Dysphagia (2011) 26:108–116
DOI 10.1007/s00455-009-9270-8
ORIGINAL ARTICLE
Functional Dysphagia Therapy and PEG Treatment in a Clinical
Geriatric Setting
Regine Becker • Rolf Nieczaj • Katrin Egge •
Almut Moll • Miriam Meinhardt • Ralf-Joachim Schulz
Received: 23 February 2009 / Accepted: 29 December 2009 / Published online: 26 January 2010
Ó Springer Science+Business Media, LLC 2010
Abstract Functional dysphagia therapy (FDT) is a non-
invasive procedure that can accompany percutaneous
endoscopic gastrostomy (PEG) treatment and supports
transitioning from tube to oral feeding. In this retrospective
study, we investigated the outcome of FDT with or without
PEG feeding. Patients with dysphagia were divided into
two groups: those with PEG feeding (N = 117) and those
with exclusively oral feeding (N = 105). Both groups
received functional training (oral motor skills/sensation,
compensatory swallowing techniques) from speech-lan-
guage therapists. Functional oral intake, weight, Barthel
index, and speech and language abilities were evaluated
pre- and post-training. The non-PEG group showed a sig-
nificant post-treatment improvement in functional oral
intake, with diet improvement from pasty consistency to
firm meals in most cases. However, even severely disor-
dered patients (with PEG feeding) showed a significant
increase in functional oral intake, still requiring PEG
feeding post-treatment but able to take some food orally.
The sooner a PEG was placed, the more functional oral
intake improved. Significantly more complications and
higher mortality occurred in the PEG group compared to
the group with exclusively oral feeding. Dysphagia treat-
ment in the elderly requires a multiprofessional setting,
differentiated assessment, and functional training of oral
motor skills and sensation and swallowing techniques.
R. Becker (&)
R. Nieczaj
K. Egge
A. Moll
M. Meinhardt
Charité – Universitätsmedizin Berlin, Campus Virchow-
Klinikum, Research Group on Geriatrics at Ev. Geriatriezentrum
Berlin, Reinickendorfer Straße 61, 13347 Berlin, Germany
e-mail: regine.becker@charite.de
R.-J. Schulz
Department of Geriatrics, St. Marien-Hospital,
University of Cologne, Cologne, Germany
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Keywords Dysphagia
Nutrition
PEG feeding tube

Functional therapy
Deglutition
Deglutition disorders
Neurogenic dysphagia occurs primarily in patients who
have suffered an acute stroke (50%), and approximately
30% of patients with cerebrovascular disease are diagnosed
with chronic neurogenic dysphagia [1, 2]. Dysphagia
manifests clinically as difficulties in eating and drinking,
the inability to swallow saliva and secretions, malnutrition
resulting in loss of weight and dehydration, and pulmonary
complications due to aspiration [3, 4].
Swallowing disorders can considerably affect a patient’s
quality of life and can be life-threatening in severe cases.
One basic principle of the care of dysphagic patients is to
provide adequate nutrition and optimal protection of the
airways to maintain the greatest possible quality of life [5].
Percutaneous endoscopic gastrostomy (PEG) or naso-
gastric tube (NGT) feeding is indicated in patients who
cannot maintain sufficient hydration and/or food supply
orally without aspiration. A retrospective data analysis has
shown that PEGs are used mainly for patients who have
suffered a stroke (65.1%) and/or dysphagia (64.1%) [6].
Because of illness severity, the mortality rate during hos-
pitalization in that study was higher in the PEG group
(17.6%) than in the control group (4.3%). Various findings
show that inserting a PEG tube is not indicated after acute
stroke but instead when chronic dysphagia is diagnosed
[4, 7]. The FOOD study [7, 8], which compared PEG feeding
with NGT feeding after a stroke (N = 321), showed a better
functional outcome (based on the Modified Ranking Scale)
in patients who had received an NGT instead of a PEG
within the first 2 or 3 weeks after stroke. Nevertheless,
mortality rates did not differ significantly. On the other hand,
other studies [9, 10] have provided empirical evidence of the
R. Becker et al.: Dysphagia Therapy in Geriatric Setting
advantages of a PEG compared to an NGT with respect to
mortality rates and different nutritional parameters (e.g.,
increase in weight, greater food supply) in the treatment of
chronic dysphagia after a stroke. In particular, the most
severely disordered elderly patients suffering from dyspha-
gia benefit from PEG treatment in terms of nutritional status,
mortality, and length of stay in the hospital [11]. One dis-
advantage of NGTs is the need for repeated replacement
because they easily get out of place and may be pulled out,
especially by geriatric patients. Ha and Hauge [12] exam-
ined 83 patients who had experienced a stroke or had other
diseases (control group). The patients received a PEG tube
when placement of an NGT had not been successful or long-
term treatment was anticipated. The PEG could eventually
be removed from 20% of the patients older than 74 years and
from 31% of the younger patients. From these findings they
concluded that the decision for early PEG treatment (within
the first 2 weeks) depends on the prognosis, the aim of
nutritional treatment, the duration of dysphagia, the patient’s
age, and concomitant diseases. Therefore, a differentiated
assessment is required.
Functional dysphagia therapy (FDT) is a noninvasive
therapeutic procedure [13–17]. Its goal is activation and
recovery of impaired functions of nutritional intake and/or
the transmission of techniques and strategies to compensate
the dysfunction and enable or maintain independent oral
feeding. Depending on the treatment goals, various thera-
peutic procedures can be applied.
Functional training exercises are designed to improve
motor skills to change swallowing physiology. Typical
exercise programs focus on improving the extent of
movement of the lips, jaw, tongue, larynx, and vocal folds;
strengthening the tongue and/or respiratory muscles; and
using the Lee Silverman Voice Treatment and the Shaker
Head Lift. These active therapy procedures are considered
to have the potential to change both behavioral and neural
plasticity [15, 16].
Compensatory treatment procedures target improvement
in the flow of food and prevention of aspiration and/or
residues. They do not necessarily change the physiology of
swallowing. Compensatory strategies include five postural
techniques: chin down, chin elevate, head turned, head
tilted, and lying down. The effectiveness of postural
changes should be evaluated during diagnostic radio-
graphic or endoscopic procedures. Further compensatory
strategies are various swallow maneuvers, including the
supraglottic swallow, super-supraglottic swallow, effortful
swallow, and Mendelsohn maneuver. These techniques are
designed to manipulate single aspects of the swallowing
mechanism to prevent aspiration and/or improve safety and
efficiency during swallowing. Sufficient cognitive abilities,
language comprehension, and muscle strength are required
to practice these swallow maneuvers.
109
Furthermore, varying sensory input affects swallowing.
Bolus characteristics like volume, viscosity, temperature,
and taste have been found to modify normal swallowing
[17]. Various sensory enhancement techniques [14] are
used to improve oral sensory awareness and delayed trig-
gering of pharyngeal swallow. These may include thermal/
tactile stimulation, presenting a sour or cold bolus, pre-
senting a larger-volume bolus or a bolus requiring chewing,
modifications in the speed of food presentation, self-feed-
ing, and increasing downward pressure of the spoon against
the tongue during feeding.
Diet modifications such as thickening liquids or soft-
ening foods and postural adjustments are traditionally
chosen for the treatment of frail dysphagic patients. These
adaptive and compensatory procedures are not efficient in
all cases, however. A recent clinical study [18] showed that
thickening of liquids did not necessarily result in greater
safety for dysphagic patients with Parkinson’s disease or
dementia. Approximately half of the participants aspirated
with all three kinds of intervention: thin liquid using the
chin-down posture, nectar-thick liquids, and honey-thick
liquid without postural adjustment.
Tube feeding does not reduce aspiration of secretions or
gastroesophageal reflux [19, 20]. Swallowing therapy must
be carried out simultaneously with PEG treatment because
‘‘disuse of the swallowing mechanism may diminish its
cortical representation and prevent functional recovery in
the long term’’ [17, p. 278]. Training procedures may
include systematic swallowing drills without using a bolus
or a gradual return to oral nutrition. Even in geriatric
medicine, there has been a gradual shift toward the devel-
opment of progressive resistance training programs [15].
Crary et al. [21] described how to initiate oral feeding in
patients who are tube fed. In the beginning of a gradual
return to oral intake, the dysphagic patient has to be able to
swallow at least small amounts of liquids or pasty foods
safely and efficiently. The return to oral intake is related to
improvement of both a patient’s cognitive status and
physiological swallowing ability. Clinical studies [22, 23]
have shown that swallowing therapy supports the transition
from tube feeding to oral feeding effectively and has a
positive impact on nutritional status.
A critical factor in evaluating the effectiveness of
treatment is the choice of measurement. It is crucial to
consult functional measurement data that describe the
improvement of actual daily oral intake and quality of life
alongside objective data from imaging techniques [24]. The
Functional Oral Intake Scale (FOIS) [25] was developed to
evaluate the ability to swallow and the transition from tube
to oral feeding. Furthermore, language, speech, and cog-
nitive abilities must be evaluated because attention, con-
centration, and comprehension influence all aspects of the
retraining and rehabilitation process. The speech-language
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110 R. Becker et al.: Dysphagia Therapy in Geriatric Setting

therapist has to treat different areas if the patient suffers not
only from swallowing disorder but also from aphasia and/
or dysarthria.
The present study addresses the issue of how severely
impaired (with PEG) and less-impaired (without PEG)
dysphagic patients benefit from FDT. We also discuss the
impact of the timing of PEG tube placement (number of
days from dysphagia diagnosis until insertion of a PEG
tube) on oral nutritional intake in dysphagic patients.
Method
Sample
This retrospective study included a sample of 222 dys-
phagic patients with different etiologies (e.g., ischemic
stroke, hemorrhagic stroke, dementia, Parkinson’s disease,
head and neck cancer). The patients received initial med-
ical treatment and care in a stroke unit or an acute hospital.
They were admitted for rehabilitation and further acute
geriatric treatment to the Center for Geriatric Medicine in
Berlin (EGZB), where dysphagia was diagnosed clinically
by speech-language therapists. A total of 117 patients
(group 1) were treated with PEG because oral intake was
not possible or insufficient during at least 10 days post
onset. The remaining 105 patients (group 2) could be fed
orally. They received a diet adapted to their dysphagia
(e.g., thickened liquids, pasty or partially pureed foods).
Patients in both groups were treated with FDT during their
stay in the hospital. Table 1 provides an overview of the
patients’ characteristics, including age, gender, length of
stay, Mini-Mental State Examination (MMSE) score, start
of treatment with PEG after admission, and mean number
of speech-language therapy sessions.
Procedure
The patients were examined using the Geriatric Basic
Assessment (Study Group Geriatric Assessment AGAST,
1997) [26]. In addition, they were diagnosed by speech-
language therapists to assess swallowing function [13],
speech intelligibility [27], and language ability [28]. If a
swallowing diagnosis indicated the need for exclusive tube
feeding, patients did not receive oral nutrition. If the
clinical evaluation was not sufficient to assess the risk of
aspiration, videofluoroscopy was conducted. In the course
of treatment, patients successively received oral nutrition
(thickened beverages/small amounts of pureed foods)
under therapeutic supervision in addition to tube nutrition.
As soon as they showed improvements in swallowing
function, the amount and frequency of oral intake were
increased [21]. A dysphagia diet plan was designed in
which viscosity of foods was increased in five steps (pasty,
pureed, semipureed, predominantly solid, slightly modi-
fied) to unmodified foods [29]. Depending on the severity
of the swallowing disorder, oral intake was determined
according to the dietary levels described above. Beverages
were thickened, if necessary. Patients with mild or mod-
erate swallowing disorders and/or good compensation of
the dysfunction did not receive additional PEG treatment.
However, patients with insufficient vigilance, poor endur-
ance capabilities, and a high risk of aspiration received
PEG treatment.

Table 1 Basic data and group characteristics

Group 1 with Group 2 without Total (N = 222) Group differences
PEG (N = 117) PEG (N = 105) Mann–Whitney
U test P value

Gender (female %) 62.4 49.5 56.3 0.054

Age at admission (years, mean ± SD) 78.8 ± 9.6 79.0 ± 8.3 78.9 ± 9.0 0.875
Length of stay (days, mean ± SD) 30.9 ± 14.1 30.3 ± 17.0 30.6 ± 15.5 0.379
MMSE score (mean ± SD) 12.4 ± 9.9 (N = 12) 18.5 ± 6.5 (N = 47) 18.5 ± 6.3 (N = 59) 0.927
Functional treatment of dysphagia, number 12.4 ± 9.9 11.7 ± 9.1 12.0 ± 9.5 0.681
of therapy sessions (mean ± SD)
Period to PEG application (days, mean ± SD) 9.0 ± 8.1 – – –
Weight change between admission -0.8 ± 3.3 -0.6 ± 3.3 -0.7 ± 3.3 0.808
and discharge (kg, mean ± SD)
Barthel index (BI) score at admission (mean ± SD) 5.2 ± 10.1 17.4 ± 20.3 10.9 ± 16.8 \0.001
BI score change between admission 3.0 ± 16.9 16.0 ± 20.9 9.1 ± 19.9 \0.001
and discharge (mean ± SD)
Number of complications (mean ± SD) 1.6 ± 1.2 1.0 ± 1.0 1.3 ± 1.1 \0.001
Mortality (%) 19.7 8.6 14.4 0.019
MMSE mini-mental state examination, SD standard deviation

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R. Becker et al.: Dysphagia Therapy in Geriatric Setting
Speech-language therapists treated all patients, follow-
ing the FDT concept [13]. The applied therapy procedures
focused on functional training exercises of motor (speech)
skills to improve the extent of movement and the strength
and coordination of the lips, jaw, tongue, velum, larynx,
and vocal folds. These procedures were combined with
sensory enhancement techniques like thermal/tactile stim-
ulation and varying bolus characteristics, including vis-
cosity, taste, and volume. Furthermore, compensatory
techniques like chin down, effortful swallowing, repeated
swallow, and supraglottic swallow were used to improve
safety and efficiency of swallowing.
Treatment was terminated for 34 patients because of
sudden transfer or death or a lack of therapeutic potential
arising from cognitive deficits. On discharge, 188 patients
were re-examined with the Geriatric Basic Assessment
[26], and swallowing function, speech intelligibility, and
language ability were reassessed.
Parameters
Nutritional intake
Actual daily oral intake was evaluated using the FOIS [25]:
(1) nothing by mouth, (2) tube-dependent with minimal
attempts of food or liquid, (3) tube dependent with con-
sistent oral intake of food or liquid, (4) total oral diet of a
single consistency; (5) total oral diet with multiple con-
sistencies but requiring special preparation or compensa-
tions, (6) total oral diet with multiple consistencies without
special preparation but with specific food limitations, and
(7) total oral diet with no restrictions. Beverages were
classified on the basis of a three-step scale: (1) nothing per
mouth, (2) thickened beverages, and (3) nonthickened
beverages.
Geriatric Assessment
The present study incorporated the following variables:
weight at admission and discharge, Barthel index (BI)
score at admission and discharge [30], and MMSE score
[31]. MMSE was not administered to aphasic or somnolent
patients.
Speech and Language Abilities
To rate the severity of aphasic disorders, the six-step
ordinary scale of the Aachen Aphasia Test [28] was used:
(0) communication impossible, (1) communication carried
out by means of incomplete or unintelligible expressions
and the meaning of what has been said has to be guessed,
(2) communication possible with the help of one’s
111
conversational partner but often thoughts cannot be con-
veyed, (3) communication possible with little help but
there are still considerable linguistic limitations, (4)speech
nonfluent and/or there are a few language limitations, and
(5) communication possible without limitations and/or
there are minimal difficulties in speech.
To rate the severity of dysarthric disorders, we used the
six-step ordinary scale from the Allensbacher Schweregr-
adskala für Dysarthrie [27]. Intelligibility of speech was
evaluated as follows: (0) cannot be assessed/no utterance;
(1) speech is unintelligible even with careful listening and
repetitions, or anarthric; (2) speech is only intelligible with
careful listening, repetitions are often necessary; (3) speech
is intelligible only with careful listening, sometimes further
questions are necessary; (4) speech is intelligible, careful
listening is infrequently necessary; and (5) speech is
intelligible without limitations.
Additional Parameters
In addition, the following parameters were taken into
consideration: time of PEG treatment (days from admis-
sion to the hospital until PEG insertion), length of stay in
hospital in days, number of speech-language therapy
sessions (duration 30 min) during hospital stay, number of
complications (e.g., wound infection, vomiting, diarrhea,
pneumonia, MRSA, abnormal blood glucose levels, uri-
nary tract infection, feeling of fullness, nausea), and
mortality.
Data Analysis
Data analysis was carried out using the statistical package
SPSS 15.0 (SPSS Inc., Chicago, IL, USA). Because of the
ordinal and categorical variables as well as the normally
distributed continuous variables, distribution-independent
nonparametric tests were used to determine differences
between groups in parameters and outcome variables. The
following tests were conducted: bivariate Spearman’s rank
correlation test (two-sided test of significance); Kruskal-
Wallis test and the Mann–Whitney U test for mean value
analyses between the examined groups; v2 test to analyze
whether relative frequencies of specific complications dif-
fer between the examined groups; and the Wilcoxon
rank-sum test for related samples to assess mean value
differences of the variables recorded at admission and
discharge. For prediction of changes in speech-language
therapeutic outcome variables (as far as there were uni-
variate relationships that had been determined in advance),
linear multiple regression with the backward elimination
technique was used. Statistical significance was set as
P \ 0.05 = significant, P \ 0.01 = highly significant, and
P \ 0.001 = most significant.
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112 R. Becker et al.: Dysphagia Therapy in Geriatric Setting

Results mean BI score of 17.4. In the course of treatment, they

Group Homogeneity
The groups did not differ significantly from each other with
respect to gender, age, number of speech-language therapy
sessions, length of stay, or MMSE score (Table 1). Group 1
patients (with PEG) were treated with PEG on average
9 days after admission to the hospital. Group 2 consisted of
patients with mild or moderate dysphagia who did not
require PEG treatment according to their swallowing
diagnosis.
Weight and BI
Table 1 shows mean values and standard deviations of the
BI score at admission as well as the difference value
between admission and discharge. There were significant
group differences regarding functional capacity (BI score
and difference value between admission and discharge,
Table 1). Group 1 (with PEG) had a mean BI score of 5.2
at admission. Patients in this group had severe functional
deficits in all areas. The mean BI score had increased by
3.0 points at discharge. Group 2 consisted of patients with
mild to moderate dysphagia (without PEG) who had a
improved by 16.6 points on average.
There was no group difference in weight change
between admission and discharge. Weight loss amounted to
0.7 kg on average.
Complications
As Table 1 shows, group 1 (with PEG) had signifi-
cantly more complications than group 2 (without PEG)
(P \ 0.001). Table 2 indicates that the total number of
complications was 169 in group 1 and 98 in group 2. The
frequency distribution (Table 2) of individual complica-
tions reveals that group 1 differed significantly from group
2 in some complications associated with PEG: abnormal
blood glucose levels, diarrhea, and vomiting. The most
frequent complication in both groups was pneumonia.
Group 1 experienced more pneumonias than group 2
(P = 0.08).
Mortality
Group 1 (with PEG) experienced significantly more mor-
tality (19.7%) than group 2 (8.6%) (without PEG)
(P \ 0.05) (Table 1).

Table 2 Absolute and relative

Complication Group 1 (with PEG) Group 2 (without PEG) v2 test
frequencies of complications in
(N = 117) (N = 105)
group 1 (with PEG) and group 2
(without PEG) Absolute % Absolute % P value

Recurrent stroke 1 0.9 4 3.8 0.153

Pneumonia 46 39.3 31 29.5 0.082
Urinary tract infection 21 17.9 24 22.9 0.229
Sepsis/urosepsis 2 1.7 3 2.9 0.449
Infections (others) 8 6.8 2 1.9 0.072
Abnormal blood glucose level 10 8.5 0 0.0 \0.01
Vomitus 9 7.7 0 0.0 \0.01
Stomach ache 3 2.6 1 1.0 0.353
Obstipation 0 0.0 1 1.0 0.473
Peritonitis 2 1.7 0 0.0 0.277
Buried bumper syndrome 1 0.9 0 0.0 0.527
Gastrointestinal bleeding 1 0.9 1 1.0 0.723
Diarrhea (Clostridia) 16 13.7 12 11.4 0.383
Diarrhea (other) 13 11.1 0 0.0 \0.001
MRSA (methicillin-resistant 16 13.7 7 6.7 0.067
Staphylococcus aureus)
ESBL (extended-spectrum 0 0.0 2 1.9 0.233
beta-lactamase)
Renal failure 2 1.7 0 0.0 0.277
Falls 7 6.0 6 5.7 0.581
Wound infection 11 9.4 4 3.8 0.081
v2 test: group 1 vs. group 2 (P Total number of complications 169 98
value)

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R. Becker et al.: Dysphagia Therapy in Geriatric Setting 113

Speech-language Therapeutic Outcome Variables
Table 3 gives the results of speech-language diagnosis at
admission and discharge for both groups. The values are
averaged as ordinary scale data. In the course of treatment,
group 1 patients (with PEG) showed highly significant
improvement in drinking (P \ 0.001) and eating (FOIS)
(P \ 0.01) from admission to discharge. Patients could be
fed orally in addition to tube feeding at discharge. The PEG
tube was removed in one patient during the hospital stay.
Many group 1 patients also suffered from global aphasia so
that communicative ability was rated ‘‘0’’ or ‘‘1’’ at
admission. In many cases, patients also suffered from
speech motor disorders so that their speech intelligibility
was rated ‘‘0’’ or ‘‘1.’’ At discharge, patients showed highly
significant improvements in speech skills (P \ 0.001) and
communicative abilities (P \ 0.01).
Group 2 patients (without PEG) who were less impaired
also showed highly significant improvements in nutritional
intake (P \ 0.001); the dietary level could be changed
from ‘‘pasty foods’’ to ‘‘solid foods.’’ At discharge, thick-
ening of beverages was no longer necessary in most cases.
Furthermore, the group showed a highly significant
improvement (P \ 0.001) in communicative abilities and
speech intelligibility.
The same analysis was conducted taking etiology and
disease severity into account. Two groups are differenti-
ated: group A consisted of patients with ischemic stroke
and group B consisted of patients who had neurological
degeneration such as dementia, recurrent strokes, or
Parkinson’s disease. Patients with hemorrhagic stroke and
head and neck cancer were excluded from this analysis
because their number was small. Table 4 gives the func-
tional recovery of both groups. Group A showed highly
significant improvement in all functional outcome vari-
ables. Even group B patients improved significantly in
functional outcome from admission to discharge, despite
less rehabilitation potential, greater frailty, and chronic
medical conditions.
Time of PEG Treatment
What effect does time of PEG treatment have on
improvement of swallowing and nutritional intake? To
answer this question, we calculated correlations with
speech-language outcome variables using Spearman’s
correlation coefficient. A highly significant negative cor-
relation emerged between time of PEG insertion and
functional improvement of nutritional intake (FOIS)
(-0.345; P \ 0.01) and between PEG insertion and

Table 3 Means of functional

outcome at admission and
discharge in group 1 (dysphagia
with PEG) and group 2
(dysphagia without PEG)
Nonparametric Wilcoxon test
for differences between
admission and discharge within
the groups, asymptotic
significance (P)
Functional outcome Group 1 with PEG Group 2 without PEG
Functional oral intake (FOIS) at admission 0.8 (N = 117) 3.0 (N = 105)
Functional oral intake (FOIS) at discharge 1.4 (N = 95), P \ 0.01 4.2 (N = 93), P \ 0.001
Beverages at admission 0.4 (N = 117) 1.2 (N = 105)
Beverages at discharge 0.8 (N = 95), P \ 0.001 1.6 (N = 93), P \ 0.001
Communication ability at admission 1.4 (N = 117) 2.7 (N = 105)
Communication ability at discharge 1.9 (N = 95), P \ 0.01 3.5 (N = 93), P \ 0.001
Speech intelligibility at admission 1.1 (N = 117) 2.3 (N = 105)
Speech intelligibility at discharge 1.7 (N = 95), P \ 0.001 3.2 (N = 93), P \ 0.001

Table 4 Means of functional

outcome at admission and
discharge dependent on etiology
of dysphagia in group A
(ischemic stroke) and group B
(neurological degeneration)
Nonparametric Wilcoxon test
for differences between
admission and discharge within
the groups, asymptotic
significance (P)
Functional outcome Group A ischemic stroke Group B neurological
degeneration
Functional oral intake (FOIS) 1.81 (N = 118) 1.88 (N = 68)
at admission
Functional oral intake (FOIS) 2.96 (N = 102), P \ 0.001 2.39 (N = 59), P = 0.011
at discharge
Beverages at admission 0.73 (N = 118) 0.82 (N = 68)
Beverages at discharge 1.22 (N = 102), P \ 0.001 0.98 (N = 59), P = 0.053
Communication ability at admission 1.91 (N = 118) 2.12 (N = 68)
Communication ability at discharge 2.66 (N = 102), P \ 0.001 2.54 (N = 59), P = 0.030
Speech intelligibility at admission 1.50 (N = 118) 1.74 (N = 68)
Speech intelligibility at discharge 2.31 (N = 102), P \ 0.001 2.27 (N = 59), P = 0.001

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114
improvement of drinking ability (difference value bever-
ages) (-0.246; P = 0.017).
Linear multiple-regression analysis showed whether
multivariate analysis could confirm the univariate rela-
tionships in group 1 identified above. The dependent var-
iable (criterion) was the difference in the FOIS scale value
between examination at admission and discharge. The
independent variables (predictors) were age at admission,
gender, weight at admission, BI score at admission, length
of stay, time in days between admission to the hospital and
PEG insertion, number of speech-language therapy ses-
sions, and number of complications. An analysis using the
backward elimination method showed that only the vari-
able of time between admission to the hospital and PEG
insertion was a significant predictor of improvement in
nutritional intake measured with FOIS (B = -0.057,
b = -0.306, P = -0.004; 95% confidence interval [CI]
for B = -0.095 and -0.019; constant = 2.05, P = 0.044,
R = 0.504, adjusted R2 = 0.173; df = 8). A corresponding
model in which the difference value of the threefold bev-
erage scale was the dependent variable showed two sig-
nificant predictor variables: time between admission to the
hospital and PEG insertion (B = -0.019, b = -0.228,
P = 0.025; 95% CI for B = -0.035 and -0.002) and BI
score at admission (B = -0.016, b = -0.274, P = 0.008;
95% CI for B = -0.027 and -0.004). This model has an
R value of 0.549, an adjusted R2 value of 0.225, con-
stant = 4.69, P \ 0.001, and df = 8.
The earlier patients received a PEG, the more they
improved in swallowing function and could be fed orally in
addition to using tube feeding, or returned to full oral
feeding at discharge. A low BI score at admission is
another significant predictor of improvement of swallowing
function in the course of treatment. Severely dysphagic
patients who had to be tube fed exclusively at admission
could receive liquids orally in addition to tube food at
discharge.
Discussion
The present retrospective study addressed the impact of
FDT on nutritional intake in dysphagic patients with or
without PEG. In practice, it is often difficult to decide
whether PEG insertion is indicated at a certain moment.
For this reason, in this study a differentiated assessment
was performed as early as possible and patients were
separated into two treatment groups, those with and those
without indication for PEG.
Patients with dysphagia and PEG (group 1) showed
insufficient vigilance, poor endurance capabilities, and a
high risk of aspiration. They had scored very low on the BI
at admission (5.2 on average) but had improved by 3 points
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R. Becker et al.: Dysphagia Therapy in Geriatric Setting
on average at discharge. In the course of treatment, patients
successively received oral nutrition (thickened beverages/
small amounts of pureed foods) under therapeutic super-
vision in addition to tube nutrition.
Further therapeutic procedures focused on functional
training exercises of motor (speech) skills to improve the
extent of movement, strength, and coordination of oro-
pharyngeal muscles and on sensory enhancement tech-
niques and swallowing maneuvers [13–15]. As soon as
improvements in swallowing function were detected,
amount and frequency of oral intake were increased [21].
There were significant improvements in oral intake (in
addition to tube feeding) after a mean number of 12 FDT
sessions at discharge. Weight loss was 0.7 kg on average at
discharge. During the short treatment period, improvement
allowed removal of the PEG tube in only one patient. If
indicated, the remaining patients were referred to ambulant
speech-language therapeutic treatment to achieve full oral
feeding. PEG removal after discharge from hospital was
not controlled.
A direct comparison with the results of the FOOD Study
[7, 8] is not possible because the present study did not
include a control group treated with NGT. However, the
current findings do show that PEG treatment combined
with FDT has the potential to produce improvement in
swallowing. Furthermore, a precise diagnosis of swallow-
ing is crucial for treating patients adequately. A methodical
limitation of the FOOD Study [7, 8] was that only those
patients whose responsible physician was uncertain about
the indication for the PEG tube or NGT tube were included
in the study.
In the present study, patients with mild to moderate
dysphagia (group 2) were not supplied with a PEG tube but
received FDT only. The treatment of group 2 patients
consisted of changes in food consistency (diet modifica-
tions), functional training exercises of motor (speech) skills
to improve the extent of movement, strength, and coordi-
nation of oropharyngeal muscles, and sensory enhancement
techniques and swallowing maneuvers [13–15]. The mean
BI score was 17.4 at admission and had improved on
average by 16 points at discharge. Patients from this group
also showed highly significant improvements in nutritional
intake, with a dietary level that could be changed from
pasty consistency of foods to solid foods. Thickening of
beverages was no longer necessary at discharge in most
cases.
Patients with mild to moderate dysphagia (group 2) also
had no or only few restrictions on certain foods at dis-
charge. Although group 1 patients could be fed orally to a
large extent (in combination with PEG feeding), they were
still dependent on dietary modifications (e.g., pureed foods,
thickening of beverages) at discharge. Therapeutic pro-
gression shows that even the severely impaired dysphagic
R. Becker et al.: Dysphagia Therapy in Geriatric Setting
patients (with PEG) benefited significantly from FDT
despite their poor rehabilitation potential. Furthermore,
significant improvements of aphasic and dysarthric symp-
toms occurred in both groups.
Patients with ischemic stroke, as well as patients suf-
fering from neurological degeneration, benefited from
FDT. The etiology of dysphagia seems to have only little
influence on functional recovery, as the results of the
present study indicate. Even patients with dementia,
recurrent strokes, and Parkinson’s disease improved sig-
nificantly in functional outcome from admission to dis-
charge, despite less rehabilitation potential, greater frailty,
and chronic medical conditions. However, systematic
research designs are necessary to investigate how disease
severity and comorbidities of geriatric patients influence
functional outcome of swallowing exercises [15].
The mortality rate in group 1 (with PEG) was 19.7%.
This value is comparable to the findings of Wirth et al.
[6], who reported an in-hospital mortality rate of 17.6%
among stroke and/or dysphagia patients with PEG treat-
ment. In group 2 of the current study, on the other hand,
the mortality rate was considerably lower at 8.6%; the
groups differed significantly with respect to mortality.
Furthermore, group 1 (with PEG) experienced signifi-
cantly more complications than group 2 (without PEG).
These differences between groups became manifest par-
ticularly for complications associated with PEG
(e.g., vomiting, diarrhea). Pneumonia was the most fre-
quent complication in both groups, but higher in group 1
(P = 0.08).
We also addressed whether early PEG treatment can
positively affect the course of severe dysphagia. Univariate
and multivariate analyses indicated that actual daily swal-
lowing function improved more the earlier group 1 patients
received a PEG (measured with FOIS). Results of multiple
regression analysis showed small but significant relation-
ships (P \ 0.05) between improvement in oral intake
through FDT and PEG treatment that started as early as
possible. The explained variance of FOIS changes through
the timing of PEG insertion was approximately 17% and
therefore rather small. In addition, there was a significant
relationship between a low BI score at admission and an
improvement of drinking in the course of treatment.
Severely disordered patients who could only be tube fed
orally at admission could receive liquids orally in addition
to tube feeding at discharge. It seems likely that additional
factors that were not included in the analysis influenced the
relationship between timing of PEG insertion and outcome
changes. These findings are consistent with the results of
previous studies [9–11] that provided evidence for better
development of nutritional status and/or functional status in
persistent dysphagia and PEG treatment compared to NGT
treatment.
115
The decision concerning the timing of intervention and
the adequacy of the chosen method is controversial in the
literature. A retrospective cohort study [32] showed that the
ability to tolerate oral intake early after stroke is an indi-
cator of improvement of dysphagia. Patients who tolerated
thickened liquids and pureed foods 14 days post onset
could be fed orally in the course of treatment with a 50%
probability. According to the described study, patients who
do not tolerate this diet 14 days post onset should receive a
PEG tube. In the present study, the severely disordered
group 1 patients received a PEG tube 9 days after admis-
sion on average (approximately 14–21 days post onset). At
discharge they could receive liquids and/or pasty foods
orally in addition to tube food, and they benefited more
from FDT the earlier the PEG tube was inserted.
In the present study, as well as in the studies of Carnaby
et al. [22] and Elmstahl et al. [23], swallowing therapy
effectively supported the return to oral feeding in patients
with severe dysphagia and PEG. From previous findings we
can infer the importance of a precise swallowing diagnosis
for patients who cannot be fed orally or who receive
insufficient intake orally. However, the decision for PEG
placement has to be well founded because of the signifi-
cantly greater frequency of complications and higher
mortality rate in the PEG group.
With the retrospective study design, we were able to
examine these questions within the short period of one and
a half years in the clinical setting of a geriatric center, but
the population was selected and there was no control group.
Further systematic investigation has to consider spontane-
ous recovery within 2–4 weeks post stroke onset. For
patients like those in group 2 (mild to moderate dysphagia,
without PEG), there might be some who recovered spon-
taneously. However, even these patients required FDT for a
short period of time to prevent aspiration and/or to improve
safety and efficiency during swallowing. In the case of a
prospective study, the groups could be divided with greater
differentiation, e.g., patients with chronic dysphagia
exclusively would have to be included in the study and
checked for etiology of dysphagia, disease severity, and
comorbidities. Based on our current findings, we recom-
mend a continuing multicenter prospective study to further
assess these questions.
In conclusion, we found that all examined dysphagia
patients benefited from FDT, whether they had to be
treated with PEG or not. In addition, patients with ischemic
stroke and those with neurological degeneration benefited
from FDT, which can help patients with severe dysphagia
and a PEG tube return to oral intake. Finally, the earlier
patients with severe dysphagia received a PEG, the more
actual daily oral intake (measured with FOIS) improved,
but there were significantly more complications and a
higher mortality rate in the PEG group.
123
116
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Regine Becker PhD
Rolf Nieczaj DSc/PhD
Katrin Egge MA
Almut Moll MA
Miriam Meinhardt
Ralf-Joachim Schulz MD