Dysphagia
Dysphagia means difficulty eating or swallowing. The number of adults living with swallowing difficulties is set to rise in line with population ageing and the increasing levels of frailty and comorbidities that occur in older adults.
Article by Linda Nazarko
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Overview
Dysphagia means difficulty eating or swallowing. Intact motor and nervous systems are essential to enable normal swallowing. There are four phases involved in a normal swallow:
- 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 area. The soft palate elevates. The epiglottis closes off the trachea, as the tongue moves backwards and the pharyngeal wall moves forward. These actions help force the food downward to the oesophagus
- Oesophageal - muscles propel food through the oesophagus. The oesophageal sphincter opens and closes efficiently. The bolus is moved to the stomach
Dysphagia becomes more common in older age and is associated with neurological problems and frailty (Cavallero et al, 2020). Older people may consider that swallowing difficulties are
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Symptoms
A person with dysphagia may present with a number of symptoms including:
- difficulty swallowing food or fluids
- coughing/choking during or after meals
- unintentional weight loss
- throat clearing
- wet gurgling voice after eating
- fever
- chills
- changes in breathing
- food or liquids traveling back up through the throat or nose after swallowing
- feeling of food or liquids being ‘stuck’ in the throat or chest
- pain while swallowing
- heartburn
- dehydration
- excessive secretions
- leakage of food or saliva from mouth (Knott, 2021)
Red flags
A red flag signals that the person requires urgent medical attention. In terms of dysphagia, there are three major red flags:
- rapidly progressing dysphagia
- suspected aspiration pneumonia or recurrent pneumonia
- inability to maintain nutrition and hydration
If a red flag is present, then the nurse should escalate the case using local protocols.
Steadily worsening dysphagia over a few weeks in an older person is suggestive of malignancy,
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Diagnosis
Dysphagia can be a transient, persistent or deteriorating symptom. If a person presents with new dysphagia or a deteriorating swallow, the nurse should follow local protocols for diagnosis. These may involve completing a dysphagia screen and possibly carrying out an initial assessment of swallowing (Lees et al, 2006; Donovan et al, 2013) (Figure 1).
If the person is unsafe or possibly unsafe to swallow, then urgent medical referral is required. Normally, when there are non-urgent concerns regarding dysphagia, the individual is referred to a speech and language therapist. They will investigate, treat or manage the condition when possible and escalate if there are concerns that cannot be managed by the therapist.
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Treatment
People who experience a reflux of gastric acid into the oesophagus can develop oesophageal scarring and stricture, which can lead to, or worsen, dysphagia (Bollschweiler et al, 2008). The use of proton pump inhibitors, such as omeprazole, can reduce acid reflux and improve swallowing.
Oesophageal carcinoma may be treated surgically or palliatively according to tumour staging and patient preference. Palliative treatment may include dilatation, stenting and other treatments (Dai et al, 2014).
Poor oral health can contribute to problems with dysphagia, including tooth loss, gum disease and infection affecting the ability to bite and chew (Furuta and Yamashita, 2013; Cichero, 2020). The nurse should check if oral health problems are contributing to dysphagia, treat any infection and advise the person to seek dental treatment.
Medication
When an individual has difficulty swallowing tablets or capsules, all medication should be reviewed. Medication reviews can be carried out by doctors or non-medical prescribers,
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Management
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 in people with dysphagia is to promote safe swallowing and to ensure that the person has food and fluids which are of the appropriate texture and thickness. Advice includes:
- sitting upright at 90 degrees when eating and drinking
- not eating or drinking when slouched or lying down
- taking small bites of food
- taking small sips of fluid
- not gulping drinks
- eating slowly
- chewing foods well before swallowing
- making sure the patient has swallowed their food or drink before taking more
- not washing down your food with drinks
- not talking when you have food in your mouth
When a person has dysphagia, speech and language therapists and
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 2: Procedures for the planning, provision and management of person-centred nursing care
5. Use evidence-based, best practice approaches for meeting needs for care and support with nutrition and hydration, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions
5.3 assist with feeding and drinking and use appropriate feeding and drinking aids
11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation
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Resources
Alagiakrishnan K, Bhanji RA, Kurian M. Evaluation and management of oropharyngeal dysphagia in different types of dementia: A systematic review. Arch Gerontol Geriatr. 2013;56(1):1–9. https://doi.org/10.1016/j.archger.2012.04.011
Almirall J, Rofes L, Serra-Prat M et al. Oropharyngeal dysphagia is a risk factor for community-acquired pneumonia in the elderly. Eur Respir J. 2013;41(4):923–928. https://doi.org/10.1183/09031936.00019012
British Association for Parenteral and Enteral Nutrition (BAPEN). Introducing MUST. 2023. http://www.bapen.org.uk/screening-and-must/must/introducing-must (accessed 22 November 2023)
British Association for Parenteral and Enteral Nutrition (BAPEN). Administering medicines via enteral feeding tubes. 2017. https://www.bapen.org.uk/nutrition-support/enteral-nutrition/medications (accessed 22 November 2023)
Beech J, Fraser C, Gardner T et al. Stressed and overworked: what the Commonwealth Fund’s 2022 International Health Policy Survey of Primary Care Physicians in 10 countries means for the UK. 2023.
https://www.health.org.uk/sites/default/files/upload/publications/2023/Stressed%20and%20overworked_WEB.pdf (accessed 22 November 2023)
Bollschweiler E, Knoppe K, Wolfgarten E, Hölscher AH. Prevalence of dysphagia in patients with gastroesophageal reflux in Germany. Dysphagia. 2008;23(2):172–176. https://doi.org/10.1007/s00455-007-9120-5
Bourdenet G, Giraud S, Artur M et al. Impact of recommendations on crushing medications in geriatrics: from prescription to administration. Fundam Clin Pharmacol. 2015;29(3):316–320.
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