The Evaluation and Management of Swallowing Disorders in the Elderly
by Jo Shapiro, M.D., and Lorraine Downey, M.S., CCC-SLP
| Geriatric Times |
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November/December 2003 |
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Vol. IV |
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Issue 6 |
Swallowing disorders may or may not be inherent to aging, however, they are relatively prevalent in the elderly population. This is because dysphagia is associated with many disorders that are much more common in the older population (Fulp et al., 1990; Jaradeh, 1994; Sonies, 1992; Tracy et al., 1989).
Physiology
A brief review of the normal oropharyngeal swallowing mechanism will provide a framework in which to discuss the pathophysiology and differential diagnosis of dysphagia.
During the oral preparatory phase, the bolus has been prepared and is sitting between the tongue and the hard palate in a groove formed by the tongue. The oral phase starts when the tongue begins an anterior to posterior pumping motion that moves the bolus posteriorly. This phase ends when the bolus passes the anterior tonsillar pillars (Groher, 1992; Logemann, 1998). Tongue dysfunction, whether caused by a neuromuscular disorder, tumor or tethering of the tongue from postsurgical changes, will prevent normal bolus movement through the oral cavity.
Absent or poor dentition may impact adequate mastication of solid foods (Locker, 2002). During the oral phase, the lips and the buccal muscles help keep the bolus from deflecting either anteriorly out of the oral cavity or laterally into the gingivobuccal sulci (Groher, 1992; Logemann, 1998).
In the pharyngeal phase, the bolus is propelled by both the pumping action of the tongue base as well as the constriction of the pharyngeal muscles. The phase begins when the bolus has passed the anterior tonsillar pillars and ends when the bolus has passed through the pharyngoesophageal sphincter (sometimes known as either the cricopharyngeal sphincter or the upper esophageal sphincter) into the esophagus. During the pharyngeal phase, velopharyngeal sphincter closure prevents the bolus from regurgitating into the nose. Palatal dysfunction, such as is seen in some neurologic disorders, can lead to velopalatal insufficiency with resultant nasal regurgitation during swallowing, as well as hypernasality of speech (Groher, 1992; Logemann, 1998). Dysfunction of either the tongue base or pharyngeal constrictor muscles leads to poor bolus propulsion through the pharynx, manifested by pooling of secretions in the pharyngeal recesses and the subjective sensation of food sticking in the throat. The pooled bolus can then easily spill over into the larynx after the swallow when the larynx is no longer in a protected position.
It is also during this phase that the larynx is closed off to the bolus by several mechanisms: anterior-superior elevation of the larynx, allowing the larynx to assume a more protected position under the tongue base; epiglottic deflection; aryepiglottic and false vocal cord closure; true vocal cord closure; and cessation of respiration. Dysfuction of any of these mechanisms can cause aspiration (Groher, 1992; Logemann, 1998).
Finally, the pharyngoesophageal sphincter (PES) is opened by passive distention, inhibition of tonic intrinsic sphincter muscle contraction and a distraction force from the anterior-superior muscle pull of the suprahyoid muscles. Pharyngoesophageal sphincter dysfunction will lead to difficulties with the bolus passing from the pharynx into the esophagus (Williams et al., 2002). Each phase should last one second or less (Groher, 1992; Logemann, 1998).
History
The most common patient-reported symptom of dysphagia is choking. Because this is a lay term that means different things to different people, it is important to further elucidate what is meant. Generally, choking can mean either the bolus entering the airway (aspiration) or the bolus becoming lodged in the pharynx or esophagus. Most patients are able to distinguish which sensation they are having by answering questions such as, "Does it feel as if the food is going down the wrong passage and making you cough, or does it feel as if what you swallow is stuck in your throat and just won't go down?" If the patient determines that the difficulty is in bolus passage, the questions in Table 1 can begin to assess the pattern and severity of the symptom.
Clearly, dysphagia is more significant in the patient who has to regurgitate the bolus back into the mouth than it is in the patient whose food feels like it might get stuck, but never actually has.
If the patient's reported symptoms are more consistent with aspiration, knowing whether they cough during swallowing and whether they have had a history of pneumonia or chronic bronchitis gives some idea as to the severity of the dysphagia.
The following questions will further elucidate the disorder:
- Do you have any pain on swallowing?
- Are there food or liquid consistencies that you have to forgo because they are likely to be more difficult to swallow?
- Have you lost weight because of your swallowing difficulties?
Excessive throat phlegm is another common symptom of dysphagia because poor swallowing clearance will result in an accumulation of secrections in the pharynx (Murray et al., 1996; Warms and Richards, 2000). This is often mischaracterized by the patient as postnasal discharge or excess saliva production requiring frequent throat clearing or spitting.
Associated Disorders
A multisystem history should be directed to the following categories of disorders that are associated with dysphagia (Table 2).
Neuromuscular. Diseases that affect the central control over muscles and nerves involved in swallowing can cause dysphagia (Shapiro et al., 1996). These include cerebrovascular accidents, Parkinson's disease, amyotrophic lateral sclerosis (ALS) (Kazandjian, 1997; Strand et al., 1996), myasthenia gravis (Colton-Hudson et al., 2002; Salazar et al., 2000) and multiple sclerosis (De Pauw et al., 2002; Thomas and Wiles, 1999; Wiesner et al., 2002).
Primary muscle disorders such as oculopharyngeal muscular dystrophy are also associated with marked dysphagia, as well as ptosis (Perie et al., 1997; Young and Durant-Jones, 1997).
Rheumatologic. Diseases such as polymyositis, dermatomyositis (Maugars et al., 1996; Scola et al., 2000) and inclusion body myositis (Buchholz and Neumann, 1999; Houser et al., 1998) can cause significant dysphagia.
Head and neck oncologic. Oropharyngeal cancer, either primarily or secondary to surgery/radiation/
chemotherapy for such disorders, can cause dysphagia due to the restriction of tongue motion, weakness of tongue propulsion, pharyngeal muscle fibrosis or paralysis, vocal cord paralysis, or pharyngoesophageal strictures. An oropharyngeal tumor will usually cause significant odynophagia if it is large enough to cause dysphagia (Eisele et al., 1991; Kronenberger and Meyers, 1994; Lazarus et al., 2000; Martini et al., 1997).
Pharyngeal structural. Zenker's diverticulum is an outpouching of the pharyngeal mucosa between the upper border of the cricopharyngeus muscle (CPM) and the lower border of the inferior constrictor muscle. The precise etiology is unknown, but it is thought to occur as a result of either fibrosis of the CPM and/or a weakness in the pharyngeal muscle fibers at the CPM/inferior constrictor junction (Shapiro, 2002).
Gastrointestinal. Although disorders such as esophageal tumors, gastroesophageal reflux-related strictures and Schatzki rings are esophageal problems, they can often cause symptoms radiating to the pharynx and therefore should be part of the differential diagnosis in patients presenting with dysphagia (Fulp et al., 1990; Jalil and Castell, 2002; Shaker et al., 1993).
Physical Examination
Subtle voice changes may be heard in the patient with dysphagia. Diseases such as ALS can cause dysarthria (Kazandjian, 1997). Vocal cord paresis may be manifested by a hoarse or breathy voice. Aspiration of secrections can cause a "wet-hoarse" voice as a manifestation of secretions bathing the vocal cords (Murray et al., 1996; Warms and Richards, 2000). Palatal dysfunction may cause velopharyngeal insufficiency, resulting in a hypernasal voice as air leaks out of the nose during phonation (Yorkston et al., 1995).
The oropharyngeal examination may reveal absent or poor dentition, decreased tongue strength or mobility, asymmetric palatal elevation, or a mass in the oral cavity. A referral to an otolaryngologist is needed to assess the patient's pharyngeal structure and function. In addition to examining the patient for any signs of a tumor, the presence of pooled secretions in the pharyngeal recesses (such as the valleculae or pyriform sinuses) should be assessed. The mobility of the vocal cords also needs to be evaluated. A full head and neck examination also should be performed.
The two most helpful tests for evaluating patients with dysphagia are the swallowing videofluoroscopy (also known as a video swallow or modified barium swallow) and the barium swallow. The video swallow is performed with small boluses of varying texture, including liquid, paste and solids. The camera follows the bolus through the oropharyngeal phases of swallowing, and the test is recorded as a videofluoroscopic tape. The images can also be digitized and stored on disc. The test should be performed by a swallowing therapist in conjunction with a radiologist experienced in this technique.
To elucidate suspected oropharyngeal dysphagia, the video swallow is the best test because it focuses on the dynamic oropharyngeal swallowing mechanism. It can detail which portion of each phase of the swallow is dysfunctional, whether there is aspiration, and whether the patient has any natural compensatory mechanisms, such as coughing, in response to penetration (when the bolus gets into the laryngeal introitus) or aspiration (when the bolus passes the vocal cords into the trachea).
Perhaps even more importantly, the test can be used to guide swallowing therapy. The patient's swallow is tested with various textures and head positions in order to assess the optimal conditions for facilitating a functional swallow (Carrau and Murry, 1999; Logemann, 1993). The test is not useful for diagnosing oropharyngeal tumors, which are best diagnosed by physical examination.
If either esophageal structural or functional abnormalities are suspected, then a standard barium swallow is appropriate (Jones and Donner, 1991; Ling and Johnston, 2001). The limitations of using this test for diagnosing oropharyngeal dysfunction include: the camera focuses on the esophagus rather than the oropharynx; a large bolus size is used which is difficult for patients with aspiration; only liquid boluses are used which may fail to detect dysphagia for paste or solids.
Presentation and Management
Although there are many disorders in the elderly that are associated with dysphagia, several are illustrative in the management of dysphagia.
Parkinson's disease. These patients often have a tongue tremor that causes a characteristic to-and-fro motion during the oral phase of the swallow. This results in an ineffectual and prolonged oral phase (Jones and Donner, 1991; Perlman and Schulze-Delrieu, 1997; Yorkston et al., 1995). In addition, there is poor bolus propulsion through the pharynx resulting in pooling of the bolus in the pharyngeal recesses. This can result in aspiration when the pooled bolus spills over into an unprotected larynx (Clarke et al., 1998; Fuh et al., 1997; Groher, 1992). These patients may also have impaired efficacy of cough following aspiration (Marik and Kaplan, 2003). Treatment is directed toward optimizing the medical management of parkinsonism, as well as working with a swallowing therapist on optimal positioning and bolus textures (Ali et al., 1996; Fuh et al., 1997; Groher, 1992; Leopold and Kagel, 1997; Volonte et al., 2002).
Cerebrovascular accident. This often causes centrally mediated swallowing incoordination that results in aspiration (Groher, 1992; Perry and Love, 2001; Yamaya et al., 2001). If the video swallow demonstrates significant aspiration, time will frequently allow for partial or complete recovery. Sometimes interim non-oral feedings may be necessary (Leslie et al., 2003). Swallowing therapy also can be effective in improving recovery (Groher, 1992; Marik and Kaplan, 2003).
Zenker's diverticulum. As previously mentioned, this disorder is felt to involve an inadequately opening PES, as well as a weakness of the muscle just proximal to the upper border of the CPM, which results in an outpouching of the pharynx. The most common symptoms include:
- difficulty propelling solid boluses through the pharynx;
- regurgitation from the pharyngeal pouch of undigested food or liquid sometimes up to 24 hours after a meal;
- frequent awakening from coughing secondary to bolus regurgitation from the pharyngeal pouch;
- aspiration pneumonia from aspiration of the contents of the pharyngeal pouch.
Because the only treatment for a Zenker's diverticulum is surgical, the risks of a diverticulectomy and/or cricopharyngeal myotomy in an elderly patient must be weighed against the risks of severe aspiration pneumonia. There are several surgical approaches, and each should be detailed with the patient and family (Chiari et al., 2003; Crescenzo et al., 1998; Kelly, 2000; Shapiro, 2002).
In summary, although dysphagia may or may not be inherent to aging, it is relatively common in elderly patients because it is associated with other common disorders. The evaluation and management of each patient can be facilitated by cooperation between the patient's internist and other specialists, such as an otolaryngologist, gastroenterologist, neurologist, swallowing therapist and radiologist.
Dr. Shapiro is chief of the division of otolaryngology at Brigham and Women's Hospital. She is also the associate director for graduate medical education for Brigham and Women's and Massachusetts General Hospitals.
Ms. Downey is a senior speech-language pathologist at Brigham and Women's Hospital specializing in swallowing disorders.
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