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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #14, #16, #25, #49, #73, #74

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LEARNING OBJECTIVES

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Learning Objectives

  • To understand the anatomy and physiology of the normal swallowing process.

  • To distinguish between presbyphagia (healthy age-associated changes in swallowing) and dysphagia.

  • To identify age-related diseases and conditions most commonly associated with the development of dysphagia.

  • To describe screening and assessment techniques, instrumental and noninstrumental, for identifying and characterizing dysphagia.

  • To summarize options available for treatment of dysphagia, including compensatory and rehabilitative approaches.

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Key Clinical Points

  1. Changes in swallowing that occur with healthy aging, termed presbyphagia, combined with age-associated diseases and conditions place older adults at risk for the development of dysphagia.

  2. Swallowing is a complex patterned response that involves coordination of 30 oral and pharyngeal muscle pairs across both the cranial and spinal nerve systems.

  3. An interdisciplinary team approach to early identification and comprehensive assessment of dysphagia will allow for effective treatment through both compensatory and rehabilitative techniques.

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INTRODUCTION

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Demographic changes related to aging necessitate that clinicians have the resources to address eating and swallowing difficulties present in older adults. The capacity to effectively and safely eat or swallow is one of the most basic human needs and also can be a great pleasure. Therefore the loss of this capacity can have far-reaching implications. Many would argue that swallowing is one of the cardinal behaviors needed to sustain life. The process of swallowing requires orchestration of a complex series of psychological, sensory, and motor behaviors that are both voluntary and involuntary. Dysphagia refers to difficulty swallowing that may include oropharyngeal or esophageal problems. More specifically, there may be difficulty in oral preparation for swallowing and/or moving material from the mouth to the esophagus and from the esophagus to the stomach.

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Although age-related changes place older adults at risk for dysphagia, an older adult’s swallow is not inherently impaired. Presbyphagia refers to characteristic changes in the mechanism of swallowing of otherwise healthy older adults. Clinicians need to be able to distinguish among dysphagia, presbyphagia, and other related diagnoses such as globus hystericus to avoid overdiagnosis and overtreatment of dysphagia. Older adults can be more vulnerable and, with additional stressors such as acute illness and certain medications, they can cross over from having a healthy older swallow (presbyphagia) to experiencing dysphagia. This chapter reviews the normal swallowing process and presbyphagia, as a healthy aging evolution, dysphagia outcomes, multidisciplinary approaches to diagnosing and managing dysphagia, and rehabilitation strategies for dysphagia care.

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IMPACT OF DYSPHAGIA

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Dysphagia prevalence depends on the specific population sampled, with community-dwelling and more independent individuals having rates near 15%. Upward of 40% of people living in institutional settings such as assisted living and nursing homes are dysphagic. Given the projected increases in the geriatric population over the next several ...

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