REVIEW ARTICLE

Swallowing Disorders in the Older Population

Colleen Christmas, MD* and Nicole Rogus-Pulia, PhD, CCC-SLP†

muscular tongue contacting the hard palate. The oral phase is

Swallowing problems, or dysphagia, are common as people age, under voluntary skeletal muscle control, thus requiring the par-
and are associated with significant negative outcomes, including ticipation of an alert person. In the pharyngeal phase, the
weight loss, pneumonia, dehydration, shortened life expectancy, tongue propels the food bolus into the pharynx, which triggers
reduced quality of life, and increased caregiver burden. In this a series of events that comprise the pharyngeal swallow
article, we will discuss the complex process of swallowing in response. These include velopharyngeal closure, base of tongue
normal circumstances and with healthy aging, then review etiol- retraction to the posterior pharyngeal wall, movement of the
ogies that contribute to dysphagia. We will discuss approaches hyoid bone and larynx, closure of the airway at three levels
to evaluating and treating dysphagia, providing relevant data (true vocal fold closure, false vocal fold approximation, ary-
where they are available. We highlight the desperate need for tenoid cartilage contact at the base of the epiglottis), con-
high-quality research to guide best practices in treating dyspha- traction of the pharyngeal muscles, and opening of the
gia in older adults. J Am Geriatr Soc 00:1-7, 2019. upper esophageal sphincter. The pharyngeal phase is
partially under voluntary control and partly involuntary.
Key words: aging; dysphagia; evaluation; intervention; Finally, the esophageal phase of swallowing consists of a
swallowing peristaltic wave of contraction that moves the food bolus
through the esophagus under involuntary control.

DYSPHAGIA
When trouble occurs with swallowing, it can be described by
the phase during which it occurs: oral, pharyngeal, or esopha-
THE HEALTHY SWALLOWING PROCESS geal dysphagia. However, often patients have physiologic
impairments that occur within multiple phases of the swallow.
T he swallowing process is remarkably complex, involv-
ing six cranial nerves, multiple muscle groups, and cor-
tical and subcortical brain signals that must be precisely
Impairments may occur in planning the motor sequence of
swallowing, coordination and timing, or anatomical structural
displacement during swallowing. These various impairments can
coordinated within a few seconds. Swallowing has been
lead to airway invasion in the form of penetration or aspiration.
described as consisting of three phases that may overlap
Penetration occurs when the bolus enters the laryngeal vestibule
with one another (Figure 1). Swallowing begins with the
but does not move below the true vocal folds and into the tra-
oral preparatory phase, during which the bolus is prepared
chea. Aspiration occurs when the bolus enters the laryngeal ves-
to be swallowed. The bolus is masticated and mixed with
tibule and moves into the trachea and lungs. Healthy
saliva for moistening and salivary amylase to begin the
individuals with intact laryngeal sensation will cough or
digestive process. During the oral phase, the food and/or
clear the throat in response to airway invasion, but many
liquid is collected into a cohesive bolus and sequentially
patients with dysphagia have impaired sensation and do
propelled toward the pharynx under the pressure of the
not respond (eg, cough or throat clear) to aspiration, ter-
med silent aspiration. During swallowing evaluations,
From the *Divisions of Geriatric Medicine and General Internal Medicine, the underlying causative biomechanical impairments are
Johns Hopkins School of Medicine, Baltimore, Maryland; and the sought to best inform the creation of a treatment plan.
†
Division of Geriatrics and Gerontology, Department of Medicine, School
Table 1 provides examples of levels of dysfunction, con-
of Medicine and Public Health, University of Wisconsin–Madison, Geriatric
Research Education and Clinical Center, William S. Middleton Memorial tributing diseases, and clinical presentation of dysphagia.
Veterans Hospital, Madison, Wisconsin.
Address correspondence to Colleen Christmas, MD, Divisions of Geriatric CAUSES OF DYSPHAGIA IN OLDER ADULTS
Medicine and General Internal Medicine, Johns Hopkins School of Medicine,
4940 Eastern Avenue, Baltimore MD 21224, MD. E-mail: [email protected] Dysphagia is not itself a disease; rather, it results from a
DOI: 10.1111/jgs.16137 variety of medical conditions. Due to the high prevalence of

JAGS 00:1-7, 2019

© 2019 The American Geriatrics Society 0002-8614/19/$15.00
2 CHRISTMAS AND ROGUS-PULIA MONTH 2019-VOL. 00, NO. 00 JAGS

Figure 1. Normal phases of swallowing.

dysphagia in older adults as well as its serious conse- interventions (eg, endotracheal intubation, tumor resection)
quences, it has been suggested that dysphagia be considered and certain medications (eg, anticholinergics) also can result in
its own geriatric syndrome.1 The most common conditions dysphagia (Table 2).
leading to oropharyngeal dysphagia include stroke, head Even healthy aging contributes to changes in eating,
and neck cancer, or progressive neurologic disease (eg, only some of which are related to swallowing per se. The
dementia, amyotrophic lateral sclerosis, Parkinson disease). aging process leads to alterations in olfaction and gustatory
There are a multitude of etiologies of esophageal dysphagia, sensation that can affect appetite, dietary selection, and
including esophagitis, achalasia, esophageal strictures, amount of oral intake. Sarcopenia (decreased muscle mass
Zenker diverticula, and others. History can be helpful in and quality with advancing age) has been shown to affect
considering etiologies to guide the appropriate workup. the muscles used for swallowing, given that they are of the
Esophageal dysphagia that begins only involving solid food skeletal type.2,3 Due to these effects, the force generation
but progresses over time to also include fluids is more sugges- capacity of the oral tongue has been shown to decrease with
tive of a mechanical issue, such as tumor or stricture, whereas advancing age, which can lead to reduced pressure genera-
esophageal dysphagia for both solids and liquids from the out- tion during the oral phase and poor bolus clearance.4-7
set suggests a motor problem, such as achalasia. Medical Changes in the muscles of mastication result in slower and

Table 1. Examples of Levels of Dysfunction, Contributing Diseases, and Clinical Presentation of Dysphagia

Phase of Examples of impairment in Examples of diseases causing Clinical presentation of

swallowing Normal function function impairment impairment

Oral Food is chewed and mixed Apraxia from dementia Dementia “Cheeking” of food, or
with saliva, and the food bolus Reduced level of Delirium oral residue of food
is moved to the back of the consciousness Medications that cause Prolonged chewing
mouth Xerostomia inattention, sedation, or dry
Tongue weakness mouth
Pharyngeal The tongue propels the food Tongue weakness Stroke Nasal regurgitation of
bolus into the pharynx, Pharyngeal weakness Pharyngeal tumor or abscess food
triggering a series of events to Vocal cord dysfunction Vocal cord trauma Wet vocal quality after
move the bolus through the Amyotrophic lateral sclerosis swallowing
pharynx and into the Parkinson disease Coughing while eating
esophagus while protecting Throat clearing
the airway Aspiration
Esophageal The food bolus is moved down Mechanical obstruction Esophageal tumor, stricture, Food impaction sensed
the esophagus by peristaltic of food bolus diverticulum in the chest area
muscle contraction, with the Esophageal muscle Esophagitis Regurgitation of
aid of gravity impairment Achalasia undigested food
Impairment of lower Progressive dysphagia
esophageal muscle tone
JAGS MONTH 2019-VOL. 00, NO. 00 DYSPHAGIA 3

and/or instrumental swallowing assessment and any recom-

Table 2. Examples of Medications that Contribute to
Dysphagia mendations made based on the results of this assessment,
such as swallowing exercises. Thus, performing swallowing
Impact on swallowing Example classes of drugs assessments on delirious patients who cannot fully partici-
pate may be futile. Finally, a swallowing evaluation by an
Reduce attention and oral Sedatives SLP can be pursued to gather further information when the
praxis Neuroleptics clinical scenario is unclear. There are two main types
Cause xerostomia Anticholinergic drugs for urinary of swallowing evaluations: a clinical evaluation, often at the
continence
bedside, and an instrumental assessment, which includes
Tricyclic antidepressants
videofluoroscopic swallowing studies (VFSSs) and fiberoptic
Weaken tongue and mouth Steroids
strength endoscopic evaluations of swallowing (FEES). There are
Impair pharyngeal phase Antipsychotics advantages and drawbacks to each and limited guidance in
Impair esophageal phase Bisphosphonates terms of preferred approaches for various clinical scenarios.
Older adults have higher rates of silent aspiration than younger
adults, further making clinical bedside evaluations less reliable
in those for whom this is suspected. Further research is indi-
inefficient chewing, which increases the risk of asphyxia-
cated to identify patients for whom these examinations are
tion.8 Aging also results in lower salivary flow rates,9
most useful prognostically and therapeutically.
which, in combination with medication effects, can lead to
When evaluating a patient for oropharyngeal dyspha-
the onset of xerostomia. Many medications older adults
gia, the SLP begins the assessment with a clinical evaluation
consume also contribute to decreased appetite, incoordina-
that involves a thorough review of medical history, an inter-
tion, and esophagitis, further exacerbating the problem.
view with the patient and/or caregiver/family, a cranial
Thus, in an older adult with concerns related to eating, it is
nerve examination, and administration of liquid and food
important to distinguish whether dysphagia is a significant
of varying textures and sizes. The goal of the clinical evalu-
contributor or if other factors predominate. When dysphagia
ation is to determine whether signs of dysphagia are pre-
contributes, the specific swallow impairments are sought, often
sent, warranting further evaluation with an instrumental
with a combination of careful history, examination, and poten-
assessment. The SLP also gains valuable information about
tially instrumental assessment of swallowing, in conjunction
the patient’s reported symptoms, cognitive state, fatigue
with a speech language pathologist (SLP).
during a meal, posture, positioning, environmental conditions,
and readiness for further evaluation. There is insufficient evi-
dence linking these assessments to clinically meaningful out-
ASSESSMENT OF SWALLOWING
comes, and the data supporting bedside evaluations alone to
Despite the frequency with which swallowing problems are determine treatment interventions are not supported by
encountered in clinical medicine, there is a striking paucity evidence.10,11
of evidence on which to base recommendations for evalua- The VFSS is the most common type of instrumental
tions and treatments. In evaluating swallowing function, an assessment. During the VFSS, various volumes and viscosi-
SLP is a critical team member when oropharyngeal dyspha- ties of barium are administered, and the oropharyngeal
gia is suspected. Esophageal dysphagia is typically evaluated region is visualized radiographically. The SLP can deter-
by endoscopy or barium swallow (esophagram), often in mine the specific swallowing impairments present as well as
partnership with a gastroenterologist to identify and treat the safety and efficiency of the swallow. The SLP also uses
the underlying etiology. If both oropharyngeal and esopha- this study to determine whether certain intervention strate-
geal dysphagia are likely, one may utilize a combined gies (eg, postural changes, dietary modifications, swallowing
videofluoroscopic swallow study with a barium swallow. maneuvers) are effective in improving swallow function,
No clear guidelines on when to consult an SLP exist; which guides the treatment plan. During FEES, a flexible
most clinicians consider consultation when there are signs endoscope is inserted through the nose and into the upper
and symptoms of swallowing problems or when the patient pharynx. This allows for visualization of the pharyngeal and
has newly developed a clinical condition highly associated laryngeal anatomy as well as the swallowing process while
with swallowing problems. More recent shifts in paradigms the patient is eating and drinking regular foods/fluids.
of care for older patients with neurodegenerative conditions In a retrospective study of nursing home patients
(eg, Parkinson disease, dementia) have resulted in the inclu- followed up for a year, researchers showed that aspiration
sion of the SLP in geriatrics and memory clinics as a mem- on VFSS predicted rehospitalization but not pneumonia or
ber of the interdisciplinary team to allow for his/her pneumonia death.12 In another cohort study, aspiration on
involvement from diagnosis through end of life. Signs and VFSS predicted both pneumonia and death, but not dehydra-
symptoms of swallowing problems are coughing while try- tion, in patients with stroke followed up for 16 months.13
ing to swallow, nasal regurgitation of food, wet vocal quality Hospitals adherent with dysphagia screening programs after
after swallowing, poor secretion management, weak cough, stroke tended to have lower rates of pneumonia than those
or a feeling of food getting stuck or requiring regurgitation. that did not utilize dysphagia screening protocols in one
Concerns may be heightened in patients with known neuro- study14; this association cannot prove causation but is
logic or aerodigestive impairments that increase the risk of intriguing. While results of some clinical evaluations and
swallowing disorders, such as stroke, or patients with head instrumental assessments (eg, VFSS and FEES) have been
and neck treated with chemoradiation. Further, it is impor- shown to be associated with important outcomes for patients
tant that the patient is able to participate in the clinical with dysphagia, others have failed to demonstrate this
4 CHRISTMAS AND ROGUS-PULIA MONTH 2019-VOL. 00, NO. 00 JAGS

benefit15; more research focused on understanding the bene- pneumonia and fatal pneumonia but there was a high risk of
fits and drawbacks of these evaluation techniques is needed. bias in all studies.16
Postural changes, such as chin down (positioning the chin
to the chest) or head turn (turning head over right or left shoul-
MANAGEMENT OF DYSPHAGIA IN OLDER der), have been shown to change the biomechanics and pressure
ADULTS generation during swallowing and to reduce the occurrence of
aspiration, depending on the swallow impairments present.17-21
Interventions for dysphagia include both compensatory and
Additionally, swallowing maneuvers, such as the effortful swal-
rehabilitative methods, with the goal of improving swallow
low, also impact swallowing physiology and may have positive
function, thereby reducing the occurrence of aspiration,
effects on pharyngeal pressure generation.
pneumonia, and choking.
Another common practice is to alter the consistency of
fluids and solids in patients with dysphagia; however, more
research is needed to elucidate the benefits and risks of this
Compensatory Techniques
practice on clinical outcomes. There are gradations of liquid
Compensatory techniques are designed to minimize or elim- and solid foods that may be recommended for a patient
inate symptoms or adverse sequelae of dysphagia but do based on what is observed to be safest and most efficient on
not change the underlying physiology of the swallow. These the VFSS. The recently developed International Dysphagia
approaches include oral care, postural changes, swallowing Diet Standardization Initiative has been successful in esta-
maneuvers, eating strategies, and dietary modifications. blishing standard international terminology and definitions
While not directly impacting swallowing function, limited for texture-modified foods and liquids22 (Table 3). While it
evidence supports the use of oral care to reduce the risk of has been suggested thicker liquids (eg, honey-thick consis-
developing pneumonia from aspiration in nonventilated patients. tency) may improve some measures of swallowing, such
In one meta-analysis, oral care interventions reduced the risk of as decreases in the occurrence of airway invasion on

Table 3. IDDSI Framework Levels, Descriptions, and Examples

IDDSI level Description IDDSI flow or fork drip/pressure test Example(s)

Level 0: thin Flows like water, fast flow Liquid flow through 10-mL slip tip Water, juice, tea
syringe within 10 s with no
residue
Level 1: slightly thick Thicker than water, more effort to Liquid flows through 10-mL slip tip “Antiregurgitation” infant formula
drink than thin liquids; primarily syringe, leaving 1 to 4 mL in
used in pediatrics syringe after 10 s
Level 2: mildly thick Flows off a spoon, slippable but Liquid flows through syringe, Nectar-thick liquids
slower than thin drinks leaving 4 to 8 mL after 10 s
Level 3: moderately Can be drunk from a cup, some Liquid flows through 10-mL Sauces and gravies, fruit syrup
thick effort required to suck through a syringe, leaving >8 mL after 10 s
standard or wide-bore straw
Level 4: extremely Usually eaten with a spoon (fork Flow test not applicable; sits in a Purees suitable for infants
thick–pureed is possible); cannot be drunk from mound/pile above the fork; a small (pureed meat, thick cereal)
a cup or sucked through a straw, amount may flow through and
does not require chewing form a tail below the fork
tines/prongs but does not flow
continuously
Level 5: minced and Can be eaten with fork/spoon; can Flow test not applicable; sits in a Finely minced or chopped meat
moist be scooped and shaped; soft and pile or can mound on a fork and served in extremely thick, smooth,
moist, with no separate thin liquid does not easily or completely flow nonpouring sauce/gravy
or fall through tines/prongs of fork
Level 6: soft and bite Can be eaten with a fork/spoon; Flow test not applicable; pressure Cooked tender meat no bigger
sized can be mashed/broken down with from a fork held on its side can be than 15 mm
pressure from fork/spoon; used to “cut” or break this texture
chewing is required into smaller pieces
Level 7: regular Normal, everyday foods of various Not applicable Any food that is hard, tough,
textures; foods may be a range of chewy, fibrous, stringy, or dry
sizes
Transitional foods Foods that start as one texture Flow test not applicable; after Ice chips, ice cream/sherbet;
and change into another texture, moisture or temperature is wafers, waffle cones; some
specifically when moisture is applied, sample can be easily biscuits/cookies/crackers
applied or with a temperature deformed and does not recover its
change shape when the fork is lifted

Note: Adapted from the IDDSI Framework and Descriptors at http://www.iddsi.org (license: https://creativecommons.org/licenses/by-sa/4.0/).
Abbreviation: IDDSI, International Dysphagia Diet Standardization Initiative.
JAGS MONTH 2019-VOL. 00, NO. 00 DYSPHAGIA 5

videofluoroscopy, increases in dehydration with decreases Additionally, feeding tubes are associated with their
in quality of life have also been reported.23 Additionally, own risks. While in most patients they are easy to insert,
studies have shown adherence to recommendations for long-term outcomes are concerning. Gastrostomy tubes are
thickened liquids to be low overall.24 Studies evaluating the associated with cellulitis, fasciitis, and bacteremia. Nasogas-
impact of modification of food and fluid consistency on the tric tubes are associated with increased agitation, frequently
incidence of aspiration for patients with head and neck can- requiring the use of restraints in patients with dementia.
cer25 and with Parkinson disease26 are low quality and They are also associated with a higher risk of sinus infec-
inconclusive. A recent Cochrane review found no qualifying tion and nasal irritation. Both forms of tube feeding repre-
studies related to altering food consistency and only two sent a significant risk factor for the development of both
studies (parts of the same clinical trial) evaluating the use of infectious and noninfectious diarrhea, which may be espe-
honey- or nectar-thick liquids vs regular liquids with a chin cially problematic in a bedridden patient with dementia
tuck posture for patients with dementia or Parkinson disease who may have bedsores. Indeed, in one cohort study of
and comorbid dysphagia. They found that both nectar- and nursing home residents with severe cognitive impairment,
honey-thick liquids reduced videofluoroscopic aspiration the placement of a feeding tube was associated with double
compared to thin liquids. While honey-thick liquids were the risk of developing a stage 2 or greater pressure ulcer
associated with higher rates of pneumonia27 compared to and slower healing of existing sores compared to matched
chin tuck posture with thin liquids, the study was not ade- patients without tubes.34 In patients with significant dys-
quately powered for pneumonia as an outcome. phagia and dementia, we know that survival is equally
Thus, we have limited and insufficient evidence to under- short with and without a feeding tube, approximately
stand the risks and benefits of compensatory approaches, 6 months. Several studies suggest that survival is shorter in
including altered fluid and food consistencies, on important patients with dementia and dysphagia who were fed by tube
clinical outcomes. Such limitations in our evidence base should rather than by hand, but this evidence is inconclusive. There
be acknowledged in discussions with families and in consider- is no evidence to support that feeding tubes prolong sur-
ing the strength of our treatment recommendations. Further vival in patients with dementia and dysphagia.35 In patients
research to elucidate the impact of these compensatory with dysphagia from acute stroke, the FOOD trial demon-
approaches on swallowing function, quality of life, and clini- strated no improvement in recovery of function or length of
cal outcomes is needed; and the creation of evidence-based stay for patients who have feeding tubes placed at admis-
protocols is desperately needed. Physicians should work with sion vs waiting for a week. Indeed, 50% of those patients
SLPs to understand the most pressing areas needing advocacy randomized to delayed placement never received a feeding
for funding of research. tube because they recovered swallowing ability in that time;
those who had early placement of feeding tubes had higher
rates of gastrointestinal bleeding and higher rates of utiliza-
Feeding Tubes
tion of feeding tubes at the end of the study.36 Further,
Feeding tubes may be placed in patients with dysphagia of while feeding tubes may contribute to elevated risk of cellu-
a variety of etiologies either with complete elimination of litis and infectious diarrhea, there is no evidence to support
oral intake or in conjunction with modification of oral the notion that infections of any kind can be reduced with
intake, often in an attempt to reduce the risk of aspiration. use of feeding tubes. Similarly, there is a paucity of evidence
When contaminated oral secretions are aspirated in high evaluating function as an important outcome or how the
enough inoculum to overcome host defenses, a poly- presence of a feeding tube impacts quality of life.
microbial aspiration pneumonia may occur with associated In 2014, the Ethics and Clinical Practice Committees of
high morbidity and mortality. Aspiration of gastric contents the American Geriatrics Society published a comprehensive
usually causes a chemical irritation to the lungs, contribut- review of the evidence about feeding tubes and dementia
ing to fever, tachypnea, and rales, usually resolving over the and issued position statements. Given the wealth of infor-
course of 24 hours without requiring antibiotics.28 This lat- mation suggesting that feeding tubes provide no meaningful
ter syndrome is known as Mendelson syndrome, or aspira- clinical benefit to patients with dementia and dysphagia and
tion pneumonitis. The placement of a feeding tube does may, in fact, be associated with some poorer outcomes, the
nothing to improve the ability to swallow. Therefore, misdi- position statement of the American Geriatrics Society sug-
rection of contaminated oral secretions, the most common gests that placement of feeding tubes in patients with demen-
contributor to aspiration pneumonia, is not reduced or tia is a practice that should be seriously reconsidered and
eliminated by the placement of a feeding tube of any endorsed careful hand feeding as the preferred, albeit labor-
kind.29,30 Further, in animal studies, it has been demon- intensive, approach.37 For patients with acute dysphagic
strated that reflux of gastric contents is increased due to a stroke, data suggest that the placement of a gastrostomy tube
reduction in the pressure of the lower esophageal sphincter may be safely delayed a week; whether longer delays are ben-
with a gastrostomy tube in place.31 Thus, it is not surpris- eficial or harmful is unknown. For patients with progressive
ing that ample evidence fails to demonstrate a reduction of motor neuron diseases, esophageal cancer, and many other
aspiration of gastric contents or the occurrence of aspira- diseases associated with dysphagia, there is precious little evi-
tion pneumonia from misdirected oral secretions after feed- dence on which to guide treatment decisions.
ing tubes are placed.32 Indeed, feeding tubes pose one of the
highest risk factors for aspiration pneumonia in these
Rehabilitative Interventions
populations.33 Ongoing research is studying whether the
use of a feeding tube alters oral flora, and whether this Rehabilitative interventions are designed to improve the biome-
change may contribute to pneumonia risk. chanics of swallowing through strength- and/or skill-based
6 CHRISTMAS AND ROGUS-PULIA MONTH 2019-VOL. 00, NO. 00 JAGS

treatment paradigms. These may include exercise regimens to engage trusted advisors, such as religious figures, family,
or training to improve planning of the swallowing motor friends, and long-term physicians, to contribute to discus-
sequence and coordination within the events of the swallow. sions. Critically important is ensuring the healthcare team
As previously mentioned, declines in force generation by facilitates a collaborative and humble approach to care,
the tongue and pharyngeal muscles have been documented acknowledging shared goals and approaching the limita-
with advancing age and in patients with dysphagia. tions in our knowledge base with humility.
Swallowing maneuvers, such as the effortful swallow and the
Mendelsohn maneuver, where the patient is instructed to vol-
SUMMARY
untarily hold the larynx in its uppermost position for 2 to
3 seconds before completing the swallow, used within an exer- Swallowing is a complex process, and dysphagia is incredi-
cise paradigm have been shown to benefit swallowing-related bly common with advancing age. Dysphagia can be asymp-
outcomes in multiple patient populations.17,38,39 Progressive, tomatic, but often contributes to significant reductions in
intensive lingual strengthening exercise regimens, facilitated by quality of life for patients and caregivers, discomfort with
devices that provide biofeedback, have also resulted in positive eating, higher risks of pneumonia and dehydration, and
changes in lingual strength with some carryover to swallowing weight loss and debility. For patients with stroke and
function for older adults and patients poststroke.40 Expiratory dementia, dysphagia is highly associated with reduced sur-
muscle strength training positively impacts other components vival, and can serve as a prompt to explore goals of care
of swallowing.41,42 The McNeill Dysphagia Therapy Program and values near the end of life. These discussions are often
is a progressive strengthening program that incorporates a highly stressful for patients and families and healthcare pro-
hard swallow across a hierarchy of progressively more chal- viders as well, so considerable effort invested in building trust
lenging feeding tasks. This approach has been shown to and understanding and valuing preferences can reduce the bur-
improve the severity of dysphagia in several patient groups.43 den involved in creating and navigating treatment plans.
A recent Cochrane review found low- and very-low- Evidence to support early evaluation and treatment of
quality evidence that swallowing interventions, as com- dysphagia in older adults is limited, and more research with
pared to no swallowing intervention, may have reduced the larger cohorts and improved study design is needed. Fortu-
number of individuals with dysphagia and chest infection nately, exciting research should shed new evidence regard-
and may improve swallowing ability. Moderate-quality evi- ing the underlying mechanisms of dysphagia in older adults
dence suggested that swallowing interventions reduced hos- and the optimal treatments for these impairments in the
pital length of stay but that these interventions did not years ahead.
reduce case fatality rate or the combined outcome of death There are many areas where this research is critically
or disability.44 Higher-quality evidence to support the posi- needed. Underlying mechanisms and the results of interven-
tive impact of rehabilitative interventions for dysphagia in tions targeting these mechanisms are still at nascent stages
older adults with a variety of etiologies is desperately needed. of investigation. Also, it has been shown that swallowing
dysfunction begins early in Alzheimer-type dementia.47
Direct interventions to strengthen and improve swallowing
THE IMPORTANCE OF COLLABORATION IN
function in early-stage dementia, at a time when the patient
DYSPHAGIA MANAGEMENT
is cognitively able to participate in such therapies and
Interprofessional team partnerships and engagement of fam- before they have a negative impact on swallowing, have a
ilies and caregivers in discussions regarding the diagnosis lot of face validity and are currently an area of active
and recommended treatment for patients with dysphagia research. The impact of swallowing evaluation and treat-
are necessary to achieve optimal care. One study demon- ment on broader health outcomes, such as pneumonia and
strated that involvement of a geriatrician in the discussion nutritional status, in older adults requires elucidation. As
at the time a feeding tube was considered in the hospital set- eating and swallowing are so intimately linked to quality of
ting resulted in a 50% reduction in the placement of feeding life, it is critical that future studies include standard mea-
tubes.45 Early involvement of an SLP will be critical to sures of the impact of evaluations and interventions on
ensuring thorough assessment and follow-up for older quality of life in those populations who are able to partici-
patients with dysphagia, especially those who require pro- pate in such an assessment.
active intervention to potentiate neural recovery (eg, stroke)
or to maintain swallow function as long as possible into
ACKNOWLEDGMENTS
disease progression (eg, dementia). Caregiver education and
training will be critical to the carryover of any recommen- Financial Disclosure: This article was partially prepared
dations, including the implementation of a rehabilitative within the Geriatric Research Education and Clinical Center
approach. In one study, use of a video-guided tool to facili- at the William S. Middleton Veteran Affairs Hospital
tate advanced care planning in patients with dementia (Madison, WI). Dr Rogus-Pulia’s research on dysphagia in
reduced the use of feeding tubes in patient for whom com- persons with Alzheimer disease is supported by the
fort measures were the preference for care.46 National Institute on Aging of the National Institutes of
The cultural values and emotional valence about feed- Health under award 1K23AG057805-01A1.
ing may have little to do with evidence or face validity Conflict of Interest: Neither author identifies any con-
when considering the evaluations and treatment plans for flicts of interest to disclose.
older adults with swallowing difficulties; all such values Authors Contributions: Both authors were involved in
should be carefully explored and will weigh on challenging the writing of this article and reviewed it for accuracy prior
decisions of this sort. Whenever possible, it may be useful to submission.
JAGS MONTH 2019-VOL. 00, NO. 00 DYSPHAGIA 7

Sponsors’ Role: The views and content expressed in 22. Cichero J, Lam P, Steele C, et al. Development of international terminology
and definitions for texture-modified foods and thickened fluids used in dys-
this article are solely the responsibility of the authors and
phagia management: the IDDSI framework. Dysphagia. 2017;32(2):
do not necessarily reflect the position, policy, or official 293-314.
views of the Department of Veteran Affairs, the US govern- 23. Newman R, Vlardell N, Clave P, Speyer R. Effect of bolus viscosity on the
ment, or the National Institutes of Health. safety and the kinematics of the swallow reflex with oropharyngeal dyspha-
gia. Dysphagia. 2015;31:232-249.
24. Krekeler B, Broadfoot C, Johnson S, Connor N, Rogus-Pulia N. Patient
adherence to dysphagia recommendations: a systematic review. Dysphagia.
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