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					 Original Article                                                                                    DOI:10.4235/jkgs.2009.13.4.195




Fluoroscopic Swallowing Study in Elderly Patients
Admitted to a Geriatric Hospital and a Long-Term
Care Facility
 Sang Jun Kim, MD, Tai Ryoon Han, MD

 Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea

 Background: No study has been done to detect the aspiration using the videofluoroscopic swallowing study in the elderly
 patients. Elderly patients admitted to hospitals or long-term care facilities may intake the food orally without any evalua-
 tion of swallowing function and may be exposed to aspiration risk, which can be eliminated by some diet modification
 based on the fluoroscopic findings.
 Methods: Sixty-three elderly patients who had an oral-feeding status were recruited in this study. They swallowed diverse
 food textures twice in the following order; liquid, Yoplait yogurt, pudding, soft-bland diet, and a regular diet. Swallo-
 wing parameters were checked as subglottic aspiration, supraglottic penetration, delayed pharyngeal reflex, and valle-
 cular and pyriform sinus residues.
 Results: Only 2 patients showed both aspiration signs and the subglottic aspiration in the fluoroscopic study. Six pa-
 tients showed the subglottic aspiration in the fluoroscopic study without any clinical sign. Seven patients who com-
 plained of aspiration signs did not show the subglottic aspiration, but all of them presented the supraglottic penetra-
 tion. Multivariate logistic regression analysis showed that no covariate was correlated with the subglottic aspiration
 whereas delayed pharyngeal reflex during liquid (p<0.001) or Yoplait (p=0.010) swallowing were correlated with aspira-
 tion plus penetration.
 Conclusion: This study demonstrates that a fluoroscopic swallowing study is important for the dysphagia diagnosis in
 elderly patients because of no significant correlation between the aspiration signs assessed clinically and the sub-
 glottic aspiration detected by the fluoroscopic swallowing study. Diet modifications, such as, liquid thickening will be
 necessary when patients demonstrate the evidence of subglottic aspiration during swallowing.

 Key Words: Deglutition, Fluoroscopy, Geriatrics


                                                                      piecemeal deglutition, premature loss of liquid, oral and phar-
  INTRODUCTION                                                        yngeal residues, and laryngeal penetration are significantly
                                                                      greater in dentate elderly persons3). These characteristics dis-
  Dysphagia is a common problem in geriatric medicine.                pose the elderly to develop dysphagia, especially in the phar-
Swallowing in the elderly is characterized by slow hyoid move-        yngeal phase, a condition in which a young patient will not
                                1)
ment, delayed pharyngeal reflex , and vallecular and pyriform         show dysphagia. Common diseases among the elderly, such as
                                             2)
sinus residues caused by muscular weakness . Frequencies of           small vessel, Alzheimer’s and Parkinson’s disease, also in-

▸Received: Jul 16, 2009 ▸Revised: Set 15, 2009 ▸Accepted: Set 25, 2009
Address for correspondence: Tai Ryoon Han, MD, PhD
Department of Rehabilitation Medicine, Seoul National University College of Medicine, 28 Yeongun-dong, Jongro-gu, Seoul 110-744, Korea
Tel: +82-2-2072-1358, Fax: +82-2-743-7473, E-mail: guitar1@snu.ac.kr

*This study was supported by a research fund from the Korean Geriatric Society in 2005.



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Sang Jun Kim: Fluoroscopic Swallowing Study in Elderly Patients

                                4)                                          12)
crease the risk of dysphagia . Moreover, the decreased de-           amount . Thus, increasing viscosity is not always a safe op-
fense systems (e.g., decreased immunity and reduced pulmo-           tion in dysphagic patients.
                                                               5)
nary clearance), increase the risk of aspiration pneumonia .           With age, elderly patients show decreased swallowing ca-
Therefore, pharyngeal dysphagia is an important health issue         pacity, delayed triggering of the pharyngeal swallow, and sig-
in the elderly.                                                      nificant vallecular and pyriform sinus residue2). Thus, it is im-
                                     6)
  In a chart review, Lin et al. found that the prevalence of         portant to know the effects of swallowing parameters, includ-
impaired swallowing was 31.9% among non tube-fed subjects            ing pharyngeal reflex delay and residue amount, on the risk of
in nursing and intermediate care facilities in Taiwan. Kawa-         aspiration in elderly patients by using a fluoroscopic study.
            7)
shima et al. found a 13.8% prevalence rate of dysphagia by             Elderly patients admitted to hospitals or long-term care fa-
means of a questionnaire to screen community-dwelling eld-           cilities have diverse diseases, and may show dysphagia from
erly in the northern region of Honshu Island, Japan. Roy et          underlying diseases or an unknown cause. Oral feeds may be
  8)
al. showed the prevalence of swallowing disorder to be 33%           given without evaluating the swallowing function, exposing
of the 117 seniors living independently in Utah and Kentucky         them to the risk of aspiration, which can be eliminated by diet
via an interview questionnaire. However, none of these au-           modification based on fluoroscopic findings.
thors performed a videofluoroscopic swallowing study, consid-          Therefore, the aim of this study was to compare subglottic
ered the gold standard for diagnosing dysphagia. This is im-         aspiration detected by fluoroscopy with the aspiration signs
portant because silent aspiration, which is difficult to detect by   seen clinically in elderly patients being fed orally at a geriatric
                                                               9)
questionnaire, occurs in up to 30% of dysphagic patients .           hospital and a long‐term care facility and to find the swallow-
Moreover, this topic will be of increasing concern as the num-       ing parameters that correlate with aspiration and penetration.
ber of geriatric hospitals and long‐term care facilities increase
in many countries.                                                     MATERIALS AND METHODS
  Methods for managing pharyngeal dysphagia are diverse.
Changing food consistency and texture (e.g., by adding food            1. Subjects
thickeners) is one example. It is generally believed that food
viscosity is inversely proportional to the likelihood of laryn-        From the inpatients at a local geriatric hospital and resi-
geal penetration or aspiration in dysphagic patients because the     dents at a long-term care facility, 63 subjects were recruited in
fast movement of food with low viscosity induces penetration         February 2005 in Gyeonggi‐do, Korea. Selected subjects had
or aspiration, whereas the slow movement with high viscosity         “oral-feed” statuses, and were competent enough to understand
will not do so in patients with delayed pharyngeal reflex.           the purpose of this study and to agree to participate. All sub-
                                                        10)
Lending support to this hypothesis is an earlier study , which       jects provided informed consent for this study. The subjects
revealed that increasing bolus viscosity greatly improves swal-      comprised 43 women and 20 men with an average age of 76.0
lowing function in patients with neurological problems. Howe-        ±7.0 years, and had various diagnoses (stroke-19; dementia-7;
                   11)
ver, another study       showed that there was more pharyngeal       Parkinsonism-5; low back pain-4; arthritis-3; hip joint frac-
retention with ultra-thick liquids, like pudding, than with apple    ture-3; others-6; no identifiable disease-16). Seven subjects
juice or apricot nectar, suggesting that high viscosity increased    with dementia had their orientation and judgment evaluated
pharyngeal retention. Postdeglutitive overflow aspiration is         through a mental status examination. All subjects, except those
found frequently in patients with pharyngeal retention, and the      with no identifiable disease, experienced disease onset at least
risk of aspiration increases markedly with increasing residual       a year prior to the beginning of this study. Time of onset was



196 J Korean Geriatr Soc 13(4) Dec 2009
                                                                Sang Jun Kim: Fluoroscopic Swallowing Study in Elderly Patients


not known in 25 patients. At the beginning of this study, 50
subjects were on a regular diet while the others were on a
soft-bland diet because of dental problems.


  2. Swallowing evaluation

  Aspiration signs were delineated as wet voice and reflex
cough during meal time. Aspiration was deemed to be present
clinically when aspiration signs were present more than once
per meal time.

  1) Fluoroscopic swallowing study

  One rehabilitation doctor (KSJ), one fluoroscopist (PKW),
                                                                      Fig. 1. Delayed pharyngeal reflexes were graded as none, mild,
and one nutritionist (HMH) performed the fluoroscopic swal-           moderate, and severe. Below figures were captured at time of
lowing studies on the 63 participants. The results were imme-         hyoid elevation (beginning of pharyngeal stage). Starting at the
diately recorded on paper as they could not be recorded as            left upper corner (clockwise direction), figures show normal and
video files for technical reasons. Subjects swallowed foods           mildly, moderately, and severely delayed pharyngeal reflex.

with diverse viscosities twice in the following order: 5 mL of
                                                                      curred when the bolus passed the laryngeal vestibule along the
water by syringe, then a spoonful of Yoplait yogurt, pudding,
                                                                      groove to the pyriform sinus), or severe (hyoid elevation oc-
soft‐bland diet, and a regular diet. All foods were mixed with
                                            ®
                                                                      curred when more than half of the pyriform sinus was filled
a 35% diluted barium solution (Solotop ; Taijoon, Seoul,
                                                                      with the bolus) (Fig. 1). This classification is similar to that used
Korea) without significant change to viscosity. In this study,                            12)
                                                                      in an earlier study . Residue amounts were graded as none,
Yoplait corresponds to the fluid-type yogurt, soft‐bland diet to
                                                                      scant (the vallecula or pyriform sinus was only coated with
the thin rice gruel, and a regular diet to the thick rice gruel
                                                                      residue), little (the height of the residue was less than half the
of the previous study13).
                                                                      total height of the vallecula or pyriform sinus), or much (the
                                                                      height of residue was more than half the total height of the
  2) Swallowing parameters
                                                                      vallecula or pyriform sinus).
  Subglottic aspiration, supraglottic penetration, delayed phar-        In recording the grades, all three investigators were re-
yngeal reflex, and vallecular and pyriform sinus residues were        quired to agree on the readings. If an investigator disagreed,
assessed using fluoroscopy with patients in the lateral position.     swallowing trials were repeated (with subject approval) until
Subglottic aspiration and supraglottic penetration were differ-       agreement was reached.
entiated based on whether the bolus entered the true vocal
fold. Delayed pharyngeal reflex was graded as none (hyoid el-           3. Statistics
evation occurred before the head of the bolus passed the man-
dibular angle), mild (hyoid elevation occurred after the head of        Fisher’s exact test was done to compare the coincidence of
the bolus passed the mandibular angle but most of the bolus           the subglottic aspiration detected by fluoroscopy to the aspira-
remained in the vallecular area), moderate (hyoid elevation oc-       tion signs found clinically. Multivariate logistic regression



                                                                                      J Korean Geriatr Soc 13(4) Dec 2009            197
Sang Jun Kim: Fluoroscopic Swallowing Study in Elderly Patients


analysis was performed to determine the aspiration risk ac-              soft-bland diet, and the regular diet. Three of 48 patients (6.3
cording to swallowing parameters (residues and pharyngeal re-            %) showed supraglottic penetration during Yoplait swallo-
flex delay). All alpha‐errors were determined to be 0.05. The            wing. Of 59 patients, two (3.4%) and one (1.7%) showed sura-
SPSS program version 12.0 program (SPSS Inc., Chicago, IL,               glottic penetration of the soft-bland and regular diets, respe-
USA) was used to perform the statistical analysis.                       ctively.
                                                                            Only two patients showed both aspiration signs and sub-
  RESULTS                                                                glottic aspiration in the fluoroscopic study. Six patients sho-
                                                                         wed subglottic aspiration in the fluoroscopic study without any
  Nine patients (14.3%) showed clinical signs of aspiration              clinical sign. Seven patients who complained of aspiration
but did not have aspiration pneumonia since admission.                   signs did not show subglottic aspiration, but they all presented
  All 63 patients successfully swallowed the liquid, but 15              with supraglottic penetration (Table 1). Fisher’s exact test did
patients refused to swallow the Yoplait, two refused the pud-            not reveal a significant correlation between the signs of aspira-
ding, and four the soft-bland and regular diet. Fluoroscopic             tion and subglottic aspiration (odds ratio [OR], 2.286; 95%
findings revealed that 31 patients showed neither subglottic as-         confidence interval [CI], [0.383, 13.635]).
piration nor supraglottic penetration, but eight patients (12.7%)           Vallecular and pyriform sinus residues for foods are pre-
showed subglottic aspiration, and 24 patients (38.1%) supra-             sented in Table 2. Most patients showed little or no pyriform
glottic penetration during liquid swallowing. No patient sho-            sinus residue after swallowing liquid, with the exception of
wed subglottic aspiration while swallowing Yoplait, pudding,             one patient who showed a substantial amount of residue.
                                                                         Much vallecular residue was found in some patients only dur-
                                                                         ing swallowing of the regular diet. However, little pyriform si-
 Table 1. Cross table of the aspiration signs detected clinically
 and the subglottic aspiration by fluoroscopic swallowing study          nus residue was observed during the swallowing of all foods.
 in 63 elderly subjects                                                  Pharyngeal reflex delays for the various foods are shown in
                                   Aspiration    No aspiration           Table 3. Delayed pharyngeal reflex occurred in some patients
                                     sign            sign                during the swallowing of liquid, soft-bland diet, and regular
 Aspiration by fluoroscopy              2                6               diet. Multivariate logistic regression analysis with backward
 No aspiration by fluoroscopy           7               48               elimination approach showed that no covariate correlated with
 Values are numbers of patients.                                         subglottic aspiration whereas delayed pharyngeal reflex during


 Table 2. Vallecular and pyriform sinus residues after swallowing of diverse food textures in 63 elderly subjects
                                   Vallecular residue                                             Pyriform sinus residue
                  L           Y             P           S           N               L         Y             P              S       N
 None            44           41            38          34          20              57        47           57          56          49
 Scant           14            4            11          14          10              4          0            3              3        5
 Few               5           3            11          11          15              1          1            1              0        5
 Much              0           0            1           0           14              1          0            0              0        0
 N/A               0          15            2           4           4               0         15            2              4        4
 Values are number of patients.
 L, liquid; Y, yoplait; P, pudding; S, soft‐bland diet; N, normal regular diet, N/A, not applicable.


198 J Korean Geriatr Soc 13(4) Dec 2009
                                                                 Sang Jun Kim: Fluoroscopic Swallowing Study in Elderly Patients


 Table 3. Degree of pharyngeal reflex delay during swallowing          signs assessed clinically and the subglottic aspiration detected
 of diverse food textures in 63 elderly subjects                       by the fluoroscopic swallowing study. Vallecular residues were
                               Delayed pharyngeal reflex               significantly greater during swallowing of the regular diet,

                     L           Y        P         S       N          whereas the pyriform sinus residues were not. Subglottic aspi-
 None                23          38       43       27       20         ration was not correlated with residues and delayed pharyngeal
 Mild                13          10       13       20       17         reflex. However, delayed pharyngeal reflex during liquid or
 Moderate            21           0        4       12       16         Yoplait swallowing correlated with aspiration plus penetration.
 Severe               6           0        1        0        6           The prevalence of aspiration in this study was 12.7% on
 N/A                  0          15        2        4        4         the fluoroscopic swallowing study, in line with the findings of
                                                                                              7)
 Values are number of patients.                                        Kawashima et al. ; however, it was lower than that of Lin et
 L, liquid; Y, yoplait; P, pudding; S, soft-bland diet; N, normal      al.’s study6), although the number of patients was too small to
 regular diet, N/A, not applicable                                     represent the prevalence in elderly patients. From this study, it
                                                                       was expected that the prevalence rate would be similar to Lin
liquid (p<0.001) or Yoplait (p=0.010) swallowing correlated with       et al.’s study6) because subjects admitted to a hospital or a fa-
aspiration plus penetration.                                           cility were enrolled. In view of the findings of a previous
  When the subjects were divided into stroke (n=19) and non-           study
                                                                               14)
                                                                                     which stated that deep laryngeal penetration often pro-
stroke (n=44) groups, four patients (21.1%) in the stroke group        gressed to aspiration, it is possible that patients showing su-
showed supraglottic penetration, and four (21.1%) experienced          praglottic penetration without subglottic aspiration might also
subglottic aspiration. The non-stroke group revealed supra-            be at risk of aspiration. If penetration cases were included, the
glottic penetration in 20 subjects (45.5%) and subglottic aspi-        prevalence rate of aspiration plus penetration would increase
ration in four patients (9.1%). The incidences of aspiration in        to 50.8%.
the two groups were not significantly different by Fisher’s ex-          The six patients who showed subglottic aspiration on the
act test (OR, 0.375; 95% CI, [0.083, 1.693]). When subjects            fluoroscopic study without any aspiration sign (silent aspira-
were dichotomized by diseases that might cause dysphagia               tion) emphasize the importance of this study. Seven patients
(stroke, dementia, and Parkinsonism) and those unlikely to do          who showed supraglottic penetration with clinical aspiration
so, the incidences of aspiration were not significantly different      signs suggest that supraglottic penetration also must not be
between the two groups by Fisher’s exact test (OR, 0.538; 95           overlooked in the detection of aspiration as only few swallow-
% CI, [0.117, 2.475]).                                                 ing trials are performed in most fluoroscopic swallowing
                                                                       studies. However, Daggett et al.15) found that 16.8% of swal-
  DISCUSSION                                                           lows showed penetration in normal subjects aged 50 and above
                                                                       in a videofluoroscopic swallowing study. Therefore, the diag-
  This is the first study on the swallowing characteristics of         nosis of aspiration must be considered in a comprehensive
elderly patients admitted to a geriatric hospital or a long‐term       manner. It will be necessary to classify penetration cases accor-
care facility using fluoroscopic swallowing study. Subglottic          ding to several steps using the penetration‐aspiration scale ,
                                                                                                                                         16)

aspiration was observed in 12.7% of patients and supraglottic          which was not done in this study.
penetration in 38.1% in the fluoroscopic swallowing study                The prevalence of aspiration between stroke and non‐stroke
whereas 14.3% of patients showed aspiration signs clinically.          groups did not show any difference. This suggests that aspira-
No significant correlation was found between the aspiration            tion in this study originated from multiple factors including



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Sang Jun Kim: Fluoroscopic Swallowing Study in Elderly Patients


poor general condition and the aging process, rather than the              to show the differences between foods.
disease itself. Four patients from the non‐stroke group with as-             The pyriform sinus residue amounts for pudding, soft-bland
piration had additional diagnoses of herniated intervertebral              diet, and regular diet were found to be unrelated to aspiration
disc, asthma, dementia, and poor oral intake without a disease             or penetration, unlike the initial hypothesis that high vis-
cause. Their average age was 76.3 ± 5.3 years. This did not                cosities are likely to increase aspiration risk as a result of
differ significantly from that of the other patients (p=0.921).            pharyngeal retention. This result differs from that of Eisen-
                                                                                               12)
They all showed a worse than moderately delayed pharyngeal                 huber et al.’s study , which may be because Eisenhuber et
reflex. They had no definite abnormal signs suggestive of                  al.’s study12) recruited more patients with moderate to severe
stroke or other diseases that could cause dysphagia. However,              pharyngeal retention. In the present study, the pyriform sinus
none of them could ambulate without assist and tended to be                residue was insufficient (residues were scant or few, not much)
bed‐bound. Deconditioning due to decreased activity might lead             to evoke overflow aspiration with all food textures.
to dysphagia. Although cervical imaging was not performed,                   The present study has a few limitations, one of which is
cervical osteophytes related to old age might be a cause of                that images could not be recorded (the fluoroscopic device did
                              17)
dysphagia in this study .                                                  not have an image storing function). Thus, this study could
  The results of this study showed that delayed pharyngeal                 only use semiquantitative data, rather than quantitative data,
reflex during liquid or Yoplait swallowing had an effect on as-            such as pharyngeal delay time. Further quantitative studies
piration plus penetration. This finding is somewhat similar to             should be done to overcome this shortcoming. Intra- and inter-
                      18)
Han et al.’s study          which showed that delayed triggering of        ater reliability was not evaluated. However, all the swallowing
pharyngeal swallowing is related to penetration/aspiration, with           parameters were easily divided into four grades and there were
an odds ratio of 2.98 during the drinking of 5 mL of water in              no contradictions between the three investigators. This study is
103 stroke patients using polychotomous logistic linear regre-             also limited because the precise characteristics of the patients
ssion. When the dependent variable was restricted to subglottic            were not known, for example, onset and lesion location (in
aspiration, no covariates, including delayed pharyngeal reflex,            cases of stroke). Nevertheless, the authors believe that the
were correlated with aspiration. This result coincides with                findings in this study can be useful to accurately detect aspira-
                        19)
Martin-Harris’ study , which concluded that a delay in phar-               tion through fluoroscopic study.
yngeal swallowing per se cannot be assumed to indicate dis-                  Having completed this study, the diets of patients who
ordered swallowing in the absence of coexisting impairments                showed subglottic aspiration were changed to the better-tol-
                                                     20)
of swallowing physiology. Schindler et al.                 observed that   erated thickened liquids, and their aspiration symptoms and
pharyngeal swallowing is delayed in healthy elderly subjects,              fluoroscopic findings improved. An attempt was made to fol-
and that elderly subjects frequently require multiple swallows             low up on these patients one year later by telephone or direct
to effectively clear a bolus from the pharynx. This coincides              contact. Although only 14 of the 63 patients (22.2%) respon-
with our results although they did not comment on vallecular               ded, responders, including patients who underwent diet mod-
                                            21)
or pyriform sinus residues. Kelly et al.          revealed that the bo-    ification, had no symptoms of aspiration or events of aspira-
lus type had a significant effect on residue scores, which dif-            tion pneumonia. However, to confirm this, another study is re-
fered from our results. This mismatch might be due to the dif-             quired to evaluate improvement in general condition and re-
ferences in residue scoring and the bolus amount. The Kelly                duced rates of aspiration pneumonia after diet modification.
        21)
study         used 10 mL of foods, while we used 5 mL of liquid              Though this study has several limitations, it demonstrates
and one spoonful of other textures, which might be too small               that a fluoroscopic swallowing study is important for diagnos-



200 J Korean Geriatr Soc 13(4) Dec 2009
                                                               Sang Jun Kim: Fluoroscopic Swallowing Study in Elderly Patients


ing dysphagia. Moreover, it reveals that diet modification, such      5. Kikawada M, Iwamoto T, Takasaki M. Aspiration and in-
as thickening liquids, is necessary when patients show evidence          fection in the elderly: epidemiology, diagnosis and mana-
of subglottic aspiration during swallowing. Additional studies           gement. Drugs Aging 2005;22:115-30.
are required to confirm the clinical usefulness of diet modifi-       6. Lin LC, Wu SC, Chen HS, Wang TG, Chen MY. Preva-
cation.                                                                  lence of impaired swallowing in institutionalized older
                                                                         people in Taiwan. J Am Geriatr Soc 2002;50:1118-23.
  CONCLUSION                                                          7. Kawashima K, Motohashi Y, Fujishima I. Prevalence of
                                                                         dysphagia among community-dwelling elderly individuals
  This study demonstrates that a fluoroscopic swallowing study           as estimated using a questionnaire for dysphagia screening.
is important for diagnosing dysphagia in elderly patients be-            Dysphagia 2004;19:266-71.
cause of no significant correlation between the aspiration signs      8. Roy N, Stemple J, Merrill RM, Thomas L. Dysphagia in
assessed clinically and the subglottic aspiration detected by a          the elderly: preliminary evidence of prevalence, risk fac-
fluoroscopic swallowing study. Diet modification, such as thi-           tors, and socioemotional effects. Ann Otol Rhinol Laryn-
ckening liquids, is necessary when patients demonstrate evi-             gol 2007;116:858-65.
dence of subglottic aspiration during swallowing.                     9. Ramsey D, Smithard D, Kalra L. Silent aspiration: what
                                                                         do we know? Dysphagia 2005;20:218-25.
  ACKNOWLEDGEMENTS                                                   10. Clavé P, de Kraa M, Arreola V, Girvent M, Farré R, Palo-
                                                                         mera E, et al. The effect of bolus viscosity on swallowing
  I especially thank Park Kun Woong for performing the flu-              function in neurogenic dysphagia. Aliment Pharmacol Ther
oroscopic swallowing studies and interpreting their results, Hy-         2006;24:1385-94.
eong Mi Hyeong for preparing the textured foods and interpre-        11. Kuhlemeier KV, Palmer JB, Rosenberg D. Effect of liquid
ting the results, and Janette Villagonzalo (Customer Service             bolus consistency and delivery method on aspiration and
Manager of Professional Editing Services) for helping with the           pharyngeal retention in dysphagia patients. Dysphagia 2001;
English writing.                                                         16:119-22.
                                                                     12. Eisenhuber E, Schima W, Schober E, Pokieser P, Stadler
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