Key learning points:
- Swallowing problems are common but are under reported and under recognised in all ages
- Often swallowing problems are not detected until a loss of weight occurs
- Pharmacists are key in assisting the patient and clinical staff to choose the appropriate medication
Eating and drinking are an important part of life, both physically and socially. Where swallowing is difficult, people may become isolated, under-nourished and frail. Dysphagia may be caused by pathology in the mouth, pharynx or oesophagus. Here the focus is on the mouth and pharynx, with an outline of the swallowing process, the frequency of swallowing problems, complications and their management.
Swallowing is essentially a reflex involving 55 muscles,5 cranial nerves and two cervical nerve roots. The swallowing control centre is situated in the medullary area of the brain stem and receives not only sensory input from the mouth and pharynx regarding the bolus, but also the respiratory centre and coordinated swallowing and breathing, and from cortical and subcortical areas resulting in the modulation of and duration aspects of the pharyngeal stage.1,2,3
Swallowing and breathing are intimately related: they both share the same path but as they pass through the pharynx, air enters the larynx and food and liquid continues to the oesophagus. When this relationship is disturbed, swallowing problems and dysphagia occurs.4
Dysphagia is always abnormal, irrespective of someone’s age. The only difference being that the timing of the different components is more critical.5,6 Dysphagia is a symptom, not a diagnosis, very much like cardiac failure and falls. Once identified the underlying aetiology needs to be sought (table 1).
Epidemiology of Dysphagia
Dysphagia is frequently under-recognised and underappreciated. Both medical and nursing staff often do not enquire as to whether their patients have difficulty swallowing unless weight loss is evident. A proportion of people living in the community as well as those in institutions will have previously unreported swallowing problems and for many this is gastro-oesophageal reflux.
Oropharyngeal dysphagia in the general population varies between 2.3% and 16%.7-12 These data are based on self-reported questionnaires and surveys.
Dysphagia occurs more commonly in the ageing population and is frequently because of accompaning medical problems. Prevalence data increased with ageing up to 26.7% for participants above the age of 76.
Using the Standardised Swallowing Assessment by Perry13, Yang et al.14 describe [in a Korean longitudinal study] an overall prevalence of dysphagia of 33.7% (95% CI, 29.1-38.4%) for people above 65 years living independently. Barczi and Robbins15 found prevalence rates near 15% in community dwellings and more independent individuals, and upward of 40% of people living in institutionalised settings such as assisted living facilities and nursing homes.
The rates are even higher in those people who are frail. In the presence of frailty, the swallow may be intact on a day-to-day basis, until medication is changed (side-effects causing drowsiness, confusion or dry mouth) or illness occurs, then dysphagia will occur. With the multiple possible aetiologies of dysphagia in this age group it is high time that dysphagia was added to the list of Geriatric Syndromes or Giants – the major illness in older people including immobility, instability, incontinence and impaired intellect/memory.
Dysphagia will occur in many disease situations, not just in the presence of neurological disease. Swallowing requires a period of apnoea, and where this is not possible (lung disease, cardiac failure) dysphagia will occur (table 1).
Presentation (Symptoms and signs)
The presentation of dysphagia will often depend on the context in which it occurs. The commonest complaints will be that food and liquid goes down the wrong way, regurgitates through the nose, causes coughing or a change of diet. In others where they cannot recognise or communicate their problem, food refusal, regurgitation, and spitting may be the presenting complaint by carers. In those people who are frail, the swallowing only becomes a problem when another stressor such as infection or medication wipes out their physiological reserve resulting in dysphagia and the risk of aspiration.
Signs of dysphagia will be a changed or wet voice, recurrent chest infection, hypoxia, a grumbling pyrexia or weight loss. Coughing is frequently a sign of airway penetration (food and liquid not going below the vocal cords).
The management of dysphagia has to be multidisciplinary.
First the problem has to be identified, by a clinical history and a swallow ,17 such as the water based, Bedside Swallowing Assessment (BSA). Any member of the clinical team can do this. Once the problem has been identified, referral to the local expert should occur. In the United Kingdom this will be the speech and language therapist. The speech and language therapist will then fully assess the patient looking at the anatomy of the swallow as well as the functional aspects.18,19,20 Following the clinical assessment, recommendations will be made to ensure that nutrition can be provided safely, and, in some situations, further assessment is required.
Various guidelines suggest that instrumental assessment of the swallow should occur where indicated, however different countries have different approaches. In the UK, the speech and language therapist will recommend video fluoroscopy and/or Flexible endoscopic evaluation of swallowing (FEES) - the approach is often dictated by local availability. Other investigations that may be required include manometry and pH monitoring where reflux is considered to be the aetiology of oro-pharyngeal dysphagia.21,22
The aim of managing swallowing is to encourage a safe swallow and ensure that the patient receives adequate nutrition23 and is able to take their medication. From a nutrition point of view there are two basic approaches: One is to modify the diet in terms of the consistency of food taken24 and the other is to modify the swallowing physiology or swallowing manoeuvres.25 Where it is not possible to swallow safely or it is not possible to ensure someone’s nutritional needs are met, enteral feeding needs to be considered. In the acute phase nasogastric feeding is the route of choice, and where necessary a nasal loop or bridle is used to keep the tube in place.26 Longer term, depending on patient choice and acceptability, a gastrostomy may be put in place, either endoscopically or radiologically.27 Some, usually younger patients, may prefer to repeatedly pass a nasogastric tube. There is at the present time a lot of hope and expectation around the management of swallowing disorders, particularly in those with neurological disease and presbyphagia.
In the case of brain injury, including stroke, there are opportunities for improvement using transcranial stimulation, pharyngeal stimulation and neuromuscular stimulation. Other approaches involve neuro feedback. Where there is reduced tongue strength, either due to brain injury, post-surgery or sarcopenia, muscle resistance training may be beneficial, not only in strengthening the tongue but also improving the swallow. Where laryngeal elevation is a problem, neuromuscular stimulation or muscle strengthening of the hyoid musculature (shaker exercise and chin tuck against resistance) offers hope.28,29
Living with dysphagia can prove to be problematical not only for the person with dysphagia but also family members. Dysphagia can lead to social isolation and embarrassment. Enterostomy feeding may take over ones life as feeding is often done over many hours, usually at night. Nasogastric feeding may affect body image. Enteral tubes are not without their complications.
Even where swallowing problems are not overt, such as in presbyphagia,5,6 dietary changes may have taken place subconsciously and people may not wish to attend events that involve eating.
Medication can pose a particular challenge in people who have an abnormal swallow. The pharmacist is key to assisting the patient and clinical staff to make the right decision. The first question is whether the medication is necessary. Is it making the swallow worse (dry mouth, confusion, reduced alertness), and if so how can it be administered? Some medications, such as statins, can dissolve, others may come as liquid or syrup formulations, and some are available as wafers, melts or skin applications.
Swallowing problems are common and may occur in non-neurological conditions. Swallowing problems are particularly prevalent in older people, and dysphagia should be recognised as a geriatric syndrome. It is important to identify this to ensure appropriate intervention and management is put into place.
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