Swallowing Disorders in the Older Population

Colleen Christmas, MD; Nicole Rogus-Pulia, PhD, CCC-SLP

Disclosures

J Am Geriatr Soc. 2019;67(12):2643-2649. 

In This Article

Causes of Dysphagia in Older Adults

Dysphagia is not itself a disease; rather, it results from a variety of medical conditions. Due to the high prevalence of dysphagia in older adults as well as its serious consequences, it has been suggested that dysphagia be considered its own geriatric syndrome.[1] The most common conditions leading to oropharyngeal dysphagia include stroke, head and neck cancer, or progressive neurologic disease (eg, dementia, amyotrophic lateral sclerosis, Parkinson disease). There are a multitude of etiologies of esophageal dysphagia, including esophagitis, achalasia, esophageal strictures, Zenker diverticula, and others. History can be helpful in considering etiologies to guide the appropriate workup. Esophageal dysphagia that begins only involving solid food but progresses over time to also include fluids is more suggestive of a mechanical issue, such as tumor or stricture, whereas esophageal dysphagia for both solids and liquids from the outset suggests a motor problem, such as achalasia. Medical interventions (eg, endotracheal intubation, tumor resection) and certain medications (eg, anticholinergics) also can result in dysphagia (Table 2).

Even healthy aging contributes to changes in eating, only some of which are related to swallowing per se. The aging process leads to alterations in olfaction and gustatory sensation that can affect appetite, dietary selection, and amount of oral intake. Sarcopenia (decreased muscle mass and quality with advancing age) has been shown to affect the muscles used for swallowing, given that they are of the skeletal type.[2,3] Due to these effects, the force generation capacity of the oral tongue has been shown to decrease with advancing age, which can lead to reduced pressure generation during the oral phase and poor bolus clearance.[4–7] Changes in the muscles of mastication result in slower and inefficient chewing, which increases the risk of asphyxiation.[8] Aging also results in lower salivary flow rates,[9] which, in combination with medication effects, can lead to the onset of xerostomia. Many medications older adults consume also contribute to decreased appetite, incoordination, and esophagitis, further exacerbating the problem. Thus, in an older adult with concerns related to eating, it is important to distinguish whether dysphagia is a significant contributor or if other factors predominate. When dysphagia contributes, the specific swallow impairments are sought, often with a combination of careful history, examination, and potentially instrumental assessment of swallowing, in conjunction with a speech language pathologist (SLP).

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