Part II

Dysphagia in Adults

Section 1
Causes and Characteristics of Dysphagia

CHAPTER 3
Aging and Dysphagia
Michael E. Groher

CHAPTER OUTLINE
Terminology 44 Intervention 45
Successful aging 44 Detection 46
Frailty 44 Screening 46
Presbyphagia 45 Treatment 47
Sarcopenia 45 Take Home Notes 48
Undernutrition 45

OBJECTIVES safety and are largely dependent on physical strength and

1. To provide an overview of the potential swallowing speed of motor performance. Detection of those who may
disorders in community-dwelling elders (CDE). be at risk for developing swallowing disorders because of
2. To present the prevalence of dysphagia in the CDE poor physical performance that accompanies advancing
population. age may be important to avoid complications of undernutri-
3. To differentiate between normal aging, frailty, and tion and aspiration pneumonia that potentially may shorten
sarcopenia. one’s life. In a systematic review of 15 observational stud-
4. To review the importance of detecting dysphagia in the
ies, Madhavan and colleagues concluded that there were
CDE population.
three factors in the CDE population that increased the risk
5. To propose interventions as a method of preventing
dysphagia and its complications in the CDE.
for dysphagia and its complications.1 These include a his-
tory of clinical disease, advancing age (>70), and frailty
Recent literature has explored the possibility that as one accompanied by a reduction in activities of daily living.
ages, persons are more liable to develop symptoms of dys- The CDE population in the USA is currently estimated
phagia that are not necessarily secondary to disease, but to to be 12 million and should grow as the population of el-
changes in a generalized diminution of one’s overall physi- ders by 2030 is estimated to be 72 million.2 Census bureau
cal profile. Such changes may or may not impact swallow statistics suggest that the majority are living at home. Five

43
44 PART | II Dysphagia in Adults

percent are living in long-term care or assisted living cen- only a diminution in physical status but also mental status
ters. Of those over the age of 85, the percentage climbs to changes including depressive syndromes, all signs short
15. There is evidence in the group of elders who are living of being classified as demented.4 Whether or not cogni-
in the community that between 15% and 40% may be impact- tive frailty is a precursor to dementia and the potential for
ed by dysphagia that has not been fully identified.1 There- dysphagia is unknown, but should be considered. Swal-
fore, it is possible that between 11 and 29 million of elder lowing disorders secondary to dementing syndromes are
persons, including 2 to 5 million of those in the CDE popu- well known (see Chapter 4). In its most severe form, frailty
lation, may be affected by unidentified dysphagia with its results in disability that may precipitate dysphagia and its
potential complications. In general, persons over the age of complications.5 While this progression seems logical, it
65 in the United States are considered elderly, although this does not account for those frail elderly who may not be
often depends on the survival statistics related to the level disabled by disease-related etiologies, but are potentially at
of healthcare provision in any given country. For instance, risk for dysphagia from the effects of aging alone. In short,
in Africa, where healthcare standards are lower, when one frailty is on a continuum of severity that may or may not
exceeds the age of 55 they are considered to be elderly. predict dysphagia. Presently, it is unknown what specific
This chapter will discuss the potential issues surround- pattern of physical deficits might classify one as frail that
ing the group of elders who live in the community who may predict reported or unreported symptoms of dysphagia.
be at risk for dysphagic complications, and the potential As one ages, various presentations of frailty with or
need to obviate its secondary consequences such as pneu- without dysphagia require investigation. Interestingly, the
monia, undernutrition, and subsequent hospitalization. presence of dysphagia in those CDE classified as frail could
be the precipitator of frailty or be a consequence of it. It is
estimated that in those elders over the age of 65 that 5%
TERMINOLOGY will be classified as frail and 47% as pre-frail.6 In those
Descriptions and definitions of CDE populations who may over the age of 85, 24% will be frail.7 There is a lack of
be dysphagic lack specific clarity that may make it diffi- evidence documenting the prevalence of dysphagia in those
cult to understand the nature of their disorder due to their who would be classified as frail and living in the commu-
potential overlapping presentations.3 As applied to a poten- nity, although it is clear that some suffer from dysphagia.
tial dysphagic CDE group, these include successful aging, Documentation of prevalence is difficult because of under-
frailty, presbyphagia, and sarcopenia. reporting and because few may seek help accepting their
dysphagia as part of the normal aging process.6,7
Some have defined frailty when an individual has three
Successful Aging or more of the following characteristics: weakness in hand
Rolfson and colleagues made the distinction between suc- grip, slow walking, decreased physical activity, self-reported
cessful aging (those free of disease-related dysphagia), but exhaustion, and unintentional weight loss.8 (See box 3-1)
who may have dysphagic complaints from normal changes in Cognitive status also may be affected, although empiri-
the aerodigestive tract, and those who may be considered frail cal data and agreement on what constitutes cognitive status
with greater risk for dysphagia’s complications.3 Such chang- changes are needed. Muscle weakness with an accompany-
es may include loss of speed in bolus delivery due to changes ing loss of speed secondary to a loss of muscle mass has been
in muscle strength, loss of dentition with secondary adapta-
tions of diet with the risk of undernutrition, changes in smell
and taste, and xerostomia as a consequence of medication side BOX 3-1 CHARACTERISTICS THAT DEFINE FRALITY
effects resulting in potential changes in sensory receptor ac-
tivation (see Chapter 2). Failure of the muscles involved in Hand grip weakness
swallow to contract rapidly and with sufficient strength may Slower than normal walking speed
A decrease in normal physical activity
result in increased residue in each stage with subsequent spill-
Self-reported exhaustion
age of contents into the airway. This may become particularly Unintentional weight loss
problematic as one progresses through the meal with accom- Subtle changes in cognitive status
panying muscle fatigue due to the effort required to finish.

Frailty Attributed to changes in skeletal muscle fibers. There is

The term frailty suggests a loss of physical strength with an evidence that as one ages, Type 2 fibers that are large and
accompanying loss of ability to compensate for the weak- react quickly are replaced by Type 1 fibers that are small
ness. Buchman and Bennett summarized a consensus con- and slowly contracting.9 These characteristics may or may
ference that used the term cognitive frailty to include not not contribute to dysphagia and often are found in normal
 Aging and Dysphagia CHAPTER | 3 45

aging. Dysphagia and its complications are more likely to on a given day may not be sufficient when classifying one
appear when the person is decompensated by metabolic with sarcopenia since measurements of motor performance
changes such as weight loss and undernutrition or by a on any given day can be variable.15
hospitalization for any medically related complaint. In this Using a screening device that included bioimpedance
circumstance, dysphagia may be transitory and disappear measures of muscle mass, hand grip strength, and gait
as the stressing agent, such as a medication that decompen- speed calculations, Ishii and colleagues found that in 1971
sated the person’s health, is removed by treatment.7 Asian CDEs the prevalence of sarcopenia in those over
the age of 65 was 14.2% in men and 22.1% in women.16
The number of those with dysphagia in this cohort was not
Presbyphagia reported. Data on the number of CDE with demonstrated
Although not typically applied as a descriptor of dysphagia dysphagia who are classified with sarcopenia are lacking,
in the CDE group, Wakabayashi suggested the use of the partially reflecting the lack of agreement on terminology
term presbyphagia to describe those with normal age- used for sarcopenia and for dysphagia. Nonetheless, there
related changes in the aerodigestive tract that may be as- continues to be increased interest in those CDE who may
sociated with frailty.10 By implication, this group may be either have preclinical dysphagia requiring preventive mea-
at risk for dysphagia when there is a change in their physi- sures of intervention or dysphagia from frailty and/or sar-
cal or heath status. This group is to be distinguished from copenia that may require prevention or direct intervention.
disease-related dysphagia in the CDE group such as from
stroke or cancer versus a third group who evidence sarcope- UNDERNUTRITION
nia and accompanying dysphagia. This distinction may be
important when planning treatment interventions. Loss of muscle mass with accompanying loss of strength
and speed of motor performance may impact swallow safe-
ty, resulting in dysphagic symptomology in the CDE. For in-
Sarcopenia stance, loss of masticatory force, lip and tongue strength, in
The definition of what constitutes sarcopenia in older co- addition to loss of dentition, may be contributing factors.17
horts may vary dependent on one’s country affiliation be- Reduction of tongue pressure generation in the CDE popu-
cause of perceived differences in premorbid size (muscle lation has been found to be associated with a low body mass
mass) and accompanying strength.10 In general, sarcopenia index and the risk for dysphagia.18 Diminution of tongue
is a reduction of lean skeletal muscle mass with a marked thickness as measured by ultrasound in the CDE has also
loss of strength and speed of movement. It is thought to be been found to be associated with undernutrition and subse-
a consequence seen most often in those who are consid- quent risk for dysphagia.19 Loss of dentition appears to be
ered to be frail, and therefore, has similar characteristics as particularly important. Sources of protein typically found in
discussed above. A related term, dysnapenia, has been pro- meat are too difficult to masticate and eventually become
posed by Clark and Manini describing patients who show absent from dietary intake.17 Additionally, dysphagic symp-
weakness and slowness of motor performance without loss tomatology may lead to negative changes in dietary prefer-
of muscle mass.11 The implication of this description is that ences that in turn may impact nutritional integrity. In sum-
slowness and weakness in performing motor tasks such as mary, poor nutritional status in the CDE may precipitate or
swallowing may serve as a precursor to the development complicate dysphagia.20 As dysphagia with accompanying
of dysphagic symptomatology and therefore should be a undernutrition worsens, immune defense systems are com-
potential marker of risk that requires monitoring. The Eu- promised, with resultant increased risk of aspiration pneu-
ropean Consensus Group on sarcopenia divided sarcopenia monia, increased hospital admissions, infection, and death.
into two categories: primary sarcopenia as a consequence In 134 CDE over the age of 70 who were admitted to a ge-
of advancing age and secondary sarcopenia as a result of riatric hospital unit with pneumonia, 55% had clinical signs
disease or undernutrition.12 Mitchell and colleagues divided of dysphagia.21 The older the patient, the more severe the
sarcopenia into three categories: presarcopenia character- pneumonia, functional status, and undernutrition.
ized as loss of muscle mass, sarcopenia characterized by
loss of strength OR physical performance, and severe sarco-
penia characterized by loss of strength AND performance.13
INTERVENTION
From these data, it is implied that those at most risk for With an increased awareness of the potential for dysphagia
the complications of dysphagia are those with severe and/or and its risk in the CDE comes an interest in how to inter-
secondary sarcopenia. It has been suggested that dysphagia vene in an effort to avoid the complications of frailty that
secondary to sarcopenia be considered a separate geriatric may result in sarcopenia, pneumonia, and death. In order to
syndrome, especially in persons over the age of 70.14 Looi- avoid these complications, there needs to be early detection
jaard et al. argued that measurement of a single performance of dysphagia risk by screening mechanisms, followed by
46 PART | II Dysphagia in Adults

in-depth evaluation if screening is failed. Evaluations should Ishii and colleagues developed a simple screening test
suggest the most appropriate intervention that may include for identifying sarcopenia.15 Since those CDE with sarco-
nutritional supplements, increased physical activity includ- penia are assumed to be at increased risk for dysphagia,
ing strength training, aggressive oral care,22 direct treatment identification of sarcopenia is important. Sarcopenia was
and compensatory interventions targeted at the mechanism measured with bioimpedance measures of muscle, handgrip
for dysphagia, or combinations of all four. strength, and gait speed. The negative predictive value to
detect sarcopenia using their screening tool was 97.2% for
men and 93.0% for women.
Detection Madhaven and colleagues developed a self-report
It has been suggested that closer monitoring of those CDE screening test to identify what they termed preclinical dys-
may be an appropriate use of resources. This is particularly phagia in a CDE population over the age of 60.24 The theo-
important since there is a suggestion that those who may retical framework used to develop the test items is presented
evidence dysphagia, regardless of severity, may not seek in Figure 3-1.
help. In this circumstance, it is easy to understand that chang- The test was validated on 335 CDE who volunteered to
es in dietary habits can easily lead to loss of muscle func- be a part of the study. After test item reduction, 17 questions
tion that further decompensates swallow, eventually leading in five areas of inquiry remained: swallowing ability (cough-
to hospitalization for pneumonia. Hospitalization with the ing, food sticking, diet level), cognition, physical skills, oral
accompanying loss of physical activity may itself lead to a health, and social support. The test was designed to be ad-
deconditioned state resulting in new dysphagic or increased ministered by any healthcare provider on any routine office
dysphagic symptomatology.23 Avoidance of this progression visit. The test is able to differentiate between those at risk
of events suggests early detection and a potential plan of in- for dysphagia and those who are not. Interestingly, the two
tervention to prevent a potentially dangerous cycle of physi- factors that predicted preclinical dysphagia were decreased
cal deterioration and its serious medical consequences. communication/cognition and a reduction of physical ac-
tivity. Items such as poor oral health and weight loss were
not strong predictors. The authors suggested that these two
Screening variables appear to be more important in dysphagia second-
The development of standardized screening tools that ac- ary to known disease, rather than in those with symptoms in
curately identify those at risk for dysphagia in the CDE the absence of demonstrated underlying medical complica-
population is important because subsequent interventions tions.
will be implemented based on their results. Screening tools In a review of studies that addressed nutritional status
are designed to detect impairment that subsequently trigger and cognition in the elderly, Daradkeh and colleagues con-
further in-depth evaluation and possible intervention (see cluded that a thorough evaluation of one’s nutritional status
Chapter 9, screening test characteristics). in the CDE is important since undernutrition often leads to

FIGURE 3-1 Proposed conceptual framework for the development of preclinical dysphagia in the CDE. Solid lines represent known causes,
while dashed lines represent reported associations. (From Madhavan A, Carnaby GD, Chhabria K, et al. Preliminary development of a screening
tool for pre-clinical dysphagia in community dwelling older adults. Geriatrics. 2018;3:90.)
 Aging and Dysphagia CHAPTER | 3 47

a poorer cognitive status and frailty.25 While there is not

total agreement on which measures one might use to test CLINICAL CORNER 3-1
nutritional status, most investigators feel that a standardized An 80-year-old uncle has noticed increased episodes of
measure that includes a dietary survey, measures of muscle coughing on liquids at mealtime but has not told anyone
mass, and blood laboratory values provide the best data. since it does not seem to bother him. He has a good ap-
petite and his weight remains stable. His physical activity
While additional research needs to be given to the iden-
is limited, and some of his family would describe him as
tification of dysphagia in the CDE population, the problem
being somewhat frail compared to 5 years ago.
of how the process of accurate identification remains. A 1. Would you say he is dysphagic? Why or why not?
consensus paper that emanated from the Japanese Society 2. What are some potential causes for his coughing
of Dysphagia Rehabilitation concluded that there needs to episodes?
be better diagnostic accuracy of how sarcopenia might im- 3. Should you encourage him to go to the doctor now
pact the muscles of swallow, and that the diagnostic criteria or wait until it gets worse?
for dysphagia caused by primary and secondary sarcopenia
require further study.26
Because of the evidence that the CDE tend not to com-
plain of dysphagic symptoms, they are at risk for under- CLINICAL CORNER 3-2
reported problems that may quickly lead to complications that An 85-year-old single woman who lives alone has lost
precipitate nutritional deficits, frailty, and sarcopenia with ac- weight over the past year because she does not feel like
companying risk for dysphagia. Therefore, it is important that eating. Most of the time, she just watches TV all day. Her
screening for preclinical dysphagia needs to be a part of every daughter is concerned that, she is not taking care of her-
routine medical examination in the CDE population. self. She has a history of congestive pulmonary disease
that is well controlled.
1. Speculate on why she may not feel like eating.
Treatment 2. Would you consider her to be at risk for dysphagia,
aspiration, and undernutrition?
Early identification of dysphagia in the CDE population is
3. What preventive approaches could you use to avoid
important because dysphagia often is accompanied by an potential complications of dysphagia?
increased risk of life-threatening pulmonary disease, de- 4. If you decided to provide intervention, how often
creased nutritional integrity with immune system compro- would you consider reevaluating her for changes in
mise, poorer cognition, reduced physical mobility includ- health status?
ing self-care compromise, and an overall reduction in one’s
quality of life (review Figure 3-1). Therefore, targeting the
otherwise healthy CDE to prevent any complications from addressed: underlying cause of sarcopenia, cause of under-
dysphagia should be the focus of the treatment intervention. nutrition, presence of dysphagia, adequacy of current nutri-
Treatment should be focused on the offending area that has tional status with a future plan, and the efficacy of providing
been identified as a potential precursor to dysphagia, or as direct endurance and resistive muscle training. In a follow-up
a contributing factor that increases the severity of existing study that was directed toward the CDE with demonstrated
dysphagia. For example, if nutritional deficits with loss of dysphagia, patients underwent exercise training directed at
muscle mass and strength are thought to be contributing improving swallow muscle strength. Ninety-one patients and
factors to dysphagia, dietary supplementation or a specif- 48 controls were randomized and instructed in tongue re-
ic change in dietary intake such as increased protein may sistance and head flexion exercises. Pre-treatment dysphagia
need to implemented. In some cases, direct treatment in- severity and nutritional measures were documented. After
tervention for dysphagia (see Chapter 10) may be appro- 3 months of treatment, the authors concluded that dysphagia
priate. In other cases, physical conditioning combined with or tongue pressure strength did not improve. Those with the
nutritional supplementation may be needed (see Clinical best nutritional integrity did have improved swallow perfor-
Corner 3-2). In a restricted systematic review, Kelaiditi and mance at the end of the study period.28
colleagues concluded that one cannot be confident whether That early, preventive-oriented interventions in the
exercise combined with an improved nutritional status actu- CDE who evidence signs of pre-clinical dysphagia can
ally improve those CDE who were considered to be frail.27 avoid the complications of dysphagia as one ages still need
Only one pilot study in their review showed positive short- to be demonstrated empirically. If early identification is
term treatment after 3 months. found to be important, particularly as it relates to survival,
In those CDE identified with sarcopenia, Wakabayashi all persons who deliver healthcare need to be aware of
and Sakuma suggested a treatment intervention that provides screening devices aimed at dysphagia detection that can be
direct rehabilitation and/or nutritional support.23 In order administered in any outpatient setting. Appropriate con-
to select the treatment of choice, five variables need to be sultations to a swallowing specialist, nutritional support
48 PART | II Dysphagia in Adults

provider, or rehabilitation therapist need to be considered 8. Cichero JAY. Age-related changes to eating and swallowing impact
if screening results suggest a risk for dysphagia and its frailty, aspiration, choking risk, modified texture and autonomy of
complications. choice. Geriatrics. 2018;3:69.
9. Larsson L, Karlsson J. Isometric and dynamic evidence as a func-
Ultimately, data may suggest that providing preventive
tion of age and skeletal muscle characteristics. Acta Physiol Scand.
interventions in the CDE, rather than ignoring the potential
1978;104:129.
consequences of dysphagia and its secondary negative ef- 10. Wakabayashi H. Presbyphagia and sarcopenic dysphagia: association
fects on nutrition, physical and cognitive status, and overall between aging, sarcopenia, and deglutition disorders. J Frailty Aging.
health, will result in better survival outcomes. It is impera- 2014;3:97.
tive that various methods and combinations of intervention 11. Clark BC, Manini TM. What is dynapenia?. Nutrition. 2012;28:495.
be tested in an effort to decide what courses of treatment are 12. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia. Euro-
the most effective, given the patient’s initial presentation of pean consensus on definition and diagnosis: report of the Euro-
symptoms. pean Working Group on sarcopenia in older people. Age Aging.
2018;39:412.
13. Mitchell WK, Williams J, Atherton P. Sarcopenia, dynapenia, and the
TAKE HOME NOTES impact of advancing age on human skeletal muscle mass and strength:
a quantitative review. Front Physiol. 2012;3:260.
1. There may be as many as 15% in the CDE population 14. Baijens LW, Clave P, Cras P, et al. European Society for Swallowing
who have dysphagia that is undiagnosed. Disorders-European Union Geriatric Medicine Society white paper:
2. Prevalence statistics of CDE in well-studied populations oropharyngeal dysphagia as a geriatric syndrome. Clin Inter Aging.
are needed in order to begin to understand those factors 2016;11:1403.
that predict dysphagia risk. 15. Looijaard SMLM, Oudbier SJ, Reinierse EM, et al. Physical perfor-
3. Normal aging causes loss of muscle strength and speed mance measures cannot identify geriatric outpatients with sarcopenia.
that may precipitate dysphagia and frailty. J Frailty Aging. 2018;7:186.
4. Frailty is a precursor to sarcopenia with increased likeli- 16. Ishii S, Tanaka T, Shibasaki K, et al. Development of a simple
screening test for sarcopenia in older adults. Geriatr Gerontol Int.
hood of dysphagia.
2014;14:93.
5. A common consequence of dysphagia is undernutrition
17. Kikutani T, Tamura F, Nishiwaki K, et al. Oral motor function and
that further compromises body mass index, disease defense masticatory performance in the community dwelling elderly. Odontol-
systems, and increase risk of dysphagic complications. ogy. 2009;97:38.
6. Early detection of dysphagia in the CDE may help to 18. Yoshida M, Kikutani T, Tsuga K, et al. Decreased tongue pressure
prevent the progression of dysphagia. reflects symptom of dysphagia. Dysphagia. 2006;21:61.
7. Strategies of intervention that are targeted towards pre- 19. Tamura F, Kikutani T, Tohara T, et al. Tongue thickness relates to
vention by introducing aggressive nutritional support nutritional status in the elderly. Dysphagia. 2012;27:556.
and/or direct treatment strategies in the CDE need fur- 20. Sura L, Madhaven A, Carnaby G, et al. Dysphagia in the elderly:
ther development with measured outcomes. management and nutritional considerations. Clin Intervent Aging.
2012;7:287.
21. Cabre M, Serra-Prat M, Palomera E, et al. Prevalence and prognostic
implications of dysphagia in elderly patients with pneumonia. Age Ag-
REFERENCES
ing. 2010;39:39.
1. Madhaven A, LaGoria LA, Crary MA. Prevalence and risk factors for 22. Maeda K, Akagi J. Oral care may reduce pneumonia in the tube-fed
dysphagia in the community dwelling elderly: a systematic review. elderly: a preliminary study. Dysphagia. 2014;29:616.
J Nutr Health Aging. 2016;20:806. 23. Wakabayashi H, Sakuma K. Rehabilitation nutrition for sarcopenia
2. Chen MY, Lin LC. Prevalence of perceived dysphagia and quality-of- with disability: a combination of both rehabilitation and care manage-
life impairment in a geriatric population. Dysphagia. 2009;24:1. ment. J Cachexia Sarcopenia Muscle. 2014;5:269.
3. Rolfson D. Successful aging and frailty: a systematic review. Geriat- 24. Madhaven A, Carnaby GD, Chhabria K, et al. Preliminary develop-
rics. 2018;3:79. ment of a screening tool for pre-clinical dysphagia in community
4. Buchman AS, Bennett DA. Cognitive frailty: rationale and defini- dwelling older adults. Geriatrics. 2018;3:90.
tion from an international consensus group. J Nutr Health Aging. 25. Daradkeh G, Essam M, Al-Adawi SS, et al. Nutritional status and cog-
2013;17:738. nitive impairment in elderly. Pak J Biol Sci. 2014;17:1098.
5. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evi- 26. Fujishima I, Fujiu-Kurachi M, Arai H, et al. Position paper by four
dence for a phenotype. J Gerontol Biol Sci Med Sci. 2001;56:146. professional organizations. Geriatrics Gerontol Int. 2019;19:91.
6. Roy N, Stemple J, Merrill RM, et al. Dysphagia in the elderly: prelimi- 27. Kelaiditi E, van Kan GA, Cesari M. Frailty: role of nutrition and exer-
nary evidence of prevalence, risk factors, and socioemotional effects. cise. Curr Opin Clin Nutr Metab Care. 2014;17:32.
Ann Otol Rhinol Laryngol. 2007;116:858. 28. Wakabayashi H, Masushima M, Momosaki R, et al. The effects of
7. Smithard D. Dysphagia in frail patients is not frailty dysphagia. Geri- resistive training of swallowing muscles on dysphagia in older people:
atrics. 2018;3:82. a cluster, randomized, controlled trial. Nutrition. 2018;48:111.