Oropharyngeal dysphagia in older persons – from pathophysiology to adequate intervention: a review and summary of an international expert meeting

Figures & data

Figure 1 Factors associated with dysphagia in older persons.

Note: ↓ Indicates decreased function. Modified from Muhle P, Wirth R, Glahn J, Dziewas R. [Age-related changes in swallowing. Physiology and pathophysiology]. Nervenarzt. 2015;86(4):440–451.²⁹

Table 1 Causes and risk factors of aspiration pneumonia

Causes	Risk factors
Impaired consciousness	Drug or alcohol abuse, general anesthesia, seizures, sedation, acute stroke and other brain lesions, head injury
Age-associated	Increasing age, polypharmacy, functional decline, poor mobility
Swallowing disorders	Esophageal stricture, esophageal diverticula, gastro-esophageal reflux, oropharyngeal dysphagia in multiple diseases
Iatrogenic	Adverse drug effects, adverse effects of medical treatment
Others	COPD, male sex, tracheostomy, tracheoesophageal fistula, ventilator-associated pneumonia, periodontal disease

Figure 2 The role of dysphagia in the development of malnutrition and dehydration in older persons.

Table 2 Some swallowing therapy techniques

Technique	Execution (rationale)	Indication	Limitations in geriatric patients
Maneuvers
Supraglottic swallow	Breath hold, double swallow, forceful expiration (closes vocal folds before and during swallow)	Reduced/late vocal fold closure	Problematic in patients with cardiovascular disease
Supersupraglottic swallow	Effortful breath hold, swallow, cough, swallow (closes vocal folds before and during swallow)	Reduced/late vocal fold closure	Problematic in patients with cardiovascular disease
Effortful swallow	Effortful tongue action (increases posterior motion of tongue base)	Poor posterior tongue base motion	May cause fatigue of swallowing
Mendelsohn maneuver	Prolong hyoid excursion guided by manual palpation (prolongs upper esophageal sphincter opening)	Poor pharyngeal clearance and laryngeal movement	May cause fatigue of swallowing
Postural adjustments
Head tilt	Head tilt posteriorly at swallow initiation (gravity clears oral cavity)	Poor tongue control	Increases aspiration risk in most older subjects
	Head tilt laterally to unaffected side (directs bolus down stronger side)	Unilateral pharyngeal weakness	May have limitations in patients with cervical spine disease
Chin tuck	Chin down (displaces tongue base and epiglottis posteriorly)	Delayed pharyngeal swallow response	May have limitations in patients with cervical spine disease
Head rotation	Rotate head to affected side (isolates damaged side from bolus path)	Unilateral pharyngeal weakness	May have limitations in patients with cervical spine disease
Facilitatory techniques
Thermal stimulation	Cold tactile stimulation to anterior faucial pillar	Delayed/absent swallow response	Poor evidence, especially in stroke patients
Gustatory stimulation	Sour or spicy bolus, capsaicin (facilitates swallow response)	Reduced oral sensitivity, delayed/absent swallow response	Promising approach
Strengthening exercises
Shaker exercise	Repeated head lifting while lying (strengthening of neck and laryngeal muscles)	Enhanced opening of the upper esophageal sphincter	May have limitations in patients with cervical spine disease; the suggested intensity may not be feasible for geriatric patients

Notes: Adapted from Gastroenterology, Volume 116/Edition 2, Cook IJ, Kahrilas PJ, AGA technical review on management of oropharyngeal dysphagia, Pages 455–478, Copyright 1999, with permission from Elsevier.¹¹²

Table 3 Patterns of oropharyngeal dysphagia in Parkinson’s disease

Phase of swallowing	Frequent findings
Oral	Repetitive pump movements of the tongue
	Oral residue
	Premature spillage
	Piecemeal deglutition
Pharyngeal	Residue in valleculae and pyriform sinuses
	Aspiration in 50% of dysphagic patients
	Somatosensory deficits
	Reduced spontaneous swallow (48 vs 71 per hour)
Esophageal	Hypomotility
	Spasms
	Multiple contractions

Note: Data from Warnecke.¹⁷⁰

MuhlePWirthRGlahnJDziewasRSchluckstörungen im Alter [Age-related changes in swallowing. Physiology and pathophysiology]Nervenarzt2015864440451 German25833400

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CookIJKahrilasPJAGA technical review on management of oropharyngeal dysphagiaGastroenterology199911624554789922328

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WarneckeTParkinsonbedingte Dysphagien. [Parkinson’s disease related dysphagia]Nervenheilkunde2014331–23135 German

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