Senescent swallowing: impact, strategies, and interventions

Abstract

The risk for disordered oropharyngeal swallowing (dysphagia) increases with age. Loss of swallowing function can have devastating health implications, including dehydration, malnutrition, pneumonia, and reduced quality of life. Age-related changes increase risk for dysphagia. First, natural, healthy aging takes its toll on head and neck anatomy and physiologic and neural mechanisms underpinning swallowing function. This progression of change contributes to alterations in the swallowing in healthy older adults and is termed presbyphagia, naturally diminishing functional reserve. Second, disease prevalence increases with age, and dysphagia is a comorbidity of many age-related diseases and/or their treatments. Sensory changes, medication, sarcopenia, and age-related diseases are discussed herein. Recent findings that health complications are associated with dysphagia are presented. Nutrient requirements, fluid intake, and nutrition assessment for older adults are reviewed relative to dysphagia. Dysphagia screening and the pros and cons of tube feeding as a solution are discussed. Optimal intervention strategies for elders with dysphagia ranging from compensatory interventions to more rigorous exercise approaches are presented. Compelling evidence of improved functional swallowing and eating outcomes resulting from active rehabilitation focusing on increasing strength of head and neck musculature is provided. In summary, although oropharyngeal dysphagia may be life threatening, so are some of the traditional alternatives, particularly for frail, elderly patients. Although the state of the evidence calls for more research, this review indicates that the behavioral, dietary, and environmental modifications emerging in this past decade are compassionate, promising, and, in many cases, preferred alternatives to the always present option of tube feeding.

Figure 1

The upper aerodigestive tract has two primary functions: breathing and swallowing. (Reprinted from Easy to Swallow, Easy to Chew Cookbook: Over 150 Tasty and Nutritious Recipes for People Who Have Difficulty Swallowing by Weihofen D, Robbins J, and Sullivan PA. 2002, with permission of John Wiley & Sons, Inc.

Figure 2

Figures 2a, b. Airway penetration, defined as entry of material into the laryngeal vestibule without passing below the level of the vocal cords. Figures 2c, d. Aspiration, defined as entry of material into the airway (trachea). Reprinted from Robbins J, Kays S, McCallum S. Team Management of dysphagia in the institutional setting. J Nutr Elderly 2007; 26: 59–104, with permission from Taylor & Francis.

Figure 3

Figure 3a. Fluoroscopic image of a barium tablet (simulating a pill) lodged in pharynx, precariously located next to an open airway. Figure 3b. Fluoroscopic image of a barium tablet (simulating a pill) lodged in mid-esophagus. Reprinted from Robbins J, Kays S, McCallum S. Team Management of dysphagia in the institutional setting. J Nutr Elderly 2007; 26: 59–104, with permission from Taylor & Francis.

Figure 4

Kaplan-Meier curve depicting 1-year survival of acute ischemic stroke patients with zero, one, and two or more bounce-backs within the first 30 days (N511,729). Time zero is discharge from index stroke hospitalization. To be included in the sample, patients had to survive at least 30 days from discharge. Reprinted from Kind AJ, Smith MA, Liou JI, Pandhi N, Frytak JR, Finch MD. The price of bouncing back: one-year mortality and payments for acute stroke patients with 30-day bounce-backs. Journal of the American Geriatrics Society. 2008; 56(6):999–1005 with permission from Wiley-Blackwell.