Geriatric Rehabilitation

From Bedside to Curbside

K. Rao Poduri, K. Rao Poduri

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781315356341
• Edition: 1
• Topic: Médecine
• Subtopic: Théorie, pratique et référence de la médecine

Geriatric Rehabilitation addresses the fact that this is an age in which individuals have increasing longevity, better health care, education and expectations of health care which present new, increasing and even radical challenges to health care providers.

The care of our older patients in rehabilitation settings demands the broad understanding of the key differences in strategies to care for older adults. The combined skills embraced in rehabilitation and geriatrics are presenting unprecedented opportunities for both fields to make substantive and even ground-breaking improvements in the lives of millions of older adults who entrust their lives to us. Rarely in one's medical career are such opportunities so evident and achievable.

Geriatric Rehabilitation edited by Dr. K. Rao Poduri, MD. FAAPMR draws on a distinguished group of authors who are the front-line providers of care to the older adults. This book presents the full spectrum of the unique care needs of older patients who need the combined skills of physical medicine and geriatrics. It provides an easily accessible means of acquiring and improving these new skills for all those involved in geriatric care.

Section III

Systemic Disorders in Geriatric Rehabilitation

15 Dysphagia in Older Adults and Its Management

Sandhya Seshadri

CONTENTS

15.1 Introduction

15.2 Epidemiology

15.3 Normal Swallowing, Dysphagia, and Presbyphagia

15.3.1 Normal Swallowing

15.3.2 Dysphagia

15.3.3 Presbyphagia

15.4 Dysphagia and Aging

15.5 Types of Dysphagia Assessment Methods and Tools

15.5.1 Types of Assessment

15.6 Bedside Swallow Evaluation

15.6.1 Instrumental Assessments

15.6.2 Modified Barium Swallow Study

15.6.3 Fiberoptic Endoscopic Evaluation of Swallowing

15.6.4 Standardized Scales

15.6.5 Mann Assessment of Swallowing Ability

15.6.6 Volume-Viscosity Swallow Test

15.6.7 Modified Barium Swallow Impairment Profile

15.6.8 Penetration–Aspiration Scale

15.7 Management and Treatment of Dysphagia

15.7.1 Compensatory Strategies

15.7.2 Texture-Modified Diets

15.7.3 Oral Care and Free Water Protocol

15.7.4 Rate of Intake and Adaptive Utensils

15.7.5 Postures and Maneuvers

15.7.6 Facilitation Techniques

15.8 Dysphagia Rehabilitation

15.9 Conclusion

References

15.1 INTRODUCTION

Oropharyngeal dysphagia is a swallowing disorder that results in difficulties with the passage of food, liquids, and secretions from the mouth to the esophagus. Symptoms of dysphagia include drooling, difficulty chewing, manipulating the bolus, and propelling it to the posterior aspect of the oral cavity, coughing before, during, or after swallowing, and moving the bolus through the pharynx. The term oropharyngeal dysphagia is sometimes used interchangeably with deglutition disorder and dysphagia. In this chapter, we will use the term dysphagia to mean oropharyngeal dysphagia. As the word suggests, oropharyngeal refers primarily to the oral (mouth) region and the pharynx, and is different from esophageal dysphagia. Speech-language pathologists (SLPs) diagnose and treat persons with oropharyngeal dysphagia, while gastroenterologists usually diagnose and treat persons with esophageal dysphagia.

Dysphagia may result in an unsafe swallow—which can result in aspiration (passage of secretions, food, and liquids into the larynx and lower respiratory tract), choking due to an inability to clear the food through the pharynx—or an inefficient swallow that can lead to malnutrition and dehydration. Several diseases such as stroke that are common among older adults can result in dysphagia. Every year approximately half a million people are diagnosed with dysphagia due to neurological disorders (1,12). An estimated 43%–54% of stroke patients with dysphagia experience aspiration and 37%–50% develop pneumonia (12,35,41). The medical outcomes of dysphagia for older adults include aspiration, aspiration pneumonia (lower respiratory tract infection secondary to aspiration), malnutrition, dehydration, and, in some cases, death (7,18). While an unsafe swallow can lead to aspiration, an inefficient swallow can lead to malnutrition and dehydration and pose serious threats to older adults. It is reported that more than half of frail older adults are at significant risk for malnutrition, and as many as 75% of adults with dysphagia are at risk for malnutrition and dehydration (35). In one study, the prevalence of malnutrition/risk for malnutrition among independently living older adults with dysphagia was 2.72 times higher than among those without dysphagia (39). In addition to poor medical outcomes, dysphagia affects the social and psychological well-being and quality of life of older adults. Eating and drinking are often social events and older adults with dysphagia can experience anxiety and depression, leading them to withdraw from social interactions. In a study on the social and psychological impact of dysphagia among 360 older adults with subjective dysphagia symptoms in clinics and nursing homes across four countries in Europe, 41% reported mealtime-related anxiety and 36% reported decreased participation in activities that entailed eating with others (13).

15.2 EPIDEMIOLOGY

The risk of diseases such as stroke and cancer increases with age. Accordingly, 10%–30% of adults over the age of 65 are estimated to have dysphagia (6). Among community-dwelling older adults, the prevalence of dysphagia ranges from 13.8% to 33% (10,15,39). The prevalence of dysphagia may be higher than reported in the literature, as data are usually gathered from self-reported questionnaires and many older adults have the mistaken belief that dysphagia is an inherent part of aging and do not report their symptoms (22). On the other hand, the incidence of dysphagia among older adults continues to increase and is commensurate with the increase in the population of older adults. In an epidemiologic study on aging and dysphagia, the dysphagia referral rates at a university hospital doubled between 2000 and 2007 from a total of 428 in 2000 to 858 in 2007 (20). In fact, referrals for older adults between 60 and greater than 90-years old, were approximately 70% of total referrals for dysphagia (20).

15.3 NORMAL SWALLOWING, DYSPHAGIA, AND PRESBYPHAGIA

Effective dysphagia management and treatment warrant an understanding of the differences between normal swallowing, dysphagia, and presbyphagia.

15.3.1 NORMAL SWALLOWING

SLPs who diagnose dysphagia distinguish between the four stages of normal swallowing, namely, the oral preparatory, oral, pharyngeal, and esophageal stages. These four stages are separated to better assess and understand the swallowing mechanism, even though they are interdependent and are part of one integrated process. The oral preparatory stage involves the preparation of the bolus (food) for the swallow, beginning with the placement of food in the mouth followed by lip closure; oral musculature tension; and mandibular, anterior velar, and lingual movements. In a synchronized manner, each part of the oral cavity (lips, teeth, tongue, jaw, and velum) contributes to the preparation of the bolus. The oral stage commences when the bolus is prepared and propelled to the posterior aspect of the oral cavity before the swallow is triggered. The pharyngeal stage begins when the swallow is triggered and involves velopharyngeal closure, base of tongue excursion, upward and anterior hyolaryngeal movement with inversion of the epiglottis, and adduction of the vocal cords. The esophageal stage commences with the relaxation of the upper-esophageal sphincter and the passage of the bolus into the esophagus. Some symptoms of dysphagia may warrant an assessment of the esophageal stage to ensure that the cause of pharyngeal symptoms do not lie in the esophagus. For example, patients may complain of feeling food “stuck in the throat” (a globus sensation) or may point to the sternum as the source of discomfort. Sometimes these symptoms are suggestive of gastroesophageal reflux and esophageal dysphagia. If a patient’s symptoms are predominantly related to the esophageal stage of the swallow, a referral may be made to a gastroenterologist or to an otolaryngologist, depending on the nature of the deficits and the presenting symptoms.

15.3.2 DYSPHAGIA

Given the complexity of the swallowing mechanism patients may experience difficulties and demonstrate deficits in any or all of the stages of the swallow leading to the diagnosis of dysphagia. Thus, a diagnostic report may include stage and severity of dysphagia with a description of the characteristics of the deficits. Symptoms of dysphagia and the deficits identified may include drooling, difficulty chewing food; prolonged mastication of food; a wet vocal quality after the swallow; multiple swallows for a single bite of food; frequent throat clearing while eating; coughing before, during, or after the swallow; and food residue in the mouth after a swallow. The presence of these and other difficulties with swallowing has a direct bearing on the health of older adults if left undiagnosed and untreated as they can lead to respiratory illnesses, malnutrition, and dehydration. In frail older adults, these symptoms can cause further weakness and a worsening health trajectory. Thus, a comprehensive dysphagia evaluation often includes patient-reported symptoms obtained during a patient interview and a description of both objective symptoms and inferred deficits based on the evaluation. Signs and symptoms of aspiration, such as coughing before, during, or after a swallow, may be indicative of deficits at different stages of the swallow: for example, an inability to manage the bolus in the oral preparatory or oral stages, resulting in premature spillage; an unprotected airway due to an inadequate epiglottic inversion during the pharyngeal stage; or aspiration of residue in the pyriform sinuses or vallecular spaces. Similarly, poor dentition and the symptoms of decreased ability to chew foods, prolonged mastication, and difficulty with manipulating the bolus in the oral cavity may suggest that the older adult may be at risk for decreased oral intake and poor nutrition. In older adults, several factors can contribute to these signs and symptoms and it is importan...