Dysphagia in the Older Population, Presbyphagia, and Sarcopenic Dysphagia

Sara Abu-Ghanem, MD, MMedSc, Airway and Swallowing Committee Member   

Demographers predict that by the year of 2050, older Americans, defined as 65 years or older, will account for 25% of the total population in high resource countries, a substantial increase from 13% in 2010.¹ Dysphagia refers to difficulty swallowing and moving a bolus from mouth to stomach. Anatomically, this may result from dysfunction at oropharyngeal, esophageal, or all levels. Dysphagia can occur at any age and affects 4% of the general population, however, it is more prevalent in the older population.² At conservative estimates, dysphagia affects about 15% of the seniors,³ 30% of those who are hospitalized,⁴ and up to 68% of those who live in nursing homes.⁵

Geriatric syndromes represent a group of common serious conditions that are not necessarily specific to but are common with aging and have significant implications on functioning and quality of life. In 2016, the European Dysphagia Working Group suggested in a position paper that oropharyngeal dysphagia should be considered a geriatric syndrome.⁶

One of the challenges in reviewing the literature on swallowing and aging is the definition of an “older” population.^7,8 Some authors define older adult with a cutoff as > 50-56 years,^9,10 while others use > 65 or 70 years.⁷ From a chronological viewpoint, the medical treatment of the older population (geriatrics) starts when patients turn 65 years old. Older adults are often further divided into three life-stage subgroups: the young-old (ages > 65 and < 75 years), the old-old (ages > 75 and < 85 years), and the oldest-old (> 85 years). Previous studies have already shown that the old-old and oldest-old groups may show even greater changes in swallow function;^11,12 however, the literature is sparse on this subject, and knowledge remains limited.

The effects of aging on swallowing are multifaceted, insidious, and frequently considered a natural part of aging. Older adults gradually develop characteristic changes in swallowing during aging; this phenomenon is called “presbyphagia.” Presbyphagia refers to characteristic natural changes in the swallowing process of otherwise healthy older adults.^13,14 Understanding what is “normal” swallowing for older patients is critical for interpreting clinical and instrumental examinations of swallow function and avoiding overdiagnosis and overtreatment of dysphagia in the older population, which might ultimately impact the individual’s quality of life.

Unlike dysphagia, presbyphagia is generally asymptomatic and is hypothesized to be the result of changes in the anatomy and physiology of the head and neck area, muscle loss (sarcopenia), reduced functional reserve, and onset of age-related illness. Presbyphagia and unnoticed dysphagia may progress to overt dysphagia with triggers that disrupt this weak equilibrium. These include onset of an acute disease, medications, or clinical complications or disorders that worsen the patient’s clinical condition and undermine adaptive swallowing strategies and compensation.

Sarcopenic dysphagia (SD) is difficulty swallowing associated with loss of both generalized skeletal muscles (muscles of the whole body) and swallowing-related muscles.^15,16 SD is a relatively new entity exclusively studied in the older population because sarcopenia and oropharyngeal dysphagia are common conditions of advanced age and have independently been considered geriatric syndromes.⁶

It was suggested that age-related loss in muscle mass can interact with age-related swallow changes (presbyphagia) to predispose sarcopenic older patients to develop overt dysphagia in setting of acute illness.¹⁷ SD is estimated to affect up to 32% of adults age 65 or older referred for dysphagia rehabilitation and 26% of community-dwelling older adults with dysphagia.^18,19

Prevalence of dysphagia among older adults was previously reported to range from 11% to 80%. This wide range can be explained by differences in the selection and inclusion criteria of the study groups, screening or assessment tools used for swallowing function, and the cutoffs for assessing the presence of dysphagia.^8,14

The three methods to assess dysphagia and swallowing function are screening tests, clinical swallowing evaluations, and instrumental exams. These methods differ in their purpose, scope, and accuracy. Screening tests for dysphagia aim to detect or predict the likelihood of swallowing dysfunction in at-risk patients who are otherwise not previously identified. Most of the screening evaluations are based on questionnaires and bedside evaluations that can be easily administered by nurses, primary care physicians, or other non-dysphagia expert personnel.

Several dysphagia assessment tools were suggested for screening in healthy older adults: the Sydney Swallowing Questionnaire (SSQ), 10-Item Eating Assessment Tool (EAT-10) questionnaire, the Standardized Swallowing Assessment, and the Volume Viscosity Swallow Test (V-VST).⁸  Abnormal screening test results usually do not provide information on the severity of the swallowing impairment or its etiology. Positive screening test results may necessitate referral to a dysphagia expert for a comprehensive clinical assessment of swallowing, which includes a full medical history, physical exam, and possibly an instrumental study.

The two main instrumental tests for evaluation of oropharyngeal swallowing physiology and function are Flexible Endoscopic Evaluation of Swallowing (FEES) and Videofluoroscopic Swallow Study (VFSS) also known as Modified Barium swallow Study (MBSS).

Despite increasing amount of literature and the importance of early recognition of dysphagia, there are significant weaknesses in the study design and quality of the current available studies. Future studies are needed to develop a single standardized, reliable, and validated dysphagia screening tool. Moreover, combined multidisciplinary effort, including otolaryngologists, gastroentrologists, speech language pathologists, and geriatrics, is needed to establish clear definitions for dysphagia in older patients, presbyphagia, and sarcopenic dysphagia. 

References

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