Dysphagia in the Elderly the

Dysphagia in the Elderly The work of Michael R. Spieker (2000) entitled: "Evaluating Dysphagia" published in the journal of the 'American Family Physician' states that dysphagia is a problem "that commonly affects patients cared for by family physicians in the office, as hospital inpatients and as nursing home residents." Problems that are known to lead to complaints of dysphagia include: Cerebrovascular accidents; Gastoresophageal reflux disease; and 3) Medication-related side-effects.

(Spieker, 2000) Spieker states that stroke patients "are at particular risk of aspiration because of dysphagia." (2000) Approximately seven to ten percent of adults over the age of fifty years of age have dysphagia although according to Spieker (2000) this number "may be artificially low because many patients with this problem may never seek medical care." Approximately 25% of patients who are hospitalized and 30 to 40% of patients in nursing homes "experience swallowing problems." (Spieker, 2000) Spieker states that "diseases of the esophagus are among the top 50 reasons that patients seek medical care, and in frequency, rank alongside problems such as pneumonia, bronchitis and otitis media." (2000) Conditions that cause dysphagia can "produce esophageal rupture, nutritional deficits and aspiration pneumonia." (Spieker, 2000) the following figure lists the differential diagnoses of Dysphasia which has been adapted from the work of Spieker (2000) Differential Diagnoses of Dysphagia Oropharyngeal dysphagia Esophageal dysphagia Neuromuscular disease Diseases of the central nervous system Cerebrovascular accident Parkinson's disease Brain stem tumors Degenerative diseases Amyotrophic lateral sclerosis Multiple sclerosis Huntington's disease Postinfectious Poliomyelitis Syphilis Peripheral nervous system Peripheral neuropathy Motor end-plate dysfunction Myasthenia gravis Skeletal muscle disease (myopathies) Polymyositis Dermatomyositis Muscular dystrophy (myotonic dystrophy, oculopharyngeal dystrophy) Cricopharyngeal (upper esophageal sphincter), achalasia Obstructive lesions Tumors Inflammatory masses Trauma/surgical resection Zenker's diverticulum Esophageal webs Extrinsic structural lesions Anterior mediastinal masses Cervical spondylosis Neuromuscular disorders Achalasia Spastic motor disorders Diffuse esophageal spasm Hypertensive lower esophageal sphincter Nutcracker esophagus Scleroderma Obstructive lesions Intrinsic structural lesions Tumors Strictures Peptic Radiation-induced Chemical-induced Medication-induced Lower esophageal rings (Schatzki's ring) Esophageal webs Foreign bodies Extrinsic structural lesions Vascular compression Enlarged aorta or left atrium Aberrant vessels Mediastinal masses Lymphadenopathy Substernal thyro Source: Spieker (2000) II.

DIFFERENTIAL DIAGNOSIS of DYSPHAGIA in the ELDERLY Spieker states that the patients who have dysphagia "may present with a variety of complaints, but they usually report coughing or choking, or the abnormal sensation of food sticking in the back of the throat or upper chest when they are trying to swallow." (2000) it is necessary that the physician conduct the patient history carefully in order to identify the causes of the dysphagia and this involves asking specific questions about the "onset, duration and severity of the dysphagia, and a variety of associated symptoms." (Spieker, 2000) a patient history that conducted carefully will answer two general questions as follows: Is the dysphagia oropharyngeal or esophageal in nature; and Is it caused by mechanical obstruction or a neuromuscular motility disorder? (Spieker, 2000) III.

TYPES of DYSPHAGIA IDENTIFIED The following descriptions are assigned to each of the types of dysphagia as noted in the work of Spieker (2000): 1) Oropharyngeal Localization - Patients with this condition present "with difficulty in initiating swallowing and also may have associated coughing, choking or nasal regurgitation. The patient's speech quality may have a nasal tone. This type of dysphagia is most often associated with stroke, Parkinson's disease or other long-term neuromuscular disorders.

(Spieker, 2000) 2) Esophageal Localization - "Patients with esophageal dysphagia present with the sensation of food sticking in their throat or chest. Motility disorders and mechanical obstructions are common. Several medications have been associated with direct esophageal mucosal injury while others can decrease lower esophageal sphincter pressures and cause reflux." (Spieker, 2000) 3) Neuromuscular Motility Disorders - "Patients with neuromuscular dysphagia experience gradually progressive difficulty in swallowing solid food and liquids. Cold foods often aggravate the problem.

Patients may succeed in passing the food bolus by repeated swallowing, by performing the Valsalva maneuver or by making a positional change. They are more likely to experience pain when swallowing than patients with simple obstruction. Achalasia, scleroderma and diffuse esophageal spasm are the most common causes of neuromuscular motility disorders." (Spieker, 2000) 4) Mechanical Obstruction - "Obstructive pathology is typically associated with dysphagia of solid food but not liquids. Patients may be able to force food through the esophagus by performing a Valsalva maneuver, or they may regurgitate undigested food.

Close questioning of the patient may reveal a change in diet to one of predominantly soft foods. Rapidly progressive dysphagia of a few months' duration suggests esophageal carcinoma. Weight loss is more predictive of a mechanical obstructive lesion. Peptic stricture, carcinoma and Schatzki's ring are the predominant obstructive lesions." (Spieker, 2000) The following chart illustrates the process of evaluation of Dysphagia as set out in the work of Spieker (2000). Evaluation of Dysphagia Source: Spieker (2000) IV.

TYPES of TESTING in DYSPHAGIA Testing types that may be used in assessing dysphagia include those as follows: Barium swallow studies; Double-contrast upper gastrointestinal evaluation; Gastoesophageal endoscopy; Manometry; pH monitoring; and Videoradiography. (Spieker, 2000) V. RECENT STUDY FINDINGS The work of Paul E.

Marik and Danielle Kaplan (2003) entitled: "Aspiration Pneumonia and Dysphagia in the Elderly" published in the 'Chest' journal states that community-acquired pneumonia (CAP) "is a major cause of morbidity and mortality in the elderly and the leading cause of death among residents of nursing homes." (Marik, 2003) the most important factor leading to pneumonia in the elderly is stated by Marik to be that of "oropharyngeal aspiration." (2003) This is because "the incidence of cerebrovascular and degenerative neurological diseases increase with aging and these disorders are associated with dysphagia and an impaired cough reflex with the increased likelihood of oropharyngeal aspiration." (Marik, 2003) According to Marik, elderly patients who present with "clinical signs suggestive of dysphagia and/or who have CAP should be referred for a swallow evaluation.

Patients with dysphagia require a multidisciplinary approach to swallowing management." (2003) This may be inclusive of "swallow therapy, dietary modification, aggressive oral care, and consideration for treatment with an angiotensin-converting enzyme inhibitor. (Marik, 2003) The work of Bautmans, et al.

(2008) entitled: "Dysphagia in Elderly Nursing Home Residents with Severe Cognitive Impairment Can be Attenuated by Cervical Spine Mobilization" published in the 'Journal of Rehabilitative Medicine' reports a study which investigated the "feasibility of cervical spine mobilization in elderly dementia patients with dysphagia, and its effects on swallowing capacity." (Bautmans, et al., 2008) the method used in this study of fifteen nursing home residents (9 women, 6 men, age range 77-98 years) with severe dementia (median Mini Mental State Examination score=8/30, percentile (P)25-75=4-13) and known dysphagia participated in a randomized controlled trial with cross-over design involved the administration of cervical spine mobilization by trained physiotherapists.

The study reports "...Control sessions consisted of socializing visits. Feasibility (attendance, hostility, complications) and maximal swallowing volume (water bolus 1-20 ml) were assessed following one session and one week (3 sessions) of treatment and control." (Bautmans, et al., 2008) Study results report "...ninety percent of cervical spine mobilization sessions were completed successfully (3 sessions could not be carried out due to the patient's hostility and 2 due to illness) and no complications were observed.

Swallowing capacity improved significantly after cervical spine mobilization (from 3 ml (P25-75=1-10) to 5 ml (P25-75=3-15) after one session p=0.01 and to 10 ml (P25-75=5-20) (+230%) after one week treatment p=0.03) compared with control (no significant changes, difference in evolution after one session between treatment and control, p=0.03)." (Bautmans, et al., 2008) Conclusions stated by Bautmans et al. (2008) include that cervical spine mobilization "...is feasible and can improve swallowing capacity in cognitively impaired residents in nursing homes.

Given the acute improvements following treatment, it is probably best provided before meals." (Bautmans, et al., 2008) The work of Rebecca S. Stone (2006) entitled: "Dysphagia in the Elderly" published in 'Inpatient Times' reports that dysphagia is "a remarkably prevalent disorder in the aging population. In independently living populations of > 65-year-olds, up to 15% may have dysphagia. In facility-based populations, the prevalence is as high as 40%.

Normal effects of the aging process, such as deterioration in salivary gland function or decreased reflexive opening of the upper esophageal sphincter, can be contributing factors to dysphagia, as can stroke or dementia.

Finally, medications, including diuretics, anti-cholinergics, anti-histamines, and beta-blockers can lead to or worsen dysphagia due to xerostomia." (Stone, 2006) Stone additionally states that when a patient has a stroke or other event that has the ability to cause an impairment to swallowing it is critical to look "for signs that swallowing is impaired" including: cough after swallow; voice change after swallow; abnormal volitional cough; abnormal gag reflex; dysphonia; and dysarthria. (Stone, 2006) Stone states that the patient should be observed carefully "during spontaneous swallowing.

If no signs of swallowing impairment are noted then the patient may be tested under direct observation using small amounts of clear liquid.

If no swallowing dysfunction is noted, the diet may be carefully advanced." (Stone, 2006) However, in the event that difficulty in swallowing or any of the foregoing stated signs are noted "the patient should be made NPO and a Speech and Swallow consult should be considered." (Stone, 2006) Treatment is stated by Stone (2006) to be "diagnosis dependent and may be medical or surgical." Practical modifications include simple steps such as crushing of pills or opening of capsules to ease and facilitate swallowing. The work of Leibovitz, et al.

(2007) entitled: 'Dehydration Among Long-Term Care Elderly Patients with Oropharyngeal Dysphagia" states that long-term care (LTC) residents in the nursing home "especially the orally fed with dysphagia are prone to dehydration. The clinical consequences of dehydration are critical. The validity of the common laboratory parameters of hydration status is far from being absolute, especially so in the elderly." (Leibovitz, et al., 2007) it is related however that "combinations of these indices are more reliable." (Leibovitz, et al., 2007) the study reported by Leibovitz et al.

is one that assessed hydration status among elderly LTC residents with oropharyngeal dysphagia and in which a total of 28 orally fed patients with grade-2 feeding difficulties on the functional outcome swallowing scale (FOSS) and 67 naso-gastric tube (NGT)-fed LTC residents entered the study." (Leibovitz, et al., 2007) That utilized as indices of hydration status include: "the common laboratory, serum and urinary tests." (Leibovitz, et al., 2007) Results are stated to have been "considered an indicative of dehydration and used as 'markers of hydration', if they were above the accepted norms." Stated as results in this study are the following: "...The mean number of dehydration markers was significantly higher in the FOSS-2 group (3.8 ± 1.3 vs.

2 ± 1.4, p = 0.000). About 75% of these FOSS-2 patients http://content.karger.com/ProdukteDB/images/entity/gteq.gif 4 dehydration markers versus 18% of the NGT-fed group (p = 0.000). A low urine output (800 ml/day) also had a significant number (2 ± 1.5) of positive indices of dehydration." (Leibovitz, et al., 2007) Liebovitz et al. states that dehydration "was found to be common among orally fed FOSS-2 LTC patients. Surprisingly, probable dehydration, although of a mild degree, was not a rarity among NGT-fed patients either.

The combination of 4 parameters, BUN, BUN/SCr, U/SOsm and UOsm, offers reasonable reliability to be used as an indication of dehydration status in daily clinical practice." (Leibovitz, et al., 2007) The work of William Osler (2003) entitled: "Captain of the Men of Death" states that community-acquire pneumonia (CAP) "is a major cause of morbidity and mortality in the elderly, with an estimated annual health-care cost in the United States of $4.4 billion." The incidence of pneumonia has bee shown in epidemiological studies to increase with aging "with the risk being almost six times higher in those ? 75 years old, compared to those < 60 years of age." (Osler, 2003) the work of Marrie (1990) states findings that 33 of 1,000 nursing home residents each year were hospitalized for treatment of pneumonia as compared with 1.14 of 1000 elderly individuals living in the community.

Rello, Rodriguez and Jubert (1996) found that COPE, heart disease, malignancy, malnutrition, congestive heart failure and diabetes mellitus has been implicated as risk factors for community acquire pneumonia in the elderly.".