Aging and Swallowing: We All have to do it!
By Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com
A summary of a talk titled: “Managing Dysphagia in Aging Adults,”
at the 2014 ASHA Healthcare & Business Institute, Las Vegas, NV
by James L. Coyle, PhD, CCC-SLP, BCS-S, ASHA Fellow
The field of medical-speech pathology can be tricky, especially when working with aging and swallowing. It differs greatly from traditional rehabilitation practices in our field, per Dr James Coyle, PhD, CCC-SLP, BCS-S, ASHA Fellow. He used the analogy of going down the rabbit hole, and “sometimes we get stuck down there.” “We find all kinds of funny things down there: Mad Hatters and such.”
In this article I wish to summarize the wonderful kernels of wisdom that Coyle shared with us on April 11, 2014. Quotations are phrases and sentences straight out of Coyle’s talk, as one cannot paraphrase perfection.
Evaluation and Treatment in Geriatrics
Evaluating and treating the geriatric population requires specific training in the functional changes that occur past the age of 65. As dysphagia clinicians we must take extreme caution to not label a swallow “impaired,” when it may just reflect the natural changes that come with age. Your 80 year old patient may have:
- longer oral preparatory phase,
- decreased sensation,
- slower swallow,
- penetration into the laryngeal vestibule, and
- slow esophageal and gastric clearance.
However, per Coyle, “it’s okay.” He advised us that the longer processing times are a normal process in aging, and we should not call it a delay. It is not broken, and it is not a problem. There are many respiratory, musculoskeletal, and sensorimotor changes in aging, but it is only when disease is “piled on top of aging” that the patient may have a significant breakdown in the swallow function. I frequently find myself referring to that final acute event as: the straw that broke the camels back.
Everything is uncertain in medicine, and we have to think more like physicians, per Coyle. In rehabilitation, maybe we have been too used to fixing or eliminating a problem with 100% accuracy. “This concept (of elimination) has to go away,” said Coyle. We do aim to lower the risk that a given medical issue will not prematurely end the patient’s life. Therefore, instead of the word “eliminate,” Coyle suggested goals to “mitigate,” “attenuate risk,” and even reducing adverse events and readmissions to the hospital. We can use goals that reflect quality of life measurements, as these have been legitimized by the World Health Organization as appropriate behavioral objectives of therapy, per Coyle. Ultimately the goal is to return to baseline or accept a new baseline, while avoiding the use of young norms. Coyle noted that there is a lot of intervention happening for people who do not need it.
Above all, Coyle cautioned that any goals that we recommend for the patient, we have to first ask the patient: “Are you on board with me as a partner?”
Summary of Age-Related Changes in Swallowing
Coyle referred to his work with others in 1999 (see reference below), when he listed these specific age-related changes in swallowing:
1) Decreased bolus propulsion forces,
2) Later pharyngeal stage onset,
3) Later airway closure, thus increasing Penetration/Aspiration Scores,
4) Cricopharyngeal muscle non-compliance (stiffness, decreased flexibility, diminished muscle tissue with changing into more fibrotic tissue), and
5) Decreased sensation of the bolus to cause a “sensory-motor oropharyngeal uncoupling.” This means that the sensory signal from the mouth does not get to the pharynx fast enough, so that the pharynx does not respond as quickly.
Homeostasis and Homeostenosis
Every organism strives to create a homeostasis in the body, which is the maintenance of a stable and constant state. A young person uses up very little functional reserve to maintain homeostasis. However, there is this nasty progressive process that starts even as we climb out of our childhood. It is called homeostenosis. As we age, there is a decline in our physiologic reserve, and we have to use up more energy and more of the baseline reservoirs to maintain homeostasis. Then, dangerously, there are less reserves leftover when an acute medical event occurs. There are also less reserves to meet life’s challenges and stressors as well. Coyle noted that geriatric researchers call the line between health and non-health in the very old patient the “precipice.” The frail and very old may have a poorer prognosis as the acute event dries up the reservoir. Pile on top of that the loss of muscle mass called sarcopenia. Per Coyle, sarcopenia may be due to decreased vascular supply, mitochondrial changes (the power generators of the muscle cell), and oxidative stress caused by environmental toxins.
Coyle suggested the Halter, et al (2009) textbook called: Hazzard’s Geriatric Medicine and Gerontology, 6th Edition. Per this textbook, the following is a list of the healthy 65 year old’s reserves compared to 20-40 year olds:
1) Vital capacity is at 70%,
2) Maximum breathing capacity is at 40%,
3) Maximum oxygen uptake is at 30% due to loss of aveoli, and
4) Cerebral blood flow is at 70%.
There is a progressive loss of perfusion across capillary membranes due to atherosclerosis and a decline in capillary surface area. There is also a decline in synaptic connections; however, a silver lining is that with direct exposure from repeated therapeutic exercises, we can grow synapsis, and there is still neuroplasticity!
Does Dysphagia = Pneumonia?
Sometimes: Hospital acquired pneumonia (a nosocomial infection) can be caused by an acute dysphagia due to various different iatrogenic conditions. The iatrogenic effect is harm caused to a patient as a side effect of medical treatment. Examples of when iatrogenic conditions could be the cause of dysphagia are: drug-induced dysphagia, vocal cord paralysis caused by recurrent laryngeal nerve damage during cardiac surgery, pre-cervical edema impinging on the pharyngeal wall after an anterior cervical discectomy, or trauma to the pharynx and larynx caused by prolonged intubation.
However, in the geriatric population, we cannot draw a straight line from dysphagia to aspiration to pneumonia. What if the original infection was a severe urinary tract infection that went into urosepsis? Maybe the original pneumonia was a hematogenous pneumonia, where infection spread to the lung via the bloodstream? The SLP may incorrectly assume the patient has a dysphagia-related aspiration pneumonia. Sure the patient may currently appear to have difficulty swallowing, but maybe it this is due to the severity of the acute illness. A prolonged hospitalization in a frail elderly patient could cause generalized weakness, lethargy, and confusion or even delirium. Then, this acute dysphagia leads to an additional aspiration pneumonia. However, if the SLP labels them as chronically dysphagic and aspirating at baseline, then he/she would incorrectly assume that this baseline caused the pneumonia. The patient will carry that label to the skilled nursing facility and may stay on thickened liquids and purees for weeks or months. This could cause malnutrition and dehydration to further complicate matters. When the SLP takes in the big picture, she recommends that this patient should receive re-evaluations after the acute illness has resolved to upgrade the diet as quickly as possible. That goal attenuates risks and focuses on quality of life.
Sometimes there is an obvious connection in the geriatric population from the medical condition to what caused the dysphagia. For example, stroke = hemiplegia = dysphagia. Dysphagia is 17.2 times more likely to be present in patients with hemiplegia and hemiparesis, per Coyle’s analysis of relative risk statistics.
However, there is no straight line from a urinary tract infection to dysphagia, congestive heart failure to dysphagia, or renal disease to dysphagia. Coyle notes how it is a “crooked line between them,” with taking “a lot of jumps to get there.”
These jumps may be related to:
- medication side-effects (See this post for blogs and links regarding medications),
- sleep deprivation,
- malnutrition/dehydration, and
- increased weakness (which may be due to a prolonged bed-bound status).
The renal patient may have metabolic acidosis which leads to delirium, which may then lead to the patient choking at a meal. Per Coyle, elderly have a 35% chance of functional decline during a hospitalization.
Another issue is sepsis, which carries with it a 60% chance of mortality. People with sepsis who have dysphagia are 50% more likely to die.
Bottom Line on Aging and Swallowing
Use a big-picture analysis on the patient’s case (See this blog about digging through the medical record). In addition to this holistic approach, Coyle urged every clinician to review every patient’s medications every day. He noted we should look at:
1) What the medications are doing physiologically for the patient,
2) What disease they are designed to treat,
3) What are the potential side effects, and
4) What is the elimination half-life (as geriatrics may have slower clearance of medications).
Coyle recommended the free apps of “Micromedex” and “Epocrates.”
I want to thank James Coyle for his many contributions to the field and for his 5 excellent sessions at the 2014 ASHA Healthcare & Business Institute. Dysphagia Evaluation Guides Treatment (Part 1 and 2) also reflect Coyle’s wisdom!
If you or a loved one is experiencing difficulty swallowing, talk with your doctor and follow these links for more information: How do I know when I need a swallowing evaluation? and How is swallowing evaluated?
References Provided by Dr Coyle:
Altman, K. W., Yu, G., & Schaefer, S. D. (2010). Consequence of dysphagia in the hospitalized patient: Impact on prognosis and hospital resources. Archives of Otolaryngology–Head & Neck Surgery, 136(8), 784-789. doi: 10.1001/archoto.2010.129
Atkins, B. Z., Fortes, D. L., & Watkins, K. T. (2007). Analysis of respiratory complications after minimally invasive esophagectomy: preliminary observation of persistent aspiration risk. Dysphagia, 22(1), 49-54.
Atkins, B. Z., Trachtenberg, M. S., Prince-Petersen, R., Vess, G., Bush, E. L., Balsara, K. R., . . . Davis Jr, R. D. (2007). Assessing oropharyngeal dysphagia after lung transplantation: altered swallowing mechanisms and Increased morbidity. The Journal of Heart and Lung Transplantation, 26(11), 1144-1148.
Halter, J. et al (2009). Hazzard’s Geriatric Medicine and Gerontology (6th ed.). McGraw-Hill.
Kriskovich, M. D., Apfelbaum, R. I., & Haller, J. R. (2000). Vocal fold paralysis after anterior cervical spine surgery: incidence, mechanism, and prevention of injury. Laryngoscope., 110(9), 1467-1473.
Robbins, J., Coyle, J. L., Rosenbek, J. C., Roecker, E. B., & Wood, J. L. (1999). Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia, 14(4), 228-232.