“ It Doesn’t Taste Good”: A Practical Approach to Eating and Nutrition in the Elderly Wednesday, April 1, 2009 Heidi Wierm...
Outline <ul><li>Review Normal Aging changes, Disease effect, Medication Effects  </li></ul><ul><li>Nutritional Needs </li>...
Normal Nutrition <ul><li>Appetite/desire, smell </li></ul><ul><li>Access to (appropriate, tasty) food </li></ul><ul><li>Ab...
Nutritional Requirements <ul><li>Individual variation…watch the weight and adjust.  </li></ul><ul><li>Guideline for calori...
Risk Factors for Undernutrition <ul><li>Alcohol or substance abuse </li></ul><ul><li>Cognitive Dysfunction </li></ul><ul><...
Normal Aging Changes  <ul><li>Alteration in body composition </li></ul><ul><li>Thinning of tooth enamel </li></ul><ul><li>...
Normal Changes in Swallow with Age “Presbyphagia” <ul><li>Oral phase changes are related to changes in muscle strength of ...
Normal Changes in Swallow with Age <ul><li>Pharyngeal phase changes can be of greater clinical significance for the oldest...
Normal Changes in Swallow with Age <ul><li>Esophageal Phase </li></ul><ul><ul><li>Studies of age related changes to UES fu...
Normal Changes in Swallow with Age: 60-80 Years Old <ul><li>Swallow Timing </li></ul><ul><ul><li>Longer oral transit times...
Normal Changes in Swallow with Age: 60-80 Years Old <ul><li>Safety and Efficiency of Swallow </li></ul><ul><ul><li>Penetra...
Normal Changes in Swallow with Age: 80+ Year Olds <ul><li>Reduced reserve, especially in men </li></ul><ul><ul><li>Hyoid a...
Normal Changes in Swallow with Age: 80+ Year Olds <ul><li>Other Findings in Healthy Dentate Elderly </li></ul><ul><ul><li>...
Normal Changes in Swallow with Age: Research Conclusions <ul><li>An older adult’s swallow is  not necessarily  an impaired...
Effect of Disease on Swallow <ul><li>It is the increased incidence of cerebrovascular disease and degenerative neurologic ...
Effect of Disease on Swallow <ul><li>Stroke </li></ul><ul><ul><li>Type and severity of dysphagia depends on size and locat...
Effect of Disease on Swallow <ul><li>ALS </li></ul><ul><ul><li>Swallowing deficits emerge when the disease enters the bulb...
Effect of Disease on Swallow <ul><li>Head and Neck Cancer </li></ul><ul><ul><li>Swallow dysfunction is related to surgical...
Diseases/Medication Effects <ul><li>Dryness </li></ul><ul><li>Decrease in acid production </li></ul><ul><li>Taste Changes ...
Associated with Dry Mouth (also Constipation) <ul><li>Drugs used to treat: </li></ul><ul><ul><li>Depression, Diarrhea/naus...
Treatment of Dry Mouth <ul><li>Limiting medications that cause, decreasing doses </li></ul><ul><li>Sucking on sugar-free c...
Impairment of Taste <ul><li>Dryness </li></ul><ul><li>Destruction of taste buds (burn, radiation) </li></ul><ul><li>Bell’s...
Medications that alter smell and taste <ul><li>Antibiotics Ampicillin, Azithromycin, Ciprofloxacin, Clarithromycin, Griseo...
How to address alterations in taste <ul><li>Re-evaluate medications </li></ul><ul><li>Treat diseases of the mouth </li></u...
Food Preparation and Texture <ul><li>Meals that Appeal </li></ul><ul><ul><li>Vary color, texture, temperature </li></ul></...
Food Preparation and Texture <ul><li>Food that is easy to eat </li></ul><ul><ul><li>Finger foods allow those with cognitiv...
Environmental Considerations <ul><li>Make Eating a Social Event </li></ul><ul><ul><li>For seniors who live alone: </li></u...
Environmental Considerations <ul><li>For Seniors Who Live in Assisted Living/Nursing Home </li></ul><ul><ul><li>Dining roo...
Environmental Considerations <ul><li>Attend to Cultural Concerns / Needs </li></ul><ul><li>Observe Rituals </li></ul><ul><...
How to improve Appetite <ul><li>Treat depression, constipation, other issues </li></ul><ul><li>Encourage physical activity...
Quality of Life Considerations <ul><li>Restrictions: salt, caloric, textures </li></ul><ul><li>Feeding Tubes </li></ul><ul...
Case discussion <ul><li>82 year old retired physician diagnosed with Parkinson’s disease in 1989, hospitalized in 1999 for...
Case discussion, continued <ul><li>Follow-up MBS 3/26/99 revealed improved swallow function and started on a blended diet ...
Case discussion, continued <ul><li>Stable for 3 years - returned for an MBS on 4/30/02 due to increased concerns and episo...
CASE STUDY, continued <ul><li>Diet consistency modified to soft, moist consistencies </li></ul><ul><li>Advised to drink ne...
CASE STUDY, continued <ul><li>Underwent surgery in 2003 and was put on clear liquids post-operatively </li></ul><ul><li>De...
References <ul><li>Bromley, Steven. Smell and Taste Disorders: A Primary Care Approach  American Family Physician,  Jan 15...
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  • H H - Nutrient availability effected by medications and diseases.
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  • H - Normal aging changes that impact nutrition, apetite, swallowing. Decr protein, decr water, incr fat, decr bone density, decr mm mass….decr in energy needs due to decr. In mm mass Loss of teeth not normal. Thinning of enamel leads to incr sensitivity to hot/cold. Denture change due to body change, particularly if wt loss. Salive decrease even worse with some diseases (rheum, connective tissue) and medications..needed for taste Decr motility…esoph, stomach (reflux, early satiety)..constipation Change in thirst increase prone to dehydration, further restriction may abe due to medial conditions, incont.
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  • H - Beware of sorbitol…can cause diarrhea, but may be beneficial as a laxative if constipation an issue.
  • H - 10% of head trauma may have alterations in taste. CN I (olfactory) qualitative taste (roses, grass) CN V (trigeminal nerve) warmth, coolness, sharpness, irritation, CN VII
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  • "It Doesn't Taste Good": A Practical Approach to Eating and ...

    1. 1. “ It Doesn’t Taste Good”: A Practical Approach to Eating and Nutrition in the Elderly Wednesday, April 1, 2009 Heidi Wierman, MD Kimberly Bassett, MS, CCC/SLP
    2. 2. Outline <ul><li>Review Normal Aging changes, Disease effect, Medication Effects </li></ul><ul><li>Nutritional Needs </li></ul><ul><li>Swallowing Changes </li></ul><ul><li>Food Preparation/Texture </li></ul><ul><li>Environmental Considerations </li></ul><ul><li>Quality of Life Considerations </li></ul>
    3. 3. Normal Nutrition <ul><li>Appetite/desire, smell </li></ul><ul><li>Access to (appropriate, tasty) food </li></ul><ul><li>Ability to feed self or be fed </li></ul><ul><li>Mouth function: chew, taste </li></ul><ul><li>Swallowing </li></ul><ul><li>Absorption </li></ul><ul><li>Transport of food/waste through body </li></ul>
    4. 4. Nutritional Requirements <ul><li>Individual variation…watch the weight and adjust. </li></ul><ul><li>Guideline for calories: </li></ul><ul><ul><li>Harris-Benedict Equation </li></ul></ul><ul><ul><li>WHO Estimated Energy Requirement </li></ul></ul><ul><li>Guideline for fluid </li></ul><ul><ul><li>30 ml/kg/day </li></ul></ul><ul><li>Guideline for protein: </li></ul><ul><ul><li>1g/kg/day </li></ul></ul><ul><li>Varied diet, consider MVI, Calcium/vit D. </li></ul>
    5. 5. Risk Factors for Undernutrition <ul><li>Alcohol or substance abuse </li></ul><ul><li>Cognitive Dysfunction </li></ul><ul><li>Decreased activity, functional limitations </li></ul><ul><li>Depression </li></ul><ul><li>Low income, limited education </li></ul><ul><li>Lack of Transportation </li></ul><ul><li>Medical Problems/Chronic Diseases, Medications </li></ul><ul><li>Teeth Problems </li></ul><ul><li>Restricted diet, poor eating habits </li></ul><ul><li>Social Isolation </li></ul>
    6. 6. Normal Aging Changes <ul><li>Alteration in body composition </li></ul><ul><li>Thinning of tooth enamel </li></ul><ul><li>Change in fit of dentures </li></ul><ul><li>Decrease in saliva production </li></ul><ul><li>Decrease in gastrointestinal motility </li></ul><ul><li>Diminished thirst </li></ul>
    7. 7. Normal Changes in Swallow with Age “Presbyphagia” <ul><li>Oral phase changes are related to changes in muscle strength of face, tongue </li></ul><ul><ul><li>Decreased lip seal for cup drinking </li></ul></ul><ul><ul><li>Reduced masticatory strength </li></ul></ul><ul><ul><li>Piecemeal swallow </li></ul></ul><ul><li>Feeding performance does not seem to be significantly affected by these oromotor changes as older adults effectively compensate by changing diet consistency and meal duration </li></ul>
    8. 8. Normal Changes in Swallow with Age <ul><li>Pharyngeal phase changes can be of greater clinical significance for the oldest old (80+) and include: </li></ul><ul><ul><li>Delay in pharyngeal swallow </li></ul></ul><ul><ul><li>Reduced pharyngolaryngeal sensory discrimination </li></ul></ul>
    9. 9. Normal Changes in Swallow with Age <ul><li>Esophageal Phase </li></ul><ul><ul><li>Studies of age related changes to UES function have been inconclusive </li></ul></ul><ul><ul><li>Primary esophageal peristalsis is preserved in the elderly, however, secondary peristalsis is less frequent or absent </li></ul></ul>
    10. 10. Normal Changes in Swallow with Age: 60-80 Years Old <ul><li>Swallow Timing </li></ul><ul><ul><li>Longer oral transit times </li></ul></ul><ul><ul><li>Elderly are more often “dippers” </li></ul></ul><ul><ul><li>Reduced tongue pressure </li></ul></ul><ul><ul><li>Longer pharyngeal delay times </li></ul></ul><ul><ul><li>Inconsistent findings of slower pharyngeal wall contraction </li></ul></ul>
    11. 11. Normal Changes in Swallow with Age: 60-80 Years Old <ul><li>Safety and Efficiency of Swallow </li></ul><ul><ul><li>Penetration occurs more frequently </li></ul></ul><ul><ul><li>Aspiration occurs no more frequently in healthy elders </li></ul></ul><ul><ul><li>Pharyngeal residue is slightly greater in elderly compared to young adults </li></ul></ul>
    12. 12. Normal Changes in Swallow with Age: 80+ Year Olds <ul><li>Reduced reserve, especially in men </li></ul><ul><ul><li>Hyoid and laryngeal maximum vertical movement significantly reduced in oldest old (80+) </li></ul></ul><ul><li>Reduced Flexibility </li></ul><ul><ul><li>Cricopharyngeal opening durations across volumes reduced in oldest old </li></ul></ul><ul><ul><li>Cricopharyngeal opening diameter across volumes reduced in oldest old </li></ul></ul>
    13. 13. Normal Changes in Swallow with Age: 80+ Year Olds <ul><li>Other Findings in Healthy Dentate Elderly </li></ul><ul><ul><li>Piecemeal swallowing </li></ul></ul><ul><ul><li>Premature loss of liquid </li></ul></ul><ul><ul><li>Oral and pharyngeal residues </li></ul></ul><ul><ul><li>Penetration </li></ul></ul>
    14. 14. Normal Changes in Swallow with Age: Research Conclusions <ul><li>An older adult’s swallow is not necessarily an impaired swallow </li></ul><ul><li>Healthy older adults exhibit a highly safe and efficient swallow </li></ul><ul><li>Older adults are more vulnerable to the effects of acute illnesses and medications and can cross the line from having a normal older swallow to being dysphagic </li></ul>
    15. 15. Effect of Disease on Swallow <ul><li>It is the increased incidence of cerebrovascular disease and degenerative neurologic disease with aging that is strongly associated with dysphagia in the elderly </li></ul>
    16. 16. Effect of Disease on Swallow <ul><li>Stroke </li></ul><ul><ul><li>Type and severity of dysphagia depends on size and location of lesion </li></ul></ul><ul><li>Parkinson’s Disease </li></ul><ul><ul><li>Dysphagia develops in approximately 50% of patients </li></ul></ul><ul><li>Alzheimer’s Disease </li></ul><ul><ul><li>Primary issue is eating / food management secondary to cognitive decline </li></ul></ul>
    17. 17. Effect of Disease on Swallow <ul><li>ALS </li></ul><ul><ul><li>Swallowing deficits emerge when the disease enters the bulbar phase </li></ul></ul><ul><li>Muscular Dystrophy </li></ul><ul><ul><li>Myotonic </li></ul></ul><ul><ul><li>Occulopharyngeal </li></ul></ul><ul><li>Myasthenia Gravis </li></ul><ul><ul><li>Characterized by global fluctuating muscle fatigue </li></ul></ul><ul><li>Multiple Sclerosis </li></ul><ul><ul><li>Factors most closely related to dysphagia are bulbar involvement and severity of illness </li></ul></ul>
    18. 18. Effect of Disease on Swallow <ul><li>Head and Neck Cancer </li></ul><ul><ul><li>Swallow dysfunction is related to surgical and radiation treatment </li></ul></ul><ul><li>Prolonged Mechanical Ventilation </li></ul><ul><ul><li>Etiology of swallowing dysfunction is multifactorial </li></ul></ul><ul><li>Medication Effects </li></ul>
    19. 19. Diseases/Medication Effects <ul><li>Dryness </li></ul><ul><li>Decrease in acid production </li></ul><ul><li>Taste Changes </li></ul><ul><li>Nausea/Anorexia </li></ul><ul><li>Speed of eating </li></ul><ul><li>Ability to feed self </li></ul><ul><li>Chewing ability </li></ul><ul><li>Dysphagia </li></ul>
    20. 20. Associated with Dry Mouth (also Constipation) <ul><li>Drugs used to treat: </li></ul><ul><ul><li>Depression, Diarrhea/nausea, Hypertension (diuretics) </li></ul></ul><ul><ul><li>Anxiety, Asthma (certain bronchodilators), Allergies and colds (antihistamines and decongestants) </li></ul></ul><ul><ul><li>Pain, Psychotic disorders, Parkinson's disease </li></ul></ul><ul><ul><li>Epilepsy </li></ul></ul><ul><ul><li>Urinary incontinence </li></ul></ul><ul><li>Diseases: Sjogren’s Syndrome, Xerostomia, Parkinson’s Disease </li></ul>
    21. 21. Treatment of Dry Mouth <ul><li>Limiting medications that cause, decreasing doses </li></ul><ul><li>Sucking on sugar-free candy or chewing sugar-free gum </li></ul><ul><li>Drinking plenty of water to help keep mouth moist </li></ul><ul><li>Protecting teeth by brushing with a fluoride toothpaste, using a fluoride rinse, and visiting your dentist regularly </li></ul><ul><li>Breathing through nose, not mouth </li></ul><ul><li>Using a room vaporizer to add moisture to the air </li></ul><ul><li>Using an over-the-counter artificial saliva substitute. </li></ul>
    22. 22. Impairment of Taste <ul><li>Dryness </li></ul><ul><li>Destruction of taste buds (burn, radiation) </li></ul><ul><li>Bell’s palsy or surgical destruction of CN VII </li></ul><ul><li>Sinusitus, Upper Respiratory Tract Infection </li></ul><ul><li>Head injury </li></ul><ul><li>Gingivitis </li></ul><ul><li>Smoking </li></ul>
    23. 23. Medications that alter smell and taste <ul><li>Antibiotics Ampicillin, Azithromycin, Ciprofloxacin, Clarithromycin, Griseofulvin, Metronidazole, Ofloxacin, Tetracycline </li></ul><ul><li>Anticonvulsants Carbamazepine, Phenytoin </li></ul><ul><li>Antidepressants/Mood Stabilizer Amitriptyline, Clomipramine, Desipramine, Doxepin, Imipramine, Nortriptyline </li></ul><ul><li>Antihistamines and decongestants Chlorpheniramine, Loratadine, Pseudoephedrine </li></ul><ul><li>Antihypertensives/Cardiac Acetazolamide, Amiloride, Betaxolol, Captopril, Diltiazem, Enalapril, Hydrochlorothiazide, Nifedipine, Nitroglycerin, Propranolol, Spironolactone </li></ul><ul><li>Anti-inflammatory agents Colchicine, Dexamethasone, Gold, Hydrocortisone, Penicillamine </li></ul><ul><li>Antineoplastics Cisplatin, Doxorubicin, Methotrexate, Vincristine </li></ul><ul><li>Antiparkinsonian agents Levodopa, Sinemet </li></ul><ul><li>Antipsychotics Clozapine , Trifluoperazine </li></ul><ul><li>Antithyroid agents Methimazole, Propylthiouracil </li></ul><ul><li>Lipid-lowering agents Fluvastatin, Lovastatin, Pravastatin </li></ul><ul><li>Muscle relaxants Baclofen, Dantrolene </li></ul>ACE inhibitors one of the most common offenders
    24. 24. How to address alterations in taste <ul><li>Re-evaluate medications </li></ul><ul><li>Treat diseases of the mouth </li></ul><ul><li>Stop smoking </li></ul><ul><li>Use spices…salt, herbs, pepper </li></ul><ul><li>Extra attention to texture, color, temperature of food. </li></ul>Individuals with impaired taste, should avoid cooking by taste
    25. 25. Food Preparation and Texture <ul><li>Meals that Appeal </li></ul><ul><ul><li>Vary color, texture, temperature </li></ul></ul><ul><ul><li>Consider offering meals in “courses”, so food temperatures are maintained for slower eaters </li></ul></ul><ul><ul><li>Use moulds to improve presentation of blended foods </li></ul></ul><ul><li>Small meals </li></ul><ul><ul><li>The elderly may benefit from being offered frequent small servings of foods that they like throughout the day </li></ul></ul><ul><li>Garnish </li></ul><ul><ul><li>Add parsley, lemon slices – provides visual </li></ul></ul><ul><ul><li>appeal </li></ul></ul>
    26. 26. Food Preparation and Texture <ul><li>Food that is easy to eat </li></ul><ul><ul><li>Finger foods allow those with cognitive impairments to be more independent </li></ul></ul><ul><ul><li>When needed, cut food up into bite sized portions prior to serving </li></ul></ul><ul><li>Add flavor enhancers that amplify the intensity of food odor </li></ul><ul><ul><li>Appealing odors can help to enhance appetite </li></ul></ul><ul><ul><li>These may be useful for elderly adults with decreased smell / taste </li></ul></ul>
    27. 27. Environmental Considerations <ul><li>Make Eating a Social Event </li></ul><ul><ul><li>For seniors who live alone: </li></ul></ul><ul><ul><ul><li>Encourage family to bring food to or invite elderly family member over or out for dinner </li></ul></ul></ul><ul><ul><ul><li>Take advantage of local “bean suppers” </li></ul></ul></ul><ul><ul><li>Set a nice table </li></ul></ul><ul><ul><li>Establish good lighting </li></ul></ul><ul><ul><li>Limit distractions </li></ul></ul>
    28. 28. Environmental Considerations <ul><li>For Seniors Who Live in Assisted Living/Nursing Home </li></ul><ul><ul><li>Dining room and ambiance </li></ul></ul><ul><ul><li>Attend to proper seat positioning, access to adaptive equipment </li></ul></ul><ul><ul><li>Have a positive attitude toward those with feeding and swallowing difficulties </li></ul></ul><ul><ul><ul><li>Take it slow… </li></ul></ul></ul><ul><ul><li>Encourage Family members to assist </li></ul></ul><ul><ul><li>Time of day </li></ul></ul>
    29. 29. Environmental Considerations <ul><li>Attend to Cultural Concerns / Needs </li></ul><ul><li>Observe Rituals </li></ul><ul><ul><li>Handwashing </li></ul></ul><ul><ul><li>Saying a blessing </li></ul></ul>
    30. 30. How to improve Appetite <ul><li>Treat depression, constipation, other issues </li></ul><ul><li>Encourage physical activity & fluids </li></ul><ul><li>Consider medications to stimulate appetite: </li></ul><ul><ul><li>Remeron </li></ul></ul><ul><ul><li>Megace (800 mg/day) </li></ul></ul><ul><ul><li>Dronabinol </li></ul></ul>
    31. 31. Quality of Life Considerations <ul><li>Restrictions: salt, caloric, textures </li></ul><ul><li>Feeding Tubes </li></ul><ul><li>Desires versus nutritional needs </li></ul>
    32. 32. Case discussion <ul><li>82 year old retired physician diagnosed with Parkinson’s disease in 1989, hospitalized in 1999 for pneumonia: required intubation </li></ul><ul><li>MBS 2/19/99 revealed severe oropharyngeal dysphagia characterized by significant pharyngeal pooling and frank aspiration </li></ul><ul><li>Underwent PEG placement and was transferred to a SNF for rehabilitation </li></ul><ul><li>Received intensive speech therapy and taught to use chin tuck </li></ul>
    33. 33. Case discussion, continued <ul><li>Follow-up MBS 3/26/99 revealed improved swallow function and started on a blended diet with thin liquids </li></ul><ul><li>Transferred to an assisted living facility from SNF </li></ul><ul><li>Eventually returned to a regular diet and PEG tube was removed </li></ul><ul><li>Ate 2 meals/day in dining room of assisted living facility – enjoyed the social contact </li></ul>
    34. 34. Case discussion, continued <ul><li>Stable for 3 years - returned for an MBS on 4/30/02 due to increased concerns and episodes of choking </li></ul><ul><li>Showed a moderate decline in swallowing function with an episode of silent aspiration on thin liquids </li></ul><ul><li>Started intensive outpatient speech therapy addressing both swallowing and voice </li></ul>
    35. 35. CASE STUDY, continued <ul><li>Diet consistency modified to soft, moist consistencies </li></ul><ul><li>Advised to drink nectar liquids </li></ul><ul><li>Advised to make sure her sinemet dose corresponded well with meals and that she try smaller, more frequent meals / day </li></ul><ul><li>Continued to go to the dining room – intake and ability to tolerate diet highly variable </li></ul><ul><li>Began to lose weight </li></ul>
    36. 36. CASE STUDY, continued <ul><li>Underwent surgery in 2003 and was put on clear liquids post-operatively </li></ul><ul><li>Developed an aspiration pneumonia and required intubation </li></ul><ul><li>Discharged back to assisted living; suffered significant weight loss and worsening of dysphagia </li></ul><ul><li>PEG replaced and received intensive speech therapy to try to improve swallowing function </li></ul><ul><li>Transferred to adjacent nursing home </li></ul>
    37. 37. References <ul><li>Bromley, Steven. Smell and Taste Disorders: A Primary Care Approach American Family Physician, Jan 15, 2000 </li></ul><ul><li>Simmons, Sandra et al. Prevention of Unintentional Weight Loss in Nursing Home Residents: A Controlled Trial of Feeding Assistance Journal of the American Geriatric Society 56:1466-1473, 2008 </li></ul><ul><li>www.healthinaging.org/aginingintheknow AGS Foundation for Health in Aging, Chapters on Nutrition, Disorders of the Mouth, Disorders of the Digestive System. </li></ul><ul><li>American Geriatric Society Clinical Guideline: Feeding Tube Placement in Elderly Patients with Advanced Dementia </li></ul><ul><li>Fucile, Sandra et al. Functional Oral-Motor Skills: Do They Change With Age? Dysphagia 13: 195-201 (1998) </li></ul><ul><li>Youmans, Scott et al. Differences in Tongue Strength Across Age and Gender: Is There a Diminished Strength Reserve? Dysphagia 24: 57-65 (2009) </li></ul><ul><li>Leslie, Paula et al. Swallow Respiratory Patterns and Aging: Presbyphagia or Dysphagia? Journal of Gerontology Vol. 60A, No. 3, 391-395 (2005) </li></ul><ul><li>Yoshikawa, Mineka et al. Aspects of Swallowing in Healthy Dentate Elderly Persons Older Than 80 Years Journal of Gerontology Vol 60A, No4, 506-509 (2005) </li></ul><ul><li>Logemann, Jeri et al. Temporal and Biomechanical Characteristics of Oropharyngeal Swallow in Younger and Older Men Journal of Speech, Language and Hearing Research Vol. 43, 1264-1274 (October 2000) </li></ul><ul><li>Logemann, Jeri et al. Oropharyngeal Swallow in Younger and Older Women: Videofluoroscopic Journal of Speech, Language and Hearing Research Vol. 45, 434-445 (June 2002) </li></ul><ul><li>Achem, Sami et al. Dysphagia in Aging Journal of Clinical Gastroenterology Vol. 39, No 5 (May/June 2005) </li></ul><ul><li>Schindler, Joshua et al. Swallowing Disorders in the Elderly Laryngoscope 112: April 2002 </li></ul><ul><li>Wright, l et al. eating Together is Important; Using a Dining Room in and Acute Elderly Medical Ward Increases Energy Intake Journal of Human Nutrition Dietetics 19: 23-26 (2006) </li></ul>

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