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The premier source of information for the management of patients with Dysphagia

Dysphagia in different patient groups

In general, patients with either acute or chronic dysphagia can be divided into three groups (7):
    1. neurogenic dysphagia,
    2. head-and-neck cancer related dysphagia,
    3. dysphagia due to aging (presbyphagia).

Neurogenic dysphagia

The neurological condition of a patient might lead to sensory problems in the oral cavity or pharynx which may lead to dysphagia. Some neurological disorders can induce weaknesses of specific muscles and muscle groups, causing food to get stuck in the pharynx. Other neurogenic disorders can induce diminished laryngeal closure resulting in (silent) aspiration. In addition, coordination of the swallowing process can be affected by certain neurological conditions negatively influencing the motor planning of swallowing. Neurogenic dysphagia can be caused by a range of neurological disorders, such as (1):
  • Stroke
  • Alzheimer’s disease
  • Parkinson’s disease
  • Multiple sclerosis
  • Amyotrophic lateral sclerosis (ALS)
  • Huntington’s disease
  • Guillain-Barré syndrome
  • Poliomyelitis
  • Sensory problems are frequently found in stroke patients, but also occur frequently in other neurological conditions (4). Due to decreased pharyngeal sensitivity, the coordination between swallowing and closure of the larynx is disrupted. As a result, the bolus enters the pharynx before the pharyngeal phase of swallowing has been triggered. In general, these patients will aspirate thin liquids (1).

    Other neurogenic disorders might cause motor problems (i.e. on the level of the pharyngeal and laryngeal muscles). Due to general muscle weakness, chewing can be difficult and the pharyngeal muscles might no longer be able to propel the bolus into the oesophagus. Food gets stuck in the pharynx and patients are at risk of choking. These patients often have less problems drinking thin liquids. In some patients, lip closure is insufficient due to facial paralysis, or the bolus cannot be collected in the centre of the tongue due to paralysis of the tongue musculature. This results in food residue in the oral cavity (1,3,4).

    Swallowing requires motor planning and coordination. It is known that some neurological conditions, e.g. stroke and dementia, can influence the motor planning of swallowing. In these cases an apraxia of swallowing can occur: a patient puts food in his mouth but seems to have forgotten what to do with it.

    Problems in the coordination of swallowing can result in a situation where certain structures (like pharyngeal constrictor or the upper oesophageal sphincter) might have a good motor response to swallowing, but this response is out of sequence. In some neurological patients for instance, the lower pharyngeal constrictors might contract before the middle pharyngeal constrictors contract, resulting in a propulsion force which directs the bolus into the direction of the oral cavity instead of the oesophagus (1,8).

    Dysphagia in patients with head-and-neck cancer

    Dysphagia can also occur after head-neck surgery. The severity of dysphagia depends on the location of the tumour and the extent of surgery. Dysphagia will be negatively influenced by postoperative (chemo-) radiation due to fibrotic changes (9). Apart from these problems, exposure of the pharynx to radiation might lead to a decreased sensitivity, which can lead to residue in the pharynx and a possible concomitant aspiration or choking (3,9). Swallowing rehabilitation in this patient group is mainly targeted on teaching compensation techniques (10).

    Presbyphagia

    The third patient group consists of patients with ‘presbyphagia’; dysphagia as a result of normal ageing. Elderly people often have more problems with thin fluids (due to the slowing down of the swallowing process) and hard consistencies (less strength for chewing). One in three of elderly people in European nursing homes experience dysphagia (2). In 70% of these cases, there is no professional treatment provided for these symptoms. Half of these patients say they eat less and 44% say they have involuntarily lost weight over the previous twelve months. It was shown that 41% of these patients are afraid of choking at mealtimes, and a large group of patients (36%) avoids eating in a group due to their frequent choking (2). Apart from (patho-)physiological problems influencing the severity of dysphagia, problems with correct posture and behavioural problems also appear to play a role (11). Staff shortages, resulting in decreased patient care, can also contribute to eating and feeding problems (2,4).


    REFERENCES:

    1. Matsuo, K., Palmer, J.B. (2008). Anatomy and physiology of feeding and swallowing: normal and abnormal. Phys Med Rehab Clin N Am 19, 691-707.

    2. Ekberg, O., Hamdy, S., Woisard, V., Wuttge-Hannig, A., Ortega, P. (2002). Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia 17, 139-146.

    3. Logemann, J. (1999). Evaluation and treatment of swallowing disorders. 2nd ed. Austin: Pro-Ed.

    4. Rofes, L., Arreola, V., Akmirali, J., Cabré, M., Camins L., García-Peris, P., Speyer, R., Clavé, P. (2011). Diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly. Gastroenterology Research and Practice Volume 2011, Article ID 818979, 13 pages.

    7. Bogaardt, H. (2009). Current aspects of assessment and treatment of dysphagia. PhD-thesis, University of Amsterdam, The Netherlands.

    8. Easterling E.A. and Robbins, E. (2008). Dementia and dysphagia. Geriatric Nursing 29, 275-285.

    9. Kuhnt, T., Becker, A., Bloching, M., Schubert, J., Klautke, G., Fietkau, R., Dunst, J. (2006). Phase II trial of a simultaneous radiochemotherapy with cisplatinum and paclitaxel in combination with hyperfractionated-accelerated radiotherapy in locally advanced head and neck tumors. Medical Oncology 23, 325-334.

    10. Simental, A.A., Carrau, R.L. (2004). Assessment of swallowing function in patients with head and neck cancer. Current Oncology Reports 6, 162-165.

    11. Steele, C., Greenwood, C., Robertson, C. (1997). Mealtime difficulties in a home for the aged: not just dysphagia. Dysphagia 12, 45-50.

     

     


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