacted. In addition, participants at the Child Development Center in Valdosta
and some members of their families were also included in this study.

Data Collection
Medical History Questionnaire

The‘investigator was invited to the Norway Senior Citizens regular monthly
meeting. At that time the written-oral script (Appendix B) was given and read to
the group, allowing time for questions. After a question and answer period, all
participants were given a Research Consent Form to complete (Appendix C).
After signing the Research Consent Form, the Medical History Questionnaire
(MHQ) (Appendix D) was provided. Questions were answered regarding someof
the items on the MHQ. Data were collected and completed in one visit.

Women of the Virtuous Women of Excellence Ministry, Child Development
Center, and the Department of Special Education and Communication Disorders
made individual appointments with the Principal Investigator so that data could
be collected. The procedure for data collection was the same for all groups. Data

41

collection was completed in one session and took approximately 45 minutes per
appointment to complete.

After providing consent to participate in the study, each participant
completed a Medical History Questionnaire (MHQ) (Appendix D). The
Questionnaire was divided into medical (15 items) and surgical (5 items)
categories. Participants answered ‘yes’ or ‘no’ to the 20 questions. Those who
answered ‘yes’ to having had a diagnosed: neurologic or degenerative disease or
cancer of the brain, oral cavity or larynx were excluded from the study because
the reported conditions could possibly interfere with the normal swallow process.
Seven women (all over 60 years old) were excluded because of medical
conditions such as history of dementia, oral cancer, stroke, and fear of the
stethoscope. Only those individuals who indicated no history of neurologic
disorder degenerative disorder or cancer of the brain, oral cavity or larynx on the
Medical History Questionnaire were participants in the study.

Swallowing Status Questionnaire

Participants who responded negatively on all of the MHQ items were given
the Swallowing Status Questionnaire (SSQ) (Appendix E). The Swallowing
Status Questionnaire consisted of nine questions, seven on the effects of aging
on swallowing status and two on their perceptions of the effects of aging on
swallowing.

Participants answered “always”, “frequently”, “sometimes”, or “rarely” to
seven swallowing questions. ‘Always’ was operationally defined as “coughing
after swallowing liquids or solids at every meal.” The term ‘frequently’ was

42

defined as “coughing after swallowing liquids or solids one time per day.”
‘Sometimes’ was defined as “coughing after swallowing liquids or solids one to
two times per month." The term ‘rarely’ was defined as “coughing after
swallowing liquids or solids one time or less per year.” Additionally, participants
were asked to answer “yes”, “no”, or “don’t know” to two perception questions.

Clinical Swallowing Examination and Cervical Auscultation

Participants who did not indicate any pathology on the Medical History
Questionnaire and completed the Swallowing Status Questionnaire were
administered the Clinical Swallowing Examination (CSE) (Appendix F) with
cervical auscultation by the investigator. The CSE consisted of 28 oral-motor
tasks to assess sensory and motor capabilities and the structure and function of
. the swallowing mechanism. Items for the CSE and cervical auscultation were
adapted fIOm Duffy (2005); Murray (1999); Hardy (1995); Love and Webb
(2001); Cichero 8 Murdoch (2002); Zenner (2000); Cichero 8 Murdoch (1998);
Nilsson, Ekberg, Olsson, Kjellin, 8 Hindfelt, (1996); Zenner, Losinski, 8 Mills
(1995); Hamlet, Penny 8 Formolo (1994); Takahashi, Groher 8 Michi (1994a);
and Takahashi, Groher 8 Michi (1994b).

The same protocol for the Clinical Swallowing Examination with cervical
auscultation was used for all participants. Participants were seated in a straight
back chair facing the Principal Investigator. Examination of the oral cavity and
laryngeal area is the standard procedure when performing a clinical swallowing
examination (Murray, 1999). Examination of the oral cavity is a procedure used
by SLPs to determine whether or not a client has deviations in the structure and

43

function of the oral mechanism (St. Louis 8 Ruscello, 1981). It is also used to
screen a client for potential oral or pharyngeal swallowing problems and
determine if further instrumental assessments or sub-specialty evaluations are
warranted (Logemann, 1998). When performing clinical swallowing examinations
to determine structure and function of the oral cavity, speech-language
pathologists have begun to use those recommended by the World Health
Organization (2001) International Classification of Function (Clark, 2005).
Structure of the Oral Cavity

Facial symmetry. To assess facial symmetry, the participant was
instructed to sit straight in a chair, relax, and to look forward and breathe quietly
through the mouth; observation of asymmetry due to drooping of the entire face
on one side or corner of mouth, or flattening of the nasolabial fold was noted.

Lip closure. Lip closure was examined when the participant’s upper and
lower lip contacted in a symmetric resting posture; any deviations were noted.

Lingual size. Lingual size was assessed when the participants opened
their mouth with the tongue resting on the inside of the oral cavity; structural
abnormalities were noted.

Tongue. The tongue was observed at rest on the floor of the oral cavity for
at least one minute; any fasciculations or tremors were noted.

Hard palate. Hard palate appearance was assessed for height and

concavity; deviations were noted.

44

Soft palate. Soft palate at rest was examined as the participants opened
their mouth wide for observation; any deviations in height, concavity and
symmetry were noted.

Condition of teeth. Assessment of the teeth was made regarding natural
or missing teeth, and whether participant had a complete set or upper or lower
dentures. Additionally, notation was made if participant had any other dental
appliances such as partials, bridges or fillings, or whether the patient was
edentulous.

Function of the Oral Structures

Labial protrusion. To assess labial protrusion, the participant was
instructed to “pucker your lips as though you were kissing or saying “oo” like
this."

Lab'ial retraction. Labial retraction was assessed by having the participant
retract the lips as if smiling or saying “ee.”

Labial range of motion. The participant alternately pursed and retracted
the lips in an exaggerated smile or grimace.

Labial strength. To assess labial strength, the participant was instructed to
“place your lips around the tongue blade and press down on it while I try to pull it
out of your mouth. Don’t let me pull it out.”

Labial seal. Labial seal was visually examined when the participant
swallowed trials of liquids and solids. Upper and lower lips had to make contact
and remained closed during bolus formation of solids and liquids; any spillage
was noted.

45

Lingual protrusion. Lingual protrusion was assessed when the participant

was instructed to “stick out the tongue.”

Lingual retraction. To assess lingual retraction, the participant was

instructed to “pull your tongue as far back into your mouth as possible.”

Lingual strength. Lingual strength was assessed on both sides of the
inner oral cavity by having the participant press against the tongue blade, as well

as by protruding the tongue against a tongue blade.

Lingual elevation. To assess lingual elevation, the participant raised the

tongue tip or blade to the upper lip, alveolar ridge or hard palate.

Lingual depression. Lingual depression was assessed by having the

participant lower the tongue tip behind the bottom teeth.

Lingual range of motion. Lingual range of motion was assessed by having
the participant move the tongue from the left corner to the right corners of the
oral cavity. Additionally, the tongue was moved in a circular motion along the

length of the maxillary, mandibular and buccal sulci.

Velar elevation. To assess velar elevation, the participant was instructed
to “say /al for as long as you can.” Additionally, participant was asked to “say lal,

lal, /a/” in order to examine sequential ability to raise and lower the velum.

Jaw at rest and during movement. To assess the mandible, the
participant was instructed to “open and close your mouth as rapidly as you can.”
Mandibular range of motion was examined when the participant was instructed to
“move your jaw to the right then to your left.”

46

Gag Reflex. To elicit gag reflex, the participant’s tonsillar pillars or tongue
base were stroked with a tongue depressor.

Volitional cough. To assess volitional cough, the participant was
instructed to “cough and clear your throat.”

Trial Swallows and Cervical Auscultation

Cervical auscultation is a noninvasive procedure used to detect
swallowing problems in clients with dysphagia. It is a Clinical process that is
gaining recognition and credibility among speech-language pathologists as a
means of detecting clinical signs of dysphagia (Cichero 8 Murdoch, 2002;
Cichero 8 Murdoch, 1998; Nilsson, Ekberg, Olsson, Kjellin 8 Hindfelt, 1996;
Hamlet, Penny 8 Formolo, 1994; Takahashi, Groher 8 Michi, 1994a; and
Takahashi, Groher 8 Michi, 1994b).

Cervical auscultation using a stethoscope, microphone, and audiotape
recorder was used on three trial swallows of liquids and three swallows of a
cracker. The Principal Investigator placed the flat side of the stethoscope over
the lateral border of the trachea immediately inferior to the cricoid cartilage
(T akahashi, Groher 8 Michi, 1994a; 1994b).

To assess swallowing sounds, participants were given three trials (5 cc
each trial of liquids (total 15 cc) and three trials of a cracker (one ounce per trial)
for mastication. The instructions and protocol remained constant for all
participants. Participants were given 5 cc of water measured in a medicine cup
for accuracy and consistency. Each participant was instructed to swallow all of
the water at one time when given instructions by the principal investigator.

47

A Littman Cardiology Ill stethoscope and an electret condenser
microphone were used to listen to swallow sounds. The microphone was inserted
into the left bifurcation of the stethoscope and audio recorded on an Optimus
portable tape recorder (Mills, personal communication, 2002). Bolus formation
was informally evaluated by observing rotary chewing of a solid bolus (from the
cracker) and formation of a liquid bolus (from the water) for deglutition. Laryngeal
elevation was manually observed for the elevation of the mandible, hyoid bone,
and larynx. Oral cavity residue was observed post swallows of solids and liquids.
Vocal quality change, salivary flow/control, and reflexive cough were noted
following all swallow trials.

Scon'ng of Clinical Swallowing Examination

Assessment of the condition of the teeth was scored as ‘+’ if present and
‘-‘if not present. lnfonnation gathered was relative to whether the patient had
natural teeth, dentures, partials, bridges, or was edentulous.

Structures were assessed as normal or abnormal. Structures received a
‘1’ if they appeared normal and a ‘2’ if they appeared abnormal.

A task executed correctly and immediately following verbal instructions
and visual demonstration was scored ‘1’. Tasks executed correctly with delay (3-
5 sec) following verbal instructions and visual demonstrations were scored" ‘2’.
Function executed incorrectly and immediately following executed tasks when
verbal instructions and visual demonstrations were scored “3”. Tasks performed
incorrectly and after a time delay following verbal instructions and visual
demonstrations were scored “4” (Appendix F).

48

Swallowing sounds were examined using a Littman Cardiology Ill
stethoscope and a microphone and scored as (1)“1” for clear audible sound
without coughing (normal); (2) “2” wet gurgly sound without coughing; (3) “3” wet
gurgly sound with immediate coughing; (4) “4” wet gurgly sound with delayed
coughing; and (5) unable to detect. Each swallow was recorded on audiotape.
Inter-rater Reliability dun'ng Training Period

Reliability training was conducted in an audiological booth to assure
constant silence during rater training. The principal investigator trained an
experienced (of 30 years) certified speech-language pathologist to judge the
swallow sounds. Although the rater had used cervical auscultation in the past,
she was not a regular user of the procedure. After training was completed, both
raters judged the swallows of 10 subjects to be normal. The ten participants
ranged in age from 23—27 years with a mean age of 23. All were college
undergraduate students - one African American and nine Caucasian. They were
not a part of the 55 participants used in the study. A Littman Cardiology Ill
Stethoscope was used by each rater to listen to swallow sounds. Each rater
judged a total of 60 swallows (three liquids and three solids). Each rater judged
three liquid trials and three solids without knowing how the other rated the
swallows until data collection was completed.

Equipment and Materials

Swallowing sounds were recorded using (1) 3M Littmann Cardiology Ill
stethoscope; (2) Radio Shack electret condenser 1 cm2 microphone; (3) an
Optimus CRT-111 Portable cassette tape recorder; and (4) Sony HF

49

audiocassette tape. Other test material included (a) a penlight; (b) latex exam
gloves; (c) sterile tongue depressors; and (d) 30cc medicine cups. The solid test
material was one 1.0 ounce Nabisco cracker. The liquid test boluses were
presented in 5.0 ml volumes of water.

The Radio Shack electret condenser microphone was an omnidirectional
microphone with frequency response of 70-16,000 Hz. Impedance was 1000
Ohms:l:20% and sensitivity at -65dB:I:3dB. An Optimus CRT-Ill portable cassette
tape recorder was used to audiotape swallowing sounds. It is a 2-track monaural
tape recorder with a frequency response of 125- 6.3 KHz :I:.6dB.

Group means, percentages, and standard deviations were calculated
using SPSS statistical software. Chi-square procedures were used to test for
statistical significance for each of the nine questions on the Swallowing Status

Questionnaire and between the 3 different age groups used in this study.

50

CHAPTER IV
RESULTS

This cross sectional study sought to document aging on oropharyngeal
swallow in nondysphagic women across the age span, whether aging changed
nondysphagic women’s perceptions of swallowing as people age, and whether
cervical auscultation was a reliable screening adjunct to the clinical swallowing
examination. Women were recruited from the communities of Norway, South
Carolina, and Valdosta, Georgia. The social status of the participants included
undergraduate students, teachers, and retirees.

Participants consisted of 55 competent nondyspahgic adult women
ranging in age from 20 to 95. Group 1 included 20 women ranging in age from
20-29 (M=25, SD=1.638); Group 2 consisted of 20 women ranging in age from
40-49 (M=‘47, SD=2.927), and Group 3 consisted on 15 women ranging in age
from 60—95 (M= 73, SD =10.036).

Fifteen participants in Group I were African American and five were
Caucasian. Group 2 consisted of 16 African American and four Caucasian.
Group 3 included 14 women who were African American and one Caucasian.

Overall 82% of participants were African American and 18% Caucasian (Table

1).

51

 

 

 

 

 

 

 

 

 

GROUP 1 (20-29) GROUP 2 (40-49) GROUP 3 (60-95)
African American 15 16 14 l
Caucasian 5 4 1
Total 20 20 15
‘ Mean Age 25 47 73

 

 

Table 1. Ethnicity, total number of participants and mean age across groups

Medical History Questionnaire

The Medical Health Questionnaire (MHQ) was administered to all

participants to rule out medical conditions associated with dysphagia.

Participants answered ‘yes’ or ‘no’ to 20 questions regarding their medical and

surgical histories. Results of the MHQ revealed medical and surgical histories

were negative for history of central nervous system disease, gastrointestinal

pathology, or head or neck carcinoma. A total of 62 women were recruited for the

study. Seven of the women were excluded because of history of stroke, oral

cancer, dementia, or fear of the stethoscope. After completing the MHQ, 55

women qualified to participate in the study (TabIeI).

Swallowing Status Questionnaire

Each participant was given the Swallowing Status Questionnaire (SSQ)

after qualifying to participate in this study. Each person answered seven

questions regarding their swallowing status and two questions regarding their

perception of the effects of aging on swallowing. The following descriptors were

used to rate the first seven questions. ‘Always’ referred to coughing after

swallowing liquids or solids at every meal; ‘Frequently’ referred to coughing after

52

swallowing liquids or solids one time per day; ‘Sometimes’ referred to coughing
after swallowing liquids or solids one to two times per month; and ‘Rarely’
referred to coughing one time or less after swallowing liquids or solids per year.
The remaining two questions were answered by using ‘yes’, ‘no’, and, don’t
know.’

Question 1 of SSQ (Figure1) asked, “In general, do you cough after
drinking liquids?” Groups 1 and 2 responded with 80 percent that they ‘rarely’
coughed after drinking liquids while 20% indicated that they ‘sometimes’ coughed
after drinking liquids. Group 3 responded with 73% “rarely” coughed after

drinking liquids, and 27% said they ‘sometimes’ coughed after drinking liquids.

1

;.
Percent-nu IGroup 2 (4049)

 

Rnroly Sometimn Frequently Alw-y.
Rotponooo

Figure1. Group mean percentages of responses across three age groups for
SSQ1 (In general, do you cough after drinking liquids?)

In reference to SSQZ (Figure 2) “In general, do you cough after

swallowing foods?” Groups 1 8 2 responded 90% ‘rarely’ and 10% responded

53

‘sometimes’. Group 3 participants indicated 93% ‘rarely' coughed after
swallowing foods while 7 percent indicated that they ‘sometimes’ coughed after

swallowing food.

 

 

 

 

 

 

 

 

I Group 1 (20-29)
B Group 2 (4049)
D Grog) 3 (80-95)

Percentages

 

 

 

 

 

 

 

 

 

 

Always

 

Figure 2. Group mean percentages of responses across three age groups for
SSQ2 (In general, do you cough after swallowing foods?)
Question 3 asked, "In general, do you cough after swallowing saliva?”
Data regarding this question are listed in Figure 3. All participants in Group I
responded 100% that they ‘rarely’ coughed after swallowing saliva. Eighty-five
percent of Group 2 indicated that they ‘rarely’ coughed after swallowing saliva
while 15% indicated that they ‘sometimes’ coughed after swallowing saliva.

Seventy-three percent of Group 3 responded that they ‘rarely’ cough after

54

swallowing saliva while 27% said they ‘sometimes’ coughed after swallowing

saliva.

 

 

 

 

 

 

 

IGroup 1 (20-29)
B Group 2 (40-49)
DGroup 3 (60-95)

Percentagee

 

 

 

 

 

 

 

 

 

 

 

 

Figure 3. Group mean percentages of responses across three age groups for
SSQ3 (In general, do you cough after swallowing saliva?)

In SSQ4 participants were asked, “In general do you take small drinks of
liquids to avoid coughing?” Eighty-five percent responded ‘rarely’ and 15 percent
of the participants in Group 1 indicated that they sometimes take small drinks of
liquids to avoid coughing. In Group 2, 70 percent of the participants responded
‘rarely’ while 30 percent indicated that they ‘sometimes’ take small drinks to avoid
coughing. Seventy-three percent in Group 3 indicated that they ‘rarely’ took
small drinks of liquids to avoid coughing while 27 percent of the participants
indicated that they ‘sometimes’ take small drinks to avoid coughing. Data

regarding responses to SSQ4 are presented in Figure 4.

55

 

 

 

70-

  
  
 
 
 
  

 

60*

 

50 ~«
Percentages
40-

 

IGroup 1 (20-29)
DGroup 2 (4049)
Group 3 (60-95)

 

 

 

 

30-

 

20-4

 

10-

 

 

 

O—l

Rarely Sometimes Frequently Always
Responses

Figure 4. Group mean percentages of responses across three age groups for
SSQ4 (In general, do you take small drinks of liquids to avoid
coughing?)

SSQS asked, “In general do you eat small bites of food to avoid
coughing?” Results revealed ninety percent of the participants in Group 1
indicated that they ‘rarely’ eat small bites of food to avoid coughing while five
percent said ‘sometimes’, and five percent indicated that they ‘always’ take small
bites of food to avoid coughing. Group 2 reported similar responses. Ninety-five
percent indicated ‘rarely’ and five percent indicated that they ‘sometimes’ eat
small bites of food to avoid coughing. Eighty percent of the participants in Group

3 reported they ‘rarely’ eat small bites of food while 13 percent indicated

sometimes to this question (Figure 5) and seven percent responded ‘always.’

56

 

  

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

100—
904/
my
704/
50%"
Percentages soJl/ IGroup 1 (20-29)
/ DGroup 2 (40-49)
40.. CIGroup 3 (60-95)
/
/
/.
o- ;

 

Rarely Sometimes Frequently Always
Responses

Figure 5. Group mean percentages of responses across three age groups for
SSQ5 (In general, do you eat small bites of food to avoid coughing?)
Regarding SSQ6 (Figure 6), “In general do you experience pain while
swallowing?” Eighty-five of the participants in Group 1 indicated ‘rarely’ while
15% indicated ‘sometimes’. Ninety-five percent responded ‘rarely’ and 5%
responded ‘sometimes’ in Group 2. Respondents in Group 3 responded with 93%

indicated ‘rarely’ while 7% responded ‘sometimes.’

57

 

 

 

 

 

 

 

 

Percentages I Group1 (20-29)
D Group2 (40-49)

D Group3 (60-95)

 

 

 

 

 

 

 

_
P": I
~s- ”— ..

Rarely Sometimes Frequently Always
Responses

 

 

 

 

Figure 6. Group mean percentages of responses across three age groups for
SSQ6 (In general, do you experience pain while swallowing?)

SSQ7 asked (Figure 7) “In general, do you experience heartburn or
indigestion following meals?” Ninety-five percent in Group 1 responded ‘rarely,’
five percent said ‘always’. Answers varied in Group 2. Fifty-five percent
responded ‘rarely’, 30 percent sometimes, and five percent said ‘frequently’, and
10 percent indicated ‘always’ to this question. Seventy-three percent of the
respondents in Group 3 indicated that ‘rarely’ while 27 percent responded
‘sometimes’ experiencing heartburn or indigestion following meals.

A chi-square analysis was performed on each of these seven questions
(SSQ1 — SSQ7). Results revealed that across groups there was a significant

difference at the p < .01 level between the response given as “rarely” compared

58

to any of the other responses. Thus, in all of the seven questions regarding their
current eating and drinking experiences, the vast majority of the subjects,
regardless of age, reported to have no difficulty with these activities. In addition,
the responses between the three age groups, on each of the seven questions,
indicated no Significant differences at the p = .01 level. That is, the age of the
women did not Show any differences regarding how they viewed their current
eating and drinking activities. The women in each age group perceived their

eating and drinking activities to be normal.

 

 

 

 

 

 

 

IGroup 1 (20-29)
El Group 2 (40-49)
D Group 3 (60-95)

Percentages

 

 

 

 

 

 

 

 

 

 

 

 

Rarely Sometimes Frequently Always
Responses

Figure 7. Group mean percentages of responses across three age groups for
SSQ7 (In general, do you experience heartburn or indigestion following
meals?)

59

Participants answered ‘yes’, ‘no’, or ‘don’t know’ to two questions
regarding their perceptions of the effects aging has on swallowing. SSQB asked
“Does getting older affect one’s ability to swallow?" Sixty percent in Group1
responded ‘yes’ and 20 percent responded 'no’ and ‘don’t know’, respectively.
Participants in Group 2 responded with 20 percent to ‘yes’, 35 percent to ‘no’ and
45 percent ‘don't know’. Twenty percent of the participants in Group 3 responded

‘yes’, 53 percent said ‘no’, and 27 percent said 'don’t know’.

 

 

  
 

l‘lGroup 1 (20-29)
El Group 2 (40-49)
I] Group 3 (60-95)

Percentages so—

 

 

 

 

 

 

Yes No Don't Know
Responses

Figure 8. Group mean percentages of responses across three age groups for
8808 (Does getting older effect one’s ability to swallow?)

In reference to 8309 (Figure 9), “Does getting older effect one’s ability to

chew?" 55 percent in Group 1 indicated ‘yes,’ 25 percent said 'no’ and 20 percent

60

said ‘don't know’. Group 2 responded with 20 percent ‘yes', and 40 percent ‘no'
and ‘don’t know', respectively. Twenty-seven percent in Group 3 indicated ‘yes',

46 percent said ‘no’, and 27 percent said ‘don’t know' to this question.

 

 

 

 

IGroup 1 (20-29)
El Group 2 (40-49)
C] Group 3 (60—95)

 

 

 

 

 

 

Yes No Don't Know
Responses

Figure 9.Group mean percentages of responses across three age groups for
8809 (Does getting older effect one's ability to chew?)

Group mean percentages were calculated for questions SSQ1—SSQ7 for
each group (Figure 10). Results revealed 89% respondents in Group 1 reported
‘rarely', 9% responded ‘sometimes', and .71% responded ‘always’. Group 2
results revealed 81% ‘rarely’, 16% ‘sometimes’, .71% ‘frequently’, and 1%
'always.’ Group 3 responded with 80% ‘rarely', 19% ‘sometimes’, and 1%

‘always' to SSQ1-SSQ7.

61

 

 

 

 

 

 

IGroup 1 (20-29)
Cleup 2 (40-49)
EIGroup 3 (60-95)

Percentages

 

 

 

 

 

 

 

 

 

 

 

 

Rarely Sometimes Frequently Always
Responses

Figure 10. Group mean percentages of responses across three age groups for
SSQ1-SSQ7.

Group mean percentages and standard deviation were calculated for
questions SSQS and SSQ9 (Figure 11). Group 1 results revealed 58%
responded ‘yes’, 23% responded ‘no’, and 20% responded ‘don’t know’. Results
of Group 2 revealed 20% responded ‘yeS’, 38% responded ‘no’, and 43%
responded ‘don’t know. Group 3 responses revealed 24% answered ‘yes’, 50%
responded ‘no’, and 27% responded ‘don’t know’ that aging did effect one’s
ability to chew and swallow. Overall, over half of Group 1 indicated that getting
older effects one’s ability to chew and swallow. Less than half of Group 2

indicated that they did not know if aging affected one’s ability to chew and

62

swallow, while half of Group 3 indicated that getting older did not effect
one's ability to chew and swallow.

Chi-square statistical analysis was performed on SSQ8-$809
respectively. Only one analysis revealed any statistically significance at the p<.05
level. The youngest group, ages 20-29, responded that more swallowing
difficulties would occur as one gets older. The two older groups did not have that
same opinion. Participants in groups 2 and 3 spread their responses across ‘yes',

‘no’, and ‘don’t know’ regarding the influence of aging on swallowing.

T” #7 N V“ '

 

lGroup 1 (20-29)
I Group 2 (4049)
_ EIGrou 3 (60-95)

 

 

 

 

Responses

Figure 11. Group mean percentages of responses across three age groups for
8808-8809.

63

Clinical Swallowing Examination and Cervical Auscultation

As a component of the Clinical Swallowing Examination (CSE)

(Appendix F), an oropharyngeal examination was performed to assess structure
and function of the swallowing mechanism on 55 nondysphagic participants
involved in the principal investigation. Ten of the 55 participants were used in the
reliability training session with the Principal Investigator and a Rater.
Modifications from Murray (1999) and McKaig and Thibodeau (1998) were used
to analyze the results.

Structure of the orofacial area included examination of facial symmetry at
rest, lip closure, lingual size, tongue at rest, hard and soft palate examination,
and condition of the teeth. No significant asymmetry was observed on the facial
area, or the lips at rest. Labial seal was functional. Observation of the tongue at
rest revealed normal appearance. No fasciculations or tremors were observed.
Hard palate width and height were judged normal. Soft palate at rest with uvula
midline was normal. All participants received a score of ‘1’ indicating structure
was normal and functioning properly for swallowing purposes.

Examination of the teeth and gingiva indicated that the participants in
Groups 1 and 2 maintained their natural teeth, while 12 of 15 of the participants
in Group 3 had missing teeth and some wore dentures; but the missing teeth
reportedly did not interfere with mastication of solid bolus. Gingiva of the
mandible, maxilla, and sublingual areas were normal. The mucous lining of the
buccal cavity was also examined. No abnormalities were noted in any of the 55
participants.

64

Function of the oral structures, which included labial protrusion, retraction,
range of motion, strength, and seal were scored using a 1-5 scale. Additionally,
lingual protrusion, retraction, strength, elevation, depression, range of motion,
velar elevation, and jaw (at rest and during movement) were examined and
scored using a 1-5 scale. Gag reflex and volitional cough were also examined.
No deficits were found in function of the orofacial structures. Velar elevation and
gag reflex were timely and functional.

Cervical auscultation was performed on 55 participants by the Principal
Investigator. All participants were given verbal instructions and three trials of
liquids (5 cc each) and of solids (cracker). Each participant sat in a chair with a
straight back. Swallow sounds were judged using a five point scoring system.

Twenty participants were included in Group 1(20-29). Participants scored
a “1” indicating clear audible sound without coughing and all demonstrated timely
posterior transfer of bolus. Laryngeal elevation/excursion also was functional.
Nineteen of the twenty participants in Group 2 had a clear audible sound without
coughing. One participant in Group 2 coughed on the first trial of liquids, scoring
a ‘3’ wet gurgly sound with immediate coughing. All 15 participants in Group 3
received a ‘1’ clear audible sound without coughing on all swallows.

Reliability

Ten of the 55 participants in this study were used for inter-rater reliability
of cervical auscultation. Four members of Group 1, three from Group 2, and three
from Group 3 were included in the inter-rater reliability session. Data were
collected during one appointment.

65

The Principal Investigator and a second rater did not confer with each
other concerning judging of the trial swallows until all data collection was
completed. A Littmann Cardiology lll Stethoscope was used by each rater. Data
collection at Valdosta State University was collected in an audiological suite to
reduce environmental noises. Participants received three trials of liquids (5 cc
each) and three of solids. Each rater placed the stethoscope at the lateral border
of the trachea immediately inferior to the cricoid.

Results of inter-rater reliability revealed that the principal investigator
judged all 60 swallows as normal, ‘1’ indicating clear audible sound without
coughing. The second rater judged the first 24 sounds of the first four
participants as ‘5’ indicating ‘unable to detect.’ All sounds that were rated “1”
were considered “norrnal”. However, the remaining six participants were judged
by the second rater as normal, ‘1’ clear audible sound without coughing. Thus
while the two raters did not agree on any of swallow sounds using cervical
auscultation for the first four participants, the raters had perfect agreement with

the remaining six participants.

66

CHAPTER V

DISCUSSION

Understanding the nature of swallowing in individuals without swallowing

disorders is a precursor to successfully evaluating persons with dysphagia.

This cross-sectional study was designed to examine the following questions:
does aging Change nondysphagic women’s swallowing status across the adult
age span? Does aging change nondysphagic women’s perceptions of swallowing
as people age? And, Is cervical auscultation a reliable screening adjunct to the
clinical swallowing examination. Fifty-five women between the ages of 20 and 95
were participants in this study. The vast majority of the participants in all three
groups regardless of age, reported to have no difficulty with chewing or
swallowingactivities. Additionally, the age of the participants did not show any
differences regarding how they viewed their current eating and drinking activities.
The women in each age group perceived their eating and drinking activities to be
normal. However, the youngest group felt that swallowing would become more
difficult as one ages. In contrast, the other two groups did not feel that age would

have a negative impact on their chewing and swallowing activities.

Cervical auscultation is gaining recognition as a screening adjunct to the clinical
swallowing examination. It was employed in this study to determine its reliability
as a screening procedure. The investigator and rater were in 100% agreement in
judging normal swallowing sounds during the training period as well as during the
study. Therefore, cervical auscultation was determined to be a reliable screening

67

adjunct to detect the normal swallow of women across the adult age span.
Significance and Clinical Implications

Advancing age increases the elderly to chronic and acute illnesses
predisposing them to conditions that may cause dysphagia. Age-related studies
of alterations in swallowing have identified several age associated impairments in
swallowing (Hudson, Daubert, Mills, 2000) such as impaired pharyngeal
peristalsis and upper esophageal opening (Shaker, et al., 1993). Logemann
(1993) indicated that normal age-related changes in the oropharyngeal area can
affect chewing and swallowing while Rademaker et al. (1988) found that
differences in swallowing function such as altered bolus transit time,
velopharyngeal closure and cricopharyngeal opening occurred with age. Further,
Sonies et al.(1988) found that as people age, there was an increase in swallow
duration. '

On the other hand, Cherney 8 O’Neill (1986) indicated that aging alone
does not cause swallowing severe enough to interfere with functional swallowing.
Hudson and Mills (2000) and Sheth and Diner (1988) contend that the ability to
Chew and swallow is unaffected by age but is affected by tooth loss. Similarly,
Fucile et al. (1988) indicated that functional eating skills did not deteriorate with
age but rather was related to denture wear. The current research concurred with
these studies, finding that healthy elderly community dwellers maintained their
functional chewing and swallowing abilities. Thus, people can expect to be able
to masticate and swallow without restrictions as they age, given no other
confounding medical conditions.

68

Logemann (1998) indicated that cervical auscultation has excellent
potential. Many researchers have advocated the use of cervical auscultation as
an adjunct to the clinical swallowing examination (Youmans 8 Stierwalt, 2005,
Leslie, 2004, 2002, Mills, 2002, Zenner, et al., 1995). The benefits of using
cervical auscultation as an adjunct to the CSE are numerous. Given the
increased incidence of dysphagia in the elderly and a need for early detection of
swallowing changes, an expeditious and accurate way of screening for
swallowing changes is paramount (Youmans 8 Stierwalt, 2005). Early detection
of such changes can warrant more advanced and specific testing. The Clinical
Swallowing Examination with cervical auscultation can provide immediate
outcomes without modifying the examination. Further, “cervical auscultation
maintains its advantages such as its naturalness, relative inexpensiveness,
noninvasiness, and availability” (Youmans 8 Stierwalt, 2005, p.195). The patient
can be seen at bedside, the food does not have to tinted with blue or green dye
for enhancement nor does it need to be coated with barium for contrast. The
patient only has to retrieve the food from an eating utensil.

Cervical auscultation can become a very effective procedure used to
diagnose dysphagia. It is cost prohibitive to use equipment such as
videofluoroscopy (VFSS) and fiberoptic endoscopic evaluation of swallowing
(FEES) in every setting to diagnose dysphagia (e.g. long-term care facilities).
Cervical auscultation is a noninvasive procedure that is used to listen to
swallowing sounds via stethoscope. The cost is inexpensive compared to VFSS
and FEES, both which requires expensive equipment as well as several skilled

69

medical personnel. Additionally, risks to patients by using radiation and allergic
reactions to barium sulfate are eliminated when cervical auscultation is used.
Although there is no procedural code or cost attached to cervical auscultation, in
most hospitals the bedside dysphagia examination is the initial step in screening
for dysphagia before extensive procedure are warranted. In addition, cervical
auscultation requires only minimal physical involvement by the patient and one
skilled professional.

Another significant aspect of this study was its focus on women across the
adult age span. Although not part of the experimental design the majority (82%)
of the participants were African American. NIH (1994) reported that women and
minorities should be included in clinical research if inferences about their health
and disease are to be made. This research addressed the above mentioned
issue. The'participants were healthy community dwellers, with varied
backgrounds, from Norway, South Carolina and Valdosta, Georgia between the
ages of 20 and 95. No other data has reported specifically concerning the
swallow mechanism across adult African American women as they age.

Limitations and Future Research

More research is needed to verify the reliability of cervical auscultation
with individuals who have dysphagia as an adjunct to the Clinical swallowing
examination. This study showed that cervical auscultation was reliable for normal
patterns of swallowing. Unexpectedly, no participants demonstrated any chewing
or swallowing difficulties during the actual food and drink trials. Stroud et al.
(2002) indicated in their study on cervical auscultation, that they found the level

70

of agreement over chance between multiple raters was 0.28, ‘fair’ agreement
(Kappa statistic 0.21- 0.40). Leslie et al. (2004) indicate that as more detailed
studies continue to be conducted in cervical auscultation (CA) and training in
using CA, reliability may improve. This should include those patients who have
suffered strokes as well as those with neurodegenerative diseases.

Another area for further study is training for judging normal and
disordered swallowing sounds. Leslie et al. (2004) used 31 SLPs to participate in
their study. Stroud et al. (2002) recruited five SLPs experienced in cervical
auscultation to judge swallowing sounds via cervical auscultation. While there
are no specific guidelines for training someone to use cervical auscultation, in a
their study Stroud et al. defined experience as “having received at least five
hours of training on cervical auscultation and having used auscultation to assess
patients for at least one session per week as part of their current job” (p.641). In
the current study, .the second rater was trained for over a week, with 100%
reliability with the principle investigator. More importantly, however, there was a
gap of several months between the training of CA with this rater and her actually
rating of the experimental sounds. Being unsure with what she was listening for,
her first four participants were all scored as ‘unable to detect’. In subsequent
participants, rater 2 and the principal investigator were in identical agreement. In
the future, if not performing cervical auscultation for a period of time,
professionals Should go through refresher training before conducting this

procedure with a patient.

71

In support of how normal swallow sounds, Selly et al. (2004) indicated that
two clear “clicks” maybe heard during each normal swallow. McKaig and
Thibodeau (1998) described the swallow sounds as (1) “ a click associated with
articulation of the epiglottis, (2) a wet pop associated with the opening of the
cricopharyngeus, and (3) a puff or huff associated with the release of subglottal
air trapped when the vocal folds closed to protect the airway. Abnormal sounds
were characterized as including “a wet sucking noise” (p. 26).

While there is no universal time frame for a person to be trained on
listening to swallowing sounds, this problem can be addressed from a
pedagogical standpoint. In a study by Sitoh, Lee, Phua, Lieu 8 Chan (2000) a ’
.geriatrician conducted a simple bedside assessment of elderly patients 24 hours
upon admission to a hospital. Being unaware of each others results, a
geriatriciari'identified 42 patients with a swallowing dysfunction, while the
speech-language pathologist’s diagnosed 40 patients to have dysphagia.

In addition, recording of the sounds can be made and utilized as training
tapes. Moriniere, Beutter 8 Boiron (2006) used cervical auscultation to assess
the acoustic sounds of swallowing. They recorded 240 recordings for the 30
subjects in their study. Leslie et al. (2004) recorded swallowing sounds on
compact discs and. mailed to 31 SLPs so that they could rate the swallow sounds
as normal or abnormal. Such recordings can be used in medical and nursing
schools, medical technology programs, and communication disorders programs
to teach their students how to listen to and judge swallow sounds. It would be
easier for medical and medical technology students to perform such training

72

since students in those programs are already trained on how to listen to lung
sounds. Once trained, health professionals such as SLPS, physicians, physician
assistants, nurses, and geriatricians, can incorporate cervical auscultation into
their routine physical examination.

Another area for further study is the consensus regarding the
instrumentation for collecting the data. Researchers have used a variety of
instruments including a Toshiba notebook computer with a hard drive via a
Littmann Cardiology lll stethoscope (Leslie, et al, 2004). Youman 8 Stienlvalt
(2005) used an accelerometer and an ICP sensor signal conditioner set to a
computerized speech Lab for recording and analysis. Takahashi et al. (1994)
used a TEAC 501 accelerometer, an electret condenser microphone and KAY
5500 DSP Sonogram and Perox B215 tape recorder to record swallow sounds.
Stroud et al. (2002) used a radiotranslucent stethoscope head containing an
electret microphone into a Panasonic 5-VHS video recorder, VFSS and audio
recorders. Given the variety of instruments used, there needs to be consensus
among researchers regarding the best type of instruments to use to listen to and
record swallow sounds.

Another limitation of this study was sample size per group, especially
participants in the old-old group. This study consisted of three groups of 20, 20,
and 15 across age group respectively. Additionally, the study composed of
primarily of African-American participants. A study of this type would need to be

, expanded upon, not only number, but gender, and other minority groups as well.

73

Conclusions

Although there are nonnal-age-related changes that occur in the
oropharyngeal area, these changes are not severe enough to interfere with
functional chewing and swallowing abilities. This study revealed that women
across the age span did not report any difficulties in their mastication and
deglutition skills. It was also shown that the youngest group felt that aging would
likely cause one to experience chewing and swallowing difficulties while the two
remaining groups did not feel aging would likely cause one to experience
difficulties with chewing and swallowing. Further, this study showed that as
women maintained their health that mastication and deglutition skills also
remained intact.

This study further revealed that cervical auscultation was a reliable
screening adjunct to the Clinical Swallowing Examination. Future research of
cervical auscultation should prove beneficial as a screening adjunct to the clinical
swallowing examination when videofluoroscopy and fiberoptic endoscopic

evaluation of swallowing are not available.

74

APPENDICES

75

APPENDIX A

Letter to Prospective Referral Sources

76

Dear Sir or Madame:

My name is Ruth Renee Hannibal. I am a doctoral candidate in the Department
of Audiology and Speech Sciences and Disorders at Michigan State University in
East Lansing, Michigan and a faculty member in the Department of Special
Education and Communication Disorders at Valdosta State University in
Valdosta, Georgia. My area of study for my dissertation is the effect of aging on
the oropharyngeal swallow in nondysphagic women (i.e., women who do not
have a swallowing disorder). I am seeking participants who meet the following
criteria: (1) women between the ages of 20-29; 40-49; 60+ (2) have no medical
history of neurologic and or degenerative diseases; (3) have no history of
diagnosed swallowing disorder and; (4) no diagnosed cancer of the mouth or
throat.

The purpose of this study is to evaluate the effectiveness of the swallow and
perceptions women have concerning swallowing as it relates to aging. Potential
subjects should understand the participation in this study is voluntary and that
there is no monetary benefit associated with participating in this study. The study
will take approximately 45 minutes.

I am requesting that you Share this information with the women in your
organizatiOn/auxiliary and women’s ministry. If there are women who are
interested, please ask them to contact me at (229) 219-1310 or at

(229) 244-9717, or email me at rrhannib@valdosta.edu. Thank you for your
cooperation.

Thank you,

Ruth Renee Hannibal

Department of Audiology and Speech Sciences
Michigan State University

East Lansing, Michigan

77

Appendix B
WRITTEN-ORAL SCRIPT

78

Written-Oral Script

Hello, my name is Ruth Renee Hannibal. I am an Assistant Professor in the
Department of Special Education and Communication Disorders at Valdosta
State University and a doctoral candidate at Michigan State University. Your
name was give to me by your president! professor. You indicated that you were
interested in participating in a study to assess women’s swallowing. Please allow
me to explain the purpose of my study so that you can decide if you still want to
participate.

There has been minimal to no research on the effects of normal aging has on the
swallowing process, particularly in women. The profession of speech-language
pathology is continuing to work with individuals across the life-span who has
swallowing disorders and is looking for ways to be cost efficient in providing
services. The use of a stethoscope to listen to swallowing sounds is still new, but
is gaining recognition among some speech-language pathologists, especially
when the individuals that they serve can not be taken to the hospital for x-rays of
their throat. This study is designed to assess the swallowing in women ages 20-
29; 40-49; 60+.

The study involves four steps: (1) reading and signing a consent form for
participation in the study; (2) answering questions concerning your medical,
surgical and swallowing history; (3) and an examination of mouth (tongue, teeth,
lips, throat); and (4) swallowing 15 cc of water and chewing and swallowing one
cracker.

There are no known risks involved in this study.

The entire study will take approximately 45 minutes and should be competed
within that time.

Now that the purpose and procedures have been explained, do you wish to
participate?

If the answer is ‘yes’ data. will be collected during the meeting and/or
appointments will be made to collect the data.

If the answer is ‘no,’ Thank you very much for your time.

79

Appendix C
Department of Communicative Sciences and Disorders

Research Consent Form for ,
“The effects of aging on oropharyngeal swallow in nondysphagia women”

80

Department of Communicative Sciences and Disorders
Research Consent Form for
“The effects of aging on oropharyngeal swallow in nondysphagia women”

Summam: There has been minimal research on the effects of the normal aging
process in swallowing in women who do not have swallowing problems. Because
of Medicare changes speech-language pathologists are looking for noninvasive
means of diagnosing swallowing problems. This study is designed to examine the
effectiveness of the use of the clinical swallowing evaluation using a stethoscope
to detect subtle swallowing problems in women ages 20-29; 40-49; 60+

Me}; This study will take approximately 45 minutes to complete.

Step 1: Reading and signing this consent form giving me permission to include
you in this research.

Step 2: Answering questions to a swallowing questionnaire. The swallowing
questionnaire is given to determine whether any reported conditions will interfere
with the normal swallowing.

Step 3: A Clinical Swallowing Examination to assess the structure and function
of the lips, tongue, hard palate, soft palate and the swallow. This involves simple
movements of these structures and using a stethoscope on the windpipe and/or
voice box to listen while you swallow.

DiscomfortisislgsL: There are no risks involved in this study. The Clinical
Swallowing Examination is a noninvasive procedure used daily in hospitals.

Benefits: There are no direct benefits or compensation from this study. The data
gathered would assist health care providers with valuable information needed to
expand the knowledge on how listening to swallowing sounds using a
stethoscope can be used as a noninvasive means for detecting clinical signs of
swallowing disorders.

Confidentialig: Your name will not be revealed to anyone other than me and
another speech-language pathologist who will assist in the data collection. The
data will be located in my office in a locked cabinet.

Your privacy will be protected to the maximum extent allowable by law.

The results of this study may be presented at professional conferences and may
appear in appropriate journals and other publications.
Your privacy will be protected to the maximum extent allowable bylaw.

81

If you have questions about this study, please contact the investigator Ruth
Renee Hannibal at (229) 219-1310, e-mail: rrhannib@valdosta.edu or regular
mail: Valdosta State University, Special Education and Communication
Disorders, 1500 N. Patterson St, Valdosta, GA 31698-0102. If you have
questions or concerns regarding your rights as a study participant, or are
dissatisfied at any time with any aspect of this study, you may contact —
anonymously, if you wish - Peter Vasilenko, Ph.D, at (517) 432-4503,

e-mail: rcrihs@rnsu.edu or regular mail: 202 Olds Hall, East Lansing, MI 48824.

 

Your signature below indicates your voluntary agreement to participate in this
study.

Name Date

 

82

Appendix D

Medical History Questionnaire

83

Medical History Questionnaire

Name BD Grp I
Please answer and circle all the questions as accurately as possible.

Have you ever been diagnosed by a doctor and/or have treatment for any of the
conditions below?

1. Lou Gehrig Disease (ALS) Yes No
2. Alzheimer’s Disease Yes No
3. Cervical Osteophytes Yes No
4. Dennatomyositis Yes No
5. Dysphagia (swallowing problem) Yes No
6. Esophagitis Yes No
7. Gastroesophageal Reflux Yes No
8. Head Injury Yes No
9. Hiatus Hernia Yes No
10. Parkinson’s Disease Yes No
1 1 . Polio Yes No
12. Spinal Cord Injury Yes No
13. Stroke Yes No
14. Transient lschemic Attack (TIA. mini strokes) Yes No
15.0thér Yes No
Surgical

Have you ever had surgery and/or radiation of the following because of
cancer?

16. Tongue Yes No
17. Neck Yes No
18. Throat Yes No
19. Esophagus Yes No
20. Brain Yes No

84

Appendix E

Swallowing Status Questionnaire

85

Swallowing Status Questionnaire

Name

 

Please circle the answers to the questions below. Use the descriptions as a
guide.

Always= coughing after swallowing liquids or solids at every meal.
Frequently= coughing after swallowing liquids or solids one time per meal.
Sometimes= coughing after swallowing liquids or solids one to two times
per month per meal.

Rarely= coughing one time or less after swallowing liquids or solids per
yeah

1. In general, do you cough after drinking liquids?

Always Frequently Sometimes Rarely
2. In general, do you cough after swallowing foods?
Always Frequently Sometimes Rarely
3. In general, do you cough after swallowing saliva?
Always Frequently Sometimes Rarely
4. In general, do you take small drinks of liquids to avoid coughing?
Always Frequently Sometimes Rarely
5. In general, do you eat small bites of food to avoid coughing?
Always Frequently Sometimes Rarely
6. In general, do you experience pain while swallowing?
Always Frequently Sometimes Rarely
7. In general, do you experience heartburn or indigestion following meals?
Always Frequently Sometimes Rarely
Perceptions

Please circle your answer
8. Does getting older affect one’s ability to swallow?
Yes No Don’t know

9. Does getting older affect one’s ability to chew?
Yes No Don’t know

86

Appendix F

Clinical Swallowing Examination

87

Clinical Swallowing Examination

 

 

 

 

 

 

 

 

Edentulous

Name Date

BD Age

Group /

Structure Score: 1= structure is normal 2= structure is abnormal
Face at rest Lips at rest
Lingual size Hard palate
Soft palate

Examination of teeth += present - = absent

Natural teeth Missing teeth

Dentures: complete upper lower

Partials: Upper lower Bridges

 

Function: Score:

1 = function is executed correctly and immediately
2 = function is executed correctly with delay (3-58)

3 = function is executed incorrectly and immediately
4 = function is executed incorrectly and delayed

 

Labial protrusion (VII): _ Full protrusion of lips

Labial retraction (VII) :
Labial strength (VII):

Labial seal (VII):
Labial ROM (VII)

Full retraction of lips

Firm grasp of tongue blade

No audible leakage of 5mL of water. No
drooling

Alternate purse and retract lips for 10 cycles

Lingual protrusion (XII):_ Fully extended tongue with no deviations
Lingual retraction (XII): _ Fully retracted tongue into the oral cavity

Lingual strength (XII):

Lingual ROM (XII): __

with no deviations

Tactile resistance against tongue blade
Contact of tongue against left and right
sides of lips and ability to sweep tongue
along length of the maxillary and
mandibular and buccal sulci

Lingual elevation (XII): _ Elevation of tongue tip or blade to upper

lip, alveolar ridge, and hard palate

Lingual depression (XII): _ Lowering of tongue tip behind bottom teeth

Velar elevation (X):

Mandible (V):

Movement upward and backward upon
phonation of la/

Ability to open and close mouth without
difficulty

88

Mandible ROM (V): _ Movement of jaw right to left without difficulty

 

 

 

Volitional cough (X): _ Strong and forceful cough

my Swallows Observational signs + = present -- = not present

Saliva Swallows: __ Ability to swallow saliva without difficulty

Bolus formation: _ Ability to perform rotary chewing of solids to form
bolus

Laryngeal elevation: __ Visual observation of elevation of larynx during
Trial swallows

Oral residue: _ No oral residue on teeth, hard palate, tongue,

Lateral or anterior residue

Vocal quality: _ Clear sustained phonation following trial
swallows
Salivary flow/control: _ No signs of drooling at rest or during or after

trial swallows

Reflexive cough: Absence of cough following trial swallows

 

Cervical Auscultation: Score:1 = clear audible sound without coughing
2 = wet gurgly sound without coughing
3 = wet gurgly sound with immediate
coughing
4 = wet gurgly sound with delay coughing
5 = unable to detect

 

Liquids Solids
1. 1.
2. 2.
3. 3.

89

 

REFERENCES

90

REFERENCES

Abella, M. Formolo, J. Penny, DC. (1992). Comparison of the acoustic
properties of six popular stethoscopes. Journal of Acoustics Society of
America 91(4) 2224-2228.

 

 

American Speech-Language Hearing Association (2000). Clinical indications for
instrumental assessment of dysphagia (guidelines). ASHA Desk
Reference. Rockville, MD. Author.

Arms, R.A., Dines, DE, 8 Tinstman, T. (1974). Aspiration pneumonia. Chest,
65(2).

Arvedson, JO, 8 Lefton-Grief, M.A. (1998).Pedia_tric videofluoroscoraic swallow
studies. A professional manual with caregiver guidelines Austin, Texas:
Communication Skill Builders.

Aviv, J.E., 'et al. (1994). Age-related changes in pharyngeal and supraglottic
sensations. Annals of otologv rhinology and lagyngology, 113110), 749-
756.

Bass, NH. (1997). The neurology of swallowing. In Micheal E. Groher (Ed.). 3rd
ed. (pp.7-35). Newton, MA.: Buttenrvorth-Heinemann.

Batchelor, B., Neilsen, S., Sexton, K. (1996). Issues in maintaining hydration in
nursing home patients who aspirate thin liquids. Journal of Medical

Speech-Language Pathology. 4(3), 217-221.

Blitzer, A. (1990). Approaches to the patient with aspiraton and swallowing
disabilities. Dysphagia, 5, 129-137.

Brozenec, S. (2000). Gastrointestinal functions. In Annette G. Lueckenotte (Ed.).
Gerontological Nursing. (.43-552). St. Louis: Mosby.

91

Cherney, L.R. 8 O”Neill, P. (1986). Swallowing disorders and the aged. Topics
in Geriatric Rehabilitation 1(4) 45-59.

 

Cherney, LR. (1994). Clinical management of dysphagia in adults 8 children.
(2"d ed.). Gaithersburg,MD: Aspen Publishers, Inc.

Cichero, J.A.Y. 8 Murdoch, BE. (2002). Detection of swallowing sounds:
Methodology revisited. Dysphagia, 17, 40-49.

Cichero,J. A. 8 Murdoch, B. E. (1998). The physiologic cause of swallowing
sounds: answers from heart sounds and vocal tract acoustics. Dysphagia,
_1_3_(1), 39-52.

Clark, HM. (2005). Clinical decision making and oral motor treatments. The
Asha Leader. 10(8). American Speech- Language Hearing Association:
MD.

Crary, MA. 8 Groher, ME. (2003). Introggction to adult swallowing disorders.
Missouri: ButtenNorth Heinemann.

Daniels, S.K., McAdam, C.P., Brailey, K., and Foundas, A.L.,(1997). Clinical
assessment of swallowing and prediction of dysphagia severity. American
Journal of Speech-Language Pathology, 6(4) 17-24.

Daniels, S.K., Brailey, K., Priestly, D.H., Herrington, l.R., Weisberg, L.A.,
Foundas, AL. (1998). Aspiration in patients with acute stroke. Archives
off thsigal Me_dicine and Rehabilitation. ,7_9_14-19.

 

Daniels, S.K., Corey, D.M., Hadskey, L.D., Legendre, C., Priestly, D.H.M,
Rosenbek, J.C., et al. (2004). Mechanism of sequential swallowing
during straw drinking in healthy young and older adults. Journal of

Speech,Language, and Hearing Research. 47, 33-34.

Dawson, J.B. (1964). Auscultation and the stethoscope. Practitioner, 193, 315-
322.

92

Ding, R. 8 Logemann, J. (2000). Pneumonia in stroke patients: A retrospective
study. Dysphagia, 15, 51-57.

Dirckx, H.H. (2001). Stedman’s concise medical dictiom for the health
professions. Illustrated. 4th ed. p. 253. Baltimore: MD:
Williams 8: Wilkins.

Dodds, W.J., Stewart, E.T., Logemann, J.A.. (1990). Physiology
and radiology of the normal oral and pharyngeal phases of
swallowing. American Journal of Roentenology, 154, 953-
963.

Donner, MW. 8 Jones, B. (1991). Aging and neurological disease.
In M.W. Donner 8 B. Jones (Eds.), Normal and abnormal
swallowing imaging in diagnosis ang thegpy (pp.189-
202). New York: Spinger-Verlag.

Dray, T.G., Hillel, A.D., Miller, R. (1998). Dysphagia caused by neurologic
deficits. Otolagyngolggic Clinics of North America, fl(3), 507-524.

Duffy, J. (2005). Motor speech disorders: Substrates, differential diagnosis and
Management (2"d ed.). United States: Elsevier Mosby.

Ebersole, P. 8 Hess, P. (2000). Toward healthy aging human needs and nursing
response. (5th ed.) St. Louis: Mosby.

Edwards, J ., Hawkins, D. (2000). Radiologic concepts in the management of

adult dysphagia. In Russell H. Mills (Ed), Evaluation of dysphagia in

adults: Expanding the diagnostic options, (pp. 65-102). Austin, TX:
Pro-Ed.

Ekberg, O., Feinberg, M.J. (1991). Altered swallowing function in elderly patients
without dysphagia: Radiologic findings in 56 cases. American Journal of
Roentgenology, @(6), 1181-1184.

93

Eckberg, O. (1997). Radiologic evaluation of swallowing. In Michael E. Groher
(ed. ). Dysphagia: Diagnosis and management (3rd ed. ). (pp. 191-222).
Butterworth- Heinemann.

Ergun, GA. 8 Miskovitz, PF. (1992). Aging and esophagus: common pathologic
conditions and their effect upon swallowing in the geriatric population.

Dysphagia, Z, 58-63.

Fucile, 8., Wright, P.M., Chan, I., Yee, S., Langlais, ME, 8 Gisel, E. (1998).
Functional oral-motor skills: do they change with age?
Dysphagia, 13(4), 195-210.

Garon, B.R., Engle, M., Orimiston, C. (1996). Silent aspiration: Results of 1,000
Videofluoroscopic swallow evaluations. Journal of NepLoReLapilitation.
_1_0(2), 121-126.

 

Gleeson, D. (1996). The effects of aging on selected parameters of
oropharyngeal swallowing. Unpublished doctoral dissertation.
Michigan State University.

Goodrich, S.J., 8 Walker, A. I. (1997). Clinical swallow evaluation. In Rebecca
Leonard 8 Katherine Kendall (Eds.), Dysphagia assgsment pry
t_re_atment plannirygfi Team approach. (pp. 59-72). San Diego: Singular
Publishing Group, Inc.

Gordon, C., Hewler, R.L., 8 Wade, OT. (1987). Dysphagia in acute
stroke. British Medical Journal, 295, 411-414.

Granieri, E. (1990). Nutrition and the older adult. Dysphagia, 4, 196-201.

Groher, M. E. (2000). The case history. In Russel H. Mills (Ed). Evaluation of
dysphagiain nadzults Expandrng the diagnostic options. (1-25). Austin,
TX. Pro-Ed.

94

Groher, ME. (1997). Mechanical disorders of swallowin . In Michael E. Groher
(Ed.). Dysphagia: Diagnosis ang management. 3 ed. 73-106.

Groher, M. 8 Bukatman, R. (1986). The prevalence of swallowing disorders in
two teaching hospitals. Dysphagia, 1, 3—6.

Hamlet, 8., Penny, D.G., 8 Formolo, J. (1994). Stethoscope acoustics and
cervical auscultation of swallowing. Dysphagia.9, 63-68.

Hanning, C., Wuttage-Hannig, A., Horrnann, A, 8 Herrmann, I.F. (1989).
Cinematographic study of the pathologic mechanism of aspiration
pneumonia. ROFO150: 260-267.

Hardy, E. (1995). Bedside evaluation of dysphagia. Bisbee, AZ.: lmaginart.

Hardy, E. 8 Robinson, N. M. (1993). _S_vygllowing disorders treatment manual,
Bisbee, AZ: lmaginart.

Hedge, MN. (2006). A coursebook on aphasia and other neurogenic language
disorders. (3rd ed.). (pp. 515-516). United States: Thomas-Delmar
Learning.

Hensel, S. L. (2000). Sensory function. In Annette Lueckenotte (Ed.).
Gerontolpgical nursing. (pp.695-720). St. Louis: Mosby.

Hetzel, L. 8 Smith, A. (2001). The 65 years and over population:
2000 Census 2000 Brief. US. Department of Commerce.
Retrieved 8/28/06 @ www. census.gov.

Horner, J., Massey, E.W., 8 Brazer, S. R. (1990). Aspiration in
bilateral stroke patients. Neurolpgy, 4_Q, 1686-1688.

Horner, J. 8 Massey, W. (1988). Silent aspiration following stroke.
Neurolggy, 38, 317-319.

95

Homer, J., Buoyer, F.G., Alberts, M.J., 8 Helms, M.J. (1991). Dysphagia
following brain-stem stroke: clinical correlates and outcomes. Archives of
Neurology, 48, 1170-1 173.

Hudson, H., Daubert, C. R., Mills, RH. (2000). The interdependency of protein-
Energy malnutrition, aging, and dysphagia. Dysphagia, fl, 31-38

Hudson, J. C. 8 Mills, R. H. (2000). Dental aspects of swallowing. In Russell H.
Mills (Ed.). Evaluation of dysphgqia in adults: Expanding the diagnostic
options, (pp. 207-237). Austin, TX: Pro-Ed.

Johnson, H. 8 Scott, A. (1993). A practical approach to saliva control. Tucson,
AZ: Communication Skill Builders.

Kahrilas, P.J., Dodds, W.J., Dent, J., Logemann, J.A.,8 Shaker, R. (1988). Upper
esophageal sphincter function during deglutition. Gastroenterolmy, 95,
52-62.

Kawashima, K., Motohashi, Y., 8 Fujishima, l. (2004). Prevalence of dysphagia
amO’ng community-dwelling elderly individuals as estimated using a
questionnaire for dysphagia screening. Dysphagia, 19, 266-271.

Kendall, K., McKenzie, 8., Leonard, R. J., Gonclaves, M. I. 8 Walker, A. (2000).
Timing of events in normal swallowing. A Videofluoroscopic study.
Dysphagia, 15, 74-83.

Kendall, K.A. 8 Leonard, P.J. (2001). Bolus transit and airway protection
coordination in older dysphagic patients. The Lagyngoscope, 111 (pt. 1),
2017-2022.

Kendall, K., McKenzie, S., 8 Leonard, R. (1997). Dynamic swallow study:
Objective measures and normative date. In Rebecca Leonard and
Katherine Kendall (Eds). Dysphagia assessment and treatment
firming: A team approach. (pp. 101-125). San Diego: Singular
Publishing Group, Inc.

 

Kuhlemeier, K.V. (1994). Epidemiology and dysphagia. Dysphagia, 9, 209-217.

Lazarus, CL. (1989). Swallowing disorders after traumatic brain injury. Journal
of Heag Trapma and Rehabilitation. 4(4), 34-41.

Leonard,R.J., Kendall, K.A., McKenzie,S., Gonclaves, MI, 8 Walker, A..(2000).
Structural displacements in normal swallowing: A videofluoroscopy study.
Dysphagia, 15, 146-152.

Leonard, R., Kendall, K., McKenzie, S., 8 Goodrich, S. (1997). The treatment
plan. In Rebecca Leonard and Katherine Kendall (Eds.). Dysphagia
assessment and treatment planning: A team approach. San Diego:
Singular Publishing Group, Inc. 181-210.

Leslie, P. (2005). Cervical auscultation: Myths and magic, evidence
and clinical implications. Paper presented at 2005 ASHA
Convention San Diego, CA.

Leslie, R, Drinnan, M. J., Finn, P., Ford, GA, 8 Wilson, J.A., (2004). Reliability
and validity of cervical auscultation: A controlled comparison using
videofluoroscopy. Dysphagia 3(4), 231-240.

Linden, P. 8 Siebens, A. A. (1983). Dysphagia: Prediciting laryngeal penetration.
Archives of Physical Medicine and Rehabilitiation, 63, 281-284.

Linton, AD. (1997). Age-related changes in the gastrointestinal system. In Mary
Ann Matteson, Eleanor S. McConnell, and Adrianne Dill Linton (Eds.).

Gerontological nursing: Concepts and practice. 2”“ ed. (pp. 317-336).
Philadelphia: W.B. Saunders Co.

Logemann, J.A. (1983). Evaluation and tre_a_t_ment of swallowing disorders. San
Diego: College-Hill Press.

97

Logemann, J.A., (1990). Effects of aging on the swallowing mechanism. In G.
Sisson and H. Pelzer (Eds). The Otolarvngologic Clinics of NortJh
America: Head and Neck Diseases in the Eldferlv. 23(6) 1045-1056.
Philadelphia: W.B. Saunders.

Logemann, J.A. (1993). Noninvasive approaches to deglutitive aspiration.
Dysphagia, 8, 331-333.

Logemann, J.A. (1997). Professional education and training. In Barbara C.
Sonies (Ed.), Dysphagia: A contintym of care. (pp. 123-134). Maryland:
Aspen Publishers, Inc.

Logemann, J.A. (1997). Structural and functional aspects of normal and
disordered swallowing. In Carole T. Ferrand 8 Ronald L. Bloom (Eds.),
Introdpction to orgnic anjdneurogenic disorders of communication
pprrent score of practice. (pp.229-246). MA: Allyn 8 Bacon.

Logemann, J.A. (1998). Evaluation and treatment of swallowing disorders (2"d
ed.). Austin,TX: Pro-Ed.

Logemann, J.A., Pauloski, B.A., Rademaker, A.W., Colangelo, L.A., Kahrilas,
P.J., 8 Smith, C. H. (2000). Temporal and biomechanical characteristics
of oropharyngeal swallow in younger and older men. Journal of Speech,

Language, and Hearing Research, 43, 1264-1274.

Logemann, J.A., Pauloski, B.R., Rademaker, AW. 8 Kahrilas, P.J.
(2002).Oropharyngeal swallow in Younger and older women:

Videofluoroscopic Analysis. Journal of speech and hearing Research, 4_§,
434-445.

Love, R.J. 8 Webb, W.G. (2001). Neurology for the speech-language
pathologist. 4th ed. Boston: Butterworth Heinemann.

Lueckenotte, AG. (2000). Overview of gerontological nursing. (pp. 1-19).
Gerontological Nursing, St. Louis: Mosby.

98

 

Madison, HE. (2000). Theories of aging. In Annette Lueckenotte (Ed.),
Gerontological Nursing, (pp. 20-33).

Mansson, I. 8 Sanberg, N. (1975). Oro-pharyngeal sensitivity and elicitation of
swallowing in man. Acta Otololarvngology, 79, 140-145.

Marik, PE. 8 Kaplan, D. (2003). Aspiration pneumonia and dysphagia in the
elderly. Chest 124 (1). 328-336.

 

Massey, B.T, 8 Shaker, R. (1997). Introduction to the field of deglutition and
deglutition disorders. In Andrienne L. Pearlman and Konrad Schulze-
Delrieu (Eds). Deglutition and its disorders: Anatovaphysiology, and
management (pp.1-15). Singular Publishing Group, Inc. San Diego.

Matteson, M.A., Beason, LB, 8 McConneI, ES. (1997). Psychosocial problems
associated with aging. In Mary Ann Matteson, Eleanor S. McConnel 8
Adrianne Dill Linton (Eds). Gerontological nursing: Concepts a_nd
practice. (2"d ed.). (pp. 653-659). Philadelphia: W. B. Saunders.

McConnell, ES. (1997). Conceptual bases for gerontological nursing practice:
Models, trends, and issues. In Mary Ann Matheson, Eleanor S. McConnell

8 Andrianne Dill Linton (Eds), Gerontological nursing: Concepts and
practice, 2nd edition (pp. 4-62). Philadelphia: W.B. Saunders Co.

McCullough, G.H., Wertz, R.T., Rosenbek, JG. 8 Dinneen, C. (1999). Clinician’s
preferences and practices in conducting clinical/bedside and
Videofluoroscopic swallowing examinations in an adult, neurogenic

population. American Journal of Speech Language pathology. 8, 149-163.

McKaig, T. 8 Thibodeau, J. (1998). Bedside assessment of swallowing safety:
The clinician’s software and user’s manual. Butterworth Heinemann:
Boston.

Miller, A. (1986). Neurophysiological basis of swallowing. Dysphagia, 1, 91-100.

99

Miller, R. (1997). Clinical examination of dysphagia. In Michael Groher (Ed.),

Dysphagia: Diagnosis and management, "d ed. (pp.169-189). Boston:
Butterworth-Heinenman.

Mills, R. (2000). Increasing the precision of the videofluoroscopy swallowing
examination. In Russell M. Mills (ed.). Evaluation of dysphagiai in adults:
expanding the diagnostic options. (pp. 103-144). Austin, TX: Pro-Ed.

Moriniere, S., Beutter, P., 8 Boiron, M. (2006). Sound component duration of
health human pharyngoesophageal swallowing: A gender comparison
study. Dysphagia, 175-182.

Murray, J. (1999). Manpal of dysphagia assessment in adults. San Diego:
Singular Publishing Group, Inc.

Murray, LL. 8 Clark, HM. (2006). Neurogenic disordfers of language: Theogy
_driven clinical practice. (pp. 23). United States: Delmar-Learning.

Murry, T. 8 Carrau, R.L. (2001). Clinical manual for swallowing disorders. San
Diego: Singular-Thomas Learning.

National Institutes of Health. (1994). Outreach notebook for the NIH guidelines

on inclusion of women and minorities as subjects in clinical research.
NIH Publication No. 97-4160.

Nilsson, H., Ekberg, O., Olsson, R., 8 Hindfelt, B. (1994). Quantitative aspects of
swallowing in an elderly nondysphagic population. Dysphagia, 11, 180-
184.

O’Donoghue, S. 8 Bagnall, A. (1999). Videofluoroscopic evaluation in the
. assessment of swallowing disorders in paediatric and adult
populations. Folia Phoniatrica et Logopaedica, ,5_1(4-5), 158-171 .

Palmer, J.B., Drennan, JO, 8 Baba, M. (2000). Evaluation and treatment of
swallowing impairments. American Family thsicia_n, 6_1(8), 2453-2462.

100

Perlman, A. (1997). Application of instrumental procedures to the evaluation
and treatment of dysphagia. In Barbara C. Sonies (Ed), Dysphagia: A
contindgm of care (pp. 137-159). Gaithesburg, MD: Aspen Publishers,
Inc.

Perlman, A. L. 8 Christensen, J. (1997). Topography and functional anatomy of
the swallowing structures. In Adrienne L. Perlman 8 Konrad Schulze-
Delrieu (Eds). Deglutition and its disorders: Anatomy. physicflpgv. clinic
diagnosis and management. San Diego: Singular Publishing Group, Inc.

Perlman, A., Langmore, S., Milianti, F., Miller, R., Mills, R.H., 8 Zenner, P.
(1991 ). Comprehensive clinical examination of oropharyngeal swallowing
function: Veteran’s Administration Procedure. Seminars in Speech add
Language. 12(3). Pp. 246-253.

Pinnington, L. L., Muhiddin, K.A., Lobeck, M. 8 Pearce, V.R. (2000). lnterrater
and intrraterreliability of the Exeter dysphagia assessment technique
applied to healthy adults. Dysphagia 15, 6-9.

Rademaker, B., Pauloski, R., Colangelo, LA, 8 Logemann, J.A. (1998). Age
and volume effects on liquid swallowing function in normal women.
Journal of Speech. Language and Hearing Research April fl(2), 275-
284.

Reynolds, P.S., Gilbert, L., Good, D.C., Knappertz, V.A., Crenshaw, C., Wayne,
S .L., Pillbury, D., 8 Tegeler, OH. (1998). Pneumonia in dysphagic stroke
patients: Effects on outcomes and identification of high risk patients.

Journal of neurological rehabilitation, g, 15-21.

Robbins, J., Hamilton, J., Lof, G., Kempster, G. (1992). Oropharyngeal
swallowing in normal adults of different ages. Gastroenterolpgy, ,1__03(3),
823-829.

Schechter, G.L. (1998). Systemic causes of dysphagia in adults. In Randall L.
Plant and Gary L. Schechter (Eds). The Otololaryngolcyqic Clinics of

North America: Dysphagia in Children and adults and Geriatrics. 3_1(3)
525-535. Philadelphia: W.B. Saunders.

101

 

Schulze-Delrieu, KS. 8 Miller, R. M. (1997). Clinical assessment of dysphagia. In
Adrienne L. Perlman 8 Konrad Schulze—Delrieu (Eds). Deglutition and

its disorders: anatomv. physiology. clinical diagnosis and management
(pp. 125-152). San Diego: Singular Publishing Group, Inc.

Selly, W.G., Ellis, P.E., Flack, F.C., Bayliss, C.R., Chir, B., Pearce, V.R. (1994).
The synchronization of respiration and swallowing sounds with
videofluoroscopy during swallowing. Dysphagia, 9(3), 162-167.

Shaw, J.L., et al. (2004). Bronchial auscultation: An effective adjunct to speech
and language therapy bedside assessment when detecting dysphagia
and aspiration? Dysphagia, 19(4), 211-218.

Sheth, N. 8 Diner, WC. (1988). Swallowing in the elderly. Dysphagia, 2, 209-
215.

Siebens, A. A. (1990). Rehabilitation for swallowing impairment. In Frederic J.
Kottke and Justus F. Lehmann (Eds). Krusen’s Mndbook of physical
medicine and rehabilitation (4th ed.), Philadelphia: W.B. Saunders

Sitoh, Y.Y, Lee, A., Phya, S.Y., Lieu, PK, 8 Chan, SP. (2000). Bedside
assessment of swallowing: A useful screening tool for dysphagia in
an acute geriatric ward. Singapore Medical Journal, fl(8), 376-381.

Smith, C.H., Logemann, J.A., Colangelo, L .A., Rademaker, A. W. 8 Pauloski,
BR. (1999). Incidence and patient characteristics associated with silent
aspiration in the acute care setting. Dysphagia, 11(1) 1-7.

Sonies, BC. (1997). Preface (Ed.), Dysphagia: A continuum of care. MD: Aspen
Publishers, Inc.

Sonies, BC. 8 Baum, B.J. (1988). Evaluation of swallowing pathophysiology.
Otolagyngologic Clinics of North America, a“), 637-648.

102

 

Sonies, B.C., Baum, B.J. 8 Shawker, TH. (1984). Tongue motion in situ
observation. Journal of Gerontology,_ 39 pp 279-283.

Sonies, B.C., Parent, L.J., Morrish, K.8, Baum, B.J. (1988). Durational aspects of
the oral-pharyngeal phase of swallow in normal adults. Dysphagia, 31110.

Spieker, MR. (2000). Evaluating dysphagia. Amerigp Family Physician.
_6_1(12) 3639-3648.

Splaingard, M. L., Hutchins, B., Sultan, LD. 8 Chaudhuri, G. (1988). Aspiration
in rehabilitation patients: Videofluoroscopy vs. beside clinical
assessment. Archives of Physical Rehabilitation. 69. 637-640.

Stroud, A.E., Lawrie, B.W. 8 Wiles, C.M. (2002).Inter- and intra-rater reliability of
cervical auscultation to detect aspiration in patients with dysphagia.
Clinical Rehabilitation. 16, 640-646.

St. Louis, K. O. 8 Ruscello, OM. (1981). The oral speech mechanism
screeningxminfiajion. Baltimore: University Park Press.

Takahashi, K., Groher, M.E., Michi, K., (1994). Methodology for detecting
swallowing sounds. Dysphagia, 9, 54-62.

Takahaski, K. Groher, ME, 8 Michi, K. (1994). Symmetry and reproducibility of
swallowing sounds. Dysphagia, 9(3) 168-173.

Thompson, PG. (1990). Aging in the 1990’s and beyond. In F. Patrick Moloneu
and Kevin M. Means (Eds). Physical Medicine and Rehabilitation: State
oflhe A_rts Review. Rehabilitation and the aging population 1(1).
pp. 157-166.

Tohara, H., Saithoh, E., Mays, K.A., Kuhlemeire, K., 8 Palmer, J.B. (2003).
Three tests for predicting aspiration without videofluoroscopy.
Dysphagia, 18, 126-134.

103

Tracy, J.F., Logemann, J.A., Jahrilas, P.J., Pothen, J., Kobara, M., 8 Krugler,
C. (1989). Preliminary observations on the effects of age on
oropharyngeal deglutition. Dysphagia, 4 90-94.

Trupe, E. H., Siebens, H., 8 Siebens, A. (1984). Prevalence of feeding and
swallowing disorders in a nursing home. A_rchieves of Physical mecflzine
and Rehabilitation 6_5_,_651-652.

 

WIlson, W.R. (1995). Nose and throat disorders. In W.B. Abrams, M.H. Beers 8
R. Berkow. (Eds). Merck Mandel of geriatrics. (2Ind ed). NJ: Merck
Research Laboratories.

Yorkston, K., Miller, R., Strand, E. (2004). Mana ement of speech arm
swallowing in degenerative diseases. (2" ed). Tucson, AZ:
Communication Skill Builders.

Youmans, SR. 8 Stierwalt, J.A. (2005). An acoustic profile of
normal swallowing. Dysphagia, 20: 195-209.

Zenner, P.M., Losinski, D.S., Mills, R. (1995). Using cervical auscultation in the
clinical dysphagia examination in long-term care. Dysphagia, 10, 27-31.

Zenner, P. (2000). The clinical examination for dysphagia. In Russel H. Mills

(ed.). Evaluation of dysphagia in adults: Expanding the diagnostic options.
(27-64). Austin, TX: Pro-Ed.

104

IIIIIIIIIIIIIIIIIIIIIIIIIIII

IljllljljljlIjjljljljlllljljljlllll