|
| |
 |
|
| ORGINAL ARTICLE |
|
| Year : 2013 | Volume
: 15
| Issue : 2 | Page : 34-36 |
|
Swallowing in the elderly
Khalid Al-Qahtani1, Valerie J Brousseau2
1 Department of Otolaryngology - Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| Date of Web Publication | 21-Jul-2020 |
Correspondence Address:
MD, MSc, FRCSC Khalid Al-Qahtani
Khalid AL-Qahtani Medical Director,King Abdul Aziz University Hospital, King Saud University
Saudi Arabia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/1319-8491.290346
Objectives: To better define the limits of normal swallowing in the elderly, our study aims to relate objective sensory and mechanical deficits measured during flexible endoscopic evaluation of swallowing with sensory testing(FEESST) to subjective quality of life data from patients and evaluate the significance of these changes.
Methods: Patients with perceived normal swallowing were recrtuited from the Montreal General ifospital. The study group were > 65 years of age and the control group <65 years of age. All patients underwent FEESST and filled the MD Anderson Dysphagia Inventory. Clinical findings and subjective opinion about swallowing capacity were assessed.
Results: The mean age was 76 in the elderly group and 21 in the control group. Patients in the study group demonstrated some mechanical impairment. There was no significant difference in sensory testing between groups. There was a significant difference in swallowing-associated quality of life between the two groups.
Conclusion: Changes in swallowing occur as a continuum over time and elderly have significant changes in function that can alter normal physiology. The normal physiology of swallowing while aging needs to be better defined to define the limits of normal and allow true definition of pathology requiring intervention.
Keywords: Elderly, Swallowing, FEESST, Dysphagia, Diglutition diorders
How to cite this article:
Al-Qahtani K, Brousseau VJ. Swallowing in the elderly. Saudi J Otorhinolaryngol Head Neck Surg 2013;15:34-6 |
| Introduction | |  |
The swallowing process involves the delicate interplay of cognitive and reflexive neurological processes to provide adequate control of multiple musculoskeletal structures. The complexity of this mechanism results in increased ratesof dysphagia and aspiration in the elderly population [1],[2] where cognitive decline, neurosensory changes(l),(2) musculoskeletal alterations 0) have been shown to affect swallowing function. Because aging alters the functional range of normal swallowing, defining pathological dysphagia in this population represents a diagnostic dilemma: the line between disease and normal degeneration is blurred. In order to define what constitutes pathology in this population, our aim is to define a normal range of function specific to the elderly population.
Flexible endoscopic evaluation of swallowing with sensory testing (FEESST) can provide comprehensive objective sensory and motor information about deglutition and has been shown to be a safe, non- radiological alternative to traditional barium swallow evaluation[2],[3].
A previous study using FEESST in the elderly has demonstrated significantly increased discrimination threshold with increased age [2]. These clinical findings have been validated by cadaveric studies demonstrating ultrastructural changes in the superior laryngeal nerves, notably a decrease in the number of sensory nerve fibers in subjects above 60 years of age [2].
Our study aims to relate objective sensory and mechanical deficits as measured and observed during FEESST to subjective data from patient questionnaires in order to evaluate the clinical significance of these changes.
| Materials and Methods | | |
Recruitment
All patients were recruited through the otolaryngology clinics of the Montreal General Hospital by phone and personal interview by an individual unrelated to the study. Exclusion criteria for controls and study patients included the following: a history of head and neck cancer, reflux disease, stroke or neurological impairment and use of anti-reflux medication. Control patients were under 65 years of age and study patient were above 65 years of age. Patients w ere recruited on a first conic first served basis and were offered 15$ for their participation. This study was conducted according to the rules and regulations of the McGill University Internal Review Board.
Demographics / History
Demographic patient data collected includes: age, gender, and race ethnicity. Patient history data collected includes; weight loss in the last 3 months, current diet, dysphagia to solids or liquids, history of throat clearing, phlegm, coughing, heartburn indigestion, smoker, diabetes. Patient were also asked to fill the MD Anderson Dysphagia Inventory [2] consisting of 20 points evaluating the impact of dysphagia on quality of life in lie3d and neck cancer patients. This validated questionnaire is mainly used in head and neck cancer and corresponds to a global assessment of quality of life relating to dysphagia. Global scores on the questionnaire were compared betw een the tw o groups using student t-test.
Examination
All examinations were performed by a single examiner. Dr. Mindy A. Black and consisted of 4 elements: physical oral motor examination, endoscopic examination, laryngopharyngeal sensory discrimination testing and swallowing evaluation. All endoscopic evaluations as pan of the FEESST \\ ere performed using a Welsh Allen endoscope and a MedTronic overlay sheath for sensory testing. To increase patient comfort, a sni3ll cotton ball covered with a 1:1 mixture of Xylometazoline hydrochloride and 4% xylocaine was applied to the nose only. leaving pharyngeal sensation intact.
Physical oral motor examination data collected included: lip symmetry, voice quality, tongue movement, tongue strength, velopharyngeal competence, gag. volitional cough, volitional swallow, spontaneous swallow, and laryngeal elevation. Endoscopic examination data collected included: vocal fold adduction, vocal fold edema, arytenoids edema, iuterarytenoid posterior commissure erythema, generalized erythema and pharyngeal squeeze.
Laryngopharyngeal sensory testing consisted in the delivery of sham and true air pulses of increasing pressure for 3 random length of 2 to 8 seconds. Patients had a light switch in hand and w ere instructed to press the button if they felt a pulse of air. Results were deemed positive if the patient correctly recognized 3 out of 5 air pulses at of given pressure. Data collected included sensory thresholds at the level of the arytenoids and trigger of the laryngo-arytenoid reflex (LAR). Each site was tested on both sides. Variation in threshold between the two groups was evaluated by student t-test.
Swallowing evaluation data collected included: testing position, prc-bolus pooling of secretions, penetration, aspiration and reflux of secretions. Further evaluation of spillage, laryngeal penetration, ability to clear the larynx, pharyngeal residue and pooling (v allecula and pyrifonn), ability to clear the pharynx (vallecula and pyriform). presence of aspiration (silent or with cough), reflux and ability to clear reflux w ere noted with respect to the following diet consistencies (foods): thin (water).(pudding) soft, puree (apple sauce), mechanical soft (canned peaches) and solid (crackers). Patients found to ha\e significant deficits were further referred to our voice bb. dy sphagia lab, occupational therapist, \oice therapist or nutritionist as needed.
| Results | | |
Demographics
For the study group, a total of 15 examinations were attempted, of which 9 (5 female and 4 males) were completed. The mean age was 76 years with a range of f>5 to S4. For the control group, a total of 6 examinations were attempted, of which 3 (2 females and 1 male) were completed. The mean age was 21 years w ith a range of 20 to 23. All patients recruited in both the study and control groups denied any dysphagia upon enrollment.
FEES
All patients reported in [Table 1] underwent FEES evaluation with all diet consistencies. All patients who experienced residue were able to clear the residue w ith prompted repeat swallow. Only individuals in the study group demonstrated impairment on FEES. All patients appeared to have a normal upper airway.
Sensory Testing
Sensory testing was ev aluated for each side and mean simulation thresholds were calculated for each patient. There was no significance between the two groups [Table 2].
Dysphagia-related QOL
The mean dysphagia-related QOL scores for the elderly group was 82 % function and that of the control group ci function. This represents a significant difference betw een the two groups (p=0.02).
| Discussion | | |
Demographics
This pilot study is the first to report some difficulty in patient tolerance w ith FEESST. Indeed, about half of all patients w ere unable to complete the evaluation due to discomfort, and this despite the use of local topical anesthesia. Unlike previously reported studies that used air-pulse integrated port nasoUiryngoseopes. this pilot stud;- used a simple laryngoscope with an ov erlay port-sheath to deliv er sensory testing air pulses. Although the use of the ov erlay sheath only increases the diameter of the nasolaryngoscope by 1,5mm. this may have been enough to decrease patient tolerance and impair recruitment. Hence we strongly recommend the use of air-pulse integrated port nasolamiaoscopes for FEESST.
FEESST
Although not significant, there appeared to be a difference in clearing capacity and sensory function between the elderly and conn-ol groups. Elderly who were found to have difficulty clearing certain Consistencies were all found to have decreased sensory thresholds, and all patients who had increased sensory thresholds had difficulty with clearance. This observation appears logical, as a decrease in sensation will impair voluntary or reflex swallow. Furthermore, some patients were found to have increased thresholds on one side of the larynx more than the other. Whether pooling was observed more on the side with increased sensory threshold was not recorded, but would of interest in further studies involving a greater number of patients.
Dysphagia-related QOL
Of particular interest, although all patients from both control and study groups denied any swallowing difficulty at recruitment, further questioning with a dysphagia-related quality of life questionnaire revealed that elderly patient had a significantly lower global dysphagia-related quality of life compared to the control group. We propose that the alterations in swallowing mechanism associated w ith aging are hardly perceptible to the elderly as they occur in a slow and progressive fashion. Hence elderly patient are not aware of this measurable impact on their quality of life and are not in a position to report it first hand to physicians. In order to prevent complications of dysphagia, it is imperative that physicians use questioning tools in order to detect and tract changes in swallow ing and determine when to initiate further investigation or treatment.
| Conclusion | | |
Changes in swallowing occur as a continuum over time such that elderly have significant changes in sensory function that can alter their normal physiology. The normal physiology of swallowing while aging needs to be better defined in order to define the limits of normal and allow true definition of pathology requiring intervention. As the aging proccss occurs mostly in a slow progressive fashion, most elderly arc unlikely to report significant changes in swallowing function over time and dysphagia-specific quality oflifequestionnaires should be used to adequately identify patients at risk of swallowing difficulty and later dysphagia-related complications.
| References | | |
| 1. | Feinberg, MJ, Ekberg, O. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. Amer J Radiol. 1991;156:293-6.  |
| 2. | Feinberg, MJ, Ekberg, O. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. Amer J Radiol. 1991;156:293-6.Marrie, T.J. Community-acquired pneumonia in the elderly .Clin Infect Dis. 2000;31:1066-78. |
| 3. | Feinberg, MJ, Ekberg, O. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. Amer J Radiol. 1991;156:293-6.Aviv JE, Hecht C, Weinberg H, Dalton JF, Urken ML. Surface sensibility of the floor of mouth and tongue in healthy controls and radiated patients. Otolaryngol Head Neck Surg. 1992 ; 107:418-23. |
| 4. | Feinberg, MJ, Ekberg, O. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. Amer J Radiol. 1991;156:293-6.Calhoun KH, Gibson B, Hartley L, Minton J, Hokanson JA, Age-related changes in oral sensation. Laryngoscope. 1992 ;102:109-16. |
| 5. | Feinberg, MJ, Ekberg, O. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. Amer J Radiol. 1991;156:293-6.Feinberg MJ. Knebl J, Tully J. Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia. 996; 11:104-9. |
| 6. | Feinberg, MJ, Ekberg, O. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. Amer J Radiol. 1991;156:293-6.Aviv JE, Kim T, Thomson JE, Sunshine S, Kaplan S, Close LG Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) in Healthy Controls. Dysphagia. 1998;13:87-92. |
| 7. | Feinberg, MJ, Ekberg, O. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. Amer J Radiol. 1991;156:293-6.Aviv JE, Kim T, Thomson JE, Sunshine S, Kaplan S, Close LG. The Safety of Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): An Analysis of 500 Consecutive Evaluations. Dysphagia. 200015:39- 44. |
| 8. | Feinberg, MJ, Ekberg, O. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. Amer J Radiol. 1991;156:293-6.Cohen MA, Setzen M, Perlman PW, Ditkoff M, Mattucci KF, Guss J. The Safety of Flexible Endoscopic Evaluation of Swallowing With Sensory Testing in an Outpatient Otolaryngology Setting. Laryngoscope. 2003; 113:21-24. |
| 9. | Feinberg, MJ, Ekberg, O. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. Amer J Radiol. 1991;156:293-6.Aviv JE, Martin JH, Jones ME, Wee TA, Diamond B, Keen MS, Blitzer A. Age related changes in pharyngeal and supraglottic sensation. Ann Otol Rhinol Laryngol. 1994;103:749-52. |
| 10. | Feinberg, MJ, Ekberg, O. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. Amer J Radiol. 1991;156:293-6.Mortelliti AJ, Malmgren LT, Gacek RR. Ultrastructural changes with age in the human superior laryngeal nerve. Arch Otolary ngol Head Neck Surg. 1990;116:1062-8, |
| 11. | Feinberg, MJ, Ekberg, O. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. Amer J Radiol. 1991;156:293-6.Chen AY, Frankowski R, Bishop-Leone J, Hebert T, Leyk S, Lewin J, Goepfert H. The Development and validation of a Dysphagia-Spccific Quality-of-Life Questionnaire for Patients with Head and Neck Cancer. The M.D. Anderson Dysphagia Inventory. Arch Otolryngol Head Neck Surg. 2001;127:870-6. |
|
Search Pubmed for