Dysphagia in the elderly

Swallowing difficulties – dysphagia - is common amongst the elderly in general, and its estimated prevalence is between 17% and 63%. Amongst those in residential or special care the proportion is 40% to 60%. ^{[1, 2]} There are many reasons why dysphagia is common amongst the elderly; as the body ages, our sensitivity ^[3] and muscle strength weaken, including in the face, oral cavity, pharynx, esophagus and the inner organs. In time, these changes mean that it takes longer to chew and swallow, and that food particles can remain lodged in the upper air pathways with increased risk of inhalation of food, and of pneumonia. ^{[4, 5]}

In combination, the effect of reduced muscle and feeling functions means that eating and swallowing ability weakens and this increases the risk for pneumonia, malnutrition, serious secondary sicknesses and, not least, a reduced quality of life. ^{[6, 7]}

In this section, we show how carers and relatives can notice the common symptoms of dysphagia in elderly people. We also talk about possible treatments and how IQoro^® can help the elderly to retain, improve and regain basic life functions like the ability to eat, chew and swallow. IQoro^® is a new and unique neuromuscular treatment method that requires just 30 seconds’ exercise, three times per day.

 

Common symptoms of dysphagia

amongst the elderly – crucial that we notice

To be able to eat, is one of our most basic and important life functions, and also plays a broader role in our quality of life. It is at mealtimes that we gather together with family and friends and they are also a central part of many other social events. Reduced swallowing ability can prevent the elderly from taking part in many different activities and can often lead to social exclusion.

It is important that those around, notice and react to the common symptoms of dysphagia. If an older person is not himself aware of his swallowing difficulties, he runs an increased risk for both pneumonia and death. ^[8] If you, or somebody close to you, exhibits any of the following symptoms ^{[4, 6, 7, 9–12]} during or after mealtimes then you should suspect dysphagia:

• Long mealtimes – it takes longer than 25 to 30 minutes to eat a normal portion.
• Chewing longer than usual.
• Leaving food on the plate – poor appetite.
• Not noticing the smell or taste of the food.
• Saliva or food spilling over the lips onto the chin and clothes.
• Running nose during mealtimes – a sign that the soft palate is not closing tightly against the nasal cavity.
• Dryness in the mouth – a lack of lubricating saliva.
• Difficulty in swallowing pills.
• Food stuck in the throat more often than usual – choking on food.
• Clearing the throat and coughing often.
• Changes in the voice – can be hoarse or gurgling.
• Difficulty in swallowing liquids with no taste, or with a water-like consistency; but with an improved ability with thicker or flavoured drinks like smoothies, yoghurt, or carbonated drinks that stimulate the senses.
• Storing food in the cheeks.
• Blockages and stoppages when swallowing.
• Acidic reflux, heartburn.
• Pain in the chest, being sick at or after mealtimes.
• Pneumonia.
• Indistinct or slurred speech – difficulty in articulating.
• Easily distracted at mealtimes in noisy and disturbed environments.
• Undernourishment – weight loss, impaired balance.
• Increased tiredness.
• Dehydration.
• Wounds take longer to heal.
  
   

Dysphagia – common amongst the elderly for many reasons.

The swallowing function is adversely affected by many of the changes in the body that come with age, for example: reduced mobility in the joints, impaired balance, reduced muscle mass (muscle atrophy), slower reactions. At the same time, we see that declining production of saliva, reduced senses of smell, taste and touch, also affect the swallowing function. Swallowing becomes slower and does not function as effectively. ^{[3–5, 11, 12]} It takes a longer time to chew and swallow, and food particles can become lodged in the upper air pathways, thus increasing the risk of aspiration of food and of pneumonia. ^{[4, 5]}

Older people over 50 years old that are otherwise healthy, will not necessarily experience problems with the swallowing function as a result of the natural ageing process.^[13] The main reason that the occurrence of dysphagia increases with age is that it is more common to be afflicted by conditions like stroke, various forms of dementia: Parkinson’s disease, MS, ALS, tumours, radiation treatment to the face, mouth, head or neck, trauma to the head and neck region or surgical operations on this part of the body. These are all illnesses and consequences of treatment that can give rise to swallowing difficulties. ^{[9, 14]}
 

Dysphagia – a cause of undernourishment and pneumonia

Dysphagia can cause various medical conditions like malnutrition, dehydration, depression, memory loss, problems with balance, reduced ability to heal wounds, oral problems, choking and pneumonia. ^[7]

Undernourishment or insufficient intake of liquids leads to reduced saliva production and in time reduced protection for teeth and the membranes of the mouth – something that then requires a higher standard of oral hygiene. Dryness in the mouth caused by reduced saliva production also makes it harder to swallow.
 

Oral hygiene – not prioritised in care of the elderly ^[16,17]

It is well known that poor oral health affects both general health and quality of life. Despite this, it is often given a low priority in care of the elderly and it is often forgotten that the elderly, with reduced food intake and nutrition, can have difficulties with their swallowing function.

Unlike in earlier years, now 60% of all 75 year olds have all their teeth remaining, or have lost only a few ^[15], and amongst those that have lost teeth more have permanent implants. Together, this gives an improved chewing ability and quality of life. On the other hand, it sets higher demands on keeping the teeth clean, that the gums are healthy and free of inflammation, and that the membranes are moist and free of cuts, to be able to eat and enjoy food.

Good oral hygiene – teeth brushed with a soft toothbrush and the gaps between them cleaned with dental floss or toothpicks – is the be all and end all of minimising the risk of pneumonia through dysphagia. It is actually not the aspiration of food in itself that causes pneumonia, but poor oral hygiene allowing bacteria to be sucked down to the lungs. Elderly people that cannot maintain good mouth care are therefore most dependent on their carers and their knowledge, ambitions and priorities. ^[18]

In addition, there is a large population of elderly that live alone in their own homes and are reliant upon relatives and health visitors helping ensure good oral hygiene, and noticing the symptoms of dysphagia and understanding that they must seek help for them.

 

Treatment methods for dysphagia in the elderly ^[11]

Elderly people with dysphagia are often offered help in the form of:

• Advice on good oral hygiene.
• Advice in correct sitting posture.
• Modification of food: energy enriched, with its consistency thickened, and paying attention to temperature and taste variations.
• Swallowing techniques.
• Techniques for head, neck and body posture during swallowing.
• Mobility and muscle training of the face, lips and tongue. Either passively; for example manually, or with electric toothbrush stimulation; or actively – by the patient himself performing the mobility training.
• Training in swallowing with small portions of, for example, thickened drinks.
  
   

Exercising with IQoro^® - unique in treating the entire swallowing process

IQoro^® is a new and unique neuromuscular treatment method that requires just 30 seconds’ exercise, three times per day. Training with IQoro^® can improve muscle strength and coordination for a safer and more effective eating and swallowing function. This training reaches the muscles in the face, oral cavity, pharynx, esophagus, and down to the diaphragm, and in this way can improve a range of various functions.

Because the exercise sessions are so short it is possible for even the weak and elderly to complete their training regime. These people can either train alone, or with assistance. Studies have shown that a normal swallowing function can be regained faster with a high intensity training, compared with low intensity or compensatory therapy. ^[22–24]

See here how a training session looks.

See here how a training session with assistance looks.

Training with IQoro^® for 1.5 minutes per day can help the elderly with:

• Swallowing difficulties - Dysphagia.
• Hiatus hernia.
• Dribbling or drooling.
• Paralysis in the face, mouth and pharynx.
• Weak face-, lip-, jaw- and tongue musculature.
• Indistinct speech.
• Postural control. ^[20]

How many weeks or months an elderly person needs to train can vary, depending upon the underlying causes of the person’s difficulties. In certain cases some maintenance training can be required after the condition has been rectified, for example with a hiatus hernia. For more information on dysphagia
 

A positive effect on many different functions

Research ^[21] shows that IQoro^® acts on and regenerates the entire swallowing process. It stimulates the sensory nerves in the mouth, and by doing this reaches the brain’s control system for the swallowing process, which is closely linked to the control systems for other bodily functions ^[19], including breathing, the ability to make speech sounds, facial expression, postural control ^[20], stomach and intestine functions, and more. This explains why exercising with IQoro^® can have a positive effect on so many different functions.

Training with IQoro^® also contributes by stimulating the glands in the lower lip and palate roof which produce the lubricating saliva, as well as the salivary glands in the cheeks and under the tongue which produce the fluid saliva. This helps to counter dryness in the mouth and is explained as follows:

training with IQoro^® reaches the brain’s control system for the swallowing process in which signals are sent via various fibres, so-called motor neurons, to the brain stem, and down to the muscles and glands to be activated. There are three different types of fibre of which the third, the General Visceral Efferent (GVE) nerve is included in the brain nerves CN Facialis and Glossopharyngeus and sends signals to the tear glands and the saliva glands, amongst others. This explains why treatment with IQoro^® can have a positive effect on dryness in the mouth.

Read more on treatment method here

Text by:

Dr. Mary Hägg, Doctor of Medicine, Post-doctoral researcher at Uppsala University specialising in orofacial medicine, Head of Department at the Speech and Swallowing Faculty: Ear, Nose and Throat Clinic at Hudiksvall Hospital, Sweden. Registered Dentist. In cooperation with MYoroface.

October 2016.

(Translation from the original Swedish text by T.W.Morris, MYoroface)

Sources:

1. Helldén, J. and E. Sjölund, Screening av dysfagi på äldreboenden i Linköpings kommun. Uppsats Logopedprogrammet, 2009, Institutionen för klinisk och experimentell medicin, Hälsouniversitetet, Linköping. Linköping.
   (English translation, “Screening for dysphagia in elderly residential care in Linköpings county, Sweden. Thesis – speech therapy programme”).
    
2. Westergren, A., et al., Prevalence of eating difficulties and malnutrition among persons within hospital care and special accommodations. J Nutr Health Aging, 2008. 12(1): p. 39-43.
    
3. Engelheart, S., E. Lammes, and G. Akner, Elderly peoples' meals. A comparative study between elderly living in a nursing home and frail, self-managing elderly. J Nutr Health Aging, 2006. 10(2): p. 96-102.
    
4. Logemann JA, Curro FA, Pauloski B, Gensler G. Aging effects on oropharyngeal swallow and the role of dental care in oropharyngeal dysphagia. Oral Dis. 2013;19(8):733–7.
    
5. Ekberg O, Feinberg MJ. Altered swallowing function in elderly patients without dysphagia: radiologic findings in 56 cases. AJR Am J Roentgenol. 1991;156:1181–4.
    
6. Cabre M, Serra-Prat M, Palomera E, Almirall J, Pallares R, Clavé P. Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing. 2009;39(1):39–45.
    
7. Serra-Prat M, Palomera M, Gomez C, Sar-Shalom D, Saiz A, Montoya JG, et al. Oropharyngeal dysphagia as a risk factor for malnutrition and lower respiratory tract infection in independently living older persons: A population-based prospective study. Age Ageing. 2012;41(3):376–81.
    
8. Parker C, Power M, Hamdy S, Bowen A, Tyrrell P, Thompson DG. Awareness of Dysphagia by Patients Following Stroke Predicts Swallowing Performance. Dysphagia. 2004;19(1):28–35.
    
9. Logemann JA. Evaluation and treatment of swallowing disorders. 2 ed. Austin, Tex: PRO-ED; 1998.
    
10. Neyens J, Halfens R, Spreeuwenberg M, Meijers J, Luiking Y, Verlaan G, et al. Malnutrition is associated with an increased risk of falls and impaired activity in elderly patients in Dutch residential long-term care (LTC): A cross-sectional study. Arch Gerontol Geriatr. 2013;56(1):265–9
     
11. Svensson P. Dysfagi – utredning och behandling vid sväljningssvårigheter. Lund: Studentlitteratur; 2010. (English translation, “Dysphagia – investigation and treatment of swallowing difficulties”).
     
12. Schindler JS, Kelly JH. Swallowing Disorders in the Elderly. Laryngoscope. 2002; 120:589–602.
     
13. Daggett A, Logemann J, Rademaker A, Pauloski B. Laryngeal penetration during deglutition in normal subjects of various ages. Dysphagia. 2006;21(4):270–4.
     
14. Ekberg O. Dysphagia: Diagnosis and Treatment. Berlin: Springer; 2012.
     
15. Hugoson, A. and G. Koch, Thirty year trends in the prevalence and distribution of dental caries in Swedish adults (1973-2003). Swed Dent J, 2008. 32(2): p. 57-67.
     
16. Chalmers, J.M. and A. Pearson, A systematic review of oral health assessment by nurses and carers for residents with dementia in residential care facilities. Spec Care Dentist, 2005. 25(5): p. 227-33.
     
17. Nicol, R., et al., Effectiveness of health care worker training on the oral health of elderly residents of nursing homes. Community Dent Oral Epidemiol, 2005. 33(2): p. 115-24.
     
18. Waldman, H.B. and S.P. Perlman, Ensuring oral health for older individuals with intellectual and developmental disabilities.J Clin Nurs, 2012. 21(7-8): p. 909-13.
     
19. Ekberg O, (2011), Röntgendiagnostiska avdelningen, Universitetssjukhuset MAS, Malmö, Normal sväljning inclusive anatomi och fysiologi, (pdf). Hämtad 2015-12-05, http://media1.dysfagi.se/2011/06/svaljningssvarigheter.pdf (English translation, “Normal swallowing including anatomy and physiology”).
     
20. Hägg M., Tibbling L. Effect of IQoro® training on impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke. Acta Otolaryngol 2016; 136 (7):742-748. DOI:10.3109/00016489.2016.1145797 http://dx.doi.org/10.3109/00016489.2016.1145797. 
     
21. Forskning bakom IQoro® – se separat artikellista, klicka här. (English translation, “The research behind IQoro^® - see separate article list here”).
     
22. Carnaby G, Hankey GJ, Pizzi J. Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. Lancet Neurol. 2006 Jan;5(1):31–7.
     
23. Lazarus C, Logemann J a., Huang C-F, Rademaker AW. Effects of Two Types of Tongue Strengthening Exercises in Young Normals. Folia Phoniatr Logop. 2003;55(4):199–205.
     
24. Logemann JA, Rademaker A, Pauloski BR, Kelly A, Stangl-McBreen C, Antinoja J, et al. A randomized study comparing the Shaker exercise with traditional therapy: a preliminary study. Dysphagia. 2009;24(4):403–11.