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Ebihara, T.; Ebihara, T. Aspiration Pneumonia and Dysphagia in the Elderly. Encyclopedia. Available online: https://encyclopedia.pub/entry/28343 (accessed on 28 March 2024).
Ebihara T, Ebihara T. Aspiration Pneumonia and Dysphagia in the Elderly. Encyclopedia. Available at: https://encyclopedia.pub/entry/28343. Accessed March 28, 2024.
Ebihara, Takae, Takae Ebihara. "Aspiration Pneumonia and Dysphagia in the Elderly" Encyclopedia, https://encyclopedia.pub/entry/28343 (accessed March 28, 2024).
Ebihara, T., & Ebihara, T. (2022, October 07). Aspiration Pneumonia and Dysphagia in the Elderly. In Encyclopedia. https://encyclopedia.pub/entry/28343
Ebihara, Takae and Takae Ebihara. "Aspiration Pneumonia and Dysphagia in the Elderly." Encyclopedia. Web. 07 October, 2022.
Aspiration Pneumonia and Dysphagia in the Elderly
Edit

Pneumonia in the elderly has been increasing on an annual basis. To a greater or lesser extent, aspiration is a major contributor to the development of pneumonia in the elderly. Antimicrobials alone are not sufficient for the treatment of pneumonia, and the condition may become intractable or even recur repeatedly. In addition, some patients with pneumonia may have no problems with eating, while others are unable to receive the necessary nutrition due to severe dysphagia. It has been found that pneumonia decreases both the muscle mass and strength of the swallowing and respiratory muscles, a condition named pneumonia-associated sarcopenia. This contributes to a pathophysiological time-axis of aspiration pneumonia and dysphagia in the elderly, in which silent aspiration leads to the development of pneumonia, and further to dysphagia, malnutrition, and low immunity. 

aspiration pneumonia pneumonia-related sarcopenia TRP agonist

1. Introduction

As Sir Osler stated, “Pneumonia is an old man’s friend”. Pneumonia among the elderly has been increasing in advanced countries, where populations are ageing at an accelerating rate. As most deaths from pneumonia in the elderly are attributed to aspiration pneumonia (AsP), its diagnosis, treatment, and prevention are important clinical topics. Clinically, AsP can be divided into ‘overt aspiration’, in which the aspiration is evident, and ‘silent aspiration’, in which the aspiration is not apparent. Videofluoroscopy is capable of detecting both overt and silent aspiration, but is unable to detect “micro-aspiration”; that is, the aspiration of small amounts of oropharyngeal secretions due to a depressed swallowing reflex during sleep. Micro-aspiration may or may not present with symptoms suggestive of aspiration, such as coughing. In particular, micro-aspiration without symptoms (i.e., silent aspiration) is important in the development of pneumonia. On the other hand, choking during a meal due to aspirated food debris or its detection in the sputum (macro-aspiration) is considered overt aspiration. As elderly patients with pneumonia often present with non-specific symptoms, such as general malaise, impaired consciousness, and loss of appetite, the onset of pneumonia may only be detected after a chest X-ray; moreover, the disease is often severe [1]. Therefore, it is important to determine the presence or absence of silent aspiration and the means for its prevention for the treatment of pneumonia in the elderly.

2. Prevalence

Pneumonia is a disease with high mortality and morbidity worldwide. In Japan, pneumonia is the leading cause of death in people aged 65 years and over, and is particularly prominent in men aged 80 years and over [2].
Despite AsP generally being more likely to occur in the elderly, the prevalence of AsP may be under-estimated. The prevalence of AsP in the USA has been estimated to be 5–15% among hospitalized patients with community- and hospital-acquired pneumonia [3][4]. Meanwhile, in a cross-sectional national survey of Japan, the prevalence rates of AsP in hospitalized community- and hospital-acquired pneumonia were 60.1% and 86.7%, respectively; this further increased with age, accounting for about 85% in those aged 80–89 years and more than 90% in those aged 90 years and older [5]. This Japanese survey involved a swallowing function test, in order to detect not only overt aspiration but also silent aspiration, and it was found that aspiration is greatly associated with the cause of pneumonia in the elderly.

3. Mechanism

The main responsible factor in the development of AsP is the deterioration of the swallowing reflex and cough reflex sensitivity due to reduced release of the neurotransmitter substance P from the nerve endings of the glossopharyngeal and the vagal nerves [6].

3.1. Cough Reflex Sensitivity

Coughs are provoked by the ligand substance P of the neurokinin 1 receptor, located in the respiratory tract and in the nucleus tractus solitarii of the brainstem [7][8][9]. In support, selective neurokinin 1 antagonists have been found to completely suppress coughing in a study in guinea pigs [10][11]. Another animal study has shown that aerosols of a substance P antagonist inhibited acetylcholine- and histamine-induced coughs, which are bronchoconstricting agents [12]. Additionally, coughing was induced through the inhalation of substance P by patients with pulmonary fibrosis [13].
However, contrary to general expectations, geriatric wards—where pneumonia patients are mainly hospitalized—are often quiet, with few coughing patients. The cough reflex sensitivity induced by chemical stimulants is typically blunted in elderly patients with repeated pneumonia [14]. Specifically, the threshold for coughing to citric acid mist in elderly people with repeated pneumonia was a concentration greater than 1.35 log mg mL−1, compared to less than 0.5 log mg mL−1 in non-pneumonia patients [15].

3.2. Swallowing Reflex

Similar to the blunted cough reflex sensitivity, the triggering of the swallowing reflex is also blunted in elderly patients with repeated pneumonia; in particular, the latency of the swallowing reflex in patients with repeated pneumonia has been found to be >5 s [15]. The provocation of the swallowing reflex was mediated by substance P in a capsaicin concentration-dependent manner [16].

3.3. Lacunar Infarction and the Upper Respiratory Protective Reflexes

The blunted swallowing reflex and cough reflex sensitivity have been associated with lacunar infarction in the basal ganglia [17]. In patients with bilateral lacunar infarction, the swallowing reflex latency is significantly higher than in other patients with unilateral or no lacunar infarction, and the swallowing reflex latency gradually increases, not only during the day but also at night, with a greater rate of change from daytime than in other patients. Additionally, the incidence of aspiration—assessed using indium chloride—was reported to be higher in elderly patients with bilateral lacunar infarction [18]. The cough reflex sensitivity in the elderly with lacunar infractions has also been shown to be depressed. Furthermore, both the swallowing and coughing reflexes, among others, were greatly impaired in those who developed AsP [17].
The production of substance P is associated with dopamine metabolism. In animal models pre-treated with dopamine 1 receptor antagonists, the provocation of the swallowing reflex was delayed, and the swallowing frequency was increased with exogenously administered substance P, while substance P antagonists decreased the swallowing frequency. In other words, the swallowing reflex and swallowing frequency are substance P-dependent, while substance P is dopamine-dependent [19]. Taken together, the presence of lacunar infarcts may suggest that the blunted swallowing reflex latency and cough reflex sensitivity are due to the reduced release of substance P.

3.4. Brain and Swallowing

Reduced activity in the insular cortex has been reported in elderly patients with repeated AsP [20]. Functional cerebral imaging during swallowing in healthy adults has shown that the primary motor and sensory areas are most activated, with additional bilateral activation of the anterior cingulate cortex, insula and basal ganglia capsules, and globus pallidus and substantia nigra [21][22][23]. Therefore, the bilateral inactivation of the insula and basal ganglia may contribute to the development of AsP.

3.5. Breathing and Swallowing

Sensory inputs to the sensory nerves reach the medulla oblongata afferentially and integrate the activity of swallowing-related muscles through central pattern generators (CPGs), such that breathing and swallowing can be appropriately coordinated. Natural swallowing begins with laryngeal closure after inspiration (post-inspiratory activity). In more detail, glutamatergic–cholinergic neurons and excitatory networks that generate neural correlates of post-inspiratory activity and inhibitory neural networks, through gamma-aminobutyric acid, contribute to the regulation of timing involved in inspiration [24]. Furthermore, inputs to the CPG from the cortical swallowing area (including the insular cortex) have also been reported to modulate these coordinated respiratory–swallowing movements. In other words, failure to provoke the upper respiratory protective reflex may interfere with the inspiratory and post-inspiratory coordination, which may contribute to the onset of AsP [25].

3.6. Comorbidities Modifying the Development of Pneumonia

Several comorbidities contribute to the development of AsP. Gastrointestinal diseases with organic problems and dysfunction are representative comorbidities of AsP. In addition to age-related gastro-oesophageal motility disorders, post-operative status following gastrectomy leads to a predisposition to aspiration of gastrointestinal contents due to reflux [26]. Furthermore, gastric reflux is more likely to occur in elderly people with hiatal hernia of the oesophagus, which has been estimated to affect one in two women over 80 years of age; furthermore, acidity (especially below pH 4) increases the swallowing reflex latency in a negatively pH-dependent manner [27]. The relationship between gastric acid and the swallowing reflex is considered as a factor affecting the occurrence of AsP. Elderly people often present with chronic constipation, some of whom may vomit due to impaired bowel peristalsis, leading to chemical pneumonitis [28]. Other factors contributing to the development of AsP have been previously reported, including dementia, physical activity impairment, gender, smoking history, decreased oral intake, and drugs such as neuroleptics, which exacerbate the swallowing reflex by lowering serum substance P, resulting in the development of AsP [29][30].
Anticholinergics are also a risk factor for AsP, as the incidence of AsP has been reported to increase in proportion to the intensity of anticholinergic side-effects such as falls, xerostomia, dry eyes, dizziness, confusion, and constipation [31]. It has also been reported that acid suppressants, such as histamine 2 inhibitors and proton pump inhibitors, tend to increase the pH of gastric juice, thereby altering the gastric flora and even the mesopharyngeal microbiota, facilitating the development of AsP [32][33]. Taken together, drugs with antidopaminergic, bowel peristalsis-reducing, or anticholinergic effects, as well as other drugs that alter the gastric microbiota, should be withdrawn and replaced by drugs with other mechanisms of action.

3.7. Pneumonia-Associated Sarcopenia

Initially, sarcopenia is defined as an age-related decrease in skeletal muscle mass and strength [34]. As a muscle atrophy other than ageing, it is already well-known in mouse models that hypoxia (8 h/day, 30 cycles/hour, FiO2 nadir = 6%) reduces the contractile properties of the diaphragm, especially as a result of muscle atrophy due to increased autophagy, prompting a compensatory metabolic adaptation that increases fatigue tolerance [35].
Since sarcopenia (assessed by grip strength and lower leg circumference) was reported as a risk factor for the development of community-acquired pneumonia in the elderly [36], a number of reports have revealed the association between pneumonia and sarcopenia.
Acute inflammation and chronic inflammation of the lungs are known to cause muscle atrophy [37]. In a retrospective database study of 739 ventilated patients, a reduction in muscle mass was observed, of which about half also had reduced muscle fiber density [38]. Furthermore, it has recently been shown that chronic aspiration and pneumonia cause a reduction in the cross-sectional area of the muscle fibers, including swallowing and respiratory muscles. In an animal model of lipopolysaccharide-induced aspiration, it has been shown that muscle atrophy of the tongue is induced by autophagy, thinning of the diaphragm by inflammatory cytokine production and the ubiquitin–proteasome pathway, and atrophy of the anterior tibialis muscle—which represents skeletal muscle—by both pathways [39].
In elderly patients hospitalized with AsP, the cross-sectional area of the erector spinae muscle, a respiratory accessory muscle, has been reported to decrease by approximately 80% during the time between admission and pneumonia healing. Further, the previous cross-sectional prospective cohort study has shown that both the inspiratory and expiratory respiratory muscle strength and trunk muscle mass were lower in the elderly with pneumonia compared to those with other respiratory diseases, which can, thus, be considered as risk factors for the development and recurrence of pneumonia [40]. With regard to swallowing, it has also been reported that the swallowing and chewing ability is related to the whole-body muscle mass; that poor swallowing ability, as assessed by the water-swallowing test, is mildly related to the upper arm circumference; and that the tongue muscle mass and tongue pressure are significantly lower in people with dysphagia than those without [41][42][43][44][45].
Finally, chronic aspiration and pneumonia lead to decreases in muscle mass and strength, resulting in reduced swallowing capacity, dysphagia due to a reduced expiratory cough peak flow, respiratory muscle fatigue, and reduced respiratory ventilation efficiency. Pneumonia-related sarcopenia leads to a negative pattern of refractory and recurrent pneumonia, as well as further progression of sarcopenia.

3.8. End-of-Life in Aspiration Pneumonia and Dysphagia

To date, no studies have examined impaired upper respiratory protective reflexes (e.g., the swallowing reflex and cough reflex sensitivity) as a risk factor for mortality in the elderly. Researchers have recently reported that under-nutrition and an impaired swallowing reflex and cough reflex sensitivity—but not an impaired oral intake capacity—were predictors of death within 90 days in elderly AsP patients [46]. Furthermore, cholecystitis and cholangitis frequently occur in the terminal stages of the disease, which are thought to be due to the loss of gallbladder contractility caused by reduced lipid intake due to fasting, which increases the viscosity of the bile, causing it to become sludgy and unable to be expelled [47].

3.9. Pathophysiological Time-Axis of Aspiration Pneumonia and Dysphagia

A noteworthy emerging finding is the time-course of AsP and dysphagia in the elderly: starting with a delayed swallowing reflex, the sensitivity of the cough reflex gradually blunts and AsP develops. The onset of AsP leads to muscle atrophy and weakness of the swallowing and respiratory muscles; that is, a state of pneumonia-associated sarcopenia. Decreases in upper airway protective reflexes and sarcopenia are likely to lead to recurrent pneumonia and further sarcopenia progression, resulting in feeding difficulties and under-nutrition. The inability to meet nutritional requirements, whether by oral intake or other nutritional routes, can be considered terminal.

References

  1. Lanspa, M.J.; Barbara, E.J.; Brown, S.M.; Dean, N.C. Mortality, morbidity, and disease severity of patients with aspiration pneumonia. J. Hosp. Med. 1996, 8, 83–90.
  2. Ministry of Health, Labour and Welfare, Japan. Available online: https://www.mhlw.go.jp/toukei/itiran/index.html (accessed on 1 March 2022).
  3. Marik, P.E. Aspiration pneumonitis and aspiration pneumonia. N. Engl. J. Med. 2001, 344, 665–671.
  4. Baine, W.B.; Yu, W.; Summe, J.P. Epidemiologic trends in the hospitalization of elderly Medicare patients for pneumonia, 1991–1998. Am. J. Public Health 2001, 91, 1121–1123.
  5. Teramoto, S.; Fukuchi, Y.; Sasaki, H.; Sato, K.; Sekizawa, M.K.T.; Japanese Study Group on Aspiration Pulmonary Disease. High incidence of aspiration pneumonia in community- and hospital-acquired pneumonia in hospitalized patients: A multicenter, prospective study in Japan. J. Am. Geriatr. Soc. 2008, 56, 577–579.
  6. Yamaya, M.; Yanai, M.; Ohrui, T.; Arai, H.; Sasaki, H. Interventions to prevent pneumonia among older adults. J. Am. Geriatr. Soc. 2001, 49, 85–90.
  7. Lecci, A.; Giuliani, S.; Tramontana, M.; Carini, F.; Maggi, C.A. Peripheral actions of tachykinins. Neuropeptides 2000, 34, 303–313.
  8. Mutolo, D.; Bongianni, F.; Fontana, G.A.; Pantaleo, T. The role of excitatory amino acids and substance P in the mediation of the cough reflex within the nucleus tractus solitarii of the rabbit. Brain Res. Bull. 2007, 74, 284–293.
  9. Mutolo, D.; Bongianni, F.; Cinelli, E.; Pantaleo, T. Role of excitatory amino acids in the mediation of tracheobronchial cough induced by citric acid inhalation in the rabbit. Brain Res. Bull. 2009, 80, 22–29.
  10. Mazzone, S.B.; Mori, N.; Canning, B.J. Synergistic interactions between airway afferent nerve subtypes regulating the cough reflex in guinea pigs. J. Physiol. 2005, 569, 559–573.
  11. Ebihara, T.; Sekizawa, K.; Ohrui, T.; Nakazawa, H.; Sasaki, H. Angiotensin-converting enzyme inhibitor and danazol increase sensitivity of cough reflex in female guinea pigs. Am. J. Respir Crit. Care Med. 1996, 153, 812–819.
  12. Sekizawa, K.; Jia, Y.X.; Ebihara, T.; Hirose, Y.; Hirayama, Y.; Sasaki, H. Role of substance P in cough. Pulm. Pharmacol. 1996, 9, 323–328.
  13. Hope-Gill, B.D.M.; Hilldrup, S.; Davies, C.; Newton, R.P.; Harrison, N.K. A study of the cough reflex in idiopathic pulmonary fibrosis. Am. J. Respir Crit Care Med. 2003, 168, 995–1002.
  14. Sekizawa, K.; Ujiie, Y.; Itabashi, S.; Sasaki, H.; Takishima, T. Lack of cough reflex in aspiration pneumonia. Lancet 1990, 335, 1228–1229.
  15. Nakajoh, K.; Nakagawa, T.; Sekizawa, K.; Matsui, T.; Arai, H.; Sasaki, H. Relation between incidence of pneumonia and protective reflexes in post-stroke patients with oral or tube feeding. J. Intern. Med. 2000, 247, 39–42.
  16. Ebihara, T.; Sekizawa, K.; Nakazawa, H.; Sasaki, H. Capsaicin and swallowing reflex. Lancet 1993, 341, 432.
  17. Nakazawa, H.; Sekizawa, K.; Ujiie, Y.; Sasaki, H.; Takishima, T. Risk of aspiration pneumonia in the elderly. Chest 1993, 103, 1636–1637.
  18. Nakagawa, T.; Sekizawa, K.; Arai, H.; Kikuchi, R.; Manabe, K.; Sasaki, H. High incidence of pneumonia in elderly patients with basal ganglia infarction. Arch. Intern. Med. 1997, 157, 321–324.
  19. Jia, Y.X.; Sekizawa, K.; Ohrui, T.; Nakayama, K.; Sasaki, H. Dopamine D1 receptor antagonist inhibits swallowing reflex in guinea pigs. Am. J. Physiol. 1998, 274, R76–R80.
  20. Okamura, N.; Maruyama, M.; Ebihara, T.; Matsui, T.; Nemoto, M.; Arai, H.; Sasaki, H.; Yanai, K. Aspiration pneumonia and insular hypoperfusion in patients with cerebrovascular disease. J. Am. Geriatr. Soc. 2004, 52, 645–646.
  21. Humbert, I.A.; Robbins, J. Normal swallowing and functional magnetic resonance imaging: A systematic review. Dysphagia 2007, 22, 266–275.
  22. Suzuki, M.; Asada, Y.; Ito, J.; Hayashi, K.; Inoue, H.; Kitano, H. Activation of cerebellum and basal ganglia on volitional swallowing detected by functional magnetic resonance imaging. Dysphagia 2003, 18, 71–77.
  23. Hamdy, S.; Rothwell, J.C.; Aziz, Q.; Singh, K.D.; Thompson, D.G. Long-term reorganization of human motor cortex driven by short-term sensory stimulation. Nat. Neurosci. 1998, 1, 64–68.
  24. Anderson, T.M.; Garcia, A.J.; Baertsch, N.A.; Pollak, J.; Bloom, J.C.; Wei, A.D.; Rai, K.G.; Ramirez, J.M. A novel excitatory network for the control of breathing. Nature 2016, 536, 76–80.
  25. Yagi, N.; Oku, Y.; Nagami, S.; Yamagata, Y.; Kayashita, J.; Ishikawa, A.; Domen, K.; Takahashi, R. Inappropriate timing of swallow in the respiratory cycle causes breathing-swallowing discoordination. Front. Physiol. 2017, 22, 676.
  26. Marumo, K.; Homma, S.; Fukuchi, Y. Postgastrectomy aspiration pneumonia. Chest 1995, 107, 453–456.
  27. Ebihara, T.; Ebihara, S.; Ida, S.; Ohrui, T.; Yasuda, H.; Sasaki, H.; Arai, H. Acid and swallowing reflex. Geriatr. Gerontol. Int. 2007, 7, 94–95.
  28. Fujii, M.; Sasaki, H. Constipation and aspiration pneumonia. Geriatr. Gerontol. Int. 2012, 12, 570–571.
  29. Nagamine, T. Serum substance P levels in patients with chronic schizophrenia treated with typical or atypical antipsychotics. Neuropsychiatr. Dis. Treat. 2008, 4, 289–294.
  30. Herzig, S.J.; LaSalvia, M.T.; Naidus, E.; Rothberg, M.B.; Zhou, W.; Gurwitz, J.H.; Marcantonio, E.R. Antipsychotics and the risk of aspiration pneumonia in individuals hospitalized for nonpsychiatric conditions: A cohort study. J. Am. Geriatr. Soc. 2017, 65, 2580–2586.
  31. Kose, E.; Hirai, T.; Seki, T. Assessment of aspiration pneumonia using the anticholinergic risk scale. Geriatr. Gerontol. Int. 2018, 18, 1230–1235.
  32. Marchina, S.; Doros, G.; Modak, J.; Helenius, J.; Aycock, D.M.; Kumar, S. Acid-suppressive medications and risk of pneumonia in acute stroke patients: A systematic review and meta-analysis. J. Neurol. Sci. 2019, 400, 122–128.
  33. Tranberg, A.; Samuelsson, C.; Klarin, B. Disturbance in the oropharyngeal microbiota in relation to antibiotic and proton pump inhibitor medication and length of hospital stay. APMIS 2021, 129, 14–22.
  34. Morley, J.E.; Baumgartner, R.N.; Roubenoff, R.; Mayer, J.; Nair, K.S. Sarcopenia. J. Lab. Clin. Med. 2001, 137, 231–243.
  35. Giordano, C.; Lemaire, C.; Li, T.; Kimoff, R.J.; Petrof, B.J. Autophagy-associated atrophy and metabolic remodeling of the mouse diaphragm after short-term intermittent hypoxia. PLoS ONE 2015, 24, e0131068.
  36. Altuna-Venegas, S.; Aliaga-Vega, R.; Maguiña, J.L.; Parodi, J.F.; Runzer-Colmenares, F.M. Risk of community-acquired pneumonia in older adults with sarcopenia of a hospital from Callao, Peru 2010–2015. Arch. Gerontol. Geriatr. 2019, 82, 100–105.
  37. Okazaki, T.; Liang, F.; Li, T.; Danialou, G.; Shoelson, S.E.; Petrof, B.J. Muscle-specific inhibition of the classical nuclear factor-κB pathway is protective against diaphragmatic weakness in murine endotoxemia. Crit. Care Med. 2014, 42, e501–e509.
  38. Looijaard, W.G.P.M.; Dekker, I.M.; Beishuizen, A.; Girbes, A.R.J.; Oudemans-van Straaten, H.M.; Weijs, P.J.M. Early high protein intake and mortality in critically ill ICU patients with low skeletal muscle area and density. Clin. Nutr. 2020, 39, 2192–2201.
  39. Okazaki, T.; Ebihara, S.; Mori, T.; Izumi, S.; Ebihara, T. Association between sarcopenia and pneumonia in older people. Rev. Geriatr. Gerontol. Int. 2020, 20, 7–13.
  40. Okazaki, T.; Suzukamo, Y.; Miyatake, M.; Komatsu, R.; Yaekashiwa, M.; Nihei, M.; Izumi, S.; Ebihara, T. Respiratory muscle weakness as a risk factor for pneumonia in older people. Gerontology 2021, 67, 581–590.
  41. Shiozu, H.; Higashijima, M.; Koga, T. Association of sarcopenia with swallowing problems, related to nutrition and activities of daily living of elderly individuals. J. Phys. Sci. 2015, 27, 393–396.
  42. Murakami, M.; Hirano, H.; Watanabe, Y.; Sakai, K.; Kim, H.; Katakura, A. Relationship between chewing ability and sarcopenia in Japanese community-dwelling older adults. Geriatr. Gerontol. Int. 2015, 15, 1007–1012.
  43. Kuroda, Y.; Kuroda, R. Relationship between thinness and swallowing function in Japanese older adults: Implications for sarcopenic dysphagia. J. Am. Geriatr Soc. 2012, 60, 1785–1786, Erratum in: J. Am. Geriatr. Soc. 2012, 60, 2385.
  44. Ogawa, N.; Mori, T.; Fujishima, I.; Wakabayashi, H.; Itoda, M.; Kunieda, K.; Shigematsu, T.; Nishioka, S.; Tohara, H.; Yamada, M.; et al. Ultrasonography to measure swallowing muscle mass and quality in older patients with sarcopenic dysphagia. J. Am. Med. Dir. Assoc. 2018, 19, 516–522.
  45. Maeda, K.; Akagi, J. Decreased tongue pressure is associated with sarcopenia and sarcopenic dysphagia in the elderly. Dysphagia 2015, 30, 80–87, Erratum in: Dysphagia 2015, 30, 88.
  46. Ebihara, T.; Miyamoto, T.; Kozaki, K. Prognostic factors of 90-day mortality in older people with healthcare-associated pneumonia. Geriatr. Gerontol. Int. 2020, 20, 1036–1043.
  47. Miyamoto, T.; Ebihara, T.; Kozaki, K. The association between eating difficulties and biliary sludge in the gallbladder in older adults with advanced dementia, at end of life. PLoS ONE 2019, 14, e0219538.
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