Treating the Aging Swallow: One Size Does Not Fit All

Dysphagia is a rapidly growing health concern in our aging population. Oropharyngeal dysphagia affects:

• More than 30% of individuals who have had a cerebrovascular accident
• Up to 80% of individuals with Parkinson’s or Alzheimer’s disease
• Up to 40% of adults aged 65 years and older
• More than 50% of institutionalized elderly³

Normal swallow function in older adults, also known as presbyphagia, is not inherently impaired. ‘Presbyphagia’ refers to characteristic age-related changes in the swallowing mechanism of otherwise healthy older adults. With advancing age, the head and neck anatomy and physiology change, affecting the aging swallow. These changes, along with the rising incidence of age-related diseases, make older adults more susceptible to dysphagia due to underlying sarcopenia and decreased functional reserve.¹⁰

Dysphagia in the elderly has serious health implications including:

• Malnutrition
• Dehydration
• Respiratory complications
• Hospital readmissions
• Increased need for institutionalized care
• Increased morbidity and mortality

Dysphagia also reduces opportunities for socialization and influences quality of life. The strong relationship between swallowing ability, nutritional status and health outcomes in the elderly demonstrates the importance of dysphagia management in this population.

Treatment of Dysphagia in the Elderly

Dysphagia treatment aims to optimize the safety, efficiency, and effectiveness of the oropharyngeal swallow, to maintain adequate nutrition and hydration, and to improve oral hygiene.

The treatment plan should always be based on results of a comprehensive clinical and whenever possible, an instrumental assessment. After forming a hypothesis based on the evaluation findings, clinicians should consider all other cognitive, environmental, medical and physical factors that may act as potential barriers to treatment progress.

Although the management of dysphagia is a multi-disciplinary team effort, the speech-language pathologist (SLP) plays a central role in the behavioral management of dysphagia in the elderly.

It is beyond the scope of this article to discuss all available treatment techniques for managing dysphagia in the elderly along with all the relevant research. However, some of the main management options available are summarized below.

Compensatory Management

Compensations are viewed as short-term adjustments to the patient’s behavior, food/liquid, and/or environment. The goal is to maintain nutrition and hydration needs until the patient can do so themselves. Compensatory strategies include postural adjustments, swallow maneuvers, bolus/environmental adaptations, and diet modifications.

Postural Adjustments

Five postural techniques (chin-down, chin-up, head turn, head tilt, and side-lying) and several postural combinations are used for swallow compensation, with reported efficacy in several populations. Each posture affects specific flows of food/liquid and relationship of oropharyngeal structures and can provide optimal compensation in patients with specific swallowing impairments.

There’s no agreement on the benefits of these techniques. For example, while some investigators report reduced aspiration using a chin down technique, others report no benefit compared to other compensations like thickened liquids.¹³ Some data also suggest that these strategies are inferior to more active rehabilitation efforts in the prevention of nutritional deficits and pneumonia.¹⁴ It is essential to test the effectiveness of these postures during instrumental examinations for best outcomes.

Swallow Maneuvers

Swallow maneuvers alter the timing or strength of particular swallowing movements. Swallow maneuvers are variants of the typical swallow, and can be used as short-term compensations and also as rehabilitative strategies.

Different maneuvers address different aspects of the impaired swallow. For example, the supraglottic swallow is used for patients demonstrating reduced airway protection during the swallow, while the Mendelsohn maneuver is useful for patients with decreased hyolaryngeal excursion and/or a decreased duration of UES opening.

The best advice for clinicians is to verify the effects of these maneuvers using swallowing imaging studies. Before introducing maneuvers in therapy, be sure to understand the rationale of each maneuver, and how they alter the swallowing mechanism.

Diet Modifications

The most common compensatory intervention in older adults is diet modification – a totally passive environmental adaptation.¹⁰ The goal of diet modification is to make oral consumption easier and thus maintain safe and adequate oral intake.

Sometimes, a modified diet may be needed as a short-term solution to minimize aspiration during an acute phase of an illness or to improve ease of PO intake. However, this approach has significant potential risks, especially when overused with elderly patients. Evidence indicates limited patient compliance with modified diets (especially thickened liquids). Modified diets may increase the risks of dehydration and malnutrition in the elderly.¹⁵ Lack of standardization and consistency between the different food and liquid textures and viscosities is also a serious concern. The recent IDDSI framework is a major multidisciplinary effort towards developing a standardized way of naming and describing texture modified foods and thickened liquids for people with dysphagia across the lifespan.

Remember that diet modifications do not equate to successful skilled dysphagia treatment. They are merely compensations and should be as short-term as possible. Clinicians should attempt to progress the patient to the least restrictive diet as quickly as possible.

Swallow Rehabilitation

The goal of swallow rehabilitation is to directly improve the physiology of the impaired swallow.

A body of literature has emerged during the past decade that suggests that loss of muscle strength with age is, to a great extent, reversible through rehabilitation exercise.⁹ Labial and lingual resistance, head-lift (Shaker) and expiratory muscle strength training (EMST) and other exercises have shown promising results, including:

• Improving functional swallowing
• Minimizing or preventing dysphagia-related morbidities
• Improving impaired swallowing physiology¹²

Strength training may even improve general force-generating capacity, increase functional reserve, stimulate motor unit recruitment, and allow patients to participate in extended task-specific exercises.²

Further research is needed to identify the subsets of dysphagic elderly patients who benefit most from various exercises and to determine treatment parameters – such as intensity, duration, and frequency of treatment – for maximizing patient outcomes.

Sensory Treatments

Sensorial enhancement strategies aim to initiate or accelerate the oropharyngeal swallow response.

A sour bolus is thought to stimulate a stronger swallow, increase strength of muscle contraction and reduce aspiration.⁷ Due to the anosmia (loss of sense of smell, resulting in loss of taste) individuals with dementia often prefer highly seasoned, flavored or sweet foods¹⁶, which can help to stimulate their swallow. Similarly, temperature modifications, such as using a cold bolus, increase sensory awareness and may affect swallowing physiology.

Recently, taste stimuli, tactile thermal oral stimulation, and pharyngeal electrical stimulation have all been shown to modulate swallowing motor pathways, cortical representation of swallowing, and potentially reverse swallowing disability.⁵ Further research is needed to determine the long-term effects of these strategies in the treatment of dysphagia in the elderly.

Alternate Nutrition and Hydration (ANH)

Populations most commonly receiving ANH include the general category of dysphagia and patients with stroke and dementia. While non-oral feeding methods provide a direct benefit in many clinical situations, especially in the acute phase of an illness, they do not benefit all elderly patients with dysphagia or nutritional decline.

Multiple studies state that there is no data to suggest that tube feeding of patients with advanced dementia prevented aspiration pneumonia or prolonged survival rates.⁸ NPO patients are also at greater risk for developing aspiration pneumonia from a higher rate of colonization of oral bacteria.⁶

Clinicians must carefully consider the potential harm of all dysphagia interventions in the frail elderly, particularly modified diets and feeding tube placements (commonly implemented in the absence of efficacy data). SLPs working with the elderly should know when and how to transition from active to passive dysphagia treatment options and shift the focus from ‘quantity’ to ‘quality’ of life.

Individualized Care

Oropharyngeal dysphagia is an unrecognized syndrome in older adults, with serious health consequences. It is insufficiently studied, poorly diagnosed, and the evidence for interventions is still weak. On the other hand, the knowledge about the pathophysiology of swallowing has increased tremendously, building a good foundation for more research on the efficacy of presently available, and development of new interventions.

Many treatment options are available to manage dysphagia in the elderly, including compensatory strategies, rehabilitative exercises, medical/surgical/pharmacologic management, alternate nutrition, and hydration options, to name a few. The most important takeaway is that dysphagia treatment in the elderly is not black-and-white. One size does not fit all; rather, goals and plans must be individualized and modified to fit given clinical scenarios.

A combination of clinical experience and expertise, the best available evidence, and most importantly, the patient’s and caregivers’ values and preferences, together lead to successful evidence-based management of oropharyngeal dysphagia in the elderly.