Abstract Background Oropharyngeal dysphagia is common in geriatric patients and a major risk factor for pneumonia. Fiberoptic endoscopic evaluation of swallowing (FEES) can identify specific swallowing abnormalities; however, apart from aspiration, the relationship of these abnormalities to pneumonia risk is not well understood. This study aimed to identify FEES-based swallowing abnormalities associated with long-term pneumonia risk beyond airway invasion alone and to develop and internally evaluate a transparent multifeature risk score. Methods In this retrospective cohort study, 98 geriatric patients underwent FEES. Nine predefined FEES-derived swallowing features were analyzed using a clustering approach to identify a multifeature constellation associated with pneumonia. In addition, three methods were tested to develop a scoring system: clustering-based feature selection, penalized logistic regression, and a weighted ensemble of decision tree stumps, all assessed using fivefold cross-validation. Results The clustering approach revealed a swallowing pattern comprising prolonged oral phase (excluding bread), delayed swallow reflex, reduced whiteout intensity, repetitive swallowing (excluding bread), piriform sinus residue, and airway invasion at PAS ≥ 3. A simple scoring system assigning one point per feature yielded an area under the receiver operating characteristic curve of 0.73 (95% CI 0.61–0.82). Each additional deficit increased pneumonia risk (odds ratio 1.82, 95% CI 1.24–2.67). The optimal Youden-optimized cut-off was ≥ 4 deficits, yielding a sensitivity of 0.46 (95% CI 0.29–0.63) and specificity of 0.89 (95% CI 0.79–0.96). Conclusions and Implications Pneumonia risk in hospitalized geriatric patients with oropharyngeal dysphagia arises from the accumulation of functional swallowing impairments rather than isolated endoscopic findings. A transparent, exclusively FEES-based multifeature score provides a pragmatic framework for risk stratification.

Abstract Dysphagia is a frequent and serious complication after stroke, associated with pneumonia, malnutrition, prolonged intensive care unit stay, and higher healthcare costs. Pharyngeal electrical stimulation (PES) is a novel therapy that may support recovery from postextubation dysphagia. This study assessed the cost-effectiveness of PES in stroke patients from a health insurance perspective. We performed a secondary analysis of a randomized controlled trial including 60 stroke patients with postextubation dysphagia, randomized to PES (n = 30) or sham stimulation (n = 30). Sham treatment involved identical device placement without stimulation. Acute hospital costs were estimated per patient using the 2025 German Diagnosis-Related Groups (DRG) reimbursement system. Mean costs were compared between groups with a one-sided t-test, and distributions were explored with boxplots. Mean DRG costs per patient were €22,392.89 (SD = €14,980.84) in the sham group and €18,127.20 (SD = €7,828.65) in the PES group. The difference was not statistically significant (p = 0.087). However, three outliers with costs >€50,593 occurred in the sham group, compared with none in the PES group (maximum €35,257.49). Although the difference in mean hospitalization costs between groups was not statistically significant, extreme high-cost outliers occurred only in the sham group in this pilot sample. This observation is exploratory and hypothesis-generating and requires confirmation in larger, adequately powered health-economic studies before firm conclusions regarding cost-effectiveness can be drawn.

The response to neurostimulation can be modulated based on the state of neural network activation prior to stimulation, a mechanism termed metaplasticity. In the swallowing system, preconditioning the pharyngeal motor cortex with non-invasive brain stimulation (NIBS) can induce metaplasticity. However, the effects of cross-modal neurostimulation, i.e. combined peripheral (pharyngeal electrical stimulation; PES) and central (transcranial direct current stimulation; tDCS) approaches, remain unknown. This study investigated the effects of PES preconditioned by tDCS on cortical activation of swallow-related network and swallowing behaviour. Twenty-one healthy volunteers (8 males, 13 females; mean age = 27.0 ± 4.8 years) participated in the study. They received, in randomized order across three separate visits, three experimental conditions in which PES (5Hz, 10 min) was preconditioned by (1) anodal tDCS (1 mA, 20 min), (2) cathodal tDCS (1.5 mA, 10 min), and (3) sham tDCS. Cortical activation of swallow-related network during "volitional" and "challenged" swallow tasks was measured using magnetoencephalography (MEG) at baseline and immediately post-intervention. Swallowing behaviour was assessed by submental electromyographic (EMG) measurements and timed water swallow test. Significant bilateral enhancement of cortical activation of swallow-related network during challenged swallow task was observed in the theta frequency following cathodal preconditioning (p = 0.042) and PES alone (p < 0.001). By contrast, anodal preconditioning significantly reduced swallow-related network activation in the alpha frequency (p = 0.037). There were no significant changes in swallowing behaviour across conditions. This is the first evidence of metaplasticity induced by cross-modal neurostimulation in the swallowing system. Future studies may focus on its clinical application in patients with neurogenic dysphagia.

BACKGROUND & AIMS:Dysphagia and malnutrition frequently co-occur and are associated with aspiration pneumonia, sarcopenia, increased mortality, reduced quality of life and restricted social participation. Yet foods and drinks for individuals with dysphagia and malnutrition are inconsistently specified and lack objective standards. This study aimed to develop a consensus-based, expert-derived framework for evaluating foods and drinks perceived suitable for individuals with dysphagia and malnutrition (FOOD-DM). METHODS:A two-round online modified Delphi study was conducted (October 2024-May 2025). International experts in medicine, speech-language pathology and nutrition were eligible with ≥5 years of clinical experience and a Hirsch-index ≥5. In round 1, participants rated nine prespecified items relating to texture, nutritional composition and labeling on a 9-point Likert scale. Consensus required ≥70% ratings at 7-9 (critically important) and <15% at 1-3 (not important). Round 2 provided aggregated results, item refinements and a comparison of the International Dysphagia Diet Standardisation Initiative (IDDSI) with quantitative texture measures expressed in the International System of Units (SI). RESULTS:Forty-eight experts participated in round 1. All nine items achieved consensus and were reaffirmed in round 2 (44/48; 92% retention). The final FOOD-DM framework comprises nine criteria across three domains: (1) Texture: availability of consistent textures, accuracy of texture descriptions (IDDSI and/or SI-based rheology), ability to customize texture, and ability to measure texture modifications (IDDSI and/or SI-based rheology); (2) Nutrition: availability of high-calorie options (e.g., 1.5-2.0 kcal/mL), flexibility to adjust calorie content, availability of high-protein options (≥20% energy from protein), and adaptable macronutrient composition; (3) Labeling: clear indications of suitability for dysphagia and malnutrition including detailed explanations of their specifics and composition. Overall, 91% of experts perceived the proposed measures as potentially helpful in improving access to appropriate nutrition; 61% favored a combined IDDSI-plus-SI model for texture description. CONCLUSIONS:Distinct from existing approaches focusing on texture or nutrition alone, FOOD-DM integrates standardized texture specification with nutritional optimization and labeling within a single framework. Implementation of the FOOD-DM framework may support standardized, customizable, and transparent nutrition and foster collaboration between clinical nutrition, dysphagia therapy, and the food industry.

Abstract Fast, highly constrained sensorimotor acts require rapid coordination of distributed cortical systems on subsecond timescales. Here, we used source-resolved magnetoencephalography to characterise time-locked cortical connectivity during voluntary swallowing in 74 healthy adults. Cluster-based network statistics revealed focal swallowing-related connectivity changes confined to anatomically selective subnetworks. Undirected phase-lagged connectivity identified theta- and low-gamma weighted phase lag index (wPLI) effects involving somatosensory, motor, supramarginal, and insular regions. Directed connectivity revealed sparse high-gamma phase slope index (PSI) subnetworks centred on the primary somatosensory cortex and anterior insula. Time-window analyses demonstrated temporally evolving low-gamma interactions between posterior parietal and insular regions, while laterality analyses showed rightward theta-band directed asymmetries during later swallowing phases. In contrast, global graph-theoretical metrics and node-level hub measures remained largely stable after correction for multiple comparisons. These findings indicate that voluntary swallowing is supported by focal, frequency-specific, and temporally structured cortical interactions rather than broad global network reconfiguration.

Background: Dysphagia in geriatric patients is associated with adverse outcomes, but often remains under-recognized in routine care. Evidence from nationwide real-world geriatric cohorts is limited, particularly regarding in-hospital outcomes and discharge pathways. Methods: We conducted a retrospective nationwide cohort study using the Geriatric Minimum Data Set (GEM-IDAS Pro), including 1403,790 geriatric hospital admissions between 2006 and 2024. Dysphagia was defined by ICD-10-GM code R13 recorded as a main or secondary diagnosis. Endpoints were in-hospital mortality, in-hospital aspiration pneumonia, and discharge destination. Multivariable logistic regression models were adjusted for age, sex, functional status at admission (Barthel Index), stroke, and dementia. Results: ICD-coded dysphagia was documented in 6.4% of admissions. In-hospital mortality was higher in admissions with dysphagia than in those without dysphagia (9.8%vs 2.7%), as was in-hospital aspiration pneumonia (7.7%vs 0.3%). After full adjustment, dysphagia remained independently associated with in-hospital mortality (OR 1.77, 95% CI 1.72-1.82) and in-hospital aspiration pneumonia (OR 10.37, 95% CI 9.95-10.81). Among patients discharged alive, dysphagia independently predicted institutional discharge (OR 1.48, 95% CI 1.45-1.51). In patients admitted from private households, dysphagia remained independently associated with non-home discharge after full adjustment including stroke and dementia (adjusted OR 1.42, 95% CI 1.40-1.45). Conclusions: In this nationwide cohort of hospitalized geriatric patients, clinically documented, ICD-coded dysphagia was independently associated with in-hospital mortality, aspiration pneumonia, and adverse discharge pathways. These findings support interpreting clinically documented, ICD-coded dysphagia as a marker of systemic vulnerability and complex care needs within a geriatric-syndrome framework.

IntroductionOropharyngeal dysphagia (OD) is a common and significant complication of Parkinson’s disease (PD), contributing to malnutrition, respiratory complications and impaired medication intake. The pathophysiology of OD in PD is heterogeneous, involving basal ganglia dysfunction with associated motor impairments in the oropharynx, cortical pathophysiology, and α-synuclein pathology in peripheral nerves. While deep brain stimulation (DBS) is an established intervention for motor symptom management in PD, its effects on swallowing function remain poorly understood and controversial. This narrative review aims to critically evaluate the current evidence on the effects of DBS on OD in PD and to outline potential future research directions, grounded in current understanding of OD pathophysiology and DBS mechanisms.MethodsA narrative review of clinical studies examining the effects of DBS on swallowing function in people with PD was conducted. Studies were identified through database searching of MEDLINE, Embase and Cochrane Library, from inception of the databases until May 2025. Inclusion criteria encompassed clinical studies and case reports investigating DBS effects on swallowing outcomes in people with PD, with no language restrictions applied. Data regarding study design, DBS intervention and stimulation parameters, swallow-related outcomes and assessment methods were extracted and compiled systematically.ResultsA total of 24 clinical studies, including prospective and retrospective observational studies and case reports, were included in this review. Evidence regarding DBS effects remains inconsistent. Subthalamic DBS shows the greatest variability: some studies report improvements in aspiration frequency or pharyngeal timing, while others describe no change or even long-term deterioration in swallowing safety. Pallidal DBS appears to neither improve nor deteriorate swallowing function, however, evidence is limited to four mainly retrospective studies with small sample sizes. Evidence on combined or alternative targets remains sparse and heterogeneous. Patient-reported swallowing outcomes are often more favorable than instrumental measures.DiscussionDBS may influence swallowing in PD, but outcomes likely depend on OD phenotypes, stimulation targets and parameters. Future research should recruit adequately powered cohorts, apply standardized instrumental assessments including detailed OD phenotyping, systematically explore stimulation parameters, distinguish short- from long-term effects, and integrate OD outcomes into DBS programming.

BACKGROUND:The aim was to evaluate the diagnostic, therapeutic, nutritional, and complication-related impact of a university-led neurogenic dysphagia outpatient clinic. METHODS:We retrospectively analyzed all patients seen at the University Hospital Frankfurt Neurogenic Dysphagia Outpatient Clinic (January 2021-July 2023). Data included demographics, neurological diagnoses, Functional Oral Intake Scale (FOIS), Penetration-Aspiration Scale (PAS) from Flexible Endoscopic Evaluation of Swallowing (FEES), nutritional status, therapy adjustments, and pneumonia requiring hospitalization. We quantified diagnostic revisions, therapeutic/nutritional interventions, and modeled pneumonia risk using logistic regression. RESULTS:Among 255 patients (mean age 65.9 years; 60.0% men), Parkinsonian syndromes (18.0%) and stroke (12.9%) were most frequent. Complications included weight loss (32.8%), choking (20.0%), and pneumonia (12.6%). Primary diagnosis changed in 38.8% of patients. Of 110 patients with initially unexplained dysphagia, 70.9% received a neurological diagnosis, most often ALS and Parkinsonian syndromes (each 19.5%). Therapy recommendations changed in 42.0% of patients, including symptomatic and disease-modifying treatments; nutritional management was dynamic (new PEG in 16.1%; removal in 50.0% of existing PEGs); 42.9% of tracheostomized patients were decannulated. Frailty (OR 1.49, p = 0.005) and PAS 8 (OR 3.67, p = 0.007) independently predicted pneumonia. CONCLUSION:A dedicated outpatient dysphagia clinic enhances diagnostic precision, optimizes therapy, and supports individualized nutritional and airway management. FEES-based phenotyping strengthens differential diagnostics and enables the identification of previously unrecognized neurological syndromes. Silent aspiration and frailty identify patients at the highest pneumonia risk. Dysphagia should be regarded as an independent therapeutic target within disease-specific neurological treatment, and dysphagia outpatient clinics should be integrated into standard neurological care pathways.

Introduction Poststroke dysphagia and impaired cough reflex contribute to aspiration and pneumonia, yet the clinical value of cough reflex testing remains unclear.Patients and methods In this prospective observational study, 395 patients who had an acute stroke admitted to an intensive care unit underwent fiberoptic endoscopic evaluation of swallowing and citric acid cough reflex testing at 0.4 mol/L. Dysphagia severity was rated using the Fiberoptic Endoscopic Dysphagia Severity Scale, with additional measures of secretion management, airway invasion and oral intake. Accuracy of cough reflex testing was calculated against fiberoptic endoscopic evaluation of swallowing. Ordinal and binary logistic regression assessed associations between cough reflex, dysphagia severity, pneumonia and mortality, including interactions.Results Cough reflex testing showed 75% sensitivity and 55% specificity for silent aspiration and 78% sensitivity and 43% specificity for any aspiration. Absent or weakened cough reflex predicted severe dysphagia, impaired secretion management, increased aspiration risk, restricted oral intake and reduced spontaneous swallowing (p<0.001). Older age, stroke severity, impaired cough reflex and dysphagia severity predicted mortality. Preserved cough reduced pneumonia risk only in mild dysphagia.Discussion Impaired cough reflex independently predicted poststroke dysphagia severity, impaired secretion management, aspiration risk, restricted oral intake and poorer functional outcome. Preserved cough conferred protection against pneumonia only in mild dysphagia, whereas in moderate to severe dysphagia aspiration burden and systemic vulnerability likely predominate, limiting clinical relevance of cough testing.Conclusion Cough reflex testing provides meaningful information on poststroke dysphagia severity and airway protection and may support risk stratification when instrumental swallowing assessment is unavailable.

Abstract Post-extubation dysphagia is frequent after severe stroke and can lead to pneumonia, delayed recovery, and dysphagia-related reintubation. We evaluated the Determine Extubation Failure in Severe Stroke (DEFISS) score, a bedside tool combining stroke-specific clinical factors, duration of mechanical ventilation, and a brief oral motor function assessment to support pre-extubation risk stratification. In a prospective single-center cohort, three blinded raters (novice, intermediate, expert) independently scored DEFISS immediately before planned extubation, which followed routine clinical care. After extubation, all patients underwent flexible endoscopic evaluation of swallowing by assessors blinded to DEFISS. The primary outcome was dysphagia-related reintubation within 120 h, and construct validity was assessed against the Fiberoptic Endoscopic Dysphagia Severity Scale. Thirty-nine stroke patients (mean age 73.9 ± 11.6 years; 54% female) were included; five (12.8%) experienced dysphagia-related reintubation. Interrater reliability was excellent (ICC_single 0.887; ICC_average 0.959), with similarly high reliability for the oral motor function component (ICC_single 0.874). DEFISS correlated with endoscopic dysphagia severity (ρ = 0.44, p = 0.005). Using a prespecified cutoff (DEFISS ≥ 4), odds of dysphagia-related reintubation increased (OR 11.1, p = 0.035) with sensitivity 0.80 and specificity 0.73. DEFISS may provide a pragmatic triage tool to prioritize early FEES and targeted dysphagia management in critically ill stroke patients.

Abstract Background Flexible Endoscopic Evaluation of Swallowing (FEES) is a core diagnostic tool in neurogenic dysphagia. Despite a structured national training curriculum in Germany, little is known about current implementation practices and outpatient accessibility. This study mapped nationwide FEES practice patterns, workforce structures, and geographic access, and identified barriers to comprehensive service provision. Methods A nationwide web-based survey was conducted among certified FEES instructors in Germany. The survey assessed provider characteristics, implementation practices, diagnostic–therapeutic integration, and perceived systemic barriers. In parallel, institutional websites were screened for publicly advertised outpatient FEES services and geocoded for travel-time isochrone analyses. Results Eighty-two instructors completed the anonymous survey (response rate 52.6%). FEES was predominantly delivered in acute hospitals (74%) and rehabilitation clinics (46%) and embedded within interdisciplinary workflows. Outpatient availability remained limited (54%), with most institutions lacking statutory reimbursement pathways; additionally, many existing outpatient services were not visible to patients online. Geospatial analysis revealed substantial regional disparities, particularly in rural and eastern regions, with only a minority of residents able to reach a publicly identifiable outpatient FEES provider within 30 min. Procedural experience varied widely, and higher monthly FEES volumes were associated with shorter examination duration (r = − 0.27, p = 0.020). Conclusions FEES is well implemented in German inpatient dysphagia care but structurally underdeveloped in the outpatient sector. Insufficient reimbursement, workforce shortages, and lack of transparency significantly impede equitable access. Strengthening outpatient infrastructure, establishing sustainable reimbursement mechanisms, and improving national visibility of services are critical steps toward ensuring continuity of dysphagia care.

Inferior frontal sulcal hyperintensities (IFSH) observed on fluid-attenuated inversion recovery (FLAIR) MRI have been proposed as indicators of elevated cerebrospinal fluid waste accumulation in cerebral small vessel disease (CSVD). However, to validate IFSH as a reliable imaging biomarker, further replication studies are required. The objective of this study was to investigate associations between IFSH and CSVD, and their potential repercussions, i.e., cognitive impairment and depression. We prospectively recruited 47 patients with CSVD and 29 cognitively normal controls (NC). IFSH were rated visually based on FLAIR MRI. Using different regression models, we explored the relationship between IFSH, group status (CSVD vs. NC), CSVD severity assessed with MRI, cognitive function, and symptoms of depression. Patients with CSVD were more likely to have higher IFSH scores compared to NC (OR 5.64, 95% CI 1.91-16.60), and greater CSVD severity on MRI predicted more severe IFSH (OR 1.47, 95% CI 1.14-1.88). Higher IFSH scores were associated with lower cognitive function (-0.96, 95% CI -1.81 to -0.10), and higher levels of depression (0.33, 95% CI 0.01-0.65). CSVD and IFSH may be tightly linked to each other, and the accumulation of waste products, indicated by IFSH, could have detrimental effects on cognitive function and symptoms of depression.

Introduction and objective:Oropharyngeal dysphagia (OD) is a potentially life-threatening disorder of the swallowing process that may significantly impair a patient's prognosis and quality of life. This study aimed to investigate the association between cough force (measured by peak expiratory flow) and pneumonia incidence in older hospitalized patients with OD and to assess the relationship between peak flow, dysphagia severity and mortality over a 4-year follow-up period. Methods:In this retrospectively longitudinal cohort study, OD was evaluated using flexible endoscopic examination of swallowing (FEES). Patients with suspected OD underwent Peak Flow (PF) measurement prior to initiation of FEES. Follow-up data were collected on pneumonia incidence, episodes, and patient survival via telephone surveys. Cox regression models, adjusted for potential confounding variables such as age and gender, were used to explore the relationship between pneumonia incidence, PF and dysphagia severity. Results:Among 98 patients (mean age 80.4 ± 8.2 years, 67% male), the median PEF was 220 L/min (IQR 150-300). Post-discharge, 38% developed pneumonia-11% had one episode and 27% had multiple episodes. Dysphagia severity was mild in 40%, moderate in 40%, and severe in 20% of patients. Over an average follow-up of 1,334 days (3.7 years), the mortality rate was 64%. Patients with lower PF experienced a significantly higher risk of developing pneumonia compared to those with higher PF (p = 0.030). Patients with severe dysphagia had a substantially lower survival rate compared to those with light or moderate dysphagia, as demonstrated by the Cox-models. Conclusion:Reduced cough force as measured by peak expiratory flow was significantly associated with an increased risk of pneumonia in older hospitalized patients with OD.

Postextubation dysphagia is a major risk factor for extubation failure in acute stroke. Pharyngeal electrical stimulation (PES) is a novel neurostimulation technique for neurogenic dysphagia rehabilitation. We conducted a randomized controlled pilot trial evaluating PES early after extubation in acute stroke (N ​= ​60) focusing on dysphagia recovery trajectories and related outcomes until discharge. Patients with severe postextubation dysphagia, defined as Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) score >4, received daily PES (real or sham, 10 ​min/day) for 3 consecutive days. By day 3, significantly fewer patients in the PES group exhibited persistent absence of spontaneous swallows (8 vs. 41 ​%) or pharyngeal sensory loss (4 vs. 55 ​%) compared to the sham group, indicating enhanced airway safety. Functional Oral Intake Scale (FOIS) score at day 3 was significantly higher in the PES group (4.1 vs 2.1 ​pts). FEDSS at days 5–7 and 8–10 showed a sustained treatment effect over time (2.4 vs. 3.7 ​pts. and 2.2 vs. 3.4 ​pts), resulting in better FOIS at discharge (4.7 vs. 3.5 pts.). PES shortened LOS in the intensive care unit (ICU) (3.1 vs. 8.5 days, p ​= ​0.008) and total hospital stay (13.8 vs. 21.9 days, p ​= ​0.004) from study inclusion. Tracheotomy rates were 13 vs. 33 ​% (p ​< ​0.067). The proportion of patients still cannulated at discharge (7 vs. 10 ​%) and the modified Rankin Scale at discharge (3.9 vs. 4.0) were comparable. PES enhanced recovery of postextubation dysphagia, improved airway safety and shortened length of ICU and hospital stay in acute stroke.

BACKGROUND:Post-stroke dysphagia (PSD) is a frequent yet overlooked complication of stroke with significant implications for rehabilitation. While international guidelines provide structured recommendations for early screening and management, guidance on long-term care remains inconsistent. This position paper synthesizes existing guidelines, identifies critical gaps, and highlights the need for standardized long-term management strategies. METHODS:Guidelines on PSD management were identified through a two-step approach. Fourteen guidelines were included from a previous systematic review (2014-2023), and two additional guidelines were identified through a systematic PubMed search (2014-2025). Inclusion criteria mandated guidelines of moderate-to-high quality (AGREE II assessment) that were published in peer-reviewed journals and provided specific recommendations for managing PSD during acute, subacute, and chronic phases. RESULTS:Analysis of 10 moderate-to-high quality guidelines revealed strong consensus on acute-phase screening and early interventions. All recommend dysphagia screening within 24 h of admission, with nine advising nil-per-os status until screening completion. There is consensus on instrumental assessments (videofluoroscopy, endoscopy), though application criteria vary. Management strategies include dietary modifications, nutritional support, oral health care, behavioral interventions, neurostimulation, and pharmacological therapies. While acute-phase recommendations are well defined, structured long-term follow-up guidance remains limited, with only one guideline specifying reassessment intervals beyond hospital discharge. CONCLUSION:The absence of standardized long-term PSD management likely reflects limited availability of high-quality evidence on long-term care. Further research is needed to establish optimal reassessment intervals, high-risk subgroups, and long-term rehabilitation strategies to improve care for stroke survivors with persistent dysphagia.

Decannulation in tracheotomized neurological patients is often complicated by severe dysphagia, which compromises airway safety and delays weaning. Additional challenges, including reduced cough strength, excessive bronchial secretions, and altered airway anatomy exacerbate weaning issues, thereby increasing morbidity and mortality. This review summarizes diagnostic procedures and therapeutic options crucial for the rehabilitation of tracheotomized patients. Key diagnostic strategies for assessing decannulation readiness focus on airway protection, airway patency, bronchial secretion management, and cough function. These are collectively introduced as the A2BC criteria in this review. Advanced tools such as flexible endoscopic evaluation of swallowing, endoscopic assessment of airway anatomy, measurement of cough strength, and intrathoracic pressure are essential components of a systematic evaluation. Therapeutic interventions encompass restoring physiological airflow, behavioral swallowing treatment, secretion management, and pharyngeal electrical stimulation. The proposed decannulation algorithm integrates two pathways: the “fast-track” pathway, which facilitates rapid decannulation based on relevant predictors of decannulation-success, and the “standard-track” pathway, which progressively increases cuff deflation intervals to build tolerance over time. Successful decannulation in neurological patients demands a multidisciplinary, patient-centered approach that combines advanced diagnostics, targeted therapies, and structured management pathways. The proposed algorithm integrates fast-track and standard-track pathways, balancing rapid diagnostics with gradual weaning strategies. This framework promotes flexibility, enabling clinicians to tailor interventions to individual patient needs while maintaining safety and optimizing outcomes.

Oropharyngeal dysphagia, prevalent in neurogeriatric populations, increases the risks of malnutrition, pneumonia, and mortality. Oropharyngeal dysphagia manifests as a multi-aetiological syndrome with diverse phenotypes. We advocate for a neurogeriatric perspective that integrates specific neurological insights with geriatric care principles to improve dysphagia management. This approach highlights the diagnostic value of disease-specific neurological dysphagia manifestations and recognises the condition as a potential target for neurological therapies, as shown by the benefits that acetylcholinesterase inhibitors in myasthenia gravis and dopaminergic agents in Parkinson's disease have against the syndrome. Age-related factors such as presbyphagia, which includes reduced pharyngeal sensation, sarcopenia, and decreased neuroplasticity, further contribute to the pathophysiology of oropharyngeal dysphagia. Cross-disease treatment strategies encompass oral hygiene, nutritional support, dietary modifications, individualised interventions to improve swallowing physiology, and emerging neurostimulation techniques that are currently under investigation. Current research aims to refine assessment protocols tailored to these interventions, identify outcome predictors to contextualise dysphagia findings, and evaluate the potential of neurostimulation or pharmacological agents, with the aim to improve quality of life and reduce mortality.

Objective:Diagnosing and treating dysphagia in patients with dementia is challenging and few studies have been performed to characterize dysphagia based on Flexible Endoscopic Evaluation of Swallowing (FEES). Therefore, we aimed to characterize and compare the dysphagia pathologies in various stages and types of dementia. Methods:This is a retrospective study of 107 hospitalized geriatric patients with dysphagia and Alzheimer's dementia, Alzheimer's dementia with moderate to severe cerebral vasculopathy (mixed dementia), and patients with dementia associated with Parkinson's syndrome who underwent FEES. A standardized FEES protocol was used to characterize the dysphagia pathologies, including premature bolus spillage, delayed swallowing reflex and bolus residue as well as penetration and aspiration and the white-out intensity. The distribution of different dysphagia pathologies was cross-tabulated with χ2 statistics across different types of dementia. Results:A comparative analysis of dysphagia pathologies across the three dementia types revealed a relatively mixed picture of various dysphagia findings in all dementia types. However, a significantly higher prevalence of bolus penetration and complex dysphagia, which was defined as presence of at least two major findings simultaneously within a patient, was seen in patients with Parkinson's-related dementia compared to other forms of dementia. In general, residue was the most frequent finding in all types of dementia (78%-100%). In contrast, aspiration was the least prevalent finding with no significant variation between dementia types. Conclusion:Although participants with Parkinson's-related dementia exhibited minor specific findings, our study revealed no distinct endoscopic dysphagia pathologies across various types of dementia.