dysphagia, geriatrics, swallowing training, quality of life

1. Dysphagia in the elderly
Sukanya Jongsiriyanyong
Faculty of Medicine Siriraj hospital , Mahidol University
17.Apr.2014

2. Ageing Society
WHO /DCO/WHD /2012.2
www.thelancet.com. Published online February 8, 2013
Population ageing
accelerating rapidly worldwide

3. HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed.
Lancet 2013; 381: 752-62.
Health and Quality of Life Outcomes 2009, 7:70.
Open Heart 2014;1:e000033.
Increased risk
of malnutrition
due to
inadequate
intake
Increased risk
of aspiration
pneumonia
Reduced
quality of life

4. Dysphagia: definition
• Difficulty or discomfort
– During the progression of the alimentary bolus
– From the mouth to the stomach
Gastroenterology Research and Practice 2011; Article ID 818979:1-13.
Clinical Interventions in Aging 2012; 7: 287–98.
Nutr Clin Pract 2009 ; 24(3): 395–413.
Geriatrics 2008; 63(5): 15-20.

5. Epidemiology
• Common in the elderly
– Aging changes
– Comorbid & treatment
• Prevalence of dysphagia
– Community-dwelling setting 15%
– Acute care/hospitalized setting 30%
– Institutional setting 40-68%
Geriatrics 2008 May;63(5):15-20.
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed
Clinical Interventions in Aging 2012; 7: 287–98.
Ann Otol Rhinol Laryngol. 2007 Nov;116(11):858-65.
Gastroenterology Research and Practice 2011; Article ID 818979:1-13.

6. Prevalence of oropharyngeal dysphagia
- Alzheimer’s disease 84%
- Dementia up to 45%
- Parkinson’s disease 52-82%
- Cerebrovascular accident 30-64%
- Regain spontaneously within 1 month
- Some still dysphagia beyond 6 month
- Aged >= 65 years Up to 40%
Gastroenterology Research and Practice 2011; Article ID 818979:1-13.
Clinical Interventions in Aging 2012; 7: 287–98.

7. HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed
“Swallowing process”
Requires orchestration of a complex series of psychological,
sensory & motor behaviors
Voluntary & involuntary
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed
Nutr Clin Pract 2009; 24(3): 395–413.
Direction
of
bolus flow
Oral cavity
Tongue
Salivary gland
Nasopharynx
Oropharynx
Hypopharynx
Epiglottis
Vestibule of larynx
False & true vocal cord
*
*
*

8. Tongue “loading”
Completion of
oropharyngeal
swallowing
Upper esophageal
sphincter opening
anticipating bolus arrival
Linguapharyngeal contact
*
*
“Swallowing phases”
-Oral preparatory (A)
-Oral propulsion (B)
-Pharyngeal phase (C-D)
-Esophageal phase (E)

9. Aging change on swallow function: Presbyphagia
• Motor changes
– Reduction in muscle mass & connective tissue elasticity
• Loss of strength (tongue) & range of motion
– Slower oropharyngeal phase of swallowing
• Slow transit of material
• Non-motor changes
– Decrements in oral moisture, taste, and smell acuity
• Reduced swallowing performance in the elderly
Clinical Interventions in Aging 2012; 7: 287–98.
Nutr Clin Pract 2009 ; 24(3): 395–413.
Gastroenterology Research and Practice 2011; Article ID 818979:1-13.

10. Nutr Clin Pract 2009; 24(3): 395–413.
Age-related change in
lingual pressure
More pooling/pocketing
in the pharyngeal recesses
Increasing the risk of adverse
consequences due to ineffective
deglutition

11. Etiology of dysphagia
• Neurological diseases
– Neurodegenerative disease
– Stroke
– Traumatic brain injury
– Peripheral neuropathy: Guillain-barre syndrome
– Myopathy
• Medications
• Others
– Tumor of aerodigestive tract, radiation, chemotherapy
– Rheumatologic disease
• PM/DM, systemic sclerosis
Clinical Interventions in Aging 2012; 7: 287–98.
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed
Nutr Clin Pract 2009 ; 24(3): 395–413.
Gastroenterology Research and Practice 2011; Article ID 818979:1-13.

12. HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed
Nutr Clin Pract 2009 ; 24(3): 395–413.

13. Warning signs of dysphagia
• Decrease alertness/cognitive dysfunction
• Changes in approach to food
• Manifestations of impaired oropharyngeal functions
Complaints or observation
– Swallowing difficulty/sensation of obstruction
– Regurgitation of food or acid
– Drooling
– Weight loss unintentionally
– Impaired breathing during or immediately after meals
– Pain on swallowing
– Leakage of food or saliva from tracheotomy site
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed
Nutr Clin Pract 2009; 24(3): 395–413.

14. Gastroenterology Research and Practice 2011; Article ID 818979:1-13.
• Clinical diagnosis
– Deglutition-specific medical history & clinical
examination
– “Screening methods”
• Exploration of deglutition: oropharyngeal dysphagia
– Gold standard
• Videofluoroscopy (VFS)
– Alternative
• Fiberoptic endoscopic evaluation of swallowing (FEES)
Diagnosis
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed

15. HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed
“Do you have difficulty swallowing food?”
100% sensitivity & 75% specificity
in detecting swallowing difficulties
in patients with parkinsonism

16. “Water swallowing”
1st: listen to voice, tongue
movement
2nd: 1-tsp-water x10 times:
say “Ah” each time
swallowing: ?wet voice?
then 1 cup of water
3rd: say “Ah”
“Toronto-bedside
swallowing screening test”

17. Gastroenterology Research and Practice 2011; Article ID 818979:1-13.
V-VST
(volume-viscosity
swallow test)
Cough
Fall in
%O2sat
>= 3%
Changes
in quality
of voice
• Sensitivity for
impaired
safety
88.2%
• Sensitivity for
aspiration
100.0%
• Sensitivity for
impaired
efficacy of
swallow
88.4%

18. Stroke. 2012;43:892-7.
Valid Items for Screening
Dysphagia Risk in Patients With
Stroke: A Systematic Review
The best combination of
non-swallowing &
swallowing items
as well as
the best swallowing protocol
remains unclear
Need valid clinical screening
instruments

19. Gastroenterology Research and Practice 2011; Article ID 818979:1-13.
-Swallowing
3-20 mL
boluses of >= 3
consistencies:
liquid, nectar,
pudding
: start with low
volume and thick
consistencies
“Videofluoroscopy (VFS)”
Most characteristic
aspiration-related
parameters
-Slow closure of
the laryngeal
vestibule
-Slow aperture
of the upper
esophageal
sphincter

20. Fiberoptic Endoscopic Evaluation of Swallowing
(FEES)
• Advantages
– Not exposed to x-ray
– Its repeatability
– Use of real food & fluid during the assessment
• Disadvantages
– Limited visualization of the dynamic oropharyngeal swallow
– Nosebleed, mucosal injury, gagging,
– Allergic reaction to the topical anesthesia
– Laryngospasm
– Vasovagal response
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed

22. Clinical Interventions in Aging 2012; 7: 287–98.
• Nutritional assessment
– If malnutrition (SGA: B-C): nutritionist role to improve
nutritional status first!!!!
• Swallowing management
– Multidisciplinary team
– No single strategy is the best for all
• Compensatory management
– Postural adjustments
– Swallow maneuvers
– Diet modifications (modification of foods/liquids)
• Swallow rehabilitation
Dysphagia management

23. Gastroenterology Research and Practice 2011; Article ID 818979:1-13.
Multidisciplinary
dysphagia team
1st _ 2nd - 3rd
Optimal strategies
to increase safety &
enjoyment
Swallowing
Clinical
Specialist
Radiologist, Geriatrician,
Nutritionist, others
Dentist or hygienist, gastroenterologist,
otolaryngologist, oncologist, neurologist
Nutr Clin Pract 2009 ; 24(3): 395–413.
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed

24. Dysphagia in the elderly
• Complicated management among geriatric patients
– Cognitive decline
– Malnutrition
– End-of-life decisions
Clinical Interventions in Aging 2012; 7: 287–98.
Nutr Clin Pract 2009 ; 24(3): 395–413.

25. Clinical Interventions in Aging 2012; 7: 287–98.

26. Gastroenterology Research and Practice 2011; Article ID 818979:1-13.
Example of swallow maneuvers: supraglottic swallow

27. Advanced Mechanical-altered Pureed
Nectar-like Spoon-thickhoney-like

28. Clinical Interventions in Aging 2012; 7: 287–98.

29. Promising modality
• Tongue pressure profile training for dysphagia post
stroke (TPPT): study protocol for an exploratory
randomized controlled trial
– Tongue pressure profile training (TPPT) vs Tongue
pressure strength-and-accuracy training (TPSAT)
– To develop interventions
– Restore functional swallowing ability
– In individuals unable to swallow thin liquids safely
Steele et al. Trials 2013; 14:126.

30. Food & liquid rate & amounts
• Eat slowly, not rushed
• Small amounts of food/liquid
• Concentrate on swallowing
• Avoid mixing food & liquid in the same mouthful
• Use stronger side of the mouth (unilateral
weakness)
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed

31. World J Gastrointest Pathophysiol 2013; 4(4): 119-25.

32. Management of patients with stroke: identification and management of dysphagia A national clinical guideline. NHS Evidence 2010.

33. Route of enteral nutrition
• 11 mo- follow up
– Incidence of complications of tube feeding
• At 2 weeks post-intubation
– Diagnosed with aspiration pneumonia
• 43% of NG tube
• 56% of gastric (G) tube
– Agitated and/or self-extubated (restraints/sedation)
• 67% of NG tube
• 44% of G tube
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed

34. Route of enteral nutrition
• Late complications
– NG tube group
• 44% incidence of aspiration pneumonia
• 39% incidence of self-extubation
– Gastrostomy group
• 56% incidence of aspiration
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed

35. Enteral tube feeding: advanced dementia
• 7 observational controlled studies
– 6 (mortality) & 1 (nutritional outcomes) & none (QoL)
• Findings
– No benefit: survival, nutritional status, prevalence of
pressure ulcers
– Lacking on the adverse effects of enteral tube feeding
• ? Benefit of enteral tube feeding in patients with
advanced dementia
Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007209.

36. Parenteral or enteral nutrition
• Parenteral nutrition
– Advantages in safety
– Equivocal physiologic & clinical outcomes
– Cost
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed

37. Modernized medicine
Palliative care Main idea
Aim Ready
Nature
Malignancy
Dementia
CHF
COPD
ESRD
Cirrhosis

38. Palliative care Doing nothing
Humanized medicine
การดูแลรักษาอย่างมีมนุษยธรรม

39. Palliative
care
Main idea
Aim Ready
Nature
World Health Organization 2008.
HAZZARD’S GERIATRIC EDICINE AND GERONTOLOGY Sixth Edition.
Interdisciplinary
care
To relief of
suffering &
achieving best
quality of life
For patients & their
loved ones

40. Palliative
care
Main idea
Aim Ready
Nature
1. Communication: breaking bad news, accurate
diagnosis, advance care planning/goal of care
2. Symptoms control
3. Disease management
4. Psycho-social-spiritual care
Memory
Comprehension
Decision making
Denial
Bargain
Anger
Depression
Acceptance

41. • Loss of appetite, weight loss & tissue wasting
• Impacts quality of life for patients & carers
Clinical
features
• Body weight/screening tool
• Reversible causes: pain, oral ulcer, medication
• Patient & carer perspectives on weight, body
image, nutrition, dietary intake
Assessment
• Nonpharmacological management
• Px causes, small & frequent meal
• Enjoy moment
• Pharmacological management
Management
Geriatric review syllabus Seventh Edition.
Am J Med Sci 2011;342(6):513–518.
Palliative Care Guidelines: Specialist Palliative Care Services in NHS Lanarkshire2013.
Anorexia & cachexia

42. • Short-term improvement of appetite
• Rapid effect; decrease efficacy@3-4 wk
• Improve well being; no significant effect on nutritional status
• Oral dexamethasone 4mg/prednisolone 30mg in the morning x 1 wk
Corticosteroids
• Need few weeks to benefit & more prolonged effect than steroids
• Megestrol acetate : starting 160mg orally daily x 1 month (160-800mg)
Progestogens
• Decrease nausea & early fullness
• Metoclopramide 10mg or domperidone 10-20 mg tid before meals
Prokinetics
Geriatric review syllabus Seventh Edition.
Nihon Ronen Igakkai Zasshi 2004;41(5):460-7.
Am J Med Sci 2011;342(6):513–518.
Palliative Care Guidelines: Specialist Palliative Care Services in NHS Lanarkshire2013.
Anorexia & cachexia: medications

43. *

44. DIETARY GUIDELINES FOR AMERICANS, 2010
Nutritional
status • Important determinant of
– Health
– Physical & cognitive function
– Vitality
– Overall quality of life
– Longevity
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed.

45. Thank you