Review Article

iMedPub Journals Medical & Clinical Reviews 2016

http://www.imedpub.com/ Vol.2 No.1:5
ISSN 2471-299X

DOI: 10.21767/2471-299X.100014

Dysphagia: A Geriatric Giant?

David G Smithard1,2*
1King’s College Hospital NHS Foundation Trust, London, UK
2Department of electronics and Digital Arts, University of Kent, UK
*Corresponding author: Smithard DG, Geriatrician, King’s College Hospital NHS Foundation Trust, London, UK, Tel: +44 1689 863000; E-mail:
David.Smithard@nhs.net
Rec date: Dec 31, 2015; Acc date: Jan 22, 2016; Pub date: Jan 25, 2016
Copyright: © 2016 Smithard DG. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Table 1 Factors required to be considered as a Geriatric Giant.

Abstract
Factor for Geriatric Giant Dysphagia
With increasing age there are changes to the physiology Age ✓
of all aspects of swallowing. Despite these changes, the
majority of older people will swallow safely. With Symptom ✓
increasing frailty the number of people presenting with
Cognitive Function (✓)
dysphagia increases either in the presence of acute illness
or with co morbidity; with significant number living in Functional Impairment (✓)
institutions.
Common ✓

The aetiology of dysphagia is multiple and is associated Multifactorial ✓

with increased dependency and mortality and as such
Morbidity ✓
dysphagia meets the criteria to be classified as a geriatric
syndrome or giant. Outcome ✓

This paper presents the case for dysphagia to be

recognised as a geriatric giant. The Normal Swallow
The essential function of the swallowing process is to
Keywords: Physiology; Dysphagia; Respiration
transfer food from the mouth to the stomach via the
oesophagus, a simple, but complex process. The process of
swallowing is separated into three phases, oral, pharyngeal
Introduction and oesophageal [2,3]. The oral phase, to be efficient, requires
adequate lip closure, a functioning tongue and the presence of
The worldwide population is increasing, such that it is saliva; the pharyngeal phase is a transfer phase between the
predicted that there will be 2 billion over the age of 65 years mouth and the oesophagus, but it is a shared space with
by 2050; the greatest proportional increase will be in those respiration. Therefore the airway needs to be protected during
over the age of 85 years. Accompanying this will be an increase this phase. Then to enter the oesophagus the upper
In people living longer with long term conditions and a oesophageal sphincter or cricopharyngeus needs to relax.
consequent increase in frail older people.
The pharyngeal phase of the swallow is a complex reflex, co-
Old age is frequently accompanied by many long-term ordinated by the swallowing centres within the medullary
conditions that affect health. Many old people will have pontine area of the brainstem [4] This reflex is modified via the
multiple long-term conditions (e.g. ischaemic heart disease, feedback loop between the pharynx, hyoid muscles and
diabetes, dementia). tongue to the cortex regarding bolus characteristics (volume
Dysphagia, difficulty in swallowing, will accompany many and consistency), which then regulates the timing of events
long term conditions and may be latent in many frail older during the pharyngeal swallow, but not the sequence of events
people, and is associated with increasing dependency and [5,6].
death. The time has come to fully recognise dysphagia as a Protection of the airway is a complex process that involves
Geriatric Giant /Syndrome. the closure of the larynx by the false and true vocal folds,
To be recognised as a Geriatric Syndrome/Giant [1] elevation and rotation forward of the larynx and backward
dysphagia has to meet accepted recognised criteria (Table 1). pressure from the base of the tongue. The Naso-pharynx is
This short paper will outline the reasons why it should be protected by elevation of the soft palate and the forward
considered thus. movement of the posterior pharyngeal wall. As the larynx

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closes off, respiration ceases to be followed by expiration There is a reduction in proprioception both in the tongue and
when the swallow has been completed. lips reducing the ability to identify texture and viscosity [17].
The neurological innervation of swallowing (Figure 1) Table 2 Medication and affect of swallowing.
comprises 6 cranial nerves as well as the pharyngeal plexus.
Cortical representation is diffuse, but work by Hamdy and Medication Affect of Swallowing
colleagues have shown that although cortical representation is
bilateral, one hemisphere is dominant. This dominance has Anticholinergic Effects

importance when the brain is injured (stroke, TBI), and if the Antidepresants
injury has affected the dominant side, the response of the Incontinence Dry Mouth
non-dominant hemisphere is important to recovery [4,7-9]. Opiates Confusion
Antipsychotics Sedation

Central Effects
Anxiolytics
Sleeping Tablets Sedation
Medication for Epilepsy Incoordination
Opiate Medication Dry Mouth

Altered Taste
Antibiotics Oral Infection

Anti-inflammatory Agents Altered Taste

Medication for diabetes (Metformin) Altered Taste

Anti-Hypertensive Agents
ACE-I Altered Taste
Calcium Channel Blockers Dry Mouth
Diuretics Dry Mouth

Cox-2 Inhibitors Reduced Cough

The sequence of events during swallowing does not change,

but the timing of events and the degree of change is different.
The oro-pharyngeal phase is prolonged [18] with a prolonged
Figure 1 Neurological control of swallowing. transit time [19] and there are more cortical areas activating
during swallow suggesting a more concentrated effort [20].
Food recognition requires more than taste alone. The The changes in the oral phase will include prolonged oral
recognition of a particular food relies on vision, smell, bolus transit [21]; there is an increase in the dippers as
proprioception and memory. Unfortunately age brings changes opposed to tippers of tongue position [22] prior to the
to these systems. Age may result in failing eyesight due to propulsion of the bolus towards the pharynx.
macular degeneration, cataracts or reduced visual field/
neglect with stroke [10]. Memory may be reduced due to Changes in the swallowing process may be affected due to
dementia resulting in the inability to recall previous frailty and sarcopenia rather than an overt disease process
experiences with food. Dyspraxia of eating/swallowing may [23]. As a consequence of both of these processes, skeletal
occur [11-13]. Not least to cope with the joys of having muscle is weak (poor quality muscle fibres and reduction in
dentures and eating. number) which may result in reduced tongue function and
pharyngeal contraction. . Isometric tongue pressures although
Saliva is crucial for a swallow and although volumes are reduced, have no clinical effect as the tongue is working at
reduced, adequate volumes are still present, until there is a submaximal pressures [24], Calve et al. have suggested that
perturbation on the system due to illness or medication (Table weakness in the tongue due to sarcopenia reduces tongue
2) [14,15]. propulsion and increases risk of aspiration [24]. However
With age there are changes in the ability to swallow, though, Logemann did note that women exhibit reduction in tongue
not infrequently the older person may not recognise that any base movement [25]. Smaller volumes are swallowed but a
changes to their swallow has occurred. Within the peripheral larger bolus is required to trigger a reflex swallow [26,27].
neurological system, there is a reduction in nerve conduction Laryngeal elevation, rotation and forward movement are
and increased conduction times due to myelin degeneration reduced. Laryngeal vestibule closure is delayed and maximal
[11,16], which reduces the effectiveness of the feedback loop. hyolaryngeal excursion is delayed [24]. The final defence of the
airway during swallowing is the cough reflex. A weak cough
reflex increases the risk of aspiration and pneumonia [28],
with normal ageing there is no change in the cough reflex,

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however the threshold concentration for citric acid does prevalence of dysphagia increases with the degree of frailty
increase in the presence of dementia (2.6 ± 4.0 mg/mL in present and the degree of dependence irrespective of
control subjects; 37.1 ± 16.7 mg/mL in patients with dementia; ethnicity [13,16,33-37]. In the presence of neurological disease
>360 mg/mL in survivors of aspiration pneumonia). (dementia/Parkinson’s Disease/Stroke) the prevalence is
higher than the general population (Table 3, Adapted from
The ability to clear the pharynx is also reduced in those over
Clavé et al. [38]). Frail older people readmitted with
65 years of age (18% vs 38%) requiring the person to
pneumonia may have a prevalence as high as 55% [39] even
undertake repeated swallows. This is evident with the need to
greater in those admitted from nursing homes [40].
undertake recurrent hyoid gestures [25] table. Pharyngeal
transit times increase. The larynx has a tendency to have a Problems may present with fatigability whilst eating,
lower resting height and does not elevate as much in younger coughing on certain consistencies and at times with
people. behavioural issues such as food refusal, spitting and the hiding
of food.
Prevalence of Dysphagia 24% of older people consider developing swallowing
problems a natural consequence of getting old [35], many old
The prevalence of dysphagia in the general population is people slowly adapt by eating slower, changing food
16-23% [29-32] increasing to 27% in those over 76 years of consistencies and taking smaller portion sizes.
age. Many older people will have swallowing problems. The

Table 3 Population and evaluation method.

Target Population Evaluation Method Prevalence References

Independently-living older people Screening 11.4%-33.7% [34,41-46]

(Questionnaires)

Clinical exploration (V-VST) 23% [47]

Hospitalized AGU Not specified/ 29.4%-47% [48,49]

Water swallow test/
V-VST

Hospitalized with CAP Water swallow test/V-VST 55%-91.7% [39,50]

Hospitalized with CAP Instrumental exploration 75% [50]

Institutionalized Screening (Questionnaires) 40% [13]

Water swallow test 38%

Screening + clinical exploration 51% [51]

Parkinson’s disease Reported by patients 35% [52]

Objective exploration 82%

Alzheimer’s disease Instrumental exploration 57-84% [53,54]

Dementia Reported by caregivers 19-30% [53,55]

Instrumental exploration 57-84% [19,53,56]

Multiple Sclerosis Screening (Questionnaires) 24% [57]

Instrumental exploration 34.30% [58]

ALS Clinical and Instrumental 47%-86% [59,60]

explorations

Acute Stroke Screening (Questionnaires) 37 - 45% [61,62]

Clinical exploration 51 - 55%

Instrumental exploration 64 - 78%

Chronic Stroke Clinical exploration 25 - 45%

Instrumental exploration 40 - 81%

CAP: Community-Acquired Pneumonia; AGU: Acute Geriatric Unit; V-VST: Volume-Viscosity Swallowing Test; NDD: Neurodegenerative Diseases; ALS:
Amyotrophic Lateral Sclerosis.

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The consequences of swallowing problems (Table 4) may be weight loss) or secondary to underlying risk or aetiological
very little for some, but in others it will result in poor nutrition, factors (dementia, diabetes, smoking).
reduced muscle strength, immobility, poor wound healing,
The management of dysphagia is similar to other long term
aspiration and pneumonia [63,64]. The consequence for
conditions including the management of environmental factors
society is a greater use of health resources at time when there
(such as smoking, alcohol, medication)
are already pressures on health systems. Mortality at 30 days
from pneumonia has been found to be 22.9% compared to The first point about management is to recognise that there
8.3% in those with dysphagia and at one year the mortality is a problem. Asking whether the ability to eat has changed
rate is doubled [65,66]. (slower, different textures, painful) and where the admission
has been due to pneumonia in older, frail populations consider
Table 4 Complications of dysphagia. aspiration as a cause.

Cough
The management of dysphagia, and particularly its
consequences, in older people may be simple. The crucial
Aspiration point is to remember to look for it; suspect that dysphagia may
Recurrent Chest Infection be a problem. Many frail older people may not complain of
dysphagia until they become unwell, and then due to their lack
Pneumonia
of physiological reserve, dysphagia ensues [74]. It is important
Malnutrition to work with the older person and be prepared to take risks. To
many the mere factor of eating and drinking is more important
Dehydration
than the risk of aspirating.
Hypoxia
When older people have swallowing difficulties, appropriate
Increased dependency investigation needs to be undertaken. This includes a swallow
Frailty
screen [75,76], swallow assessment by speech and language
pathologists and then investigation typically with
Death videofluoroscopy or Fibreoptic endoscopic evaluation of
swallowing . In some cases manometry is required to detect
The relative risk of pneumonia is 6 fold for those greater oesophageal problems or pH monitoring for reflux [77].
than 75 years compared to those under 65. Those living in care
When dysphagia is suspected a referral should be made to a
homes are 33 times as likely to be admitted to hospital with a
speech and language therapist for a full assessment of
pneumonia compared to those living in the community [37].
swallowing, clinically initially and later via videofluoroscopy or
Oral health is an important factor in the occurrence of
FEES depending on clinical need or availability. This should be
pneumonia. With poor dental care and the presence of
followed by advice as to food texture, speed of swallowing and
dentures, not only is mastication less effective, the risk of oral
swallowing manoeuvres. Where there evidence of significant
infection with anaerobes and yeast is quite high. Keeping the
cognitive impairment a more pragmatic approach may have to
mouth clean, particularly in the most dependent people will
be taken, such as watching them eat a meal or take a drink.
reduce the risk of infection [67,68].
Other simple measures include: review medication, stop
What should not be under estimated is the psychological
anything that may worsen the ability to swallow (drugs causing
consequences of dysphagia such as anxiety, and depression
a dry mouth; drowsiness etc), check dental plates for infection;
[69,70] and quality of life in general [71].
check positioning and if appropriate, how people are fed.

Co-existent Long Term Conditions Within the hospital setting, both the Matero Hospital in
Barcelona (P Clavé personal communication) and the Royal
It is an unfortunate fact that as people age, they suffer from Berkshire in Reading UK (M Gosney personal communication)
multiple chronic diseases all of which can exacerbate or result have developed projects aimed at reducing aspiration
in dysphagia. The commonest neurological medical complaints including the use of elevation of the head end of the bed, or
associated with dysphagia are stroke (50%), dementia (up to sitting upright at meal times, mouth wash and routine
93%), Parkinson’s Disease (39%) and Motor Neurone Disease. screening. In Japan [78], dental hygienists and dentists are
However cardiac failure, chronic obstructive lung disease and employed to improve mouth care. Recent work in stroke
rheumatoid arthritis are other medical conditions that are patients has suggested that the use of Metoclopramide may
associated with dysphagia [72,73]. reduce the risk of aspiration [79], whereas routine prescribing
of antibiotics did not help [80,81].
What can be done?
A Geriatric Syndrome/Giant
As has been mentioned earlier, the poor outcome
associated with dysphagia has a multifactorial component, The term geriatric Syndrome was first used in 1909 [1].
either that due to the dysphagia itself (aspiration, infection, Originally there were four recognised syndromes or giants, this
has been added to in recent years with Sarcopenia and frailty

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ISSN 2471-299X Vol.2 No.1:5

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