Dysphagia literally means difficulty eating, drinking or swallowing (Royal College of Speech and Language Therapists (RCSLT), 2022). Intact motor and nervous systems are essential to enable normal swallowing. The prevalence of conditions that affect swallowing rises with age (Patel et al, 2018; Cohen et al, 2021). The number of older people in the UK population is rising, so increasing numbers of people are at risk of dysphagia. The number of people aged 90 years and over in the UK has increased by more than 250% in the last 30 years, and was 609 503 in mid-2020 (Office for National Statistics, 2021).
Understanding dysphagia
There are four phases in a normal swallow (Table 1). Oropharyngeal dysphagia is described as difficulty initiating a swallow or passing food through the region of the mouth or throat. Oesophageal dysphagia refers to difficulty in transferring material down the oesophagus in the retrosternal region (Malagelada et al, 2015). Although oropharyngeal dysphagia can occur in up to 50% of older people and 50% of people with neurological conditions, and is associated with aspiration, severe nutritional and respiratory complications and even death, it is under-diagnosed and under-treated. Oesophageal dysphagia is less common and less severe, but with better recognised symptoms caused by diseases affecting the enteric nervous system and/or oesophageal muscular layers. There is a growing awareness among health professionals of oropharyngeal dysphagia (Clavé and Shaker, 2015).
Table 1. Components of the normal swallow
| Phase | Mechanism |
|---|---|
| Oral preparatory stage | Food is ground, chewed and mixed with saliva to form a bolus |
| Oral | Food is moved back through the mouth with a front-to-back squeezing action, performed primarily by the tongue |
| Pharyngeal | The food enters the upper throat areaThe soft palate elevatesThe epiglottis closes off the trachea, as the tongue moves backwards and the pharyngeal wall moves forwardThese actions help force the food downward to the oesophagus |
| Oesophageal | Muscles propel food through the oesophagusThe oesophageal sphincter opens and closes efficientlyThe bolus is moved to the stomach |
Around 11% of adults living in the community have dysphagia (Holland et al, 2011). It is common in older people and 10–27% of older people living at home have dysphagia (Holland et al, 2011; Almirall et al, 2013; Madhavan et al, 2016).
Causes of dysphagia
Dysphagia is a symptom that may occur because of a number of conditions. It is common in older adults but may also occur younger adults and in children. Causes can be categorised as obstructive, neurological and others. Table 2 outlines the causes of dysphagia.
Table 2. Causes of dysphagia
| Obstructive | Neurological | Other |
|---|---|---|
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Dysphagia is associated with neurological problems and frailty (Patel et al, 2018; Cohen et al, 2021). Dysphagia may be undiagnosed because the older person adapts to the dysphagia and does not seek medical help. The individual may develop complications such as weight loss or chest infections and healthcare staff may not consider that dysphagia is a contributing factor (Clavé and Shaker, 2015). Clinicians should be alert to the clinical features of dysphagia and should check if the person is experiencing swallowing difficulties when assessing and treating older people and those at risk of dysphagia (Smithard, 2015). Certain people have greater risks of dysphagia than others (Table 3).
Table 3. Conditions and prevalence of dysphagia
| Condition | Prevalence of dysphagia |
|---|---|
| Age-associated frailty | 51–53% (Patel et al, 2018; Cohen et al, 2021) |
| COPD | 27% (Turley and Cohen, 2009; Lin and Shune, 2020) |
| Dementia | 13–86% depending on type of dementia and severity (Espinosa-Val et al, 2020) |
| Multiple sclerosis | 31–43% (Solaro et al, 2013; Aghaz et al, 2018) |
| Stroke | 13–94% dependent on location and size of lesion (Langdon and Blacker, 2010; Arnold et al 2016) |
| Parkinson's disease | 11% and 87% depending on the disease stage, the disease duration and the assessing method (Schindler et al, 2021) |
How to identify people with dysphagia
Dysphagia, especially oropharyngeal dysphagia, is under-recognised and under-diagnosed (Smithard, 2015; Clavé and Shaker, 2015). The best way to identify dysphagia is to ask people who attend the surgery if they have any problems with swallowing. A survey of 791 people aged 60 years and over attending 17 community pharmacies was carried out by pharmacists and found that almost 60% had difficulty swallowing medication: patients reported opening tablets and crushing medications. Older people were asked if they had informed their GP and 72% reported that they hadn't been asked (Strachan and Greener, 2005).
The person with dysphagia may present with a number of symptoms and if the clinician is not alert to the possibility of dysphagia these may not be immediately identified as possible symptoms of dysphagia. Table 4 outlines the clinical features of dysphagia.
Table 4. Clinical features of dysphagia
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Red flags
When dysphagia is suspected the clinician should check for red flags that indicate the need for urgent medical attention. The term ‘red flags’ was introduced in the 1980s and is used to signal that the person requires urgent medical attention. In dysphagia there are three major red flags:
- Steadily worsening of dysphagia over a few weeks in an older person is suggestive of malignancy and patients should be urgently referred under the 2-week rule in England. Men over the age of 65 with new onset weight loss and worsening dysphagia have a 9% risk of cancer (Jones et al, 2007). Most (90%) people referred under the 2-week rule do not have cancer (Cancer Research, 2022)
- If the person is clinically unwell and has a suspected aspiration pneumonia the clinician should treat or escalate the case using local protocols
- If the person is unsafe or possibly unsafe to swallow then urgent medical referral is required.
Assessment in general practice
History taking can enable clinicians to determine if urgent medical referral is required. History taking and examination can enable clinicians to determine the cause of dysphagia in some cases. Bedside swallowing tests have been developed to screen for oropharyngeal dysphagia. A systematic review of these tests identified four tests with sensitivity of ≥70% and specificity of ≥60% (Kertscher et al, 2014). These were the Toronto bedside swallowing screening test (TOR-BSST©) (Martino et al, 2009), the volume-viscosity swallowing test (V-VST)(Clave et al, 2008), the 3-ounce water swallow test (Suiter and Leder, 2008) and the cough test (Wakasugi et al, 2008). A test often used in general practice is based on the 3 ounce swallow test (GP Notebook, 2018).
If a person presents with new or deteriorating swallow the practice nurse should follow local protocols. These may involve completing a dysphagia screen and possibly carrying out an initial assessment of swallowing. Figure 1 illustrates the components of an initial swallowing assessment. It is important to have training before conducting a swallowing assessment.
Treatment of causes of dysphagia
Older people are more likely to develop swallowing problems because ageing is associated with decreased gastro-intestinal motility (Grassi et al, 2011). Medication reviews and discontinuation of medications that affect gastrointestinal motility, such as anticholinergics, may help.
People who suffer from a reflux of gastric acid into the oesophagus can develop oesophageal scarring and stricture and this can lead to or worsen dysphagia (Bollschweiler et al, 2008). Lifestyle advice and treatment with a proton pump inhibitor such as omeprazole can reduce reflux and lifestyle advice can resolve the situation (Philpott et al, 2017).
Poor oral health can contribute to problems with dysphagia; tooth loss, gum disease and infection affects the ability to bite and chew (Furuta and Yamashita, 2013; Cichero, 2020). The practice nurse should check if oral health problems are contributing to dysphagia, treat any infection and advise the older person to seek dental treatment if necessary.
Specialist referral and investigations
People identified as having dysphagia are normally referred to a speech and language therapist (SLT) for further assessment: this involves in-depth assessment of the patient's clinical history, current medical status, including nutritional and respiratory status, cranial nerve function and swallowing function. The SLT may also use video fluoroscopy, fibreoptic endoscopic evaluation of swallowing (FEES) and ultrasound. They can also measure tongue strength using validated instruments. The SLT may recommend dietary and fluid modification and other treatments. They can provide rehabilitative therapy using exercise protocols and tools with validated outcomes. Fluid and dietary modifications aim to improve nutrition and hydration and reduce the risks of aspiration pneumonia.
Aspiration is the term used when foods or fluid passes through the vocal folds and enters the airway. It be caused by impaired laryngeal closure or because of the overflow of food or liquids retained in the pharynx. The properties of the aspirate are also important. Acidic material (such as orange juice) can set up an inflammatory reaction in the lungs and cause serious damage. Aspiration that is not accompanied by a cough is known as ‘silent aspiration’. Silent aspiration is more likely to cause major respiratory problems (Almirall et al, 2013).
The importance of fluids and diet
Dysphagia increases the risk of malnutrition and dehydration and can affect health and quality of life (Cichero and Altman, 2012). An estimated 3 million people in the UK are malnourished and older people are at greatest risk (Elia and Russell, 2011). The Malnutrition Universal Screening Tool (MUST) can be used to work out malnutrition risk and provides guidance on actions to be taken (BAPEN, 2016).
In many cases it is not possible to treat dysphagia and the aims of care are to maintain nutrition and hydration, reduce the risk of aspiration pneumonia and ensure that the person is able to take medication.
The key to maintaining nutrition and hydration is to promote safe swallowing and to ensure that the person has food and fluids which are of the appropriate texture and thickness. Table 5 provides guidance on how to advise a person or care givers on safe swallowing.
Table 5. Advice on safe swallowing
| 1. Sit upright at 90 degrees when eating and drinking |
| 2. Do not eat or drink when slouched or lying down |
| 3. Take small bites of food |
| 4. Take small sips of fluid |
| 5. Do not gulp drinks |
| 6. Eat slowly |
| 7. Chew foods well before swallowing |
| 8. Make sure you have swallowed your food or drink before taking more |
| 9. Do not wash down your food with drinks |
| 10. Do not talk when you have food in your mouth |
In the past, the UK used different descriptors for levels of food thickness to other countries. In 2019, all services in the UK adopted the international framework. This change aimed to ensure that people with dysphagia are supported more consistently and, therefore, more safely (IDDSI, 2019)
Pureed food can look unappetising and this can be off putting to the person with dysphagia. It is possible to buy pre-prepared meals of thickened pureed food that resemble normal food. Caregivers can also make pureed food look more appetising by using moulds to mould pureed thickened food. Moulds can easily be purchased online.
Medication
Older people with dysphagia may struggle to take medication and all medication should be reviewed. The review should consider if a specific medication is necessary, if any medication is contributing to dysphagia, if easier to swallow medication is available and if medication can be safely crushed. Figure 2 outlines this process.
Is the medication necessary?
Medication is not always reviewed regularly in general practice due to work pressures. Non-medical prescribers in general practice can use the STOPP/START screening tool. It checks that all drugs are clinically indicated (O'Mahony et al, 2015). The criteria for discontinuation are:
- Any drug prescribed without an evidence-based clinical indication
- Any drug prescribed beyond the recommended duration, where treatment duration is well defined
- Any duplicate drug class prescription, eg two concurrent non-steroidal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors (SSRIs), loop diuretics, angiotensin-converting enzyme (ACE) inhibitors, anticoagulants (optimisation of monotherapy within a single drug class prior to considering a new agent).
Is medication causing or contributing to dysphagia?
Anticholinergics are a class of drugs that block the action of the neurotransmitter acetylcholine in the brain. This action reduces spasm of smooth muscles. They are used to treat diseases like asthma, incontinence, allergies, gastrointestinal cramps and muscular spasms, and are also prescribed for depression and insomnia. Side effects of anticholinergic medications include dry mouth and slowing of movement throughout the gastro-intestinal system. The side effects increase with each anticholinergic medicine taken. This is known as the ‘cholinergic burden’ (Salahudeen et al, 2015).
Medicines that may be contributing to dysphagia should be discontinued if at all possible. If the person has a condition that requires treatment the prescriber may consider an alternative medication that is less likely to cause swallowing difficulties.
Easy to swallow formulations
Sometimes tablets and capsules are large and difficult to swallow. It may be possible to prescribe an easier to swallow formulation. For example, paracetamol comes in tablets and caplets. Many people find the capsule shape of a caplet easier to swallow.
Crushing, splitting, removing from capsules and mixing with food
The clinician should check if the patient or his or her caregiver is crushing medications (Bourdenet et al, 2015). Crushing medication can affect the absorption (pharmacokinetics) and effects (pharmacodynamics) of medicines. Some medication should never be crushed. Modified release medicines that are crushed can result in a large amount of the medicine being released quickly. This can lead to ineffective treatment, adverse effects or, in some cases, death. Cytotoxic and hormone medication should not be crushed as this places the person who crushes the medication at risk (BAPEN, 2018).
Splitting is the process of cutting or splitting a medicine in two or more pieces in order to make it easier to swallow or to provide the correct dose.
Removing medicine from a capsule can render it ineffective, as the capsule is designed to protect the medication from stomach acid and ensure it is properly absorbed. Practice nurses should seek advice from a pharmacist before recommending or agreeing with this practice.
If medicine is mixed with food it can be difficult to determine how much, if any, of the medicine has been taken. Medicines can interact with food and drink. There is little research into how common this practice is when a caregiver gives a person medication at home. The Patients Association (2015) found that in 70% of care homes surveyed medication was being mixed with food and drink.
Liquid medicines and alternative routes
Liquid medicines may be helpful but as they are not available in modified release form they may have to be given more often. Liquid medicines may require refrigeration and some require shaking before use. Clinicians should consider different routes including topical, sublingual, buccal, rectal and parenteral.
Some medicines are available in oro-dispersible formulations. These are designed to dissolve quickly in the mouth. These medicines include medicines to treat gastro-oesophageal reflux – this is common in dysphagia.
Conclusion
Dysphagia can have a major impact on a person's life. It can affect the ability to remain hydrated and nourished and increase the risk of infection and ill health. The practice nurse can, by routinely enquiring about swallowing difficulties and assessing and supporting the person with dysphagia, make a real difference to a person's quality of life.
Further resources:
- Dysphagia guide, e-learning resource. https://www.e-lfh.org.uk/programmes/dysphagiaguide/
- Educational resources Rosemont Pharmaceuticals: https://www.rosemontpharma.com/health-professionals/education-resources
- Helpful video guidance of how to test drink thickness using a 10 ml slip tip hypodermic syringe here: http://iddsi.org/framework/drink-testing-methods/ There are also useful ways of checking food textures on the IDDSI site
- The BAPEN tool is available on line (https://www.bapen.org.uk/e-learning-portal). It consists of three modules. Each module includes case studies and care plans appropriate for the work place and an online assessment, together with the ability to print off certificates of achievement
- BAPEN also provides a free downloadable booklet on the use of MUST. http://www.bapen.org.uk/screening-and-must/must/introducing-must
KEY POINTS:
- Dysphagia is common and affects around 11% of adults. Dysphagia is often undiagnosed and untreated
- Dysphagia may be longstanding or detected when the person presents for treatment
- Established and diagnosed dysphagia may be stable or unstable and swallow can deteriorate suddenly
- It is important to ensure that hydration and nutrition are maintained and that the person is able to take medication
- Using safe swallowing techniques and food and fluids of the appropriate texture reduces the risk of aspiration
CPD reflective practice:
- What would make you suspect that an individual had dysphagia?
- Why is it important to review medication in dysphagia?
- In what circumstances would you consider an emergency referral?
- How will you change your practice as a result of reading this article?