Caring for Aging Adults with Dysphagia

Your dad used to love your homemade sourdough bread. Now, he can barely get it down. Should you be worried about him?

Some parts of aging are unavoidable: We all slow down, tire more easily, and take longer to do the things we once took for granted. This includes swallowing. Older adults sometimes experience a disruption to swallowing safety, which may cause food or water to enter the lungs, placing them at risk for pneumonia. They may also experience a disruption to swallowing efficiency and need more time or effort to get everything to go down the right way. When difficulty or disruption in swallowing becomes persistent, it could be a sign of a disorder known as dysphagia.

Dysphagia is typically blamed on damaged, weakened, or destroyed muscles and/or nerves in the head and neck. It can be triggered by a wide range of injuries and diseases such as stroke, Parkinson’s, amyotrophic lateral sclerosis (ALS), which is also known as Lou Gehrig’s disease, and head and neck cancer. Researchers at NYU Steinhardt are also studying the extent to which an age-related decline in the size of the throat muscles may contribute to swallowing difficulties.

Solid numbers for the prevalence of dysphagia are hard to come by, though a 2015 survey in the Netherlands suggests that as many as 12 percent of adults in the country have some kind of swallowing difficulty. Researchers agree that prevalence increases with age, and a 2012 study calculated that up to 6 million older Americans may be at risk.

6 million
older Americans may be at risk for dysphagia.

Despite its surprisingly common nature, the condition is sometimes called an “invisible disorder” because its symptoms can be hidden from public view. The consequences of dysphagia can be devastating, however: malnutrition, dehydration, chronic choking, and aspiration, in which food or liquid enters the lungs. Food or liquid that enters the lungs, in turn, can trigger aspiration pneumonia, a potentially life-threatening bacterial infection.

Dysphagia can also lead to isolation and depression. Many patients must eat slowly and carefully to avoid choking and aspirating while maintaining a nutritious diet. They may need to eat using compensatory postures or techniques such as turning or tilting their head in a certain direction. Those experiencing dysphagia may also require considerable dietary changes, such as switching to soft or liquefied foods. When one of life’s joys instead becomes a burden, many stop eating with family or friends, avoid restaurants, and withdraw from social activities.

Fortunately, there are resources that help the caregivers of aging relatives or friends identify potential warning signs. According to SwallowStudy.com, a visit to the doctor for a swallowing evaluation might be warranted for individuals who:

Successfully diagnosing dysphagia may require a team of specialists such as a speech-language pathologist and an otolaryngologist — an ear, nose, and throat doctor. After reviewing a patient’s medical history and swallowing difficulties, specialists typically choose one of two evaluation methods: a modified barium swallow study (MBSS) or a fiber optic endoscopic evaluation of swallowing (FEES). 

During an MBSS, the patient swallows different consistencies of barium, a radio-opaque substance that can be visualized in an X-ray. The specialist then captures the swallowing of the barium in a movie X-ray to watch each swallow in real time and identify any instances of aspiration and/or dysfunction in timing or mechanics.

During a FEES, a specialist threads a thin, tube-like digital camera called an endoscope into the patient’s nose and through the nasal cavity until it hovers just above his or her throat. There, it records the patient’s swallowing motions as he or she responds to liquid, food, or a puff of air.

Although doctors and therapists can seldom eliminate swallowing difficulties in older adults, some problems respond well to therapy. For dysphagia related to muscle weakness, for example, some patients have reported significant improvement after exercise therapy (sometimes in the form of swallowing “boot camps”) in which they undergo a form of strength training for head and neck muscles. Sometimes, relatively simple modifications to posture or swallowing techniques like the “chin tuck” method can prevent food from entering the windpipe. Difficulties caused by gastroesophageal reflux disease, or GERD, can be addressed through lifestyle modification and/or medication, while doctors and therapists may try other interventions ranging from dilating the esophagus to surgically removing blockages.

Depending on the type and extent of an individual’s swallowing difficulties, speech-language pathologists, doctors, and dieticians may also suggest one of several modified diets. Those who can still eat food may be switched to safer diets of soft, minced and moist, pureed, or liquefied food. Others may be put on a diet of mildly thick, slightly thick, or thin drinks. In the worst cases, patients must be fed through gastric tubes.

No two people are alike, but some foods are notoriously bad for those who have swallowing difficulties, including dry and crusty breads, tough or dried meats, fibrous vegetables and fruit like pineapple, and sticky foods like peanut butter. Other foods are more easily swallowed, such as yogurts and smoothies, meatloaf, applesauce, soft fruits, tender cooked vegetables, and other foods that don’t require a knife to be cut or broken apart.

Consulting with a speech-language pathologist or a dietician can be critical for finding foods that are safe and nutritious while also aesthetically pleasing and appetizing.

Treating an older loved one with dysphagia can require a delicate balance. Overly strict diet modifications may have the unintended consequence of making eating a dreary chore, further isolating an older friend or relative and significantly harming his or her quality of life. Consulting with a speech-language pathologist or a dietician, then, can be critical for finding foods that are safe and nutritious while also aesthetically pleasing and appetizing. Greater awareness of dysphagia among older individuals, better treatment options, and a growing focus on high-quality and swallow-friendly foods can all help return the joy to mealtimes.

Citation for this content: Speech@NYU, the online masters in speech pathology from NYU Steinhardt.