Auris Nasus Larynx 41 (2014) 294–298

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Auris Nasus Larynx

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Predictor of rehabilitation outcome for dysphagia

Akihiro Kojima a,*, Yoshimasa Imoto a, Yoko Osawa b, Shigeharu Fujieda a
a
Division of Otorhinolaryngology Head & Neck Surgery, Department of Sensory and Locomotor Medicine,
Faculty of Medical Science, University of Fukui, Japan
b
Department of Otorhinolaryngology, Tannan Regional Medical Center, Fukui, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Objective: Predicting whether dysphagia will resolve is very difficult, but is obviously important for
Received 9 March 2013 patients and their families as well as for physicians. This study retrospectively evaluated potential
Accepted 9 December 2013 prognostic indicators for dysphagia in order to examine the feasibility of predicting the outcome.
Available online 20 February 2014
Methods: Data on 123 patients who received initial treatment for dysphagia between April 2008 and
March 2010 were reviewed. The patient population included 63 men and 60 women, with a mean age of
Keywords: 81.4 years. All the patients underwent physical examination and video-endoscopy (VE) at the initial
Dysphagia
assessment, and video-fluorography (VF) was also done if necessary. We used the ‘‘Food Intake Level
Prognosis
Aspiration pneumonia
Scale’’ (FILS) to classify the severity of dysphagia as follows: ‘‘no oral intake’’ (FILS score: 1–3), ‘‘oral
Disuse syndrome intake and alternative nutrition’’ (FILS score: 4–6), and ‘‘oral intake alone’’ (FILS score: 7–10). The
patient’s age, primary disease, cognitive ability, and general condition were evaluated as potential
factors associated with the severity of dysphagia. Each patient underwent assessment at every 2 weeks
to evaluate the progress of their dysphagia.
Results: Forty-six patients were classified as ‘‘no oral intake’’ (FILS score: 1–3) at the initial examination
and subsequently showed improvement to ‘‘oral intake and alternative nutrition’’ (FILS score: 4–6) or
‘‘oral intake alone’’ (FILS score: 7–10). They were compared with 43 patients who were also ‘‘no oral
intake’’ at the second examination after training in swallowing. The combination of stroke and cognitive
dysfunction showed a sensitivity of 75.9% (22/29) and specificity of 78.3% (18/23) for predicting no
improvement of dysphagia, and was a statistically significant parameter. The presence of disuse
syndrome showed a sensitivity of 66.0% (31/47) and specificity of 71.4% (30/42) for predicting no
improvement of dysphagia, and this was also a significant parameter.
Conclusion: The results of this study suggest that a combination of factors other than stroke, including
cognitive dysfunction and a decrease in activity of daily living (ADL) influence the outcome of dysphagia.
It is not rare for patients who resume oral intake to be readmitted within a year for symptoms such as
fever. Therefore, effective rehabilitation programs should be developed for the impairments of elderly
patients and common disabilities such as dysphagia.
ß 2014 Elsevier Ireland Ltd. All rights reserved.

are often susceptible to dysphagia for a variety of reasons [2]. The

1. Introduction
Patients who are unable to take food orally are deprived of an
important source of pleasure. Efforts to treat dysphagia are
meaningful to support our patients’ dignity [1]. Elderly people
Abbreviations: VE, video-endoscopy; VF, video-fluorography; FILS, Food Intake
Level Scale; ADL, activity of daily living; CDR, Clinical Dementia Rating Scale; MRS,
Modified Rankin Scale.
* Corresponding author at: Division of Otorhinolaryngology Head & Neck
Surgery, Department of Sensory and Locomotor Medicine, Faculty of Medical
Science, University of Fukui, 23 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun,
Fukui 910-1193, Japan. Tel.: +81 776 61 8407.
E-mail address: kojimaa@u-fukui.ac.jp (A. Kojima).
common causes include central nervous system disorders such as
cerebrovascular disease (stroke) and Parkinson’s disease. Less
frequent causes include chronic respiratory failure and the
bedridden state in elderly persons who sustain injuries. About
30–50% of patients with stroke experience dysphagia accompa-
nied by aspiration in the acute phase, but this decreases to about
5% in the chronic phase [3]. However, silent aspiration can be
observed in 28–38% of patients for 2–3 months after the
occurrence of stroke [4].
It has also been reported that 20% of stroke patients who
experience dysphagia die of pneumonia, suspected to be due to
aspiration, within 5 years [5]. Furthermore, the mortality rate of
aspiration pneumonia increases rapidly with age in elderly people

0385-8146/$ – see front matter ß 2014 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.anl.2013.12.009
 A. Kojima et al. / Auris Nasus Larynx 41 (2014) 294–298 295

Table 1 Table 2
Grouping of Food Intake Level Scale (FILS). Assessment sheet in the examination.

Food Intake Level Scale Evaluation lists in the examination Evaluation

No oral intake Patient’s name

Level 1: No swallowing training is performed except for oral care Diagnosis
Level 2: Swallowing training not using food is performed Eating before examination Self-supported/partial assistance/total
Level 3: Swallowing training using a small quantity of food is performed assistance/tube feeding/NPO
Oral intake and alternative nutrition Lifestyle before examination Independent ambulation/bedridden
Level 4: Easy-to-swallow food less than the quantity of a meal (enjoyment Communications Good/fair/slightly impaired/poor
level) is ingested orally Retention of sitting position OK/requires support/impossible
Level 5: Easy-to-swallow food is orally ingested in one to two meals, but Closing mouth OK/weak but possible/impossible
alternative nutrition is also given Saliva in mouth Dry/no/slight/much
Level 6: The patient is supported primary by ingestion of easy-to-swallow Saliva in cervical esophagus No/slight/much/present in the larynx
food in three meals, but alternative nutrition is used as a complement Cough reflex, glottal closure Good/fair/impaired/no reflex/closure
Oral intake alone Swallowing reflex Good/fair/impaired/no reflex
Level 7: Easy-to-swallow food is orally ingested in three meals. No Clearing throat Good/fair/impaired/impossible
alternative nutrition is given Water swallow test Negative/positive Water: mL
Level 8: The patient eats three meals by excluding food that is particularly Concurrent findings Velopharyngeal dysfunction/premature
difficult to swallow pharyngeal entry/vocal cord paralysis
Level 9: There is no dietary restriction, and the patient ingests three meals Overall assessment
orally, but medical considerations are given Food Intake Level Scale Level
Level 10: There is no dietary restriction, and the patient ingests three
meals orally (normal)

position. Patients also practised repetitive swallowing to prevent

[6]. These reports indicate that accurate assessment and control of
dysphagia are essential. Elderly patients often have various
impairments, depending on their primary disease, such as
dementia, while aging also leads to general functional impairment.
This makes diagnosis and assessment more difficult. Previous
attempts at the assessment of dysphagia have employed the
Logemann scale [7] and the 8-point penetration-aspiration scale
[8]. While these scales give some insight into the pathology of
aspiration, they do not indicate the clinical severity of dysphagia.
We considered that a scale for the overall assessment of dysphagia
should integrate a number of factors, including the severity,
frequency of complications, and difficulty of treatment. Accord-
ingly, we employed the Food Intake Level Scale (FILS), which is
commonly used in Japan, for the present study. This scale allows
the severity of dysphagia to be assessed in a simple manner, which
should make it clinically useful (Table 1) [9]. In the present study,
we explored the factors associated with the prognosis of
dysphagia.
2. Materials and methods
The subjects were 123 new patients who presented to our
hospital with dysphagia. Their mean age was 81.4 years and there
were 63 men and 60 women. At the initial examination, 68 patients
had cerebrovascular disease (stroke), 16 had neurodegenerative
disorders, 12 had heart failure and chronic respiratory failure, 6
had malignant tumors of the digestive tract or other sites, 10 had
head injury associated with multiple trauma, and 11 had other
conditions. The swallowing team examined the patients and
reviewed each patient’s medical record and swallowing assess-
ment sheet (Table 2) before performing video-endoscopy (VE).
When the team decided that the assessment of the timing and the
extent of laryngeal elevation or the patency of the cervical
esophageal opening during the pharyngeal stage of deglutition was
necessary, the patient underwent video-fluorography (VF) at the
first and second examinations. At treatment, all patients received
indirect and direct training in swallowing from speech therapists.
Indirect training involved exercising the organs related to
swallowing without food intake. This included exercising the
neck, lips, and tongue; breathing exercises; throat clearing;
induction of the swallowing reflex (e.g., ice massage of the
mouth); elevation of the head; and supraglottic swallowing. Direct
training was done with food intake. The patients swallowed gelatin
jelly (to reduce food residue in the pharynx) in an easy-to-swallow
aspiration. At each visit, the swallowing team nurses gave oral care
training involving brushing of the oral cavity, tongue, and teeth
followed by aspiration (repeated two or three times per visit)
according to the oral care guideline of our hospital. The mean days
from the onset to a rehabilitation start are 9.5 + 0.8 (mean  SE)
days. If necessary, VE and VF were performed at the second and third
visits for further assessment of swallowing. Patients who were ready
for oral nutrition started oral intake of food with the guidance and
assistance of a speech therapist and nurses. The other patients started
tube feeding (e.g., via gastrostomy or per nasal). Otolaryngologists
and speech therapists played a central role in deciding the indication
and goal of the swallowing rehabilitation in the hospital for each
patient.
Dementia was rated (excluding patients with slightly impaired
consciousness) by using the Clinical Dementia Rating Scale (CDR-J)
[10,11] as none to mild dementia (CDR scale: 0, 0.5, or 1) or
moderate to severe dementia (CDR scale: 2 or 3). ADL were graded
on the Modified Rankin Scale (MRS) [12] as self-supporting (MRS
score: 0–3), requiring partial assistance (MRS score: 4; patients
who required some assistance with locomotion and ambulation),
or requiring total assistance (MRS score: 5) based on locomotion
and ambulatory ability [13]. Data were analyzed statistically with a
non-parametric test.
3. Results
The dysphagia ratings of the 123 patients are shown in Table 3.
The rating was no oral intake (FILS score: 1–3) in 85 patients, oral
intake and alternative nutrition (FILS score: 4–6) in 14 patients,
and oral intake alone (FILS score: 7–10) in 24 patients. Patients
who were classified as ‘‘no oral intake’’ at the initial examination
and subsequently improved to ‘‘oral intake and alternative
nutrition’’ or ‘‘oral intake and alternative nutrition’’ after 2–4
weeks were compared with those who were ‘‘no oral intake’’ at the
initial examination and showed no subsequent improvement.
Among those who were ‘‘no oral intake’’ at the initial examination,
46 patients showed improvement at the second examination (24
were ‘‘oral intake and alternative nutrition’’ and 22 were ‘‘oral
intake alone), but 39 showed no change (Table 4). Four of those
who were able to eat at the initial examination became ‘‘no oral
intake’’ at a subsequent examination (three were ‘‘oral intake and
alternative nutrition’’ and one was ‘‘oral intake alone’’ at the initial
examination) (Table 4). Of 43 patients who showed temporary
296 A. Kojima et al. / Auris Nasus Larynx 41 (2014) 294–298

Table 3 (patients)
Number of patients in classification of swallowing functions in FILS. 25

Food intake level scale Initial Second

examination examination 20
of patients of patients

No oral intake 85 43 15 Dysphagia

Level 1 10 9 Improved
Level 2 52 31
10
Level 3 23 3 No change or
Oral intake and alternative nutrition 14 33 degenerate
Level 4 3 15 5
Level 5 0 2
Level 6 11 16
0
Oral intake alone 24 47 61∼70 71∼80 81∼90 91∼100 101∼110 (age)
Level 7 17 22
Level 8 4 9 Fig. 1. Rate of dysphagia by age among patients. Forty-six patients improved
Level 9 3 10 dysphagia. Forty-three patients did not improve dysphagia.
Level 10 0 6

improvement of dysphagia, 9 subsequently showed deterioration
within 2 months.
Whether age had an influence on the recovery of eating and
swallowing functions was assessed (Fig. 1). Patients in their
70s were more likely to show improvement than those in their 80s,
but the difference was not significant. Fewer patients in their
80s showed improvement than those in their 70s, but the
difference was also not significant.
Stroke symptoms and cognitive functions were compared
between patients who were classed as ‘‘no oral intake’’ at the initial
examination, but improved to ‘‘oral intake and alternative
nutrition’’ in 24 patients or ‘‘oral intake alone’’ in 22 patients,
total 46 within 2–4 weeks, and the others who remained as ‘‘no
oral intake’’ for the entire study period (from the first to third
examinations), total 43 patients (Table 5A). Of 52 patients with
stroke symptoms, 25 showed improvement to ‘‘oral intake and
alternative nutrition’’ or ‘‘oral intake alone’’ at 4 weeks after the
initial examination, while 27 showed no improvement from ‘‘no
oral intake.’’ Among 37 patients without stroke symptoms, 21
showed improvement of dysphagia and 16 showed no improve-
ment. Thus, the presence or absence of stroke symptoms showed a
sensitivity of 51.9% (27/52) and a specificity of 56.8% (21/37) for
predicting improvement of dysphagia, so stroke was not a
statistically significant predictor.
Among 29 patients having stroke symptoms and cognitive
dysfunction (CDR: 2 or 3), 7 showed improvement of dysphagia
and 22 showed no change. Among 23 patients who had neither
stroke nor dementia (CDR: 0, 0.5, or 1) 18 showed improvement of
dysphagia and 5 did not change. Thus, this combination had a
sensitivity of 75.9% (22/29) and specificity of 78.3% (18/23) for no
improvement of dysphagia and was a statistically significant
predictor (P < 0.01) (Table 5B).
Dysphagia was also compared between patients with or
without disuse syndrome. Among the 47 patients with disuse
syndrome (MRS score: 4 or 5), 16 and 31 patients respectively
showed improvement of dysphagia (to ‘‘oral intake and alternative
nutrition’’ or ‘‘oral intake alone’’) or no change at 4 weeks after
the initial examination. Among the 42 patients without disuse
syndrome (MRS score: 0–3), 30 and 12 patients respectively
showed improvement of dysphagia and no change. Disuse
syndrome had a sensitivity of 66.0% (31/47) and specificity of
71.4% (30/42) for identifying no improvement of dysphagia, so it
was also a significant predictor (P < 0.01) (Table 5C).
Furthermore, the influence of fever (a temperature 38.5 8C)
within 2 months after the initial examination was assessed by
comparing patients who showed improvement with those who did
not show improvement of dysphagia. Among patients who showed
improvement, 12 had fever (26.0%), 26 had no fever (56.5%), and 8
had no body temperature data (17.4%) during the 2-month period.
Among those without improvement of dysphagia, 20 had fever
(46.5%), 22 had no fever (51.2%), and 1 had no data (2.3%)
(Table 6A). Indicated in many reports, non-ingestion patients
tended to contract aspiration pneumonia than oral nutrition
patients.
Among the patients with improvement of dysphagia, 24 (52.2%)
were readmitted with symptoms such as fever and malnutrition

Table 4
Number of patients changing in FILS at initial and second evaluations.
 A. Kojima et al. / Auris Nasus Larynx 41 (2014) 294–298 297

Table 5
Number of clinical features (stroke, stroke with dementia and disuse syndrome)
with prognosis of dysphagia.
A Stroke
+ Total
Dysphagia improved (levels 4–10) 25 21
Dysphagia no change (levels 1–3) 27 16
B Stroke with dementia
+ Total
Dysphagia improved (levels 4–10) 7 18
Dysphagia no change (levels 1–3) 22 5 27
C Disuse syndrome symptom
+ Total
Dysphagia improved (levels 4–10) 16 30
Dysphagia no change (levels 1–3) 31 12
Table 6
Number of patients in high fever up episodes within 2 months and readmission
within a year.
A High fever up within 2 months
+ Unknown
Dysphasia improved (levels 4–10) 12 26 8 46
Dysphagia no change (levels 1–3) 20 22 1 43
B Readmission within a year
+ Died
Dysphasia improved (levels 4–10) 24 18 4 46
Dysphasia no change (levels 1–3) 14 17 12
within 1 year, 18 (39.1%) were not, and 4 patients (8.7%) died.
Among those without improvement of dysphagia, 14 (32.6%) were
readmitted, 17 (39.5%) were not, and 12 (27.9%) died. There were
no significant differences of these outcomes between the patients
with and without improvement of dysphagia (Table 6B).
4. Discussion
In this study, we demonstrated that the prognosis of dysphagia
was worse in (1) stroke patients with dementia and (2) patients
with disuse syndrome. Among 46 patients who returned to oral
intake, 12 experienced fever (38.5 8C) within the subsequent 2
months. This suggests that dysphagia frequently showed recur-
rence/exacerbation depending on the patient’s condition.
Parenteral nutrition (including via a nasogastric tube, gastric
tube, or central venous line) can prolong survival when oral intake
is impossible. For chronic parenteral nutrition, many authors have
recommended gastrostomy tube feeding [14], but it significantly
impairs patient QOL. Generally, the incidence of aspiration
pneumonia is high whether patients with dysphagia receive tube
feeding or not [15]. A significantly increased risk of aspiration
pneumonia has been reported in patients with dysphagia who are
on nasogastric tube or gastrostomy tube feeding [16]. This means
the risk of pneumonia is high even in patients who are unable
to eat.
A CT scanning investigation of patients with dysphagia has
revealed that the risk of dysphagia is generally higher among
patients who have three or more infarcts, ventricular dilatation, or
cerebral atrophy. The findings of that study suggested that a
combination of factors, including extrapyramidal tract damage,
intellectual dysfunction, and disturbance of consciousness, in
addition to bilateral pyramidal tract lesions, are involved in
development of dysphagia [17]. The overwhelming majority of
patients in the present study had cerebrovascular disease (stroke),
but the prognosis of dysphagia was only poor when the patients
had concomitant cognitive dysfunction. There is no clear evidence
that cognitive disturbance affects swallowing dynamics at the oral
stage or the pharyngeal stage and causes aspiration [18,19].
However, progression of dementia does weaken cognitive func-
46
tions required for eating and swallowing and serves to exacerbate
43 dysphagia. The present study demonstrated that stroke combined
with dementia as well as disuse syndrome were important
negative prognostic factors. Swallowing problems associated
with the progression of dementia include a decreased willingness
25 to eat, decreased ability to differentiate among foods, and
decreased attentiveness during eating. These changes may lead
to a poor appetite and eating disorder and also increase the risk of
poor nutrition [20,21].
It has been proposed that aspiration pneumonia can be avoided
46 by lowering the threshold of cough reflex, which is a protective
43
airway reflex [22,23]. Careful oral hygiene can reduce bacterial and
fungal flora in the oral cavity [24,25]. Accordingly, continued oral
care is recommended in patients with dysphagia. A number of
clinical studies have demonstrated the efficacy of swallowing
exercises. Carnaby’s clinical study that investigated the efficacy of
swallowing exercises for different diseases demonstrated that such
exercises reduce the risk of pneumonia and improve QOL [26].
Total Among the various swallowing exercises, elevation of the head
reported by Shaker et al. [27] is well known. In the present study,
patients performed blowing, swallowing/breathing, pushing, and
the Mendelsohn maneuver among other exercises. The period from
the onset of severe dysphagia to the beginning of swallowing
Total
training could be also important factor to the prognosis. In the case
of cerebrovascular disorder, patients should receive indirect or
43 direct swallowing training from speech therapists as early as
possible.
Treatment of dysphagia requires a team-based approach
because these patients often have a number of problems. The
team members may vary between hospitals, but the eating/
swallowing team at our hospital is typically comprised a physician,
speech therapist, nurse, physical therapist, and occupational
therapist. The specialists raise specific issues and report their
functional assessments while the physician leads the team. Taking
a transdisciplinary approach, the team sets goals that are designed
to improve the QOL of patients. When the patient is unable to
maintain an adequate oral intake, the decision to start parenteral
nutrition is made as a team. When a patient’s chief complaint is
dysphagia, the risk of aspiration pneumonia tends to be low. This is
because they are aware of their problem and can control
swallowing even if dysphagia is severe. On the other hand,
patients who do not complain of dysphagia despite having
impaired swallowing are generally at risk of serious complications
such as pneumonia and asphyxia, even when dysphagia itself is not
severe [28]. Complete reversal of dysphagia is often difficult.
However, just as patients with severe paralysis after a stroke can
regain the ability to walk through rehabilitation, patients with
dysphagia can also learn to eat again, even if some swallowing
abnormalities persist. When the patients could not continue to
receive trainings after the discharge from the hospital, some of
them were readmitted within 1 year with symptoms such as fever
and malnutrition. Therefore, swallowing training is an important
factor for the patients after their discharge from the hospital.
Functional goals vary between patients, but the primary goal
should be avoidance of undernutrition and dehydration. Helping
the patient to achieve his/her desired eating style and reducing the
level of care required should be the next goals. Setting achievable
goals is not easy, but goals are required and should be fully
explained to the patient and family members. Without any goals,
the patient and family may become anxious. However, setting
unrealistic goals can lead to excessive dependence of the patient
298 A. Kojima et al. / Auris Nasus Larynx 41 (2014) 294–298
and family on the hospital staff. Because few studies have
investigated the prognosis of dysphagia, we often have to rely
on our own clinical experience. However, the number of elderly
patients with dysphagia is increasing, so aggressive rehabilitation
should be pursued to achieve functional recovery. At the same
time, a better objective method for assessing the prognosis of
dysphagia is needed.
References
[1] Buchholz DW. What is dysphagia? Dysphagia 1996;11:23–4.
[2] Gleeson DC. Oropharyngeal swallowing and aging: a review. J Commun Disord
1999;32:373–95.
[3] Perry L, Love CP. Screening for dysphagia and aspiration in acute stroke: a
systematic review. Dysphagia 2001;16:7–18.
[4] Horner J, Massey EW. Silent aspiration following stroke. Neurology
1988;38:317–9.
[5] Iwamoto T, Shimizu T, Akazawa A, Kikawada M, Nisimura T, Takasaki Y. Long
term prognosis of patients with initial cerebral thrombosis and the MRI
findings. Nihon Ronen Igakkai Zasshi 1999;36:128–35.
[6] Leder SB, Suiter DM. An epidemiologic study on aging and dysphagia in
the acute care hospitalized population: 2000–2007. Gerontology 2009;55:
714–8.
[7] Logemann JA. The dysphagia diagnostic procedure as a treatment efficacy trial.
Clin Commun Disord 1993;3:1–10.
[8] Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale.
Dysphagia 1996;11:93–8.
[9] Kunieda K, Ohno T, Fujishima I, Hojo K, Reliability Morita T. Reliability and
validity of a tool to measure the severity of dysphagia: Food Intake LEVEL Scale.
J Pain Symptom Manage 2012;12:467–8.
[10] Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. A new clinical scale for
the staging of dementia. Br J Psychiatry 1982;140:566–72.
[11] Meguro K, Ishii H, Kasuya M, Akanuma K, Meguro M, Kasai M, et al. Incidence
of dementia and associated risk factor in Japan. J Neurol Sci 2007;260:
175–82.
[12] Banks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin
scale: implications for stroke. Stroke 2007;38:1091–6.
[13] The National Institute of Neurological Disorders and Stroke: classification of
cerebrovascular disease III. Stroke 1990;143:383–9.
[14] Park RH, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJ, et al. Randomised
comparison of percutaneous endoscopic gastrostomy and nasogastric tube
feeding in patients with persisting neurological dysphagia. BMJ
1992;304:1406–9.
[15] Feinberg MJ, Knebl J, Tully J. Prandial aspiration and pneumonia in an elderly
population followed over 3 years. Dysphagia 1996;11:104–9.
[16] Adachi M, Ishihara K, Abe S, Okuda K, Ishikawa T. Effect of professional oral
health care on the elderly living in nursing homes. Oral Surg Oral Med Pathol
Oral Radiol Endod 2002;94:191–5.
[17] Iwamoto T, Koshibu J, Kikawada M, Yoneda Y, Uno M, Takasaki M, et al.
Findings of bedside swallowing assessment and brain computerized tomog-
raphy in patients with chronic cerebral infarction, and their outcome. Nippon
Ronen Igakkai Zasshi 2001;38:651–8.
[18] Chouinard J. Dysphagia in Alzheimer disease: a review. J Nutr Health Aging
2000;4:214–7.
[19] Hasegawa Y, Yamamoto T, Inagaki T, Suzuki K. A swallowing study, based on
clinico-pathological evaluation, performed by video-fluoroscopy. Nippon
Ronen Igakkai Zasshi 2000;37:63–7.
[20] Parker C, Power M, Hamdy S, Bowen A, Tyrrell P, Thompson DG. Awareness of
dysphagia by patients with following stroke predicts swallowing perfor-
mance. Dysphagia 2004;19:28–35.
[21] Wasson K, Tate H, Hayes C. Food refusal and dysphagia in older people with
dementia: ethical and practical issues. Int J Palliat Nurs 2001;7:465–71.
[22] Imoto Y, Kojima A, Osawa Y, Sunaga H, Fujieda S. Cough reflex induced by
capsaicin inhalation in patients with dysphagia. Acta Otolaryngol
2011;131:96–100.
[23] Sitzmann JV. Nutritional support of the dysphagic patient: methods, risks, and
complications of therapy. J Parenter Enteral Nutr 1990;14:60–3.
[24] Yoneyama T, Yoshida M, Matsui T, Sasaki H. Oral care and pneumonia. Lancet
1999;354:515.
[25] Watando A, Ebihara S, Ebihara T, Okazaki T, Takahashi H, Asada M, et al. Daily
oral care and cough reflex sensitivity in elderly nursing home patients. Chest
2004;126:1066–70.
[26] Carnaby G, Hankey GJ, Pizzi J. Behavioural intervention for dysphagia in acute
stroke: a randomized controlled trial. Lancet Neurol 2006;5:31–7.
[27] Shaker R, Kern M, Bardan E, Taylor A, Stewart ET, Hoffmann RG, et al.
Augmentation of deglutitive upper esophageal sphincter opening in the
elderly by exercise. Am J Physiol 1997;272:1518–22.
[28] Bülow M, Olsson R, Ekberg O. Do dysphagic patients with an absent pharyngeal
swallow have a shorter survival than dysphagic patients with pharyngeal
swallow? Prognostic importance of a therapeutic videoradiographic swallow-
ing study (TVSS). Acta Radiol 2005;46:126–31.