Swallowing

Swallowing difficulties, medically known as dysphagia, are most apparent to an older person, their family and hospital staff when the person is eating, drinking or taking medication. Swallowing difficulties can have an acute onset during illness and may be short term in nature or they can be a symptom of severe illness and become more severe due to neurological diseases such as Parkinson’s disease or dementia.

Mild swallowing difficulties are common in older people, particularly in those over the age of 80. There are many strategies we can implement to optimise food and fluid intake to avoid the difficulties becoming more severe and avoid a series of cascading risks.

This topic provides an overview of swallowing difficulties. It recommends actions that we and our organisations can take, in addition to health service policy and procedures, to provide quality care to older patients with swallowing difficulties.

Swallowing process and its impact on health

Swallowing difficulties (dysphagia) range from mild to severe, can be short or long term in duration, and acute or progressive in nature. Although it is not considered a normal part of ageing, dysphagia can occur due to the physiological ageing process, especially in people over 80. However, it is often a symptom of an underlying disease or condition.

Swallowing is a complex process that relies on many nerves and muscles of the mouth, throat and oesophagus¹. Swallowing difficulties can cause problems with drinking, eating, chewing, controlling saliva, taking medications and protecting the airway². An older adult with swallowing difficulties is at increased risk of pain³, dehydration and malnutrition.

Swallowing problems can mean that food and fluids entering the airway (laryngeal penetration) or the lungs (aspiration) can cause chest infections (aspiration pneumonia), choking or even death.

The swallowing process

The normal adult swallowing process occurs in four stages:

• Oral Preparatory Phase – also known as the pre-oral stage, involves the cognitive response to food and fluid and the ability of the person to think about eating. This is the initial phase, which starts with the mouth closing and chewing the food.
• Oral Transit Phase – is where the tongue works to move the food back towards the throat. Food and liquid is chewed and mixed with saliva, which is then pushed into the pharynx by the tongue.
• Pharyngeal Phase – is where the soft palate elevates and creates pressure within so food doesn’t go back into the nose. The food or fluid reaches the pharynx and triggers the swallow reflex. This acts to protect the airway so that food or fluid pass into the oesophagus and not into the lungs.
• Oesophageal Phase – is the final stage and involves the passage of the food and fluids down the food pipe (the oesophagus) into the stomach⁴.

Dysphagia

Dysphagia occurs when one or more of the four phases of swallowing is disrupted.

There are two main types of dysphagia:

Oropharyngeal dysphagia – trouble with moving food around the mouth and forming a bolus, as well as ‘initiating a swallow’. Patients are often medically unwell, and the most common causes are neurological disorders, such as stroke, Parkinson’s disease and dementia⁵.

Oesophageal dysphagia – the sensation of having food stuck in the throat or chest when swallowing and patients may complain of chest pain. Causes include gastro-oesophageal reflux disease (GORD), cancer, Zenker’s diverticulum, infection, inflammation, motility disorders and certain types of medications⁶. Oesophageal tract changes, which may contribute to swallowing difficulties, are common in people over 80 years.

Causes of dysphagia are varied and patients may present to hospital in the acute or chronic stage with varying symptoms. Patients who are severely ill or have a disability or who have suffered from stroke, brain injury, Parkinson’s disease or dementia, are especially at risk of developing dysphagia⁶.

Impacts of dysphagia

The more unwell an older patient is and the more their overall function is affected, the more vulnerable they are to developing swallowing problems. Critically ill older patients with dysphagia are at higher risk of developing life-threatening conditions, including aspiration and aspiration pneumonia, obstruction, pneumonitis and abscess^7,8.

Aspiration

Aspiration occurs when material is ingested and ends up in the lungs. This may be food particles, fluids, oropharyngeal secretions containing infectious agents⁹ or bacteria, which can cause an inflammatory condition⁸. Patients with dysphagia are at increased risk of developing aspiration, as are patients who are critically ill.

Silent aspiration and silent strokes

Silent aspiration is aspiration without any key clinical symptoms and signs, making it difficult to identify without imaging and assessment¹⁰. However it is common, occurring in more than 50 per cent of patients who aspirate⁵.

Similarly, ‘silent strokes’ are those occurring without symptoms and they are also a common cause of swallowing difficulties.

Aspiration pneumonia and pneumonitis

Dysphagia is also a risk factor for aspiration pneumonia – pneumonia caused by inhaling secretions or food that have been colonised by bacteria. Aspiration pneumonitis is caused by aspirating gastric contents. It is the most common cause of death in patients with dysphagia.

Malnutrition and dehydration

Older adults in hospital who have swallowing difficulties of any type are prone to weight loss and developing malnutrition and dehydration, which can severely impact their ability to recover from illness or surgery and remain independent and can increase the risk of other problems including delirium and falls.

Swallowing and ageing

Dysphagia is not considered a normal part of ageing; however, it can occur due to the physiological ageing process, especially in people over 80. Older people may have difficulty swallowing (mild) or may not be able to swallow at all (severe).

The ability to swallow can be affected by:

• loss of muscle mass and strength
• faitigue or exhaustion
• loss of dentition
• a decrease in mouth and tongue movements
• changes in eating habits and taste buds (often due to loss of senses of taste and smell)
• extended time in eating and drinking
• difficulty managing oral secretions¹¹
• food taking longer to travel down the oesophagus to the stomach.

For older people in hospital, swallowing difficulties can prolong recovery time and contribute to functional decline, frailty and loss of independence. Severe dysphagia is often indicative a person is in the end stage of their disease.

Hospital provides an ideal opportunity to identify signs of swallowing difficulties and help older patients achieve and maintain optimal nutrition and hydration during their stay. This assists us to prevent cascading problems such as delirium, incontinence, falls and pressure injuries.

Identifying people at risk of swallowing problems

Screening older people for swallowing difficulties is vital to avoid choking, dehydration, malnutrition and extended hospital stays due to complications with other illnesses. When swallowing difficulties are identified early, we can tailor care and treatment to respond to each person’s biological and medical needs, their abilities and their lifestyle and cultural preferences.

Screening patients who present with a stroke

Prompt screening is particularly important after stroke as no food, drink or oral medications should be given to the patient until it is clear there are no swallowing problems.⁷

Screen all patients who present with a stroke within 24 hours of hospital admission.

Speech pathologists recommend using the ASSIST (Acute Screening for Swallow in Stroke) screening tool (and training staff in its use), which is the most widely used, thorough, evidence-based dysphagia screen. It is one component of The Victorian Dysphagia Screening Model and consists of five short questions.

Screening patients with certain medical conditions

Many medical conditions can impact on the normal swallowing process. Finding out whether a person has experienced any difficulty is crucial, particularly with the following conditions:

• Parkinson’s disease and other neurological problems
• head strike due to a fall
• depression
• dementia (mild, moderate or severe)
• delirium
• previous surgery to the mouth, throat, nose, spine or brain
• cancer of the mouth, throat, head or neck
• GORD
• multiple comorbidities
• frailty which is associated with a high risk of dysphagia and malnutrition⁸.

Oral health should be screened at the same time as swallowing. Poor oral health and dental issues can seriously impact on swallowing and enjoyment of foods and liquids

Signs of swallowing difficulties

Look for signs of:

• difficulty swallowing or lack of swallowing⁷
• coughing before swallowing⁷, during meal times, or after eating
• heartburn⁷
• drooling^12,13
• taking a long time to eat and drink, wasting food
• altered level of alertness or reduced response
• speech or voice changes as they may indicate silent aspiration. Look for slurred speech, a weak, hoarse, crackly, gurgling or wet-sounding voice. If in doubt, ask family members if they have noticed any recent vocal changes
• a history of recurrent chest infections¹⁴ or suspected aspiration
• tongue, facial or lip weakness or altered appearance
• pocketing food or tablets in the cheeks
• the patient describing food as sticking to the roof of their mouth or throat, or the sensation of a ‘lump’ or discomfort in the throat or chest, or frequent throat clearing during meal times (can indicate GORD)
• unexplained weight loss⁷
• reluctance to swallow food, water or medication.

“I had difficulty swallowing tablets when I was in hospital. I had to take my teeth out and I didn’t want the staff to see me, but they have to see you swallow. They have to make sure that you take the medication. I don’t know if anything can be done about that. It was just my vanity but… It’s an issue”. Consumer

Gather information from the patient, their family and carers

If we observe any of the signs or symptoms of swallowing difficulties or the patient complains of any of these problems, we should gather further information from the patient and their family and carers, explore the history of these issues, raise the concern with the treating team and work together to mitigate any immediate risks.

As a first step, ask the patient, their family and carer:

• about the severity and duration of their swallowing problem
• if they have been self-managing this issue, and if so, ask them what strategies have been helping them
• to describe the location of the difficulty in swallowing
• about the types of foods or liquids which make swallowing difficult
• whether the swallowing issue is progressive or intermittent⁷
• if they are experiencing reflux, as it is often associated with dysphagia.

Swallowing and discharge planning

The ability to swallow and eat and drink easily is important for our health and wellbeing. As clinicians, we can help patients make a smooth transition from the hospital to their home or care facility.

A change in a patient’s swallowing ability can be daunting for an older person and their family to manage once they leave the hospital. To improve outcomes in this area:

• check that the patient understands their treatment goals and provide them with handouts and information to aid in their comprehension
• inform the patient's family and carers about the swallowing issues and ongoing interventions required so they can work closely with the patient to keep them well
• emphasise the importance of maintaining safe swallowing and good nutrition while at home or an alternative care facility
• provide verbal and written information about safe swallowing practices if these have been recommended, as well as oral hygiene and food preparation
• stress the importance of keeping well hydrated to sustain recovery and assist with managing dysphagia; dehydration can lead to a dry mouth and throat which will affect swallowing ability
• ensure the patient and their family and carer are aware of how to take prescribed medication
• provide the patient with information on where to purchase nutritional supplements if needed and check that they have the funds to do so
• consider referring the person to a community dietitian and speech pathologist to provide ongoing support
• refer the patient to social support services if necessary
  • There is a risk of older patients with dysphagia becoming socially isolated, as they may be reluctant to eat in front of others¹⁵
  • Find out if the patient was experiencing social isolation prior to their admission, and help them with strategies and referrals to access support
• recommend that the patient has regular dental checks as dental hygiene is an important factor in managing dysphagia.