Joseph R. Anticaglia MD
Medical Advisory Board
Trouble swallowing in the elderly has received keen interest in recent years. Oropharyngeal Dysphagia — “OD” involves difficulty moving food or liquids comfortably from the oral cavity, mouth and throat, to the esophagus (food pipe). Some have proposed to characterize OD as a geriatric syndrome, a clinical disorder especially prevalent in the elderly.
More than 30 nerves and muscles are involved in the swallowing process.
Because of aging and illnesses, the elderly are particularly susceptible to damage to these vital nerves and muscles. Such damage often results in dysphagia (difficulty swallowing).
Ruth is a 76 year old lady who presented to the emergency room complaining of coughing, shortness of breath, having a fever and no appetite. Five years ago she suffered a stroke and according to the patient, “recovered 100%”. Her doctor is treating her for diabetes, hypertension and “high cholesterol.”
A chest X-ray report, done on her most recent visit to the E.R. indicated she had pneumonia. Upon further questioning, it was revealed she has been losing weight, had difficulty swallowing and experience several episodes of pneumonia over the past 14 months.
Oh previous visits to the E.R., she was given antibiotics, medications to thin the mucus, medications for her nerves and sent home. On this visit, Ruth was admitted to the hospital for further evaluation.
After many tests, different specialists and much expense, she was diagnosed as having pneumonia and dysphagia. The muscles in the mouth and throat were not working in a coordinated fashion. At times, food and liquids spilled across the voice box (larynx) into the wind pipe and lungs causing aspiration pneumonia.
Prevalence
The prevalence of dysphagia is expected to increase with the aging of the population in the United States. By 2030, it is estimated that 1 in 5 US residents will be age 65 years or older. Presently, about one-half of residents in nursing homes are reported to have feeding difficulties.
Although normal aging has been associated with a decline in nerve function, a reduction in muscle mass and cerebral atrophy, aging alone does not seem to be the sole culprit when it comes to dysphagia. Something else is at play.
Comorbidity
Comorbidity is the presence of two or more chronic conditions or diseases in a patient It is more common in the elderly. In Ruth’s case, the interactions of diabetes, hypertension, stroke (and the medication for her nerves) combined to disrupt the swallowing mechanism
In a previous post it was noted, swallowing “dysfunction can be due to anatomic changes (trauma, radiation therapy, post- surgery trauma, infections or cancer). It can also be caused by muscle weakness due to Myasthenia gravis or neurologic disorders such as Parkinson’s disease. Vascular lesions, e.g. stroke, can also disrupt the normal passage of food into the stomach.” There are many other examples of comorbidities that lead to dysphagia.
Drugs
Medications can interfere with the swallowing mechanism. They can disrupt the muscles in the mouth and pharynx preventing the easy passage of food and liquids to the esophagus.
Long term antibiotic therapy and chemotherapy have made it easier for painful infections to grow in the mouth and pharynx and more difficult to swallow. A detailed history of medical problems, current medications, allergies, previous surgeries are particularly relevant in the elderly.
Multiple diseases and medications are associated with advancing age. The European Society for Swallowing Disorders observes that oropharyngeal dysphagia is a “highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis.”
OD has been underdiagnosed and undertreated. Highly trained specialists and sophisticated tests are needed to properly treat this growing, geriatric population. Ruth half-jokingly once said, “Getting old is hard to swallow.”
REFERENCES
Anticaglia, Joseph R. MD; Dysphagia “Why Do I Have Trouble Swallowing?” H.C. Smart, 2017
Laura WY Baijens; Oropharyngeal Dysphagia as a Geriatric Syndrome; Clin. Interv. Aging; European Society for Swallowing Disorders; Published online 2016 Oct 7.
Reuben DB. Geriatrics syndromes. In: Beck AC, editor. Geriatrics Review Syllabus. 2nd ed. New York: American Geriatrics Society; 1991. pp. 117–231
Clave P, Rofes L, Carrión S, et al. Pathophysiology, relevance and natural history of oropharyngeal dysphagia among older people. Nestle Nutr Inst Workshop Ser. 2012;72:57–66. (Pub Med)
Crary MA, Groher ME. Introduction to Adult Swallowing Disorders. Philadelphia, PA: Butterworth Heinemann; 2003.
Muhammad Aslam MD and M.F. Vaezi MD, PhD, MSc Dysphagia in the Elderly; Gastroemterol Hepatol (N.Y.)2013 Dec; 9(12): 784–795.
Barczi SR, Sullivan PA, Robbins J. How should dysphagia care of older adults differ? Establishing optimal practice patterns. Semin Speech Lang. 2000;21(4):347–361. [Pub Med)
Cook IJ, Weltman MD, Wallace K, Shaw DW, McKay E, Smart RC, Butler SP Influence of aging on oral-pharyngeal bolus transit and clearance during swallowing: Am J Physiol. 1994 Jun; 266(6 Pt 1):G972-
This article is intended solely as a learning experience. Please consult your physician for diagnostic and treatment options.