March 14, 2011

Dealing With Dysphagia
By Maura Keller
For The Record
Vol. 23 No. 5 P. 24

Often underdiagnosed, this swallowing condition can be a precursor to more serious health problems.

Swallowing function can deteriorate with age, as older adults’ teeth are often weak or absent; the mucosal surfaces in the mouth and throat tend to become less moist; and there may be a loss of muscle strength in the mouth and throat that slows swallowing and makes it difficult to swallow hard or dry solid foods. But it’s dysphagia, or problems with neural control or structures in any part of the swallowing process, that often makes the eating process extremely challenging for older adults.

Key Concerns
Older adults’ proper nutritional intake is a key concern under normal circumstances. When normal changes in swallowing are exacerbated by dysphagia, other concerns arise, including poor nutritional status and dehydration, loss of appetite and subsequent weight loss, less enjoyment in eating, and the possibility of food entering the airway and leading to aspiration pneumonia.

“The more common causes of mild dysphagia are sensory or motor problems of the pharynx and esophagus,” says Chandra M. Ivey, MD, director of laryngology, voice, and swallowing disorders at ColumbiaDoctors Eastside in New York City. “These increase in frequency as people age and often respond well to swallowing therapy.”

Ivey says the prevalence rates vary based on different studies, but “dysphagia affects between 7% and 35% of the population; most quote about 20%,” she says. “While this number includes all adults, it is accepted that older adults and people with acid reflux are more commonly affected. More importantly, only half of those with symptoms of dysphagia discuss them with their physician.”

Dysphagia in older adults is often mild for long periods of time. “This is due to age-related changes in laryngeal and pharyngeal sensation as well as very mild discoordination between oral and pharyngeal phases of swallowing that allows the food to safely pass the vocal cords on the way to the stomach,” Ivey says. “Because these are often mild, they go undiagnosed until a larger medical problem arises and then the swallowing problems may be exacerbated due to weakness or deconditioning.”

According to Joseph R. Spiegel, MD, medical director of the Jefferson Voice and Swallowing Center in the otolaryngology department at Philadelphia’s Thomas Jefferson University Hospitals, the most life-threatening complication of dysphagia is aspiration (food, liquid, or secretions “leaking” into the lungs).

“Because of the high incidence of lung disease and general weakness in the elderly, it is especially dangerous,” Spiegel says. “Aspiration after stroke has a 15% mortality rate. Aspiration pneumonia is the leading cause of hospitalization and death in nursing home residents. Dysphagia also contributes to malnutrition, which can be found in as many as 50% of patients in long-term care facilities. Dysphagia can also result in patients having improper intake of their medications.”

Identifying Contributing Factors
So what are the key indications that an older adult is suffering from dysphagia? According to Claire Kennedy, MS, RD, LDN, a registered/licensed dietitian working at the Norwell Visiting Nurse Association and Hospice in Norwell, Mass., and an outpatient dietitian at Tufts Medical Center in Boston, some observable signs indicating potential problems include the following:

• coughing while eating or drinking;

• choking on food, fluid, or medication;

• a gurgly sounding voice, especially after eating or drinking;

• difficulty swallowing food or fluid; and

• the pocketing of food on one side of the mouth.

“Healthcare providers need to be more proactive in looking for swallowing problems, especially in regards to medication review,” Kennedy says.

Questions physicians can ask that offer clues related to potential dysphagia problems include the following:

• Do you often cough or choke after eating or drinking?

• Does it sometimes feel as though food is going down the “wrong way”?

• Do you often feel that food is stuck in your throat?

• How long does it take you to eat a meal?

• Is eating sometimes less enjoyable than it had been previously?

• Have you recently experienced weight loss without trying to lose weight?

The gold standard for assessing and diagnosing dysphagia is a modified barium swallow in which a patient is given small amounts of thin liquids and/or barium and/or a small piece of a cookie or cracker. The assessment includes x-ray and video of the swallowing process to determine which stage of swallowing is involved.
Esophageal reflux has been found to change sensation at the level of the pharynx and can affect swallowing. “Individuals may feel that they have a lump in the throat that causes difficulty with food passing,” Ivey says. “Reflux may also cause thick mucus that interferes with comfortable swallowing.”

Changes in the structure of the esophagus may also cause difficulty when swallowing. “For example, Zenker’s diverticulum causes a ‘pocket’ in the esophagus where food gets stuck and can often be regurgitated. Strictures of the esophagus may also impede passage of food,” Ivey says. “Structural disorders such as these may be amenable to surgical intervention once they are identified.”

More significant swallowing problems may indicate a neurologic problem or, in some cases, a mass that must be properly diagnosed and treated. While these are less common, they may be serious and require proper diagnostic work-up.

Treatment Options
Treatment for dysphagia includes the involvement of both a speech language therapist and a registered dietitian. “Health professionals, particularly speech therapists, work with patients to improve the safety of their swallow with compensatory techniques, strengthening exercises, electrical stimulation, adaptive devices, and more,” says Sandra Woodruff, MS, RD, LDN, ACSM-CPT, coauthor of The Soft Foods for Easier Eating Cookbook. “This is frequently helpful for stroke victims, but in other cases, the problem can be progressive, and soft or puréed foods—and in severe cases tube feeding—may be necessary permanently.”

A speech therapist typically identifies the specific problem and makes recommendations that may include changes in positioning or posture when eating or drinking, exercises to strengthen or improve swallowing muscles, techniques to aid in swallowing more safely, or changes in consistency of foods (such as puréeing or mashing them) and the possibility of adding thickeners to fluids to improve ease of swallowing.

A dietitian can outline the appropriate consistency of foods that minimizes the difficulties of swallowing and eating.

Other considerations include catering to patients’ food preferences as much as possible; providing time for a leisurely, relaxed mealtime without distractions such as TV; and eating with family or friends.

Woodruff notes that patients who require soft or puréed foods are rarely happy with the food choices they are offered. “Even if the foods taste like the foods they have eaten all of their lives, the altered texture makes the food unappetizing to them,” Woodruff says. “As a result, they tend to eat less or rely primarily on sweets such as ice cream, puddings, and milkshakes for nutrition.” This can result in a dangerously inadequate and imbalanced diet that may compromise a patient’s ability to heal, hasten disease processes, and/or cause undesirable weight loss, which can become life threatening in older patients.
“The goal of the practitioner should be to offer the most permissive yet safe diet for a patient,” Ivey says. “This often involves thickening liquids to ensure the patient does not aspirate. If oral intake is not sufficient to meet caloric needs, alternative methods for feeding may be considered. Nutrition support can be helpful in constructing a healthy diet for those with restrictive eating needs due to swallowing problems.”

Susan I. Wranik, MS, MA, CCC-SLP, president of Susan I. Wranik Associates, LLC in Chevy Chase, Md., says many healthcare professionals rush to put older patients on a puréed diet as a cure-all, which it isn’t.

“Many older adults have respiratory issues and erratic breathing, rendering it difficult for them to suck uniformly from a straw,” Wranik says. “They get too much liquid, cough, and this places them at risk for aspiration. Remember, your mouth is the first and last frontier. It’s the way we, as infants, explore the world around us. It’s also the last decision-making experience for many. Others can decide when you will go to bed, when you will be changed, and what you will eat, but no one can make another person swallow. Eating is one of life’s pleasures. Quality of life should be the guiding force in all decision making.”

— Maura Keller is a Minneapolis-based writer and editor.