How do you treat difficulty swallowing in the elderly?

Approximately 15 million American adults experience difficulty swallowing, known as dysphagia, with rates as high as 70% in nursing homes. When considering how to treat difficulty swallowing in the elderly, a holistic approach is necessary, combining dietary modifications, swallowing therapy, and environmental adaptations to ensure safety, nutrition, and quality of life.

Quick Summary

Treatment for difficulty swallowing in the elderly requires a multifaceted approach, often guided by a speech-language pathologist, involving compensatory strategies like dietary modifications (texture-modified foods, thickened liquids), rehabilitative swallowing exercises, and postural adjustments during meals to improve safety and function.

Key Points

• Professional Assessment is Key: A speech-language pathologist (SLP) should perform a comprehensive swallowing evaluation to develop an individualized treatment plan.

• Dietary Modifications are Essential: Adjusting food textures and thickening liquids can make swallowing safer, but patient preference and compliance must be considered.

• Posture Matters During Meals: Specific head and body positions, such as the chin tuck, can redirect food flow and protect the airway from aspiration.

• Rehabilitative Exercises Strengthen Swallowing Muscles: SLPs can teach exercises to improve muscle strength and coordination, which can lead to long-term improvements.

• Medication Requires Careful Management: Consult a pharmacist and doctor about alternative forms of medication, and never crush pills without medical guidance.

• Oral Hygiene is Critical: Regular and thorough mouth cleaning reduces bacteria, which in turn reduces the risk of aspiration pneumonia.

• Early Intervention Prevents Complications: Addressing dysphagia early can prevent more serious health problems like malnutrition, dehydration, and pneumonia.

Understanding Dysphagia in the Elderly

Difficulty swallowing, or dysphagia, is a serious concern for many older adults and can arise from a number of factors. The intricate process of swallowing involves the coordinated movement of over 30 muscles, along with the corresponding nerves. With age, the muscles can weaken, and conditions such as stroke, Parkinson's disease, or dementia can disrupt the neurological pathways controlling swallowing. Untreated dysphagia can lead to severe health complications, including malnutrition, dehydration, weight loss, and aspiration pneumonia, which occurs when food or liquid enters the lungs.

The Role of the Speech-Language Pathologist (SLP)

For seniors experiencing dysphagia, a speech-language pathologist is a key member of the care team. An SLP conducts a thorough swallowing assessment to determine the specific nature and severity of the swallowing problem, often utilizing imaging studies like a modified barium swallow study (MBS) or a fiberoptic endoscopic evaluation of swallowing (FEES). Based on this evaluation, the SLP can recommend a tailored treatment plan combining compensatory and rehabilitative strategies.

Core Treatment Strategies

Treating dysphagia in the elderly is not a one-size-fits-all solution; it requires an individualized plan based on the underlying cause and the patient's specific needs.

Compensatory Strategies

These are temporary adjustments designed to make eating and drinking safer in the short term. The goal is to maintain nutrition and hydration while the patient works toward improving their swallowing function.

• Dietary Modifications: A crucial part of dysphagia management is adjusting the texture of food and liquids. This can range from pureed and mechanically altered foods to thickened liquids.

  • Thickened Liquids: Thin liquids like water or coffee can be particularly dangerous as they move too quickly for a compromised swallow reflex. Thickeners, available as powders or gels, can be added to achieve a safer, slower consistency, such as nectar-thick or honey-thick.
  • Texture-Modified Solids: Foods that are soft, moist, and cohesive are easier to swallow. This may involve pureeing, mincing, or mashing foods. Avoid hard, dry, or sticky foods that can pose a choking hazard.

• Postural Adjustments: Changing the position of the head and body during meals can alter the flow of food and liquid to protect the airway.

  • Chin Tuck: Tucking the chin toward the chest while swallowing can help protect the airway.
  • Head Turn: Turning the head toward the weaker side can close off that side of the throat, directing food to the stronger side.

• Environmental and Behavioral Adaptations: Simple changes to the mealtime routine can significantly improve safety.

  • Slow, Mindful Eating: Encourage smaller bites, chewing thoroughly, and taking time between swallows.
  • Minimize Distractions: A quiet, calm environment can help the individual focus on the task of swallowing.

Rehabilitative Strategies

These therapies aim to improve the underlying physiological impairments of the swallow through specific exercises and techniques.

• Swallowing Exercises: An SLP can prescribe exercises to strengthen the muscles involved in swallowing. These may include:
  • Lingual Resistance Exercises: Strengthening the tongue to improve bolus control.
  • Effortful Swallow: Instructing the patient to swallow with as much effort as possible to increase muscle force.
  • Mendelsohn Maneuver: Teaching the patient to voluntarily hold the larynx at its highest point during swallowing to improve its function.
  • Expiratory Muscle Strength Training (EMST): Using a device to strengthen the expiratory muscles, which can improve swallowing function.

A Comparison of Thickening Agents

When modifying liquids, it's important to understand the different types of thickeners available. The International Dysphagia Diet Standardization Initiative (IDDSI) provides a framework for standardizing food and drink textures.

Feature	Starch-Based Thickeners	Xanthan Gum-Based Thickeners
Common Brands	Thick-It, Thick & Easy	Simply Thick, Thick & Clear, Clear DysphagiAide
Appearance	Often opaque and slightly cloudy	Generally clear
Taste	Can alter the flavor and leave a grainy aftertaste	Flavorless and odorless
Texture	Can change over time (e.g., thicken further, become lumpy)	Consistent texture that does not continue to thicken over time
Preparation	Requires careful mixing to avoid lumps	Mixes easily and instantly with liquids
Patient Acceptance	Often less accepted due to changes in taste and texture	Higher patient compliance due to neutral taste and clear appearance
Suitability	Effective, but potential for poor compliance and dehydration due to palatability issues	Can encourage better hydration and compliance, suitable for a wide range of liquids

Special Considerations and Medical Interventions

Medication Management

Pill-swallowing can be a significant challenge. A pharmacist should be consulted to determine if medications can be crushed or if liquid alternatives are available. Mixing crushed pills with a soft food like pudding or applesauce may help, but always confirm safety with a healthcare provider first.

Alternative Nutrition and Hydration

For severe dysphagia where oral intake is no longer safe or sufficient, alternative methods may be necessary. This includes placing a feeding tube to deliver nutrients directly to the stomach or intestines. This is typically a last resort and involves a careful discussion with the care team about the potential risks and benefits, as it does not prevent aspiration pneumonia in all cases.

The Importance of Oral Hygiene

Dysphagia and poor oral health are linked, as residual food and bacteria in the mouth increase the risk of aspiration pneumonia. Regular, thorough oral care is essential for all seniors with swallowing difficulties.

The Caregiver's Role

Caregivers are vital in the management of dysphagia. Training in safe feeding techniques, understanding diet modifications, and monitoring for signs of trouble are crucial responsibilities. Caregivers should be vigilant for signs like coughing during or after eating, a gurgling voice, or unexplained weight loss, and promptly report concerns to a healthcare professional.

Conclusion

Treating difficulty swallowing in the elderly requires a thoughtful, personalized plan developed by a multidisciplinary team. By combining diet and postural modifications with rehabilitative exercises, and, when necessary, advanced medical interventions, it is possible to manage dysphagia effectively. The goal is always to improve safety, maintain adequate nutrition and hydration, and preserve the individual's quality of life. Ongoing assessment and adaptation of the treatment plan are essential for long-term success. For more detailed information on rehabilitation strategies and the role of speech-language pathologists, you can visit the American Speech-Language-Hearing Association website for educational resources on dysphagia treatment.

Frequently Asked Questions

What are the first steps to take if an elderly person shows signs of difficulty swallowing?

If you notice signs like coughing during meals, a wet voice after swallowing, or unexplained weight loss, the first step is to consult their primary care physician. The doctor will likely refer them to a speech-language pathologist (SLP) for a formal swallowing evaluation.

How do speech-language pathologists (SLPs) help treat dysphagia?

SLPs use a variety of techniques to help with dysphagia. They assess the swallowing problem, recommend specific diet and liquid texture modifications, and teach swallowing exercises and maneuvers to strengthen and coordinate the muscles involved in swallowing.

Are thickened liquids the only solution for difficulty swallowing liquids?

While thickened liquids are a common strategy to slow the flow and improve control, they are not the only solution. An SLP may also recommend postural changes or other swallowing techniques. Patient compliance can also be an issue, so other strategies are often explored.

What foods should be avoided when treating difficulty swallowing in the elderly?

You should generally avoid hard, crunchy, sticky, or dry foods that are difficult to chew and swallow. This includes things like nuts, raw vegetables, hard bread crusts, and sticky candies. Foods with mixed textures, like a broth-based soup with solid vegetables, can also be challenging.

Can dysphagia be reversed or is it a permanent condition?

For many, especially those who have experienced a stroke, swallowing therapy can significantly improve or resolve dysphagia. For others with progressive neurological conditions, the focus shifts to managing the condition and maintaining safety as effectively as possible.

Is it safe to crush medication for someone with dysphagia?

You should never crush a person's medication without explicit instructions from a pharmacist or prescribing doctor. Crushing certain medications can alter their effectiveness, dosage, or absorption. Always seek professional medical advice first.

What is aspiration pneumonia and how is it related to swallowing problems?

Aspiration pneumonia is a lung infection caused by inhaling food, drink, or saliva into the lungs. In individuals with dysphagia, this risk is higher because their swallowing mechanism may be impaired, allowing material to enter the airway. Proper management of dysphagia is key to preventing this serious complication.