PRESBYPHAGIA MARKERS IN THE COMMUNITY-DWELLING

ELDERLY POPULATION

by

Naomi Dreyer

A Thesis
Submitted to the Faculty of Purdue University

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In Partial Fulfillment of the Requirements for the degree of

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Master of Science
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Department of Speech, Language, and Hearing Sciences

West Lafayette, Indiana
August 2017




ProQuest Number: 10605096




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THE PURDUE UNIVERSITY GRADUATE SCHOOL

STATEMENT OF COMMITTEE APPROVAL

Dr. Georgia Malandraki, Chair

Department of Speech, Language and Hearing Sciences

Dr. Jessica Huber

Department of Speech, Language, and Hearing Sciences

Dr. Zhongming Liu

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School of Biomedical Engineering

Approved by:
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Dr. Keith Kluender
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Department Head
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To FSD and EWD, because “trying is not achieving.” Thank you.

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TABLE OF CONTENTS

LIST OF TABLES .............................................................................................................. v

LIST OF FIGURES ........................................................................................................... vi
CHAPTER 1 INTRODUCTION ........................................................................................ 1
CHAPTER 2 LITERATURE REVIEW ............................................................................. 3
2.1 Normal Anatomy and Physiology of Swallowing .................................................... 3
2.2 Aging: Anatomical Changes in the Head and Neck Area......................................... 7
2.3 Aging: Physiological Changes in Swallowing.......................................................... 9
2.3.1 Measures of Interest ........................................................................................ 12
2.4 Aims and Hypotheses ............................................................................................. 15

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2.4.1 Aim 1 ............................................................................................................... 15
2.4.2 Aim 2 ............................................................................................................... 16
CHAPTER 3 METHODOLOGY ..................................................................................... 17
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3.1 Participants.............................................................................................................. 17
3.1.1 Inclusion and Exclusion Criteria ...................................................................... 17
3.2 Data Collection ....................................................................................................... 17
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3.2.1 Screening.......................................................................................................... 17
3.2.2 Experimental Session ....................................................................................... 19
3.3 Data Analysis .......................................................................................................... 21
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3.3.1 Swallowing Physiology Analysis .................................................................... 21

3.3.2 Statistical Analysis .......................................................................................... 23
CHAPTER 4 RESULTS .................................................................................................. 25
4.1 Reliability Results ................................................................................................... 25
4.2. Demographic Data ................................................................................................. 25
4.3 Results of Analyses for Aim 1 ................................................................................ 26
4.4 Results of Analyses for Aim 2 ................................................................................ 31
4.4.1 Duration Measures ........................................................................................... 31
4.4.2 PA Scale Scores ............................................................................................... 38
CHAPTER 5 DISCUSSION ............................................................................................. 40
5.1 Overview of findings .............................................................................................. 40
5.2 Limitations and Future Directions ......................................................................... 47
5.3 Conclusion ............................................................................................................. 49
REFERENCES ................................................................................................................. 51
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LIST OF TABLES

Table 2.1: Muscle involvement in the stages of swallowing...............................................5

Table 2.2: Definitions of Durations Measures...................................................................13
Table 2.3: The Penetration-Aspiration Scale.....................................................................14
Table 3.1: Swallowing Duration Boundaries for Analysis................................................22
Table 4.1: Demographic Data............................................................................................26
Table 4.2: Descriptive Statistics for Duration Measures and Qualitative Comparisons
with Young Adult Data Provided in the Literature................................................27
Table 4.3: Number of Subjects with Longer Duration Measures than the Mean Durations
of Young Adults.....................................................................................................30

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Table 4.4: Penetration-Aspiration Scale Results...............................................................31
Table 4.5: Spearman Correlations between PA Scale Scores and Age and between PA
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Scale Scores and Tongue Pressure.........................................................................39
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LIST OF FIGURES

Figure 4.1: Means and SDs of Duration Measures Across Bolus Types..........................29
Figure 4.2: Oral Transit Durations by Bolus Type............................................................32
Figure 4.3: Pharyngeal Transit Durations by Bolus Type.................................................33
Figure 4.4: Pharyngeal Transit Time Durations and Tongue Pressure Values..................34
Figure 4.5: Durations of the Delay of the Pharyngeal Swallow by Bolus Type................35
Figure 4.6: Figure 4.6 Pharyngeal Swallow Delay and Tongue Pressure Values.............35
Figure 4.7: Durations of the Delay of the Pharyngeal Swallow by Age............................36
Figure 4.8: UES Transit Time Durations by Bolus Type..................................................37
Figure 4.9: UES Transit Time Durations by Gender.........................................................38

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ABSTRACT

Author: Dreyer, Naomi K. MS

Institution: Purdue University
Degree Received: August 2017
Title: Presbyphagia Markers in the Community-Dwelling Elderly Population
Committee Chair: Georgia Malandraki

As we age, our swallowing changes. These changes, as a whole, are termed presbyphagia,

and are part of the normal aging process; they do not represent a disorder of any kind.

However, they may affect the safety and efficiency of the older-adult swallow. In this

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study, we selected the most frequently cited markers of presbyphagia in the literature and

determined their prevalence and severity in a continuously recruited sample of

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community-dwelling adults over the age of 60.
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CHAPTER 1 INTRODUCTION

Deglutition, or swallowing, not only sustains life, but is an important factor in

quality of life. Across cultures, food is both an element of survival and a social mainstay;

not being able to eat can have consequences that range from socially isolating to life-

threatening (Roy, Stemple, Merrill & Thomas, 2007; Bhattacharyya, 2014). Because

swallowing requires a complex interaction between muscles and nerves, as well as both

sensory and motor areas of the brain and brainstem, natural changes to the swallowing

process occur as an individual ages. These changes are termed presbyphagia. While the

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literature demonstrates that presbyphagic swallowing differs from the swallowing
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patterns of younger adults, an individual with presbyphagia does not necessarily have a

swallowing disorder (Leslie, Drinnan, Ford, & Wilson, 2005; Ney, Weiss, Kind, &
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Robbins, 2009).

Dysphagia, the general term for swallowing disorders of numerous etiologies,

affects 9 million individuals per year in the United States alone (Bhattacharyya, 2014). It
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can occur as a result of a number of medical conditions, including dementia, Parkinson's

disease, multiple sclerosis, and cerebral palsy, or in consequence of a stroke or traumatic

brain injury (Logemann et al., 2008; Galvin et al., 2011; Malandraki et al., 2016). Many

of these conditions affect primarily the older-adult population. To better understand the

manifestations of dysphagia in these aging patient populations, it is imperative to first

have a thorough knowledge of how the physiology of the swallow changes in healthy

individuals as they age. This will serve as a baseline against which swallow function or

dysfunction can be assessed.

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Research studies have consistently shown swallowing-related differences between

groups of younger and older individuals. Specifically, evidence shows significant

differences in the speed, strength, efficiency, and safety of the swallow (McKee et al.,

1998; Logemann et al., 1995; Rosenbek et al., 1996; Logemann et al., 2000; Yokoyama

et al., 2000). However, although these changes occur in many aging individuals, they do

not occur in everyone. Importantly, we do not know how frequent/prevalent they are

within the older community-dwelling population and why they occur in some but not all

older adults. Thus, the overall aim of the current study was to investigate the relative

frequency of physiological markers of presbyphagia in a random sample of older adults,

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and explore whether these markers are correlated with or predicted by factors such as
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age, sex, or measures of lingual strength.

To provide a framework for the study, Chapter 2 outlines the anatomy and
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physiology of the normal and aging swallow, and delineates the specific aims and

hypotheses of this project. Chapter 3 covers the materials and methods used in this study,
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Chapter 4 delineates the results, and Chapter 5 further discusses the findings in light of

the current literature on presbyphagia.

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CHAPTER 2 LITERATURE REVIEW

2.1 Normal Anatomy and Physiology of Swallowing

The process of deglutition is traditionally divided into several phases: the oral

phase (subdivided into oral preparatory and oral transport), the pharyngeal phase, and the

esophageal phase (Logemann, 1998). These stages begin with the entry of food into the

oral cavity and end with the bolus exiting the esophagus into the stomach.

During the oral phase of swallowing, food or liquid in the oral cavity is

manipulated into a bolus and moved posteriorly in preparation for the swallow (Miller,

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1999). This phase is often described as having two parts, preparation and transport. The
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oral preparatory phase begins with the individual recognizing the presence of food or

liquid in the oral cavity and making the decision to eat or drink it (Logemann, 1998). The
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length and complexity of this phase depends on the amount and viscosity of the food or

liquid being consumed. If the food must be masticated, or chewed, the tongue initiates

this process by moving it laterally between the teeth (Logemann, 1998). In addition to the
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up-and-down movements of the jaw, significant rotary motion is used to break the food

up into smaller pieces (Luschei & Goodwin, 1974), which combine with saliva to form

the bolus. Mastication can be further subdivided into the initial transport component—the

lateral movement of food by the tongue—and the reduction component, or the steady

movements that break up the food to form a bolus (Lang, 2009). While mastication

appears to be largely a motor process, sensory signals help the individual to manage the

bolus throughout (Miller, 1999), keeping it out of the lateral sulci between the gums and

cheeks, and from falling too far anteriorly or posteriorly before the individual is prepared

to swallow.
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The oral stage involves a number of facial and lingual muscles (Doty & Bosma,

1956) (see Table 2.1 for a review); the number of muscles involved is notable for the

current study because muscles undergo a number of changes as individuals age. These

changes will be discussed in sections 2.2 and 2.3. At all ages, however, the consistency of

the bolus determines how these muscles will be used (Peyron et al., 2004). Liquids are

cupped against the roof of the mouth, and a groove is formed by the genioglossus, the

main muscle of the tongue body, to guide them into the oropharynx. Solids of different

consistencies require different levels of manipulation using the tongue and various

muscles of the face and jaw (Hiiemae & Palmer, 1999). For more viscous solids that

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require prolonged oral preparatory time, movement in the oral cavity is coordinated with
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movement of the velum so that the individual can chew and breathe simultaneously

(McFarland and Lund, 1995). Numerous muscles are also involved in jaw opening and
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closing, as well as containing and manipulating the bolus in the oral cavity (see Table

1.1). In addition, labial seal must be preserved throughout to ensure that none of the bolus
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is lost anteriorly.
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Table 2.1 Muscle involvement in the stages of swallowing

Stage of Muscles Involved Function of muscles

Swallowing
Oral Preparatory Lateral pterygoid Depress jaw during
Stage Mylohyoid biting/mastication
Geniohyoid
Digastric (anterior belly)
Temporalis Elevate jaw during
Masseter biting/mastication
Medial Pterygoid
Orbicularis oris Contain bolus in the oral cavity
Buccinator
Intrinsic lingual muscles (superior longitudinal, Movement of tongue and hyoid
transverse, vertical, inferior longitudinal) bone
Extrinsic lingual muscles (genioglossus,
hyoglosses, styloglossus)

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Suprahyoid muscles (geniohyoid, thyrohyoid)
Infrahyoid (sternohyoid, omohyoid)
Oral Transport Stage Mylohyoid Initiation of oral transport stage
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Mylohyoid, Digastric (anterior belly), internal
pterygoid, geniohyoid, stylohyoid,
styloglossus, superior pharyngeal constrictor,
Posterior movement of bolus for
pharyngeal triggering

palatoglossus, palatopharyngeus, lingual

muscles
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Pharyngeal Stage Mylohyoid Elevate/move hyolaryngeal
Digastric (anterior belly) complex anteriorly and
Geniohyoid superiorly
Thyrohoid
Stylohyoid
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Pharyngeal Constrictors Assist inferior bolus movement

Cricopharyngeous Opens upper esophageal

sphincter

Esophageal stage Muscularis propria (longitudinal muscles), Peristalsis to move bolus into the
muscularis mucosae (circular muscles) stomach
Sources: Logemann, 1998; Miller, 1999; Jean, 2001

In the oral transport phase, the tongue pushes the bolus, now ready to be

swallowed, posteriorly through the oral cavity. In doing so, it forms an angle with the

tongue tip raised towards the alveolar ridge at the anterior roof of the mouth and the

posterior portion of the tongue lowered. This movement creates the first of a succession