Dysphagia in the Elderly

“Dysphagia in the Elderly” was written by Becky Davies. Edited/reviewed by Katie Dodd, MS, RDN, CSG, LD, FAND. Becky is a dietetic intern and GI nutritionist @beckyrashidifard.

Do you know a loved one who has difficulty swallowing? Perhaps you see them coughing, choking, or having trouble while eating. This article will review swallowing difficulties (dysphagia), how to treat dysphagia, and the importance of receiving treatment early.

What is Dysphagia?

Dysphagia is also known as a swallowing disorder. Or difficulty swallowing.

Dysphagia can occur in any three phases of swallowing:

  • oral (in the mouth)
  • pharyngeal (top of the throat)
  • or esophageal (lower throat/ epsophagus)

Patients may feel a sensation of food being delayed or stopped in its passage from the mouth to the stomach (1).

Dysphagia can have many causes. However, it can often result from scar tissue formation. This scar tissue causes a narrowing in the throat or esophagus (2).

The scar tissue may be called a Schatzki ring, or esophageal ring. Schatzki rings are often asymptomatic until the ring becomes a small diameter (3).

Dysphagia in the Elderly text with images of pureed food

Symptoms of Dysphagia in the Elderly

Those with dysphagia often experience the following symptoms:

  • coughing while eating or drinking
  • choking on food, fluid, or medication
  • a gurgly sounding voice after eating or drinking
  • difficulty swallowing food or liquid
  • the pocketing of food on one side of the mouth (4)

The symptoms of dysphagia can present differently from person to person. For example, some people may choke on food making dysphagia very obvious. Others may only have a minor cough or gurgly sound after eating.

Causes of Dysphagia in the Elderly

Causes of dysphagia in elderly patients may include age, illness, and medication interactions.

Age

Dysphagia affects 10-33% of the elderly population (5).

The elderly are at an increased risk of getting dysphagia due to illnesses that affect swallowing.

Older adults in assisted living and nursing homes are greatly impacted. In fact, up to 40% to 60% of residents have feeding difficulties (1).

Illness

Dysphagia is most common in those who have experienced a stroke, Alzheimer’s Disease, or Parkinson’s Disease. In fact, dysphagia impacts about 37-78% of stroke patients (1,5).

Sensory or motor problems in the throat can cause dysphagia. Also, those with obesity or gastroesophageal reflux disease (GERD) have a higher rate of developing dysphagia (6, 8).

Medications

Medications may decrease muscle functioning, impacting chewing, swallowing, and movement of food through the intestines. As a result, these scenarios can create dysphagia.

In addition, chemotherapy, immunosuppression, and long-term antibiotic therapy can create infections in the esophagus, resulting in dysphagia (1).

Image of masked healthcare person testing for Dysphagia in the Elderly

Diagnosis

Healthcare professionals can identify and assess dysphagia through a multidisciplinary approach.

Identify Dysphagia

A healthcare provider can ask the patient the following questions:

  1. Do you often cough or choke after eating or drinking?
  2. Does it sometimes feel as though food is going down the “wrong way”?
  3. Do you often think food is stuck in your throat?
  4. How long does it take you to eat a meal?
  5. Is eating sometimes less enjoyable than it had been previously?
  6. Have you recently experienced weight loss without trying to lose weight? (4)

Additionally, the EAT-10 assessment tool can be used to identify those at risk for dysphagia.

Diagnosis Dysphagia

The best way to diagnose dysphagia is the modified barium swallow. This is a fancy test in which a patient ingests small amounts of thin liquids, barium, and/or a small piece of a cookie or cracker. Then, there is an x-ray and video of the swallowing process to determine which stage of swallowing is involved (4).

A videofluoroscopic swallow study or a fiberoptic endoscopic evaluation may be used to further diagnose dysphagia. Also, a neurologic examination is needed for every dysphagia patient and includes testing of all cranial nerves (1).

Treatment

A multidisciplinary approach is needed to treat dysphagia in the elderly.

For example, health care professionals like doctors, speech-language pathologists, and registered dietitians create appropriate treatment plans.

Older adult at desk with healthcare team member

Treatment best practices include behavior change, oral care, dietary changes, swallowing retraining, medication, or surgery (5, 7).

Speech-Language Therapy

A speech-language pathologist can help patients with swallowing training. Training includes strengthening exercises, electrical stimulation, or using adaptive devices.

Language therapists can provide recommendations such as changes in positioning or posture when eating or drinking and techniques to aid in swallowing more safely (4, 7).

Speech therapists can make recommendations on dysphagia diet consistency levels following proper testing.

Nutrition

Registered dietitians can assist with dietary modifications and suggestions based on the nutritional status of the patient. For example, dietitians can recommend meals with the right texture around ingredients they enjoy to ensure adequate nutrition.

The right consistency of food is important to minimize swallowing difficulties. Changing the consistency of foods (such as puréeing or softening them) or adding thickeners to fluids can help ease swallowing and decrease the risk of aspiration.

The consistency of food and fluid varies from person to person. It is very important to work with your healthcare team to determine the right diet for you.

Dietitians also cater to patients’ food preferences and encourage a relaxed mealtime without distractions.

One downside of eating with dysphagia is many patients don’t enjoy soft or pureed foods. As a result, patients may eat less or eat a limited variety of foods.

These behaviors may result in inadequate or imbalanced nutrition. In turn, this can lead to unintended weight loss. Or it can slow the healing process in those with wounds.

If oral intake is not enough to meet caloric needs, alternative methods for feeding may be considered. Depending on the situation, tube feeding may be an option to help avoid malnutrition (4).

Oral Hygeine

Those with dysphagia are at an increased risk for aspiration pneumonia. This can lead to hospitalizations or other health complications.

Good oral hygiene is extremely important for those with dysphagia.

Research has shown that good oral hygiene may help prevent aspiration pneumonia. This includes regular cleanings, removing plaque from the teeth, gums, and dentures. Oral antimicrobial rinses may also be beneficial. You can learn more in our article Nutrition and Oral Health for Seniors.

Medication

Medication may be effective for swallowing disorders caused by a neurological or muscular disorder. These include Parkinson’s disease, hypothyroidism, hyperthyroidism, myasthenia gravis, or polymyositis (4).

Procedures

Dilation therapy can increase the size of the swallowing channel. In addition, doctors can perform an esophageal stent placement where they place a thin tube in the esophagus to expand the narrowing (7).

Surgery

Surgery may be required depending on the stage of dysphagia. For example, doctors can cut in or around the esophagus or throat muscles to improve swallowing.

Risk factors if left untreated

Untreated dysphagia can result in aspiration, pneumonia, malnutrition, and reduced quality of life.

In older patients, dysphagia symptoms may start mildly. Because cases are usually mild, they go undiagnosed until a more significant medical problem arises. By this time, swallowing difficulties may be worse due to weakness or deconditioning.

If left untreated, life-threatening complications can happen, such as aspiration. Aspiration is when food and liquid secretions leak into the lungs. In particular, aspiration after stroke has a 15% mortality rate.

Risk of pneumonia is higher due to aspiration. Aspiration pneumonia is the leading cause of hospitalization and death in nursing home residents.

Last, dysphagia can cause malnutrition. About 50% of patients in long-term care facilities suffer from malnutrition. Dysphagia can also result in patients having an improper intake of their medications (4).

Conclusion

Dysphagia in the elderly is common. In that case, it’s crucial to receive a diagnosis and treatment plan from health professionals, personalized to the patient’s needs. Proper treatment decreases the risk of complications and mortality.

Be sure to work with your health care team for individual advice. Do not delay as dysphagia can lead to very serious medical complications.

References

  1. Aslam M, Vaezi MF. Dysphagia in the elderly. Gastroenterology & Hepatology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999993/. Published December 2013. Accessed November 11, 2021.
  2. Dysphagia, aspiration and stricture. American Head & Neck Society. https://www.ahns.info/survivorship_intro/dysphagia-aspiration-stricture/. Published July 24, 2019. Accessed November 11, 2021.
  3. Schatzki Ring: What is it, causes, treatment … –Osmosis. https://www.osmosis.org/answers/Schatzki-ring. Accessed November 11, 2021.
  4. Keller M. Dealing With Dysphagia. Aging Well. https://www.todaysgeriatricmedicine.com/archive/winter2011_p8.shtml. Published 2011. Accessed November 11, 2021.
  5. Thiyagalingam S. Dysphagia in Older Adults. Mayo Clinic Proceedings. https://www.mayoclinicproceedings.org/article/S0025-6196(20)30902-2/fulltext. Published 2021. Accessed November 11, 2021.
  6. Abrams R. Swallowing Disorders Treatment. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/swallowing-disorders-treatment. Published 2021. Accessed November 11, 2021.
  7. Camilleri M, Malhi H, Acosta A. Gastrointestinal Complications of Obesity. Gastroenterology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5609829/. Published May 2017. Accessed November 11, 2021.

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