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 . 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 . The rate of social interaction and number of social partners frequently decreases with age . 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 . Advanced age alone is a risk factor for malnutrition . 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 . 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 . 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 . 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 . 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.
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