SLP’s, think back to your first independent experience performing a clinical bedside swallowing evaluation or modified barium swallow study. Were you nervous? If so, why? Was it because you knew it was your assessment that may define the outcome of a person’s ability to eat or drink safely, or at all? You wanted to be right! You wanted to do everything you could for this person and make sure you were making the best possible decisions for this person. It All Lay On Your Shoulders! Did you question yourself? Did you have the knowledge and confidence to make an appropriate diet recommendation, or worse, recommend alternative nutritional measures if the person required it? Not a decision made easily. We should ask ourselves this question: Are we equipped with the knowledge and skills to do this?
According to the ASHA website “swallowing problems (dysphagia) may be classified as oropharyngeal or esophageal. Oropharyngeal dysphagia refers to difficulty in the passage from the mouth to the esophagus. In esophageal dysphagia, there is a disordered passage of food through the esophagus”. Epidemiological studies document prevalence to be over 20% in the adult (over 50) population, although difficult to determine, as the only determinate can be on reported cases, with a known underreporting.
Swallowing disorders common in the elderly may cause dehydration, weight loss, aspiration pneumonia and airway obstruction. Dysphagia, may occur because of a wider variety of structural or functional conditions, including stroke, cancer, neurological disease and gastroesophageal reflux disease. According to ASHA the literature varies greatly concerning the incidence and prevalence of dysphagia in different health care settings. Several studies report that dysphagia is present in:
- 61% of adults admitted to acute trauma centers
- 41% of individuals admitted to rehab settings
- 30%-75% of patients in nursing homes
- 25%-30% of patients admitted to hospitals
There are numerous sources stating the Modified Barium Swallow as the Gold Standard in swallowing assessment including the following:
1) The MBS is the “Gold Standard” or “criterion” for observation and identification of oropharyngeal swallowing abnormalities. Mechanics of Swallowing: ASHA Healthcare Business Institute 2012; Joseph Murray, PhD, CCC-SLP, BRS-S
2) Videofluoroscoy is considered the gold standard for dysphagia assessment. Dysphagia Screening: ASHA Healthcare Business Institute 2012; Debra Suiter, PhD, CCC-SLP, BRS-S .
Courtesy of Swallowing Diagnostics, Inc.
I had been working in various environments with the client base of dysphagia for over 10 years when I started my own mobile modified barium swallow study company. I always tried to keep in touch with my colleagues over the years and eventually was honored with the ability to be in a teaching role for Master’s Level Students. This enabled me to be able to provide instruction, not only for dysphagia but Modified Barium Swallow Studies at Nova Southeastern University. In developing this program, I always have the students refer to a few ASHA documents.
As part of the requirement by ASHA in their document, “Knowledge and Skills Needed by Speech-Language Pathologists Providing Services to Individuals With Swallowing and/or Feeding Disorders”
The following are stated as basic competencies required:
A knowledge of:
- normal and abnormal anatomy and physiology related to swallowing function.
- signs and symptoms of dysphagia.
- indications for, and procedures involved with, instrumental techniques used to assist in diagnosis and management.
- proper procedures for analyzing and integrating clinical and instrumental information into a formal diagnosis of swallowing and feeding disorders with appropriate written documentation.
- basic management issues, including how to determine candidacy for intervention, as well as how to implement compensations and habilitative/rehabilitative therapy techniques.
This leaves us with the question, Can we distinguish between, normal and normal aging characteristics of the swallow and disordered swallowing?. With each passing birthday we change a bit one year to the next and as we reach our golden years these changes become more evident. Throughout our lives we are continually adapting to our current state of mind and body. Swallowing, a natural body process for most, changes at a gradual rate from infancy to seniority. Research in this field has strived to define these natural changes, identifying when the physiology of the swallow becomes disordered, and creating solutions to keep the swallow function safe.
Courtesy of Swallowing Diagnostics, Inc.
The term “presbyphagia” refers to natural changes within the swallowing mechanism for aging adults and it is essential SLPs, and others caring for the elderly, understand these characteristics to provide the most effective treatment and care. As the prevalence of swallow disorders increases with age, and as characteristics of presybyphagia may put the patient at risk for aspiration, it is crucial SLPs, medical professions, and caregivers identify when these characteristic changes that occur as we age, transition to a dysphagic swallow which may increase a persons risk for aspiration pneumonia.
For example: as people age the increased time of the swallowing mechanism may be beneficial as this allows more time to recruit the necessary motor units to create sufficient pressure to transport the bolus through the oral, pharyngeal, and esophageal tracts (Welford, 2006).
However, in some cases a patient many not be able to achieve a safe swallow and the increased time required to initiate the swallow, and reduced control of the bolus result in aspiration risk, therefore the patient has switched from presbyphagia to dysphagia requiring dysphagia intervention (Robbins, 2006).
There are many factors medical professionals take into considerations when assessing a patient’s ability to swallow safely. A contributing factor to these common changes as we age is sarcopenia (the loss of muscle mass associated with the natural aging process). The average person begins to lose muscle mass around the age of 30. Around age 50, muscle mass is typically reduced by 10% and increases to a reduction of 40% by age 70. It has been found that the natural deterioration of buccal(cheek), labial(lip), and lingual(tongue) strength, ROM, and coordination may result in reduced intake, prolonged chewing(mastication), reduced ability to control food or liquids in the mouth(bolus cohesion and control) and slowed swallowing(AP transit). These changes may result in decreased PO intake, malnutrition, and increasing risk for aspiration pneumonia.
Declines in lung function (pulmonary elasticity) and respiratory muscle strength have been associated with the normal aging process. As specialists in swallowing, SLPs must consider that these factors contribute to a patient’s productive cough response, which serves as a defense mechanism for the respiratory system. Therefore, possibility of decreased lung function can be viewed as an attributing cause of aspiration. Lange et al. found increasing age and decreased forced expiratory volume to be significant predictors of pneumonia related hospital admissions and mortality.
When presybyphagia is compounded by an onset of a new disorder (such as a stroke), gradual decline due to a progressive disease (Parkinson’s disease), or a new health condition (surgery requiring intubation) the level of dysphagia can increase to severe. In some cases a SLP may create an intervention plan consisting of swallow strategies, oropharyngeal/respiratory exercises, and diet modifications, to reduce residues and incidence of penetration and aspiration. When working with patients with cognitive impairments, implementation of swallow strategies and exercises may not be an option. With these clients, a modified diet, may be the safest option. This should be confirmed by objective assessment techniques such as the Modified Barium Swallow Study (MBSS).
Links of Interest
- For video clip examples of the normal adolescent swallow, the aging swallow and disordered swallow, please visit Swallowing Diagnostics Inc, on Facebook. https://www.facebook.com/pages/Swallowing-Diagnostics-Inc/158081210939517
- Evaluation and Treatment of Swallowing Impairment, Am Fam Physician. 2000 Apr 15;61(8):2453-2462. Jeffrey B. Palmer, M.D., Good Samaritan Hospital, Baltimore, Maryland, Jennifer C. Drennan, M.S., and Mikoto Baba, M.D., SC.D., Fujita Health University, Nagoya, Japan.
- Mechanics of Swallowing: ASHA Healthcare Business Institute 2012; Joseph Murray, PhD, CCC-SLP, BRS-S
- Dysphagia Screening: ASHA Healthcare Business Institute 2012; Debra Suiter, PhD, CCC-SLP, BRS-S .
- Kaldy, J., & Kamel, H. (2005). Sarcopenia: Hidden but harmful risk to resident independence. Assisted Living Consult, 18-21.
- Logemann, J., Pauloski, B., Rademaker, A., & Kahrilas, P. (2002). Oropharyngeal swallow in younger and older women: Videofluoroscopic analysis. Journal of Speech, Language and Hearing Research, 45, 34-44.
- Robbins, J., Duke Bridges, A., & Taylor, A. (2006). Oral, pharyngeal, and esophageal motor function in aging. Goyal & Shaker GI Motility Online, Retrieved from http://www.nature.com/gimo/contents/pt1/full/gimo39.html
- Welford, A. T. (2006). Reaction time, speed of performance, and age. Annals of the NewYork Academy of Sciences, 515, 1-17.