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

Assessment of Swallowing

Despite the frequency with which swallowing problems are encountered in clinical medicine, there is a striking paucity of evidence on which to base recommendations for evaluations and treatments. In evaluating swallowing function, an SLP is a critical team member when oropharyngeal dysphagia is suspected. Esophageal dysphagia is typically evaluated by endoscopy or barium swallow (esophagram), often in partnership with a gastroenterologist to identify and treat the underlying etiology. If both oropharyngeal and esophageal dysphagia are likely, one may utilize a combined videofluoroscopic swallow study with a barium swallow.

No clear guidelines on when to consult an SLP exist; most clinicians consider consultation when there are signs and symptoms of swallowing problems or when the patient has newly developed a clinical condition highly associated with swallowing problems. More recent shifts in paradigms of care for older patients with neurodegenerative conditions (eg, Parkinson disease, dementia) have resulted in the inclusion of the SLP in geriatrics and memory clinics as a member of the interdisciplinary team to allow for his/her involvement from diagnosis through end of life. Signs and symptoms of swallowing problems are coughing while trying to swallow, nasal regurgitation of food, wet vocal quality after swallowing, poor secretion management, weak cough, or a feeling of food getting stuck or requiring regurgitation. Concerns may be heightened in patients with known neurologic or aerodigestive impairments that increase the risk of swallowing disorders, such as stroke, or patients with head and neck treated with chemoradiation. Further, it is important that the patient is able to participate in the clinical and/or instrumental swallowing assessment and any recommendations made based on the results of this assessment, such as swallowing exercises. Thus, performing swallowing assessments on delirious patients who cannot fully participate may be futile. Finally, a swallowing evaluation by an SLP can be pursued to gather further information when the clinical scenario is unclear. There are two main types of swallowing evaluations: a clinical evaluation, often at the bedside, and an instrumental assessment, which includes videofluoroscopic swallowing studies (VFSSs) and fiberoptic endoscopic evaluations of swallowing (FEES). There are advantages and drawbacks to each and limited guidance in terms of preferred approaches for various clinical scenarios. Older adults have higher rates of silent aspiration than younger adults, further making clinical bedside evaluations less reliable in those for whom this is suspected. Further research is indicated to identify patients for whom these examinations are most useful prognostically and therapeutically.

When evaluating a patient for oropharyngeal dysphagia, the SLP begins the assessment with a clinical evaluation that involves a thorough review of medical history, an interview with the patient and/or caregiver/family, a cranial nerve examination, and administration of liquid and food of varying textures and sizes. The goal of the clinical evaluation is to determine whether signs of dysphagia are present, warranting further evaluation with an instrumental assessment. The SLP also gains valuable information about the patient's reported symptoms, cognitive state, fatigue during a meal, posture, positioning, environmental conditions, and readiness for further evaluation. There is insufficient evidence linking these assessments to clinically meaningful outcomes, and the data supporting bedside evaluations alone to determine treatment interventions are not supported by evidence.[10,11]

The VFSS is the most common type of instrumental assessment. During the VFSS, various volumes and viscosities of barium are administered, and the oropharyngeal region is visualized radiographically. The SLP can determine the specific swallowing impairments present as well as the safety and efficiency of the swallow. The SLP also uses this study to determine whether certain intervention strategies (eg, postural changes, dietary modifications, swallowing maneuvers) are effective in improving swallow function, which guides the treatment plan. During FEES, a flexible endoscope is inserted through the nose and into the upper pharynx. This allows for visualization of the pharyngeal and laryngeal anatomy as well as the swallowing process while the patient is eating and drinking regular foods/fluids.

In a retrospective study of nursing home patients followed up for a year, researchers showed that aspiration on VFSS predicted rehospitalization but not pneumonia or pneumonia death.[12] In another cohort study, aspiration on VFSS predicted both pneumonia and death, but not dehydration, in patients with stroke followed up for 16 months.[13] Hospitals adherent with dysphagia screening programs after stroke tended to have lower rates of pneumonia than those that did not utilize dysphagia screening protocols in one study;[14] this association cannot prove causation but is intriguing. While results of some clinical evaluations and instrumental assessments (eg, VFSS and FEES) have been shown to be associated with important outcomes for patients with dysphagia, others have failed to demonstrate this benefit;[15] more research focused on understanding the benefits and drawbacks of these evaluation techniques is needed.

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