"Diagnosis and Management of Dysphagia in Seniors"
Sponsored by Long Beach Memorial Medical Center
Goal for this educational activity:
Long Beach Memorial Medical Center designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education.
The California Board of Registered Nursing recognizes category 1 courses approved for credit by the American Medical Association toward meeting the continuing education requirements for license renewal.
Coursework which meets the standard of relevance to pharmacy practice and has been approved for continuing education by the Medical Board of California, shall, upon satisfactory completion, be considered approved continuing education for pharmacists.
The online content was developed through a collaboration of a nationally-noted dysphagia expert who is a speech language pathologist (Jeri Logemann, Ph.D.), a radiologist (Charles Stewart, M.D.), and a pharmacist (Diane Aschman, MS) as a part of the project Dysphagia Care Among Seniors in Los Angeles County funded by the UniHealth Foundation.
Dysphagia Care Among Seniors in Los Angeles County is a screening and education program targeted at residents of independent and assisted living facilities in Los Angeles County suffering from undiagnosed, untreated or under-treated swallowing disorders. With this pilot program, screening and education materials have been developed, and apparently healthy residents benefited from early identification and treatment for this potentially debilitating condition.
"Diagnosis and Management of Dyspagia in Seniors" was developed as an education program for clinicians, assisted/independent living residents, their families and caregivers about the risks of dysphagia, its sequellae as well as the potential intervention strategies.
Participants are instructed to read the 14 sections of course material and then fill in the information fields before taking the Exam. When finished answering ALL of the questions, click on the 'Submit My Test Now' button. Your results will come back to you immediately. Please print the results page as your course completion verification.
The estimated time to complete this educational activity is 1 hour. Long Beach Memorial Medical Center designates this educational activity for a maximum of 1. AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Upon completion of this educational program, primary care physicians will be able to:
Definition and Etiology of Dysphagia
An average of 10 million Americans is evaluated annually for swallowing disorders.2 Dysphagia is more specifically defined as unsafe or inefficient swallowing secondary to changes in oropharyngeal physiology. It is most common in older individuals and can adversely affect their quality of life, or can lead to more serious medical issues.
Many causes have been identified for dysphagia in the elderly, including:
Prevalence of Dysphagia
The prevalence of dysphagia increases with age and is particularly problematic for older patients. The risks—including weight loss, dehydration, and aspiration—can be devastating to this population of patients.6 7 Early identification and treatment of swallowing problems can have a significant positive impact on overall health and quality of life.
A recent study (Dysphagia Among Seniors in Los Angeles County) was conducted to determine the prevalence of undiagnosed dysphagia in seniors in independent senior living centers or associated with senior care networks. Three hundred seventy-nine (379) seniors signed consents and completed an evaluation with a speech-language pathologist (SLP). A random sample of 162 also completed a Modified Barium Swallow exam (MBS) and responded to a newly developed observable signs of dysphagia questionnaire. The results of the MBS were used to determine prevalence and to validate the new questionnaire. The MBS identified a prevalence of 10.5% dysphagia in this sample of previously undiagnosed seniors.12 This percentage of seniors living independently is significant considering the risks they face if they remain undiagnosed and untreated.
Risks Associated with Dysphagia
The identification of dysphagia is critical to the management of both physical and emotional risks associated with this disorder. According to the American Speech-Language Hearing Association, dysphagia can result in:
"The consequences of dysphagia vary from social isolation to the embarrassment of choking or coughing at mealtime, to physical discomfort, and to potentially life-threatening conditions. Both overt aspiration and silent aspiration may lead to pneumonia, exacerbation of chronic lung disease, or even asphyxiation and death."14
Clinical Screening and Diagnosis
Although the screening and diagnosis of dysphagia are not difficult, many patients remain undiagnosed due to a number of factors:
Many patients will not volunteer information about swallowing issues because they:
Therefore it is important for physicians to be aware of all these factors that allow seniors to remain undiagnosed. By educating themselves and their patients, these seniors can more easily be identified and treated. The first step is to understand the complexities of the swallowing process. The following section details this process and is followed by descriptions of the observable signs most helpful in screening for dysphagia.
Understanding the swallowing process is often helpful in recognizing a swallowing disorder and is critical in developing a treatment protocol. Normal swallowing can be divided into the following 3 phases:
Oral Preparatory Phase
In Image A18, food, the material colored green is being prepared for swallowing. This involves the use of the lingual, mandibular and labial musculature for mastication with the food formed into a bolus and held anterolaterally against the hard palate by the tongue. This process requires the taste, temperature, touch, and proprioception senses for formation of a bolus the right size for the consistency being swallowed.
Oral Transit Phase
The oral transit phase (images B and C) involves lifting the bolus on to the front of the tongue and then pushing it posteriorly, toward the pharynx. Sequential anterior-toposterior tongue elevation contributes to triggering the pharyngeal phase of the swallow as the bolus moves into the pharynx.
Images D and E demonstrate how the bolus moves through the pharynx. Elevation and retraction of the velum, lead to velopharyngeal closure. This prevents material from entering the nasal cavity. The bolus is then pushed further into the pharynx toward the cricopharyngeal sphincter by backward movement of the tongue base and the sequential contraction of the pharyngeal constrictor muscles. The larynx closes at three levels: the true vocal folds, soft (false) vocal folds, and arytenoid cartilages, preventing material from entering the airway. The elevation of the hyoid bone and larynx is followed by relaxation of the cricopharyngeal muscle and opening of the upper esophageal sphincter, allowing the bolus to pass into the esophagus.
Image F shows the final phase of the swallowing process. In this phase a peristaltic wave pushes the bolus sequentially from the cervical esophagus down through the esophagealgastric sphincter into the stomach. The act of swallowing usually interrupts the expiratory phase of breathing, while the completion of expiration occurs when swallowing ends. In situations where the swallowing is initiated during the inspiratory phase of ventilation, a brief expiration may ensue after completion of swallowing. Abnormalities of swallowing could result from defects in any of the components of the stages of swallowing enumerated above.
A thorough patient history can reveal many of the symptoms that patients are unwilling to volunteer. The most obvious observable signs to ask the patient about fall into one of the following categories:
The questionnaire below is a quick way to have your patients self assess these observable signs and to determine if your patient is at risk for dysphagia. This questionnaire was validated by comparing responses to the results of the MBS procedure. The 10 items on the Self-Test below were found to be the most effective in predicting the presence or absence of dysphagia.5
To Calculate a Score:
Total Score: ____*
*If your total score is 7 or greater you should consider consulting your physician.
This self-test is a guide only and not a diagnosis of dysphagia. It is possible to have a total score of zero and still have dysphagia. It is also possible to have a score greater than 7 and not have dysphagia. However, the higher your score the more likely it is that you have some form of dysphagia.
Reference: Logemann JA, Stewart C, Hurd J, Aschman D, Matthews N, Reimer T, Calahan S, Taylor S, & Burton W (2008, February). Dysphagia Care Among Seniors in Los Angeles County: Planning and Pilot Study. (UniHealth Foundation, Grant 912). Los Angeles, CA.
If a patient is determined to be at risk (i.e. a score of 7 or greater), they can be referred to an ASHA (American Speech-Language-Hearing Association) certified SLP (Speech- Language Pathologist), who can perform a more thorough evaluation of feeding and swallowing. ProSearch is a searchable database that contains ASHA's online listings of more than 10,300 programs that employ audiologists and SLPs who hold the Certificate of Clinical Competence (CCC) from the American Speech-Language-Hearing Association (ASHA). The following is a link to this database: http://www.asha.org/findpro/
Programs and private practitioners who appear within this listing do so voluntarily and currently represent only a percentage of SLPs and audiologists who hold ASHA's Certificate. For more information, please contact the Action Center at: firstname.lastname@example.org
Once a patient is referred, the SLP will take a careful history of medical conditions and symptoms, look at the strength and movement of the muscles involved in swallowing, and will observe feeding to see posture, behavior, and oral movements during eating and drinking. They may also perform special tests to evaluate the swallowing process mentioned above. This will often include a Modified Barium Swallow (MBS), which is a videofluoroscopic study of the oral cavity and the pharynx. The protocol for the MBS allows for diagnosis of oropharyngeal dysphagia, while maintaining a low risk for aspiration. The MBS is the most frequently used diagnostic study and is considered to be the gold standard. However, a specific protocol for the MBS must be followed in order to achieve accurate results.
Assessment of oropharyngeal swallowing typically begins with a modified barium swallow (MBS), the 'gold standard' for assessment of the oral cavity, pharynx, larynx, and cervical esophagus during swallow. The patient is typically given 2 swallows each of small to large amounts (1, 3, 5, 10 ml) of thin liquids, followed by two swallows of pudding consistency barium and two swallows of ¼ of a Lorna Doone® cookie coated with barium pudding (3 ml). This examination enables the clinicians to determine the normalcy of the oropharyngeal swallow as it adjusts to accommodate various bolus volumes and viscosities. If the esophagus is of interest, then a barium swallow should be completed, not a modified barium swallow. Fiberoptic endoscopic examination of swallowing is also a possible assessment tool, particularly for examination of the anatomy of the pharynx and larynx before and after swallowing. During the swallow, the pharynx and larynx close and cannot be seen.
The modified barium swallow is usually conducted by a speech-language pathologist and a radiologist as a team. During the MBS, should the patient exhibit significant swallow impairment, treatment strategies are introduced to improve the swallow. Such treatments may include postural changes to redirect food, heightened sensory input via the taste and texture of the bolus when placed in the oral cavity, voluntary changes in swallow such as holding the airway closed sooner or later or prolonging the opening of the upper esophageal sphincter and finally, exercises to strengthen musculature in the oral cavity, pharynx, and/or larynx. The goal of the MBS is to keep the patient eating by mouth safely and efficiently.
MBS Requires at least 30 Frames Per Second
A recent study revealed that 'in order for the disorders of the pharyngeal stage of swallow to be seen and recorded, the videofluoroscopic study must be recorded at least at 30 frames per second.'1 While this was a small study, it did report that for 30% of the patients, aspiration was only visible for 1/30 of a second. Similarly, the duration of visibility of a tracheo-esophageal fistula was 1/30 of a second in 50% of the patients. Thirty frames per second has been standard protocol for MBS studies of oral and pharyngeal swallowing for over 30 years. A multi-institutional study conducted by Brandt et al. 20 required that all MBS studies be recorded at a uniform 30 frames/second, allowing sufficient precision to visualize some swallowing disorders. CAUTION: newer digital fluoroscopic equipment is sometimes run at 15 to 20 frames per second. At those speeds, any disorder with a duration of less than 1/20 per second could be missed by the examiner. As institutions are considering the purchase of new video recording and fluoroscopy equipment, they should ensure that the equipment has the capability to record at least 30 frames per second.
Patient Referral and Diagnosis
Intervention and Treatment Strategies
Once the speech-language pathologist (SLP) determines a patient to be positive for dysphagia, they will devise a treatment plan for the patient. Treatment varies greatly depending on the cause, symptoms, and type of swallowing problem. A SLP can recommend the best treatment strategy, but most therapies involve three components.
Healthy Aging: Keeping Your Swallowing Intact
Normal swallowing requires that the muscles in your mouth and throat and tongue remain flexible and that your swallow reflex remains intact. As we age, the neuromuscular system and body reflexes needed for swallowing tend to become slower. This is not much different than the impact of aging on the rest of the body. There is evidence that exercise in aging seniors can help to keep your body flexible and strong as you become older and help you to maintain function, decrease falls, etc. To keep your swallow flexible and normal as you age, it is recommended that you do each of these aerobic exercises 2-3 times a day. You might want to add them to an aerobics class if you are taking one, or do them with your friends. Each cycle should take about 5 minutes. If you experience any problems doing these exercises, contact your doctor or speech pathologist.
These therapies are the gold standard in the management of dysphagia. However, their success depends on the patient's ability to understand the recommended strategies and the willingness to follow their treatment plan. The primary care physician could play a major role in ensuring that patients follow their plans and achieve a successful outcome.
Most patients will recover and/or improve with clinical treatment. Many of the preferred treatments are behavioral but there are surgical options as well. The greatest barrier to the successful treatment of dysphagia is lack of education.
This educational program was made possible by a grant from the UniHealth Foundation.
The authors would like to thank the clinicians at Rancho Los Amigos National Rehabilitation Center in Downey, California and Casa Colina Centers for Rehabilitation in Pomona, California for completing the study screenings and video fluoroscopies. We would also like to acknowledge Muveddet Harris in the Northwestern University Swallow Physiology Lab and Mary Smessaert in the Department of Communication Sciences and Disorders at Northwestern University who under the direction of Dr. Jeri Logemann evaluated all data.
Charles A. Stewart, M.D. and Jane Hurd, MPA are co-principal investigators of the Dysphagia Among Seniors in Los Angeles County: Planning and Pilot Study (2008). Charles A. Stewart, M.D. is the Chairman of the Department of Medical Imaging and Acting Chief Medical Officer at Rancho Los Amigos National Rehabilitation Center, and Clinical Associate Professor of Radiological Science at the David Geffen-UCLA School of Medicine. Jane Hurd, MPA is a healthcare administrator with experience at hospitals affiliated with both the USC School of Medicine and David Geffen-UCLA School of Medicine. She holds an MPA from the University of Southern California.
Diane J. Aschman, MS, a pharmacist entrepreneur with over 25 years in the healthcare industry, is President of Advancing Health LLC.
Jeri Logemann, Ph.D. is Ralph and Jean Sundin Professor of Communication Sciences and Disorders at Northwestern University, and Professor of Otolaryngology and Maxillofacial Surgery and Neurology at Northwestern University Medical School. She has published and lectured widely both nationally and internationally on evaluation and treatment of swallowing disorders.
Nancy L. Matthews, MA, manager of the Dysphagia Among Seniors in Los Angeles County: Planning and Pilot Study (2007), has over 20 years experience developing and managing 'Quality of Life' programs and services which serve the community and currently is a lecturer at California State University, Long Beach.
Diagnosis and Management of Dysphagia in Seniors
Please fill in the information fields below before you take the Exam. When you have finished answering ALL of the questions, click on the 'Submit My Test Now' button. Your results will come back to you immediately.
Please print the results page as your course completion verification.