Chapter 10 Etiology and Risks of Swallowing Disorders

BOX 10.4 Signs of Dysphagia ●

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Drooling or spilling food from the mouth Increase in secretions or phlegm ● Difficulty chewing

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Coughing or choking before, during, or after swallowing foods, liquids, or medications

● Pocketing of food in the cheeks ●

● ●

Rocking the tongue back and forth or exces- sive tongue movement

Food left in the mouth or on the tongue after swallowing

Excessive mouth movement during chewing and swallowing, including tongue thrusting

● Facial weakness ●

● ●

Swallowing two or three times with each bolus

Repeated or frequent throat clearing through- out the meal

Complaint of food caught or sticking in the throat or chest when swallowing

● Refusing to eat ● Change in appetite

● Heartburn or acid reflux ● Decrease in fluid intake

●

“Wet” vocal quality; hoarse, breathy vocal quality; or gargly breathing

● Frequent respiratory infections ● Vomiting

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Prolonged eating time, which can lead to frustration and social stigma

● Weight loss ● Dehydration ● Fever

● Self-modification of diet

156) offers information on interpreting patient reports about dysphagia symptoms (22).

COMPLICATIONS OF DYSPHAGIA Both oropharyngeal and esophageal dysphagia result in the reduced ability to obtain adequate nutrition by mouth and reduced safety during oral intake. Aspiration pneumonia, malnutrition, and dehydration are great concerns for those with dysphagia. Aspiration results from food or liquids, including bodily secretions, entering the lungs rather than the stomach. Aspiration can be asymptomatic (silent) or symptomatic. These foreign substances irritate the lung tissue and predispose the oropharynx to bacterial colonization, increasing the risk of infection and even

death (23,24). As many as 50% of dysphagia cases result in pneumonia; mortality is associated with up to 70% of aspiration cases (25-27).

The relationship between dysphagia and aspiration pneumonia is not entirely clear. Not all cases of aspira- tion lead to pneumonia (28), and aspiration pneumonia can occur in those who don’t have dysphagia (28-31). In fact, aspiration of saliva occurs commonly in many people, often during sleep (29,30). Older adults with dysphagia will continue to swallow and aspirate reflux, oral bacteria, and secretions even if thickened liquids are ordered (31). Box 10.6 (see page 151) (32) lists the strongest predictors of aspiration pneumonia in nursing facility residents.

Dysphagia can result in reduced or altered oral intake of foods and liquids, which, in turn, can con- tribute to lowered nutritional status. Recent studies have suggested that elderly community dwellers are also at risk for dysphagia and associated deficits in nutritional status and increased pneumonia (33). The etiology of malnutrition is complex and multifactorial but is primarily disease related and associated with an increase in nutritional requirements or an increase in nutrient loss. In addition to disease- related causes of malnutrition, difficulties in eating or swallowing play an important role. Clave et al determined that the pres- ence of malnutrition in residents with dysphagia was significantly higher than in those without dysphagia (36.8% vs 13.2%) (34). Other research indicates that the prevalence of malnutrition and dehydration may be as high as 75% in patients diagnosed with oropharyn- geal dysphagia, with morbidity as high as 50% (35-37).

In addition to nutritional inadequacy and clear association with aspiration and death, dysphagia greatly reduces the enjoyment of eating, self-esteem, security, work capacity, exercise, and leisure. Ekberg et al found that only 45% of older adults (average age 71.6 years) diagnosed with dysphagia enjoyed eating, 41% experienced anxiety or panic during mealtimes, and 36% indicated they avoided eating with others due to their dysphagia (38).

Due to the vast numbers of individuals currently

affected by dysphagia and the projected growth of the population most likely to develop it (33), the costs of dysphagia are physiological as well as social and monetary. Average hospital stays for those diagnosed with dysphagia were more than 40% longer than those without it (4.04 days vs 2.40 days) (39). When controlling for age, comorbidities, ethnicity, and pro- portion of time alive, Bonilha et al determined the one-year cost to Medicare for individuals with dys- phagia following an ischemic stroke was $4,510 higher per year than for persons without dysphagia