Management of

Dysphagia in Elderly
Shanojan Thiyagalingam

Swallowing

Dysphagia: subjective sensation of difficulty or

abnormality in swallowing

Odynophagia: pain with swallowing

Globus sensation: persistent/intermittent

nonpainful sensation of lump/foreign body in throat

between meals, and absence of dysphagia,

odynophagia, motility d/o, GERD

Dysphagia

range from inability to initiate swallow, to sensation

of hindrance of solid/liquid from esophagus to
stomach

Types:

oropharyngeal: difficulty initiating swallow

esophageal: difficulty swallowing few seconds

after initiating swallow and sensation of food
stuck in esophagus

Importance of Dysphagia

seen in progressive neurologic d/o like ALS, MS,

illness during end of life (ie: demetia), stroke

affects pleasurable activities:

social interactions, communication, intimacy,

food consumption

When to suspect

overt coughing, chocking during or after meals

sensation of food caught in throat, regurgitate liquid or

solids

silent aspiration in 40% of of patients who aspirated

indirect markers: wet/gurgly voice while eating/

drinking, protracted meal times, avoid certain foods
or liquids, unexplained fever/cough or other signs of
PNA including alterations in secretion characteristics
(vol, color, viscosity)

SLP

Speech-Language Pathologist

experts in assessment/management of
oropharyngeal swallowing disorders

maximize comfort and quality of life in pts with

swallowing difficulties

Clinical History

getting pts description of complaint about swallowing is

key to understand physiological basis

location of disorder (though not accurate per se)

ie: hx of tumor, hx of reflux, etc

ie:throat (oropharynx or esophagus) vs chest

(esophagus)

eating habits (solids, liquids, feed themselves, total calorie

intake, length of meal time, effort, alleviating/
exacerberating factors - positioning/meds/time of day)

Physical Exam

Cranial Nerves motor function:

symmetry, speed, strength, accuracy, ROM (ie: tongue affect solid

bolus formation)

strength of cough after aspiration

weak voice/respiratory force

timing of cough after aspiration

Gag reflex not indicative of swallowing function; only for clearance of

noxious stimuli from oral or digestive tract

oral hygiene: less saliva, difficulty forming bolus, aspirating colonized

bacteria, dried secretions can obstruct airways during swallowing

Direct Observation

SLP trained to identify warning signs that indicate

chewing and swallowing difficulties

screen of swallowing function

at bedside by trained nurse or SLP: pass/fail test

to see if safe to eat/drink; doesnt tell cause so
cant tell whats right management/prognosis

if fail test or risk for aspiration then must do

comprehensive swallow study by SLP

Instrumental Evaluation

Videofluoroscopic Evaluation aka Modified Barium Swallow (MBS) study

1st choice test b/c comprehensive, ease, noninvasive

noninvasive, <5 min, looks at stages of oropharyngeal swallow mechanism but not details like structural integrity

seated upright, swallows a variety of barium-coated foods

SLP and radiologist together; replay video slowly to analyze

Barium study

looks at esophageal function; concentrates on anatomy of esophagus, stomach, duodenum

seated upright, swallows a variety of barium-coated foods

identify mucosal and anatomical abnormalities, esophageal strictures, esophageal motility

Fiberoptic examination of oropharyngeal swallowing (FEES):

bedside by trained SLP

oropharynx, larynx visualized transnasally using dye-marked foods for laryngeal penetration, aspiration, pharyngeal
retention post-swallow

mucosal integrity, laryngeal function (ie: vocal folds adduction) but not overall swallowing pattern

Management

treat reversible causes (ie: fungal inf, reflux, etc)

key criteria for oral nutrition: effortless, efficient, safe swallow

compensatory swallow strategies:

alter head/neck posture to redirect bolus flow, heighten

sensory awareness, changing bolus characteristics

challenges:

ie: pt may want to chew preferred food longer than eat

less tasty thick liq in shorter times

Nutritional Issues

Oral feed

goal: max calories in shortest effort

hand feeding (intimate contact with caregiver, pt)

remove distraction at mealtime, give sensory

clues, assistive feeding utensils, posture (ie:
slumping, hyperextended neck), scheduled
mealtimes

Nutritional Issues

Nonoral feed

gastrostomy, jeujenostomy tube endoscopically, radiologically,

surgically

impacts family and patient

give only when benefit>harm; some dementia pts will have net
harm

even if NPO can give small amt liq or food in some pts for
pleasure

tube feed doesn't eliminate aspiration: poor oral hygiene,

reflux tube feed content

GE Reflux Precautions

give PPI, prokinetics, elevate head of bed to 45

degrees, freq small meals, upright posture for 1 hr
after eating

Tracheostomy Tube and Oral

Intake

can still feed but must deflate tracheostomy cuff at

esophagotracheal wall

but should do tracheal suction after meals

Swallowing Rehab

done commonly in pts with head/neck cancer

Surgery for Vocal Cord

Paralysis

in patients with terminally ill diseases with unilateral

vocal cord paralysis causing significant aspiration
and poor quality of life resulting in nonoral feeds

relatively safe procedure for pt with shortened life

expectancy if performed by experienced
otolaryngologist

Administering Medication

powder, liquid, inhaler, lozenge, suppository,

crushed w/ or w/out semithick food,

DONT crush delayed release medications due to

rapid release causing fatal overdose

stop noncritical meds

Reference

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