Introduction

As speech-language pathologists, we are frequently tasked with treating “the swallow”. We are trained to identify abnormalities in the anatomy and physiology of the oral, pharyngeal, and laryngeal (and, some may say, respiratory and esophageal) structures. Our interventions often focus on rehabilitating the swallow through strengthening exercises and/or compensating for deficits through behavioral strategies and diet modifications.

However, swallowing is often situated within the broader context of the mealtime process. Thus, is it appropriate to, and are we able to, treat only “the swallow”? Safe and effective swallowing is certainly critical. Yet, the shared mealtime also embodies the connection between biological necessity (mortality) and socialization. This relationship may be particularly relevant for our rapidly aging population.

The Shared Mealtime and Aging

The shared mealtime incorporates two of our most fundamental and pervasive human needs that ultimately drive behavior: basic physiological requirements for food and interpersonal involvement [1-2]. Efforts to link isolated improvements in nutrition, swallow function, social engagement, and communicative function to survival and quality of life are longstanding. Malnutrition, weight loss, and swallowing impairments are associated with decreased survival and increased anxiety, social isolation, and depression [3-6]. Beyond enhancements in quality of life, social relationships also exert an independent influence on survival [7]. However, such an isolated emphasis on either biology/physiology (e.g., nutrition, swallow function) or interaction/psychosocial behavior may lack ecological validity given the frequent overlap of these activities. In fact, their influences may indeed not be isolated.

The mealtime may be a particularly important process for older adults. Malnutrition is a serious, yet often unrecognized, health threat particularly for the elderly [8]. The rate of social interaction and number of social partners frequently decreases with age [9]. Further, older adults are particularly vulnerable to the onset of dysphagia given the typical age‐related changes that occur in anatomical, physiological, and neural mechanisms underlying swallowing function (presbyphagia) and a generalized diminished functional reserve [5, 10]. As disease prevalence increases with age, older adults may also be more at risk for developing dysphagia as a comorbidity of these diseases and treatments or as a result of the additional stress placed on their system by these diseases (e.g., the combination of acute illness and a diminished functional reserve). Thus, it is important to not only consider the disordered swallow when treating older adults with dysphagia, but to also consider the interaction between the swallow and other components of the mealtime.

The “Biology/Physiology” of Mealtimes

A primary health concern for older adults is appropriate nutrition; the anorexia of aging has been estimated to occur in approximately 15-30% of all elderly individuals, depending on setting [11]. Advanced age alone is a risk factor for malnutrition [12]. Many factors place older adults at particular risk for malnutrition. While numerous age-related physiologic changes negatively influence food intake over the life span, social and psychological factors also play an important role [13]. Physical changes, changes in taste, disease, availability of transportation, difficulty accessing or preparing food, and anxiety, depression, loneliness, or grief call all result in older adults limiting their food choices, forgetting to eat, or choosing not to eat [14-16].

Ultimately, we are given the task of ensuring and enhancing both safety and quality of life for our patients with dysphagia. Swallowing does not happen in isolation. Eating does not happen in isolation. We must broaden our definitions used in clinical practice, that drive our assessments and interventions of dysphagia, to accurately reflect the multifactorial nature of the mealtime process.

Dysphagia is also a contributor to, and interacts, with malnutrition and dehydration [17-18]. Older adults may be at greater risk for malnutrition secondary to dysphagia itself, but also as a result of therapeutic interventions. For example, individuals may limit or alter their food and liquid intake due to difficulty swallowing or due to low acceptability of modified diet/swallow strategy recommendations. Thus, particular attention should be given to nutritional requirements and the prevention of malnutrition when treating dysphagia, particularly in older adults.

Social Interaction, Aging, and Eating

Individuals do not exist, or thrive, in isolation. Converging evidence across animal and healthy and clinical human populations points to the benefits of enrichment, social interaction, and engagement [7, 19-22]. In the aging literature, research has suggested that meaningful social interaction and engagement may provide a physical, cognitive, and psychosocial buffer from the negative changes associated with aging, at a time when health may be most vulnerable [19, 23-26]. Social relationships are, in fact, central for not only enhancing quality of life, but also for decreasing mortality, exerting an independent influence on survival comparable to other well-accepted risk factors [7]. This suggests that social relationship factors should be added to the list of risk factors, such as smoking, diet, and exercise, commonly emphasized by physicians, health professionals, and the public media.

The shared mealtime may be a particularly crucial opportunity for social engagement as it plays a central role in our daily lives. The mealtime can reinforce our physical, psychological, and emotional connections to our families, our social networks, and ourselves. Humans connect food to rituals, symbols, and beliefs, allowing for the reaffirmation, transformation, and maintenance of relationships with others [27]. A link between emotion and food consumption, especially food consumption in the presence of others, has also been previously noted. This relationship is multi-directional: eating a meal leads to increased energy and happiness levels, eating in company enhances the emotional experience of dining, spending time with friends and eating are two of the top activities engaged in to create positive emotion, social companionship is associated with greater food intake, and food itself encompasses strong emotional meaning [28-33].

Dysphagia can disrupt this natural process. Swallowing problems can result in decreased social participation and increased anxiety, social isolation, and depression [5]. Given the importance of social engagement for both mortality and quality of life, particularly for older adults, we must then also be aware of the affects of dysphagia, including its associated treatments, on mealtime dynamics.

Dysphagia in the Context of Mealtimes

The information above strongly suggests the importance of considering the influence of dysphagia on malnutrition and mealtime social interaction – and the influence of nutrition and engagement on overall well-being. Yet, many clinically relevant questions remain. For example, how do all of these elements interact? How does the physiology of swallowing change to accommodate the demands of conversation? Should we be assessing swallow physiology and aspiration risk during mealtime conversation? How is this process changed in the presence of dysphagia? Is one component “more important” than the other(s)? To safety? To quality of life? Does this vary individual to individual?

While questions remain to be answered that will help guide future clinical practice, it is clearly necessary to frame the assessment and treatment of dysphagia within the context of the mealtime. Nutritional needs and social interaction are two important factors to consider. Ultimately, we are given the task of ensuring and enhancing both safety and quality of life for our patients with dysphagia. Swallowing does not happen in isolation. Eating does not happen in isolation. We must broaden our definitions used in clinical practice, that drive our assessments and interventions of dysphagia, to accurately reflect the multifactorial nature of the mealtime process.

References

  1. Baumeister, R. F. & Leary, M. R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin, 117 (3), 497-529.
  2. Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50, 370-396.
  3. Karvonen-Gutierrez, C. A., Ronis, D. L., Fowler, K. E., Terrell, J. E., Gruber, S. B., & Duffy, S. A. (2008). Quality of life scores predict survival among patients with head and neck cancer. J Clin Oncol, 26, 2754–2760.
  4. Mick, R., Vokes, E. E., Weichselbaum, R. R., & Panje, W. R. (1991). Prognostic factors in advanced head and neck cancer patients undergoing multimodality therapy. Otolaryngol Head Neck Surg, 105, 62-73.
  5. Ney, D., Weiss, J., Kind, A. J. H., & Robbins, J. (2009). Senescent swallowing: Impact, strategies, and interventions. Nutrition in Clinical Practice, 24(3), 395-413.
  6. Shune, S., Karnell, L. H., Karnell, M. P., Van Daele, D .J., & Funk, G. F. (2012). The association between severity of dysphagia and survival in patients with head and neck cancer. Head & Neck, 34(6), 776-784.
  7. Holt-Lunstad, J., Smith, T. B., & Layton, J. B. (2010). Social relationships and mortality risk: A meta-analytic review. PLoS Med, 7(7), e1000216. doi:10.1371/journal.pmed.1000316.
  8. Maher, D. & Eliadi, C. (2013). Malnutrition in the Elderly: An Unrecognized Health Issue. Journal of Nursing. http://rnjournal.com/journal-of-nursing/malnutrition-in-the-elderly-an-unrecognized-health-issue.
  9. Carstensen, L. L. (1992). Social and emotional patterns in adulthood: Support for socioemotional selectivity theory. Psychology and Aging, 7(3), 331-338.
  10. Robbins, J., Hamilton, J. W., Lof, G. L., & Kempster, G. B. (1992). Oropharyngeal swallowing in normal adults of different ages. Gastroenterology, 103(3), 823-829.
  11. Malafarina, V., Uriz-Otano, F., Gil-Guerrero, L., & Iniesta, R. (2013). The anorexia of ageing: Physiopathology, prevalence, associated comorbidity and mortality. A systematic review. Maturitas74(4), 293-302.
  12. Forster, S. & Gariballa, S. (2005). Age as a determinant of nutritional status: a cross sectional study. Nutr J., 4(28).
  13. Morley, J. E. (1997). Anorexia of aging: Physiologic and pathologic. American J Clinical Nutrition, 66, 760-773.
  14. Markson, E. W. (1997). Functional, social, and psychological disability as causes of loss of weight and independence in older community-living people. Clin Geriatr Med. 13, 639-652.
  15. Meier, R., & Stratton, R. J. (2008) Basic concepts in nutrition: epidemiology of malnutrition. E Spen Eur E J Clin Nutr Metab., 3(4), e167-e170.
  16. Vandewoude, M. F. J., Alish, C. J., Sauer, A. C., & Hegazi, R. A. (2012). Malnutrition-sarcopenia syndrome: Is this the future of nutrition screening and assessment for older adults? J Aging Res. doi:10.1155/2012/651570
  17. Foley, N. C., Martin, R. E., Salter, K. L., & Teasell, R. W. (2009). A review of the relationship between dysphagia and malnutrition following stroke. Journal of Rehabilitation Medicine41(9), 707-713.
  18. Serra-Prat, M., Palomera, M., Gomez, C., Sar-Shalom, D., Saiz, A., Montoya, J. G., … & Clavé, P. (2012). Oropharyngeal dysphagia as a risk factor for malnutrition and lower respiratory tract infection in independently living older persons: a population-based prospective study. Age and ageing41(3), 376-381.
  19. Hertzog, C., Kramer, A. F., Wilson, R. S., & Lindenberger, U. (2008). Enrichment effects on adult cognitive development: Can the functional capacity of older adults be preserved and enhanced? Psychological Science in the Public Interest, 9(1), 1-65.
  20. House, J. S., Landis, K. R., & Umberson, D. (1988). Social relationships and health. Science, 241, 540-545.
  21. Nithianantharajah, J., & Hannan, A. J. (2006). Enriched environments, experience-dependent plasticity and disorders of the nervous system. Nature Reviews Neuroscience, 7(9), 697-709.
  22. van Praag, H., Kempermann, G., & Gage, F. H. (2000). Neural consequences of environmental enrichment. Nature Reviews Neuroscience, 1(3), 191-198.
  23. Bassuk, S., Glass, T., & Berkman, L. (1999). Social disengagement and incident cognitive decline in community-dwelling elderly persons. Annals of Internal Medicine, 131, 165-173.
  24. Bennett, D. A., Schneider, J. A., Tang, Y., Arnold, S. E., & Wilson, R. S. (2006). The effect of social networks on the relation between Alzheimer’s disease pathology and level of cognitive function in old people: A longitudinal cohort study. Lancet Neurology, 5(5), 406-412.
  25. Christensen, H., Korten, A., Jorm, A., Henderson, A., Scott, R., & Mackinnon, A. (1996). Activity levels and cognitive functioning in an elderly community sample. Age Ageing, 25, 72-80.
  26. Zunzunegui, M. V., Alvarado, B. E., Del Ser, T., & Otero, A. (2003). Social networks, social integration, and social engagement determine cognitive decline in community-dwelling Spanish older adults. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 58(2), S93-S100.
  27. Mintz, S. W. & Du Bois, C. M. (2002). The anthropology of food and eating. Annual review of anthropology, 31, 99-119.
  28. Brown, L., Edwards, J., & Hartwell, H. (2013). Eating and emotion: Focusing on the lunchtime meal. British Food Journal, 115(2), 196-208.
  29. de Castro, J. M. (1994). Family and friends produce greater social facilitation of food intake than other companions. Physiology & Behavior, 56(3), 445-455.
  30. de Castro, J. M. & de Castro, E. S. (1989). Spontaneous meal patterns of humans: Influence of the presence of other people. American Journal of Clinical Nutrition, 50, 237-247.
  31. Livingstone, K. M., & Srivastava, S. (2012). Up-regulating positive emotions in everyday life: Strategies, individual differences, and associations with positive affect and well-being. Journal of Research in Personality, 46, 504-516.
  32. Locher, J. L., Yoels, W. C., Maurer, D., & Van Ells, J. (2005). Comfort foods: An exploratory journey in the social and emotional significance of food. Food Foodways, 13(4), 273-297.
  33. Ochs, E., & Shohet, M. (2006). The cultural structuring of mealtime socialization. New Directions for Child and Adolescent Development, 2006(111), 35-49.