Introduction and Overview
This course is a great topic – The aging swallow. Most of us have had graduate courses in dysphagia; those have been pretty standard over the past couple of decades in graduate programs. However, what I think may be lacking in our knowledge is related to what an aging swallow looks like. What is normal, and what is not?
I realize some of you may be retired, work in a school setting, or may just have friends or family who are aging. Even if you do not work with the adult population, it is great that you have joined us today, because really, this is something that any SLP, no matter the setting, should have a basic knowledge of.
Presbyphagia vs Dysphagia
Presbyphagia is the decline in swallowing that is associated with normal aging, and normal aging changes are not considered a disorder. However, when you add in secondary factors, multiple medical comorbidities, other health factors, diseases, etc., then the risk of dysphagia increases. A study by Roy and colleagues (2007) looked at the aging population, which generally refers to people aged 65 and above. Thirty-three percent of people surveyed in this investigation reported that they were currently having difficulties with swallowing. That means one-third of the people who were in this investigation!
With dysphagia, the statistics on the incidence in the aging population really varies. The more comorbidities, the more disease processes that a patient has, the higher the likelihood that the patient will actually have dysphagia instead of presbyphagia. It is estimated that between 300,000 and 600,000 Americans per year experience dysphagia. The Center for Disease Control said that in 2014, there were 1.4 million Americans living in skilled nursing settings with dysphagia. That means that about 65 to 70% of patients in long-term care are reporting some type of dysphagia. Let's think about that: how many of those patients are on altered diets? Or how many patients who do not report dysphagia are on altered diets? You begin to see how much of a focus this needs to be.
When you have disordered swallowing, it can lead to aspiration and result in aspiration pneumonia. It can lead to modification of diets or liquid consistencies. It can lead to weight loss, failure to thrive, and inability to maintain nutrition or hydration. It can also lead to depression, social withdrawal, isolation, or even death. When you are writing your evaluations, it is important to include a medical necessity statement about what will happen or what could happen if you do nothing for this patient.
When we look at weight loss, what should we consider? According to the National Institutes of Health (NIH), weight loss of 5% in one month or 10% over six months is considered unhealthy, and it is associated with an increased mortality rate. That is why - for those of you who may be in an assisted living/residential long-term care setting - weight loss is a quality measure (QM) that is carefully monitored by the Center for Medicare and Medicaid Services (CMS).
The Normal Aging Swallow
Let's talk about the normal aging swallow, presbyphagia. For someone who is 65 years old or older with a normal swallow, you will see decreased strength in lips, tongue, mandible, pharynx, and larynx. That is normal. That decreased strength is going to mean more time to initiate the swallow, to prepare the bolus, and to manipulate the bolus. Decreased lingual and pharyngeal strength can also lead to the necessity of multiple swallows to clear the valleculae. Typically, patients will clear their vallecular space on their own. However, when there is a disorder, many times that will not occur. That is how you can differentiate between normal and disordered swallowing. Infrequent penetration, especially on liquids, is somewhat normal, but frequent penetration or deep penetration or even aspiration is abnormal. The penetration should not reach the level of the vocal folds. When it does, it is on the penetration/aspiration scale.
Xerostomia, dry mouth, is common. The salivary glands are not producing as much saliva, and when you do not have as much saliva then it becomes a little harder to talk. In addition, it also leads to difficulty forming a cohesive bolus. If your mouth is very dry, the saliva is not there to mix with the food and form that cohesive bolus. These are the patients who may be taking sips during the mastication process.
The upper esophageal sphincter opening may not fully relax in normal aging motor function. This can cause the globus sensation; that is, of food or pills “getting stuck.” The peristaltic wave of the esophagus is also weakened, and that is called presbyesophagus. And then, the vocal folds will normally begin to atrophy or thin somewhat. Sometimes you might see some slight bowing as well.
As we talked about, the oral phase is a little bit prolonged in normal aging. Nikhil and colleagues (2014) published the following information: In a normal adult, the initiation of the swallow after anterior to posterior (A-P) transfer is approximately one second. For a normal aging person, it is approximately 1.2 seconds. Anything beyond that can be considered disordered.
As you age, the sense of taste decreases with age. Your sense of smell decreases. Do any of you know the last taste that patients will have remaining? Sweetness is the last taste to go. With patients who are in hospice or patients who have decreased PO intake and say the food just does not taste normal, or just does not taste good, sometimes you can actually trick the taste buds a little bit by adding sugar or sweetener to the food. That is a great trick for patients with dementia as well. The decrease in smell, of course, also goes hand in hand with that declining taste ability.
We already talked about the reduction of saliva secretion. The sensitivity of the vocal folds decreases. Vocal folds thin, and that can lead to an inability to fully protect the airway during the swallow.
Other Factors of Aging
There are changes in nutritional requirements that come with aging. Patients do not always need as many calories as they once did. Their metabolisms are slowing down. They are not quite as active, and they do not need as many calories. So you may see the PO (oral) intake decrease slightly, and that is absolutely normal.
Nutritional requirements for patients are also going to change. Vitamin D deficiencies can occur. Patients are outdoors a lot less. They are indoors more, so they are not getting the natural vitamin D from sunlight, and that can contribute to vitamin D deficiency.
A decrease in calcium can also affect bone health. That is when you start seeing osteoporosis, and patients who are more likely to have bone fractures. There are also decreases in protein, which goes along with decreases in muscle mass. We will talk about sarcopenia in a little while, but you need protein for muscle mass.
Nutritional supplements are often prescribed in order to maintain patients' weights. Sometimes patients get appetite stimulants as well. Patients will get nutritional supplements in the form of drinks, or sometimes chews.
You will also see changes in dentition. The teeth are shifting. There may be tooth loss. The patient may have lost her teeth earlier and may have dentures, but if she starts losing weight, her dentures do not fit as well.
You also may see kyphosis, or changes in posture. Kyphosis is that slumped posture that you often see within the aging population. That can lead to posture that is not appropriate for adequate PO intake.
Etiologies of Dysphagia
Static neurological disorders such as strokes and superior laryngeal nerve (SLN) palsy can cause dysphagia. With SLN palsy, you will see reduced bolus control, decreased or incomplete vocal fold closure, some pretty severe bowing of the vocal folds, and decreased airway protection.
Then there are progressive neurological disorders. Those are amyotrophic lateral sclerosis (ALS), muscular sclerosis, Parkinson's disease, Alzheimer's disease, myasthenia gravis, and Duchenne muscular dystrophy. With progressive neurological disorders there is a lot of incoordination of the swallow, increased risk of aspiration, and increased time for mastication and bolus manipulation. Especially in patients with Parkinson's disease, there will be a lot of issues with respiration -- the breathe/swallow cycle. In patients with Alzheimer's, there is reduced awareness of the food in their mouths, so they may start pocketing and holding food in their mouths, and displaying decreased clearance of the bolus and more stasis in the oral cavity.
Cancer is another etiology. Tumors for head and neck cancers, radiation, and chemotherapy can all have major effects on swallowing. Many times, for patients with head and neck cancer who are going to undergo radiation or chemotherapy, the doctors or the medical team will suggest a feeding tube because of the sores that are in the mouth, the intense nausea, and the effects of the radiation. If it is not head and neck cancer, chemotherapy or radiation can still cause dry mouth and sores in the mouth, and so the causes of dysphagia are not due to head and neck cancer alone.
There are also pharyngeal disorders that can cause swallowing problems, such as Zenker's diverticulum or cricopharyngeal achalasia. There are gastroesophageal disorders as well. Gastroesophageal reflux disease (GERD) is probably the most common, but you also see patients with hiatal hernias, esophageal strictures, or with Barrett's esophagus. In the aging population, things that affect GERD include the kyphotic positioning, reduced mobility, lying down more. All of these factors are going to increase the likelihood of reflux because the patient is immobile or is not at an upright position, and so that is going to increase their aspiration risk as well.
Lastly, there are chronic conditions that cause dysphagia, such as diabetes, chronic obstructive pulmonary disease (COPD), arthritis, etc. Arthritis is not just in the fingers and the toes; it can be anywhere in the body. And then many times, with patients with COPD, you see very poor respiratory support. They are masticating, but during that mastication process, they have to stop chewing to try to breathe because they cannot chew and breathe at the same time. They get winded very easily. The breathe-chew-swallow sequence is interrupted. That is where expiratory muscle strength training, which we will talk about a little later on today, can be very beneficial.
Other Factors in Dysphagia
Polypharmacy can contribute to dysphagia. The more medications a patient is on, the higher the risk of polypharmaceutical side effects. For those of you who work in healthcare settings, especially those who work in long-term care settings, I saw a figure that said anything over seven medications puts the patient at a huge risk for polypharmaceutical side effects on cognition as well as swallowing. I chuckled at that a little bit because in the setting that I work in, what patient does not have seven medications? Most of them come in with a laundry list of medications. And depending on what the medications are, they can decrease the appetite, increase gastrointestinal (GI) issues, or cause xerostomia. They can cause sores or ulcers in the mouth. So while a medication may be helpful for one condition, it may actually cause issues with another condition, and then you add a second medication and it just kind of snowballs.
Sarcopenia is the loss of muscle mass or strength. You usually see this in individuals over the age of 50. Once a patient hits the age of 50, anything over a 1/2 to 1% loss per year is actually considered a disorder. One study that I referenced found that in adults over age 70, about 1/3 have sarcopenia or loss of muscle mass.
Effects of Dysphagia
In your current setting, what do you feel is the biggest challenge related to dysphagia? Is it dislike of the current diet consistency? Is it families who are non-compliant with diet recommendations? Is it weight loss? Or is it something else? Wow, this is overwhelming, 83% of you say that your number one challenge is dislike of current diet consistency. I would say that is mine as well. I see a lot of issues with non-compliance as well, though. When you have patients who dislike their current diet consistency, there is a fine line to walk because you know what is probably the safest diet consistency with the least risk. However, you have to weigh the benefits versus the risks. If the patient is somewhat safe, but maybe not always safe, and is going to maintain his nutrition and hydration better on a specific diet consistency, then that needs to be something we think about.
I am hoping that those of you who work with adults or are making diet recommendations have at some point actually tried every consistency. I hope you have tried the pureed trays, the mechanical soft trays, and the liquid consistencies that you actually give to patients in your facility. If your facility uses the powder-based thickener, try that. If you use pre-thickened or pre-packaged then try them. It is my firm belief that I should not give a patient anything that I have not tasted myself. For those of you who have tasted these thickened liquids, they are not necessarily the most palatable stuff that you have ever experienced. Because according to what type of thickener is used, you can have some graininess, or some little globs of gels. I have some sensory issues sometimes with things like Jell-O® and thickened liquid gelatins, so I would not be the perfect candidate for thickened liquids.
One of the effects of dysphagia is decreased motivation or enjoyment for eating due to the social isolation, activity limitations, increased effort and time to eat, or embarrassment. One night I was at a restaurant and I actually saw a gentleman pull out a pack of thickener and thicken his wine. I commend him for acclimating to the point where he knows what is best for him and it does not matter. But other patients may be very embarrassed to be out in public.
Here is a story about a lady I treated at one point. She had had a motor vehicle accident and had been seven years with nothing by mouth (NPO). This lady’s goal was to be able to eat when she took her son out every week. She lived in a residential facility - skilled long-term care - and her son lived in a residential facility for adults with mental disabilities. Her weekly outing was to go to a restaurant with him. That was their special time every week. When she came to me, her goal was to not just sit there and watch him eat, because he did not want to eat if she could not eat. Her goal was to be able to take a few bites or a few sips of something during that weekly meal with her son. We did some pretty intensive therapy, and after a couple months of really intense strengthening, we got her where she could tolerate nectar-thickened liquids and a mechanical soft diet. The first time I watched her take a bite of something to eat after not having anything for seven years, her eyes lit up. I will never forget it -- it was chocolate pudding. She just had a glow, and she said, "That is the best chocolate pudding I have ever had in my entire life."