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 Table of Contents  
Year : 2022  |  Volume : 17  |  Issue : 3  |  Page : 779-785

Dysphagia in the elderly: A multidisciplinary approach

1 Department of General Medicine, Lifecare Hospital, Abu Dhabi, United Arab Emirates
2 Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
3 Department of General Medicine, School of Medical Science and Research, Sharda University, Greater Noida, Uttar Pradesh, India

Date of Submission07-May-2022
Date of Decision18-Jul-2022
Date of Acceptance17-Aug-2022
Date of Web Publication2-Nov-2022

Correspondence Address:
Prof. Monica Gupta
Department of General Medicine, Government Medical College and Hospital, Sector 32, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_194_22

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The process of eating and swallowing is a complex physiologic process requiring volitional as well as reflexive activities and involving multiple structural and functional elements. Dysphagia is a geriatric syndrome resulting in multiple negative health consequences. Dysphagia can have profound adverse influences, including malnutrition, dehydration, aspiration pneumonia, and depression poor quality of life in the elderly. With the aging of the population across the globe, health-care providers are encountering older patients with dysphagia either due to oropharyngeal or esophageal disease. Barium swallow remains a low-cost initial alternative for luminal and esophageal motility assessment. A variety of emerging modalities can help detect anatomical and functional deficits. These include fiberoptic endoscopic evaluation of swallowing, videofluoroscopic swallow study, high-resolution pharyngeal manometry, and esophagogastroduodenoscopy. This review provides a comprehensive review of diagnostic modalities and addresses several issues regarding the collaborative management of elderly persons with dysphagia, including a brief discussion on how swallowing mechanisms are affected by the aging process.

Keywords: Aging, dysphagia, elderly, geriatric, management, swallowing disorders, swallowing mechanism

How to cite this article:
Gupta M, Gupta M, Gupta A. Dysphagia in the elderly: A multidisciplinary approach. J Datta Meghe Inst Med Sci Univ 2022;17:779-85

How to cite this URL:
Gupta M, Gupta M, Gupta A. Dysphagia in the elderly: A multidisciplinary approach. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Feb 1];17:779-85. Available from: http://www.journaldmims.com/text.asp?2022/17/3/779/360188

  Introduction Top

Adult human performs about 600 swallows/day.[1] The practice of swallowing is intricate, but a precise process involving the sequential coordination of muscles and nerves and is divided into three phases – oral, pharyngeal, and esophageal.[2] The oral phase of swallowing is a voluntary process that includes biting, mastication, mixing it with saliva, preparation of the food bolus, and propelling it into the pharynx. During the pharyngeal phase (predominantly involuntary), the airway is sealed off (passage to the nose by the elevated soft palate, to the oral cavity by medialized faucial pillars and lifted base tongue, and to the larynx by folded back epiglottis and closure of true and ventricular vocal folds), and the bolus is passed into the esophagus. The esophageal phase of swallowing involves the bolus passing to the stomach by peristaltic contractions and gravity. Dysphagia refers to difficulty in the progression of food or liquid bolus from mouth to stomach. It is an important cause of concern in older individuals.

  Materials and Methods Top

Search strategy

Studies were sought through an extensive bibliographic search on PubMed advanced search option. The search utilized the MeSH Terms (Elderly) AND (dysphagia) and search was limited to review articles published in the English language in the elderly populations aged more than 65 years, updated to July 2022 since inception. This search yielded 691 studies. These were further refined for only reviews published in the past 10 years, yielding 209 results.

Eligibility criteria for selection of studies

Of the 209 studies retrieved, only those review articles were included in this systematic review that dealt with the topic of clinical approach (238 results) and management (183 results) of dysphagia in the elderly. Finally, 52 studies were evaluated for their completeness and scientific merit. Animal studies were excluded. Scientifically important older cross-references cited by the recent articles were also included.

  Review Top

According to various studies, the prevalence of dysphagia in the elderly is between 12% and 60%, though many go unreported due to compensatory changes by the patient.[3] The swallowing function in the elderly deteriorates with age and is multifactorial. It may be mechanical, i.e., structural or neurological, or both. Mechanical dysphagia is due to luminal compromise by intrinsic pathology or extrinsic pressure. The neurological occurs in motility disorders. If it occurs due to changes in swallowing physiology, due to aging, like loss of teeth, decrease in saliva formation, and poor muscle strength, the term presbyphagia is used.[4] Dysphagia can result in malnutrition, weight loss, and lower airway infection due to aspiration. Thus, it should be regarded as a warning sign for an early diagnosis. A comprehensive history with a quick screening questionnaire like the eating assessment tool -10, helps in the identification of individuals that need intervention.[5] It is a 10-question tool, which the patient answers by self-reporting their symptoms on a 4-point scale, ranging from “no problem” to a “severe problem.”

  What are the Symptoms Indicating Dysphagia? Top

Any symptom of dysphagia should be thoroughly evaluated in the elderly. The following symptoms need careful evaluation.[6]

  • Coughing while eating or drinking
  • Choking while eating or drinking
  • Change in voice – wet voice
  • Difficulty swallowing, i.e., food or liquid or both sticking in the throat/chest
  • Oral/nasal regurgitation of food or liquid or acid
  • Taking longer to eat
  • Weight loss
  • Recurrent chest infections.

A detailed history in patients of dysphagia helps in differentiating between oropharyngeal and esophageal causes. Oropharyngeal dysphagia (OD) may manifest as transfer dysphagia, i.e., difficulty in initiation of swallowing, food adhering to the throat, coughing or choking while swallowing, and nasal or oral regurgitation. The esophageal dysphagia will have the sensation of food stopping or sticking after swallowing, chest pain, and regurgitation with aspiration pneumonia.[7] Commonly, the OD may be due to neurological or muscular disease and local oropharyngeal lesions, whereas esophageal dysphagia results from mechanical obstruction or motility disorder.[8] The type of food item leading to dysphagia also helps in localizing the site and type of pathology-dysphagia to liquids is predominantly oropharyngeal while to solids is more commonly esophageal. The dysphagia to solids is mainly due to obstruction of food passage, while to liquids is due to vocal fold paralysis, leading to aspiration. Dysphagia to both solids and liquids may suggest generalized neuromuscular incoordination or severe obstruction. If the dysphagia is sudden in onset, rule out trauma or ingestion of foreign body (chicken, fish bone, or denture), while in gradually progressive conditions, malignancy is the likely reason.[9] Furthermore, patients with dysphagia, due to mechanical cause, complain of symptoms at the start of the meal, while patients with motility disorder feel symptoms after several boluses. Thus, the mechanical obstructive one will regurgitate a single bolus for relief, while motility disorder patients will bring out a large amount of swallowed meal. Gastroesophageal reflux disease (GERD) presents with heartburn, and regurgitation with commonly seen extra-esophageal manifestations such as otitis media, laryngitis, cough, asthma, and aspiration pneumonia.

Medications are known to influence the process of swallowing, and therefore, a complete review of the medications should be carried out. Commonly three different reasons are attributable to drugs-side effects like dry mouth due to impaired salivary production, medicinal erosion or injury to the mucous membranes, and complication of the desired medication effect.[10] OD is a common occurrence with antipsychotics, benzodiazepines and antidepressants, antiparkinsonian and chemotherapy agents, anticholinergics, and antihistamines.[10] It is important to rule out any previous neuromuscular disease and head injury on history. History of any surgery on the oral cavity, pharynx, neck, and radiation therapy also should be asked for.

  What are the Causes of Dysphagia? Top

Aging results in cerebral atrophy, the decline in lean muscle mass, fat deposition in muscle fibers and decreased muscle strength, causing frailty, and dysfunctional swallowing.[11],[12] However, many of them remain asymptomatic due to compensation (reducing bolus or meal size and avoiding challenging food) despite the prolongation of oral and pharyngeal phases radiologically.[13] Therefore, dysphagia needs investigations to identify the potentially treatable cause. The various causes are enumerated below.

Neurogenic causes may be cerebrovascular accidents, head injury, degenerative disorders such as Parkinson's disease, Alzheimer's disease, or demyelinating diseases such as multiple sclerosis. The elderly may also be affected by myasthenia gravis, Guillain-Barre syndrome, tardive dyskinesia, and esophageal motility disorders such as achalasia and diffuse esophageal spasm. As highlighted above, various medications may aggravate cognitive dysfunction (anti-epileptics, anti-anxiety, and anti-emetics); cause xerostomia (anti-cholinergics, anti-psychotics, anti-depressants, opiates)[14] or pill esophagitis (tetracyclines, steroids, nonsteroidal anti-inflammatory drugs) and opioid-induced esophageal dysfunction needs to be kept in mind.[15]

Mechanical causes include laryngopharyngeal or esophageal tumors, thyroid masses, neck osteophytes,[16] Zenker's diverticulum, proximal esophageal web, distal esophageal rings (Schatzki) and esophageal stenosis following radiotherapy or head–neck surgery, scleroderma, Crohn's disease, foreign bodies, pressure by neck nodes, aberrant right subclavian artery, and enlarged left atrium. Eosinophilic esophagitis is being increasingly recognized on biopsies.

Sarcopenic dysphagia is another entity associated with age-related loss of skeletal muscles mass affecting swallowing-related muscles.[17] It is important to differentiate whether dysphagia is neuro-muscular or mechanical because etiology is the key to the management.

  What All to Examine? Top

In general, the physical for the level of alertness, orientation, and cooperation should be examined. The key cranial nerves involved in swallowing are Vth to XII except VI. The cranial nerve I is also examined if poor smell and taste is reported.

The face is examined for facial muscle function, lip closure, and jaw opening and closing. The oral cavity should be examined for tongue mobility, strength, teeth loss, mucosal irregularity and adequate saliva formation. The oropharynx was examined for soft palate mobility and any mass occupying the lumen. Check for gag reflex, larynx for vocal cord mobility, hypopharynx for pooling of saliva or growth, and neck for any mass (enlarged node or thyroid), laryngeal crepitus, and elevation on the dry swallow.

Water swallow test is done to identify the phase of swallowing with the disorder with 3 oz (90 ml) of water given for drinking without interruption, looking for drooling, cough, nasal regurgitation, aspiration, and voice post swallow.[18] The test has a high negative predictive value, hence those who pass the test need not go for further testing.

  How to Investigate the Patient? Top

Various investigations are available which help in defining the anatomic level-oro-pharyngeal/esophageal, the mechanism-neuro-muscular/mechanical, the quantum of dysfunction, and the specific pathology. Videofluoroscopy is considered the gold standard investigation in patients with OD.[19] If done in the presence of a speech therapist, it helps in the assessment of bolus manipulation, tongue motion, soft palate elevation, the elevation of the hyoid, laryngeal closure, cricopharyngeal muscle contraction, and aspiration.[20] Most information is provided by the lateral view; however, the anteroposterior view provides information of the laterality of bolus flow and the side of pharyngeal residue. The barium swallow study is the first investigation to be asked for in esophageal dysphagia. It is sensitive for both extrinsic (mediastinal mass, blood vessels, lymph nodes) and intrinsic (strictures, ring, achalasia, web, neoplasm) obstructions.[9] The assessment of the motor function of the esophagus is best done by low-density barium (100% g/v), as it flows easily and provides good contrast. In patients with a high risk of aspiration iodinated, nonionic contrast should be used. The patient is assessed in upright and prone oblique position to look for peristaltic contractions. Endoscopic evaluation is considered, if imaging is normal, for seriously ill patients on the bed and for evaluation of compensatory maneuvers.[9] Using fiberoptic scope, the upper aerodigestive tract is evaluated in both phonatory and swallowing tasks. Fiberoptic endoscopic evaluation of swallowing (FEES) with laryngopharyngeal sensory testing is done using endoscopically delivered standardized air puffs to the laryngeal mucosa to elicit the laryngeal adductor reflex (test for superior laryngeal nerve).[21] The biopsy may be undertaken from suspicious areas to diagnose eosinophilic esophagitis, Barrett's esophagus, or malignancy.[9]

Both videofluoroscopic swallow study (VFSS) and FEES are complementary to each other. The limitations of VFSS are the risk of radiation exposure and need to transport the patient to the radiology setup, besides the limited time of observation and lack of therapeutic intervention. The limitation of FEES is that the bolus in the oral cavity cannot be evaluated properly due to obscured view. It is also more invasive and can be quite uncomfortable to the patient.

If both VFSS and FEES fail to give some conclusive diagnosis, then high-resolution manometry is performed to measure the pressure and patterns of peristalsis. The solid catheter has 36 circumferential sensors sequentially placed at distances of 1 cm to quantitatively record pressure changes when passed through the nose into the esophagus. It may reveal dominant age-related changes, viz. increased upper esophageal sphincter restriction and pharyngeal contractility and reduced distal esophageal contractility and lower esophageal relaxation.[22] Esophageal pH monitoring helps in determining if acid reflux is present and is causing dysphagia by inducing “esophageal mucosa sensitivity.”[23] These investigations are further elaborated in [Table 1].
Table 1: Investigations in a case of dysphagia

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With recent advances in technology, new modalities for the evaluation of swallowing have come. Ultrasound is an inexpensive, radiation-free tool, to evaluate muscle morphology and oral, laryngopharyngeal kinematics.[28] Scintigraphy with nuclear tracer-laden bolus avoids radiation exposure and provides a good evaluation of early pharyngeal entry, pharyngeal transit time as well as postswallow pharyngeal residue.[29] Dynamic magnetic resonance imaging (MRI) allows real-time capture of all phases of deglutition with high-resolution evaluation of the anatomic structures.[30] For dynamic MRI, the test meal, like buttermilk, is spiked with gadolinium chelates. It avoids radiation exposure, but the recumbent position, the test being done, is not physiological for swallowing. The functional lumen imaging probe is helpful to quantify the radial force of esophagogastric junction sphincter strength and also a more accurate measurement of esophageal distensibility that affects bolus transport.[31] It is based on the principle of impedance planimetry and is particularly useful in the diagnosis of achalasia and eosinophilic esophagitis. An MRI brain may be indicated if the central nervous system nondegenerative and degenerative diseases are suspected.

  Specialists Involved in Dysphagia Management Top

An interdisciplinary team approach to the management of dysphagia in the elderly is essential to treat the pathology, reduce symptomatic dysphagia and improve nutrition and decrease the risk of laryngeal aspiration.[32] However, each professional's role may differ according to the responsibilities and resources allocated and standards of care. The various team members that need to collaborate are summarized in [Table 2].
Table 2: Specialists involved in dysphagia management

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The aim of treating the elderly with dysphagia is to have a secure swallowing mechanism, to maintain nutrition and prevent aspiration. The treatment is broadly classified as behavioral, medical, and surgical. After a review of medications potentially causing dysphagia, patient/caregiver should be counseled to avoid foods that are hard, fibrous, dry and chewy or crunchy or even large pills that may pose a choking risk.[41] Dietary modification in food texture and bolus size is the most common strategy in dysphagia management. Meat and bread commonly cause choking as they need more than 20 chewing strokes per bolus, which requires too much stamina and intact molars, often lacking in the elderly.[42] Thickening of liquid feed reduces aspiration in patients of OD but carries the risk of dehydration and urinary tract infection.[43],[44]

Certain postural adjustments can be taught to patients and caregivers, which are compensatory interventions that are helpful in a range of specific clinical conditions. Chin-up widens the oropharynx and helps the movement of the bolus from the mouth into the pharynx, which is useful in patients with the oral or lingual defects. Chin tuck improves airway protection during swallowing in patients with risk of aspiration, by closing the laryngeal vestibule, narrowing the oropharynx and reducing the distance between the hyoid bone and the larynx.[45] A head “turn” to the laryngeal/pharyngeal paralyzed side closes this paralyzed side preventing the retention and aspiration of the bolus. A head “tilt” to the stronger side directs the food bolus down the stronger side by gravity.[30]

Conservative management of GERD involves eating small meals, limiting fatty food, chocolate, alcohol, coffee, and not lying down after meals or elevation of the head end of bed. American Gastroenterological Association recommends proton-pump inhibitors (short term for healing erosive lesions and long term for symptom control) for patients with proven GERD.[46] Prokinetic drugs may be used to improve gastric emptying, reducing intragastric pressure and events of reflux. In addition topical therapy with sucralfate and dilation of peptic stricture may be done.[47] Occasionally, antireflux surgery like fundoplication may be needed.

Upper esophageal sphincter ablative therapies such as botulinum toxin injection, cricopharyngeal dilatation, and cricopharyngeal myotomy are the good therapeutic option in patients with cricopharyngeal bars and Zenker's diverticulum.[48] Open transcervical techniques have been replaced by less invasive endoscopic ones, with similar results.[49]

Achalasia treatment is not curative but is directed toward symptom relief. Depending on the stage of disease, it varies from pharmacological (oral calcium channel blockers/endoscopic botulinum toxin injection), balloon dilation, and myotomy to esophagectomy.[50] Esophageal stenosis is treated with opening (bougie or balloon dilatation) or removing the narrowed segment, depending on the specific cause. The esophageal stents may be inserted for palliation, to maintain the large internal lumen allowing the patient to eat a less restrictive diet.

Ineffective motility disorders can be managed conservatively by asking the patient to have meals in the upright position, chew well, and frequently take liquid during meals. Spicy food also helps by increasing the amplitude of esophageal contractions.[51] Spastic disorders of the esophagus are treated by smooth muscle relaxants (peppermint oil, calcium channel blockers such as nifedipine and nitrates) or neuromodulators (tricyclic antidepressants like amitriptyline).[52]

In the past, many head-and-neck cancer patients often experienced dysphagia in the postoperative period, however, with the usage of new surgical reconstruction techniques using a variety of flaps, it has become uncommon.[53] Similarly, previously following radiotherapy, long-term dysphagia was common due to xerostomia, oral mucositis, neuropathy, edema, fungal infection, and fibrosis-causing trismus.[54] Chewing gums, honey, lozenges, and synthetic saliva was often prescribed to increase salivary flow, as emollient or as salivary replacement.[55] With radiation dose restriction associated with intensity-modulated radiotherapy, this complication is not often encountered.

Finally, tube feeding via percutaneous endoscopic gastrostomy (PEG), or nasogastric tube (NGT) feeding is considered for enteral nutrition if conservative medical and surgical methods fail. PEG has a lower risk of aspiration pneumonia, especially in patients with retained secretions in the pyriform sinus or leaks into the laryngeal vestibule.[56] Although guidelines recommend PEG for long term and NGT for short term, many Asian countries continue to utilize the latter for long-term palliation.[57],[58]

The swallowing difficulty in the elderly leads to a multitude of health consequences. They may be physical such as asphyxiation, dehydration, malnutrition, frailty, or aspiration leading to pneumonia, thus increasing morbidity, hospital admissions/readmissions, and higher mortality.[59] Older adults, especially men, have seven times higher risk of choking than < 5 years old children.[60] Psychological problems such as social isolation and depression may occur as the patient avoids eating with family and friends, affecting the quality of life.[61] It also increases the burden on the caregiver (emotional, physical, and financial) and thus affects the psychosocial well-being of the entire family.[62] Mostly caregivers are the spouses, who themselves are aging and have their own healthcare needs. The children “sandwich generation” have difficulty balancing child rearing, elder care, and workplace demands.[63] Accordingly, an overall balanced approach with family support and supervised teamwork is essential to maintain nutrition and prevent anticipated complications.

  Conclusion Top

Dysphagia affects a significant number of the older population and is multifactorial. It is important to understand that many frail elderly with neurologic disease may have considerable but unrecognized dysphagia, with the potential risk of malnourishment, aspiration pneumonia, and related complications. Dysphagia diagnosis and management need a multidisciplinary approach. The treatment has to be disease specific and tailor-made on an individual basis. Structured assessment and appropriate approach to safer swallowing techniques, as elaborated, geriatric rehabilitation, and adequate palliative care is the keystone of management in most elderly patients.

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  [Table 1], [Table 2]


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