Dysphagia is a geriatric syndrome that affects 10% to 33% of older adults. Generally, it is defined as difficulty swallowing . Many patients who have undiagnosed dysphagia adapt to it through behavioral modifications, while others experience silent aspiration.
For these reasons, it is difficult to accurately quantify the prevalence of dysphagia. The highest prevalence is found in hospitals and nursing homes.
Oropharyngeal dysphagia occurs more frequently in older adults who have a neurological disorder (Alzheimer’s disease, 80%; Parkinson’s disease, 60%; cerebrovascular accident [CVA], 37%-78%).
Patients with dysphagia are at increased risk for other serious illnesses, such as stroke patients, who are at increased risk for pneumonia and malnutrition. Furthermore, they are 33.2% more likely to be transferred to a post-acute care facility.
Dysphagia can also be associated with poor physical performance and a higher mortality rate.
In fact, a large cross-sectional study of nursing home residents with dysphagia found 24.7% mortality at 6 months, compared with 11.9% in those without dysphagia. On the other hand, in different studies it has been proven that they are 1.7 and 3.8 times more likely to die than patients without dysphagia.
Dysphagia is associated with a longer hospital stay. Hospitalization costs are higher compared to patients without dysphagia. They also tend to suffer a decrease in quality of life, especially social and psychological, including fear and anxiety, both in the patient and their caregiver.
Likewise, it has been observed: greater concern about symptoms of asphyxiation and caregiver exhaustion, which influences the management of the needs of an unknown illness.
In one study, nearly 30% of people studied reported avoiding eating with others, and 41% experienced anxiety about their problem eating. Counseling has proven to be helpful in allowing patients and families to be more informed about what to expect in the future. Given the prevalence of dysphagia in older adults, and its numerous adverse outcomes, it is now considered a geriatric syndrome that affects the patient’s independence and quality of life .
| Aging and swallowing |
There are very few comprehensive guidelines for the management of dysphagia in older adults. Even some of them, who are healthy, may experience changes in the structure, physiology and innervation of the swallowing mechanism, called presbyphagia . These specific changes can lead to a decrease in range of motion and the generation of pressure and speed of movements.
Older adults often have a lower sense of smell or taste , due to changes in teeth, oral hygiene, and salivary flow. Furthermore, there is reduced muscle contraction, which decreases the strength and function of the tongue, lips, velum, and jaw.
Some older adults present hypertrophy, resulting from fat deposition and increased connective tissue. This can lead to reduced mobility and delayed force generation. All of these changes can cause an alteration in the speed and effectiveness of bolus movement within the oral cavity.
In the pharyngeal region, older adults may also experience a delay in the onset of the swallowing reflex.
On the other hand, inadequate anterior movement of the larynx can be observed, due to the decrease in the elasticity of the connective tissue, which reduces the opening of the esophagopharyngeal sphincter. With these pharyngeal alterations, some older adults may be at greater risk of food penetration and aspiration.
In the esophageal region , the normal transfer of the food bolus requires between 8 and 20 seconds. The elderly may have less flexibility of the upper part of the esophageal sphincter.
| Other effects of the esophagus |
Aging brings with it a reduction in the contraction of the smooth muscles of the esophagus, the appearance of non-peristaltic contractions and a delay in the emptying of the esophagus. Likewise, presbyphagia can cause dysphagia, as a result of a stressor, delirium, dementia, adverse medication effect, or hospitalization.
| Etiology |
Dysphagia can be classified into 3 categories :
- Oral
- Pharyngeal
- Esophageal (oral and pharyngeal types are commonly classified together as oropharyngeal dysphagia).
The oral phase of swallowing consists of a voluntary process that requires attention and coordination. The individual forms and moves the bolus from the mouth to the pharynx. Oral dysphagia occurs when problems occur in the process of formation and movement of the bolus, in the region of the pharynx.
The pharyngeal phase of swallowing is a predominantly involuntary process, involving the swallowing reflex, which runs from the pharynx to the esophagus. Patients may experience dysphagia when the swallowing reflex is interrupted or in the muscles involved in the transfer of the bolus from the pharynx to the esophagus.
Common causes of oropharyngeal dysphagia in older adults are: Alzheimer’s disease, Parkinson’s disease, dementia, and stroke.
The esophageal swallowing process involves the innervation of intrinsic nerves, without the important participation of the central nervous system. Esophageal dysphagia occurs when there is pathology along the esophageal tract (i.e., peristalsis, tissue injury, etc.). Common causes of esophageal dysphagia are strictures, drug-induced esophagitis, and infectious etiologies.
| Importance of a good medical history |
In 80% of patients with dysphagia, a detailed clinical history allows the specific type of disease to be identified. In older adults, warning signs must be recognized . For the clinical history, 5 specific questions are important .
| 1. What happens when you try to swallow? |
Patients may describe difficulty moving food and liquids in the mouth, or swallowing, suggesting pathology in the oral stage of swallowing. If the patient reports coughing, choking, or nasopharyngeal regurgitation, it may be a pathology of the pharyngeal swallowing structures.
You should ask about the presence of frequent throat clearing. If the patient reports retrosternal sticking of food, chest pain or heartburn after swallowing, an esophageal pathology, such as stricture, could be suspected.
| 2. Do you have problems chewing? |
Caregivers of patients with dysphagia may report that the time it takes the patient to eat is prolonged, that chewing is laborious, or that the swallowing movement is repeated several times. These symptoms are common in patients with dementia, due to poor motor coordination or apraxia.
You should consult your dentist to rule out the use of poorly fitting dentures. The causes of difficulty chewing are: painful oral lesions; dry mouth due to dehydration or use of anticholinergic medications.
| 3. Do you have difficulty swallowing solids, liquids, or both? |
Patients with difficulty swallowing liquids are usually affected by oropharyngeal dysphagia, while if the difficulty occurs with solids, it is often esophageal dysphagia.
Patients with difficulty swallowing, both liquids and solids, have difficulty in all phases of dysphagia.
| 4. Describe the onset, duration, and frequency. |
Sudden onset of dysphagia may be related to a stroke, food impaction, or foreign body. A slow and progressive onset can be attributed to a neurodegenerative disease such as Alzheimer’s dementia.
The frequency of dysphagia provides guidance. For example, if swallowing difficulty is intermittent for solids, it is likely due to esophageal membranes. If the meal time is prolonged, it could be due to peptic stricture or neoplasia.
| 5. What are the associated symptoms? |
Dysphagia is commonly caused by systemic diseases which, in turn, are responsible for other associated symptoms. For example, the patient may describe that when swallowing, there is facial asymmetry or numbness and cough. These associated symptoms are possible indicators of a stroke.
If the patient presents cognitive disorders in addition to other signs (packaging of food, prolonged meal time, need to advise the caregiver to assist swallowing, weight loss), it could be that dysphagia is present in the context of dementia. .
Weight loss could be the manifestation of a malignancy, a common differential diagnosis in this population.
| Physical exam |
The physical examination should focus on the neuromuscular components of swallowing, which aids in diagnosis and treatment.
The water swallowing test is quick and useful, and can be performed simply by asking the patient to swallow water. In elderly care and rehabilitation settings it is very useful to have a glass of water next to the patient’s bed, to determine if there is aspiration in the acute phase.
Aspiration is manifested by airway response (coughing/choking) and voice changes (weak/gurgling). To radiographically detect aspiration, it was found that ingestion of 1-5 ml of water was 71% sensitive and 91% specific and that swallowing sips of 90-|100 ml of water was 91% sensitive and 53% specific.
On the physical examination, special attention should be paid to the head and neck areas as well as the neurological examination.
Vital signs may provide clues to dehydration, weight loss, orthostatic hypotension.
If there is decreased consciousness, it may be due to swallowing problems (mainly in the oral phase).
The evaluation of the oral cavity allows us to check whether dentures are poorly fitted, the state of oral hygiene or the presence of gingivitis, dryness or mucosal lesions, such as thrush (candidiasis) or herpes and ulcerations. Tongue atrophy or fasciculation may also be found, which are common signs of motor neuron diseases.
On examination of the neck , the doctor may observe muscle asymmetry, a cervical mass, or lymphadenopathy.
The opening of the upper esophageal sphincter can be evaluated by observing and palpating the area of the thyroid cleft, which allows evaluation of the displacement of the larynx when the patient swallows normally. (2-4cm); This maneuver is essential. Other important observations are tone, muscle mass and gait.
A cognitive evaluation, including assessment of functional status and memory, is useful for differential diagnosis .
| Screening, consultations and tests |
Treatment of oropharyngeal dysphagia requires a collaborative team approach consisting of a swallowing therapist, a primary care physician, and a dietitian, which has been shown to give better results.
The goal is to treat the underlying pathology, control symptoms and meet nutritional needs.
For oropharyngeal dysphagia, there are 2 therapeutic options: compensation and rehabilitation.
- Compensatory interventions help minimize the symptoms and adverse effects of dysphagia. However, these interventions do not change swallowing physiology.
- On the other hand, rehabilitation measures involve concerted training, and are necessary to optimize the physiology of normal swallowing.
With compensatory interventions, the patient and caregiver receive advice to modify the amount and speed of feeding, promoting slow eating habits and conscious swallowing. Family members or caregivers can help in this process by providing cues or helping during the meal.
Oral care is also useful as it reduces the development of fatal pneumonia.
- Patients and caregivers should take general precautions to prevent aspiration during meals, such as sitting upright and avoiding distractions while eating.
- To prevent postprandial aspiration, it helps to elevate the head of the bed at least 30º while the patient rests.
- The swallowing therapist may recommend common swallowing maneuvers, such as the effortful swallow and the Mendelsohn maneuver.
- Patients can make changes such as bending the chin until it is close to the chest.
- Keep in mind that patients with moderate to severe dementia may have difficulty remembering that they must make maneuvers or postural modifications to swallow.
Diet modification is one of the most compensatory measures, widely used to help treat dysphagia. Traditional classifications of modified diets are derived from the National Dysphagia Diet options .
Options for ingestion of solids are pureed, mechanically modified, crushed, blended foods. Options for liquid consistency are: thin, nectar thick, thick like honey, and thick like pudding.
The newest classification system is derived from the International Dysphagia Diet Standardization Initiative . It is a method to describe diets for dysphagia, which range from level 0 to level 7. In addition to these recommendations, there are others from institutions that implement other dietary consistencies.
| Diets for dysphagia | |
| National Dysphagia Diet | International Dysphagia Diet Standardization Initiative |
| Solid Foods Regular Advanced Mechanically Altered Puree | Regular Easy to chew Chopped and moist Puree Blended |
| Liquids Thick pudding Thick honey Nectar or thick juice | Extremely thick Moderately thick Slightly thick Slightly thick Thin or thin |
As the diet is modified, the acceptability of foods may decrease due to altered taste, texture, and appearance, all of which contribute to malnutrition. In fact, modified diets have been proven to be low in calories.
In a study of patients with dysphagia and dementia, those who consumed liquids with the consistency of thick honey had an immediate positive effect on preventing aspiration of liquids, compared to those who consumed liquids with the consistency of nectar or thick juice. However, at 3 months of follow-up, patients who drank liquids with a thick honey consistency had a higher incidence of pneumonia compared to those who consumed thick juices or thin liquids, changing chin posture.
Tap water protocols (including the Farzier Free Water Protocol , as well as its modifications) allow the patient to drink tap water (unthickened liquid), especially if they are at risk for aspiration. The patient must meet the swallowing therapist’s specific criteria. However, a small 2017 study found no differences from the control group, even among hospitalized patients who had already experienced a lung complication.
One review found that the Frazier Free Water Protocol showed low-quality evidence of increased lung complications related to its use. Some medical groups do not accept the use of tap water protocols. They recommend not rigorously following the protocols and, instead, relying on a good clinical history, medical judgment and considerations about the possible risks that the patient has, which may vary from day to day.
The other method for managing dysphagia is rehabilitation.
Swallowing therapists can conduct strength- and skill-based training. Swallowing therapy helps optimize the physiology and function of oropharyngeal swallowing, (i.e., safety and efficiency), while decreasing the severity of dysphagia. Rehabilitation approaches can vary widely. Swallowing rehabilitation includes intensive, highly structured programs, such as the McNeill Dysphagia Therapy Program, as well as personalized, physician-designed treatment.
Rehabilitation may involve different graded swallowing exercises (e.g., tongue gripping and strengthening) and/or swallowing of different specific consistencies. In 2019, a small study of stroke patients with dysphagia focused on the McNeill Program and found decreased dysphagia severity and improved oral intake compared to usual care.
In another randomized study, patients with ischemic stroke and dysphagia, aged 55 to 65 years, admitted to a hospital in the acute stage, were assigned to receive usual treatment or a structured multimodal strategy, including caregiver education, training compensatory swallowing and exercises. The use of the Program achieved an improvement in cough, swallowing reflex and swallowing time.
| Esophageal dysphagia: diagnosis and treatment |
Treatment of esophageal dysphagia depends on the etiology and may require the intervention of a gastroenterologist.
Before a study or intervention, it is very important to share decision-making with the patient and/or their family. There are conservative and procedure-based strategies. Clinicians should review medications that could cause esophagitis, xerostomia, and/or esophageal dysmotility.
For the diagnosis and treatment of esophageal dysphagia, esophagogastroduodenoscopy (EGD) is essential. However, in older adults, EGD should be considered with caution due to its increased risk of aspiration. If the risk of aspiration during EGD is high (eg, history of aspiration pneumonia), the use of anesthesia should be considered.
Alternatively, an esophagram offers a non-invasive option. However, it is important to consider that an esophagram serves as a diagnostic test, while EGD provides an opportunity for direct visualization and treatment (ie, esophageal dilation).
Treatment of esophageal dysphagia, which is often structural in nature, depends on the etiology. Treatment of gastroesophageal reflux is important in patients with dysphagia caused by a Schatzki ring, esophagitis, or peptic stricture. Therapeutic responses and the need to repeat EGD should also be evaluated in patients undergoing esophageal dilation.
| Ethical dilemmas |
In dysphagia, the defense of ethical principles---benefit, non-maleficence, and autonomy---can be problematic. The importance of eating related to quality of life varies among individuals. Decisions regarding dietary modification should take into account culture and social values/expectations.
Autonomy is more complicated for patients who have cognitive impairment, as they may lack the ability to make decisions . When considering food and fluid restrictions to prevent complications, it is necessary to balance the risks with the harm that may be caused by depriving the patient of the pleasure of eating of his or her choice.
In the US, due to overwhelming evidence, the American Geriatrics Society and the Choosing Wisely campaign made recommendations against the use of feeding tubes in patients with advanced dementia. Feeding tubes are associated with increased agitation, physical/chemical restrictions, and pressure ulcers. |
Multidisciplinary work, with the collaboration of the patient, family, provider and swallowing therapist, is useful for counseling and offering available options that reflect the patient’s wishes.
Early discussion of the options will allow the patient and caregivers time to understand and collaborate in decision-making, to avoid feelings of guilt related to the decision being made.
| Technology in dysphagia |
Regarding technological devices used in the treatment of dysphagia, a 2018 Cochrane review provided evaluation of various stimulant techniques in patients with acute and subacute stroke.
These techniques include various types of stimulation: electrical --- neuromuscular, pharyngeal ---physical, transcranial direct current, and transcranial magnetic. These swallowing therapies did not have a significant effect on function (death, dependence or disability) but, to varying degrees, reduced hospital stay, degree of dysphagia and pulmonary complications. Infectious.
Other therapeutic advances were devices designed to monitor biofeedback during swallow therapy tasks, such as surface electromyography, tongue manometry, superficial laryngeal manometry, pharyngeal manometry, plethysmography, and respiratory accelerometry.
A 2019 systematic review focusing on a heterogeneous group of given primary diagnoses (stroke, Parkinson’s disease, traumatic brain injury), at high risk of bias, showed that treatments involving surface electromyography, accelerometry, Tongue or biofeedback therapy can improve some physiological factors of the swallowing process. However, improvements in swallowing function and reduced dependence on feeding tubes have not been established.
| Conclusion |
Dysphagia is a geriatric syndrome of increasing frequency. It affects morbidity, mortality and days of hospitalization. The authors emphasize the importance of obtaining a good clinical history and physical examination, as well as understanding the management strategies for oropharyngeal and esophageal dysphagia in older adults.
Patients may experience improvement by implementing structured, multimodal dysphagia therapy programs. However, tolerance to such therapies in frail older adults or those suffering from advanced dementia is questionable. More research is needed to study dysphagia in older adults.
