Tough to swallow
Dysphagia affects a number of older adults and for caregivers, there are several approaches to ease the problem.
BY: Ang Zi Qin
Dysphagia is the medical term for swallowing difficulties. It can happen at any of the three stages of swallowing – oral (manipulation of food/drinks in the mouth), pharyngeal (eliciting swallow triggers, the throat muscles working to squeeze food down the food pipe) and oesophageal (the muscles in the food pipe working to bring food down to the stomach) stages.
Dysphagia can result from damages to the nervous system (i.e. stroke, head or spinal cord injury, progressive neurodegenerative disease, etc) and/or from medical problems affecting the head and neck region (i.e. head and neck cancers, surgeries or trauma). It is also not uncommon in the older population and it is termed as presbyphagia.
Dysphagia in older adults
Ageing is a predisposing factor in dysphagia secondary to a loss in muscle mass and tissue elasticity. These result in muscle weakness, and reduced extent of movement and flexibility. These changes often result in a general slowness in the whole eating and swallowing process. For example, taking a longer time to chew, greater difficulty chewing harder foods, and increased effort to swallow larger spoonful of food down. In addition to motor changes, there will be less acute sense of smell, change in taste, drier mouth, and reduced eyesight. These could in turn make a meal less palatable than it had been.
Although ageing does increase the presence of dysphagia, its signs can be overcome by simple strategies and modifications. The major contributing factor leading to dysphagia is age-related diseases that can occur in elderly or adults. To summarise, broad categories of the diseases are identified – neurological disease (stroke, dementia, Parkinson disease, etc), respiratory diseases (COPD (chronic obstructive pulmonary disease) and asthma), cancer (throat, nasopharyngeal, oesophageal, etc), metabolic disorders, cardiac diseases, etc.
Dysphagia may or may not resolve over time, for some, recovery may be partial. The prognosis of dysphagia is dependent on its cause and comorbidities of the affected individuals.
Signs & possible consequences
Some of the common signs of dysphagia in older adults are:
- Difficulties in or absence of chewing.
- Difficult or laboured swallowing.
- Gurgly voice or throat noises after swallowing.
- Choking/coughing on food/liquids.
- Respiratory distress or shortness of breath after swallowing.
- Recurrent chest infection.
- Spiking temperature.
- Unexplained weight loss.
When dysphagia is not carefully managed, it can lead to other medical complications such as dehydration, malnutrition and aspiration pneumonia.
Aspiration pneumonia occurs when diet, fluids and/or saliva enters our airways and lungs. The entrances to our lungs and stomach are just next to each other. Aspiration is a medial term used to describe something foreign entering our lungs. Some people do cope with small amount of aspiration. However, others may not be able to tolerate it as well and their lung tissues get irritated and infected – resulting in aspiration pneumonia.
The management of dysphagia is multidisciplinary. It involves the expertise of a speech therapist, dietician, doctor(s) and carer(s). The speech therapist plays a central role in dysphagia management in terms of:
- Diagnosing and identifying the extent and severity of dysphagia.
- Provide recommendations for appropriate diet and fluid consistencies.
- Identify suitable exercises or strategies for the affect individuals.
- Educate and train individuals and/or their carer(s) on the management of dysphagia.
There are several ways to address one’s swallowing difficulties, in fact dysphagia management can be highly individualised depending on a person’s needs and wants.
After the completion of a swallow assessment, the speech therapist may recommend modification to the individual’s diet and fluid consistencies if the current one would compromise safety or ease of swallowing. A modified diet consistency refers to a change in the food texture and/or size, e.g. soft food, minced sides or blended food.
Consistencies of drinks vary from thin (normal consistency) to the thicker version such as nectar-like or honey-like thickness. Based on the type or extent of dysphagia, the speech therapist will recommend suitable consistencies to complement the individual’s swallowing ability.
Other changes to feeding may also include changes in posture during feeding or swallow manoeuvres. The purpose is to reduce the aspiration risk and/or to facilitate the transition of food/fluids from the mouth down to the stomach. The implementation of these strategies is highly specific to different swallowing deficits and may not be effective or suitable for every individual. Suitability of these strategies is usually verified via an instrumental swallow assessment before they are implemented.
For individuals who present with potential for rehabilitation, swallow exercises will be prescribed to improve swallow status such as muscle strengthening, increased range of movement or flexibility of movements to the jaw, lips, tongue or throat. Do note that not all exercises are suitable to every individual as each exercises target different swallow muscles and may have contraindications to one’s medical condition.
Lastly but most importantly, is for the speech therapist to impart the knowledge and skills to the individual and/or carers regarding dysphagia (the type and severity), recommend a suitable management and how to execute the recommendations. It is important to raise awareness such that the individuals and carers have the knowledge and coping ability to manage dysphagia at home on a daily basis.
Ang Zi Qin is a speech therapist at Changi General Hospital.