Dysphagia in the elderly: management and nutritional considerations

Figures & data

Table 1 Conditions that may contribute to dysphagia⁴

Neurologic disease

Stroke

Dementia

Traumatic brain injury

Myasthenia gravis

Cerebral palsy

Guillain–Barré syndrome

Poliomyelitis

Myopathy

Progressive disease

Parkinson’s disease

Huntington disease

Age-related changes

Rheumatoid disease

Polydermatomyositis

Progressive systemic sclerosis

Sjögren disease

Other

Any tumor involving the aerodigestive tract

Iatrogenic diagnoses

Radiation therapy

Chemotherapy

Intubation tracheostomy

Medication related

Other, related diagnoses

Severe respiratory compromise

Adapted from Groher ME, Crary MA. Dysphagia: Clinical Management in adults and children. Maryland Heights, MO: Mosby Elsevier; 2010.

Table 2 Examples of postural adjustments

Technique	Performance	Intended outcome	Reported benefit
Body posture changes
Lying down	Lie down/angled Reduce impact of gravity during swallow	• Increased hypopharyngeal pressure on bolus	• Increased PES opening^Citation60
Side lying	• Lie down on stronger side (lower)	Slows bolus Provides time to adjust/protect airway	• Less aspiration^Citation56
Head posture changes
Head extension/chin up	• Raise chin	Propels bolus to back of mouth Widens oropharynx	Reduced aspiration^Citation61 Better bolus transport^Citation14
Head flexion/chin tuck	• Tucking chin towards the chest	• Improves airway protection	• Reduced aspiration^Citation56,Citation57,Citation61
Head rotation/head turn	• Turning head towards the weaker side	Reduces residue after swallow Reduces aspiration	Less residue^Citation62 Reduced aspiration^Citation56

Table 3 Examples of swallow maneuvers

Swallow maneuver	Performance	Intended outcome	Reported benefit
Supraglottic swallow	• Hold breath, swallow, and then gentle cough	• Reduce aspiration and increase movement of the larynx	• Reduces aspiration^Citation66
Super supraglottic swallow	• Hold breath, bear down, swallow, and then gentle cough
Effortful swallow. Also called ‘hard’ or ‘forceful’ swallow	• Swallow ‘harder’	Increased lingual force on the bolus Less aspiration and pharyngeal residue	• Increased pharyngeal pressure and less residue^Citation67,Citation68
Mendelsohn maneuver	• ‘Squeeze’ swallow at apex	• Improve swallow coordination	• Reduced residue and aspiration^Citation69

Table 4 Levels of modified diet⁷⁷

Level	Description	Examples of recommended foods
Four Levels in the National dysphagia diet
Level 1: dysphagia pureed	Homogeneous, cohesive, and pudding like. No chewing required, only bolus control	Smooth, homogenous cooked cereals Pureed: meats, starches (like mashed potatoes), and vegetables with smooth sauces without lumps Pureed/strained soups Pudding, soufflé, yogurt
Level 2: dysphagia mechanically altered	Moist, semi-solid foods, cohesive. Requires chewing ability	Cooked cereals with little texture Moistened ground or cooked meat Moistened, soft, easy to chew canned fruit and vegetables
Level 3: dysphagia advanced	Soft-solids. Require more chewing ability	Well moistened breads, rice, and other starches Canned or cooked fruit and vegetables Thin sliced, tender meats/poultry
Level 4: regular	No modifications, all foods allowed	No restrictions

Adapted from Groher ME, Crary MA. Dysphagia: Clinical management in adults and children. Maryland Heights, MO. Mosby, Elsevier; 2010.

Table 5 Examples of exercise-based swallow rehabilitation approaches

Program	Focus	Intended outcome	Reported benefit
Lingual resistance	• Strengthening tongue with progressively increasing intensity	Increased tongue strength Improved swallow	Increased tongue muscle mass Increased swallow pressure Reduced aspiration^Citation76
Shaker/head-lift	Strengthening suprahyoid muscles Improve elevation of larynx Increasing UES opening	• Improve strength of muscles for greater UES opening	Increased larynx elevation Increased UES opening Less post-swallow aspiration^Citation80
EMST (expiratory muscle strength training)	Strengthening submental muscle Improve expiratory pressures for better airway protection	Improve expiratory drive Reduce penetration and aspiration	Better penetration-aspiration scores in Parkinson’s disease Increased maximum expiratory pressure Increased submental muscle electromyography activity during swallowing^Citation81,Citation89
MDTP (McNeill dysphagia therapy program)	• Swallow as exercise with progressive resistance	• Improve swallowing including strength and timing	Improved swallow strength Improved movement of swallow structures Improved timing Weight gain^Citation68,Citation91,Citation92

Abbreviations: UES, Upper Esophageal Sphincter.

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