Swallowing Problems in the Elderly
Swallowing difficulties—or “dysphagia”—are particularly common in the elderly and can lead to dehydration and malnutrition. Dysphagia can be related to a variety of other medical issues, or it can occur as a part of the progression of dementia.
Brief Overview of the Swallowing Process
Although the act of swallowing seems like a no-brainer, it is actually a fairly complex process involving a variety of nerves, as well as voluntary and involuntary muscles. The swallowing process can be broken down into three distinct stages: oral, pharyngeal (throat), and esophageal (esophagus). Swallowing problems can occur during any of these three stages.
During the oral stage, food is moistened with saliva as it is chewed, and it is formed into a soft, easy-to-swallow ball called a “bolus.” The bolus is then propelled by the tongue toward the back of the mouth in preparation for swallowing.
In the pharyngeal stage, involuntary muscle activity occurs to close off the airway, preventing food from entering the nasal cavity, trachea, and lungs. The food is then swallowed and propelled into the esophagus.
During the esophageal stage, a series of involuntary muscle contractions moves the food down the esophagus to the stomach.
Causes of Swallowing Problems in Older Adults
Swallowing difficulties in adults can be caused by conditions that are structural, neurological, or muscular in nature. Determining the cause of the problem can be helpful in coming up with strategies to improve swallowing.
In the elderly, poor dentition--no teeth or ill-fitting dentures--is a common cause of swallowing problems, and is one of the more easily addressed issues. Decreased saliva secretion caused by medications or dehydration can make formation of a soft, easy-to-swallow bolus difficult.
Neurological diseases such as Parkinson’s, Multiple Sclerosis, and ALS frequently cause swallowing problems as the disease progresses. GERD and acid reflux can cause esophageal narrowing due to the formation of scar tissue. Stroke survivors may lack the muscle strength and control needed for safe and effective swallowing. Persons with cancers of the head or neck, or those who have sustained a head or spinal injury may also subsequently experience swallowing problems. People with Alzheimer’s will frequently demonstrate increasing difficulty with swallowing as the disease progresses.
Signs and Symptoms of Swallowing Problems
Most of the time people with swallowing problems will exhibit one or more of these signs and symptoms:
- Frequent throat-clearing
- Pain while swallowing
- A sensation that something is “stuck” in the throat
- Clear nasal secretions dripping from the nose
- Coughing or choking
- Shortness of breath
- “Pocketing” food: food accumulates in the cheeks as the person continues to eat
- A voice that sounds “wet” rather than clear
- An increase in chest congestion after eating
- Drooling and difficulty managing saliva
Stroke survivors and others with decreased sensation may sometimes not exhibit signs of swallowing difficulties. This may lead to a condition called “silent aspiration.” In silent aspiration, food “goes down the wrong pipe,” and ends up in the airway instead of the stomach, causing a type of pneumonia known as aspiration pneumonia.
Diagnosing Swallowing Problems
Aside from a thorough physical exam, a physician may order one or more tests to gain a better understanding of swallowing problems.
A “barium swallow” involves a series of xrays taken after the patient drinks a liquid containing radioactive barium. The barium helps to illuminate the throat and esophagus on the xrays so that they can be observed. The physician may then observe the appearance of different consistencies of food as they travel from the throat to the stomach, noting how the muscles involved with the swallowing process are functioning. The test also indicates whether food is being aspirated into the respiratory system.
The doctor may also recommend an endoscopy, or visual examination of the esophagus. This is performed by placing a thin tube with tiny camera down the throat so that the esophagus can be examined for any scarring, lesions, or ulcerations.
Coping With Swallowing Problems
Working with a speech therapist can be beneficial for those with swallowing problems because the therapist can recommend exercises to strengthen muscles involved with swallowing as well as safe swallowing techniques. The speech therapist can also make recommendations regarding diet.
Changing the consistency of solid foods and liquids can make a big difference, and a speech therapist can help to determine which consistency would be appropriate. Depending on the severity of the swallowing problem, changing from solid food to a minced or puree diet may be needed. Frequently, people with severe swallowing problems have a great deal of difficulty with regular-consistency--or “thin”-- liquids. A thickening agent can be added to liquids to make them easier to swallow, and a speech therapist can determine the correct consistency for liquids.
Suggestions for People with Swallowing Problems:
- Sit in a quiet room with no distractions--people with swallowing difficulties need to focus on their swallowing!
- Sit upright at a 90 degree angle with the head tilted slightly forward
- Use a spoon for portion control, taking small half-teaspoon sized bites
- Chew thoroughly
- Swallow, then swallow again two or three more times to make sure all food is cleared from the mouth
- A spoon can be used for thickened liquids to control portion size
- Don’t use straws
- Many medications can be crushed and mixed with applesauce for easy (but bad-tasting!) swallowing. Check with the doctor as to whether there are any medications that should not be crushed
Dealing with dysphagia can be very frustrating for older adults, especially for stroke survivors. It can lead to depression and loss of self-esteem, as well as malnutrition and dehydration. Providing emotional support to people with swallowing difficulties is crucial; they are facing the loss of one of their most basic functions, and it can be devastating. Offering words of encouragement and demonstrating patience can show them that you understand and care.