Presbyphagia to Dysphagia: Multiple Perspectives and Strategies for Quality Care of Older Adults

Abstract

The aging population is rapidly growing, requiring speech–language pathologists to better manage a caseload that includes older adults who have a variety of needs. The purpose of this review is to summarize and discuss the current available evidence that will allow speech–language pathologists to make informed clinical decisions when working with older adults. To facilitate this, this article first establishes an understanding of both normal and disordered swallowing physiology in older adults, including how to differentiate between functional changes to swallowing (presbyphagia) and dysphagia. Other important factors to consider, such as caregiver burden, are also discussed so that clinicians can learn how to best support aging in place. Best practices for screening both community-dwelling older adults and residents of long-term care are identified as part of a framework introduced to guide decision making. The critical components of clinical swallow assessments are reviewed, including the adoption of an ethnographic approach and why nutritional status, urinary tract infections, and delirium are important considerations when working with older adults. Factors contributing to, and associated with, aspiration and aspiration pneumonia are also discussed so that clinicians better understand how to take a comprehensive approach to care, as well as consider the impact and influence of a temporary dysphagia versus a more chronic presentation. Finally, the evidence for management of dysphagia in this specialized population is reviewed, highlighting the importance of identifying physiological deficits, feedback, and taking a multidisciplinary approach to care.

Swallowing and secretory senescence

“…Presbyphagia develops in parallel with the senescence process and the transition from presbyphagia to dysphagia occurs when any pathological condition, overlapping with an already reduced functional reserve such as in the case of an elderly patient, destabilizes the precarious balance which is based on adaptation and compensation strategies 11 . For this reason, presbyphagia cannot be considered as a real pathological state, but it can become so by falling into an acute situation of dysphagia 12 . The prevalence of dysphagia in the elderly population is estimated at around 13% at the age of 65, rising to 16% between 70-79 years of age and 33% in the elderly aged over 80 11 .…”

“…Currently, the Volume Viscosity Swallow Test (V-VST), the Sydney Swallowing Questionnaire (SSQ), and the Eating Assessment Tool-10 (EAT-10) are the 3 validated protocols available, but the most widely used one, especially in institutionalized patients, is the EAT-10. The V-VST is more difficult to administer because it requires an adaptation of the protocol according to the patient's response to each swallowed act, although it has a good sensitivity and specificity in diagnosing oropharyngeal dysphagia (94 and 88%, respectively), therefore it is not the first protocol to choose in case of large-scale screening 12 . The EAT-10 investigates the swallowing difficulties encountered by the patient or his/her caregiver with 10 entries by assigning a score from 0 to 4 for each entry (0 = no problem, 4 = serious problem).…”

“…A final score > 3 suggests that the patient is at high risk of dysphagia. The sensitivity and specificity of this test are 89 and 82%, respectively; this protocol is likely to be administered in the GP surgery both to the patient and the caregiver, or in the waiting room during the wait, and is, therefore, the most suitable one in daily practice 12 .…”

“…If the results of questionnaires or a strong clinical suspicion lead to the diagnosis of presbyphagia and probable dysphagia, it is necessary to complete the diagnostic procedure by means of instrumental investigations that make it possible to better identify the functional defect. These investigations consist in the study of swallowing by videofluoroscopy or fiberoptic endoscopic evaluation 12 . Study of swallowing by videofluoroscopy, or barium meal, is the only imaging examination that allows to investigate all 4 stages of swallowing.…”

“…Study of swallowing by videofluoroscopy, or barium meal, is the only imaging examination that allows to investigate all 4 stages of swallowing. This remains the pivotal study in the diagnosis and evaluation of the dysphagia patient and is useful in determining the most suitable rehabilitation strategy and possible therapy 12 . Fiberoptic endoscopic evaluation of swallowing.…”