Characteristics of Dysphagia in Older Patients Evaluated at a Tertiary Center

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1 The Laryngoscope VC 2014 The American Laryngological, Rhinological and Otological Society, Inc. Characteristics of Dysphagia in Older Patients Evaluated at a Tertiary Center Pelin Kocdor, MD; Eric R. Siegel, MS; Rachel Giese, MD; Ozlem E. Tulunay-Ugur, MD Objective: To determine laryngoscopic and videofluoroscopic swallowing study (VFSS) findings in geriatric patients with dysphagia; to evaluate management. Study Design: Retrospective chart review. Methods: Patients over 65 years old complaining of dysphagia, seen at a tertiary laryngology clinic, were included. Head and neck cancer and stroke patients were excluded. Demographics, laryngoscopic findings, swallowing studies, and treatment modalities were reviewed. Results: Sixty-five patients were included. Mean age was 75 years old (range ) with female predominance of 67.6%. Weight loss was seen in 9.2% of the patients. Whereas 52.3% of the patients complained of solid food dysphagia, 53.8% were choking on food. On laryngoscopy, 15.3% of the patients had pooling in the pyriform sinuses, 30.7% had glottic gap, 18.4% had vocal fold immobility, and 3% had hypomobility. VFSS showed that 38.4% of the patients had pharyngoesophageal dysphagia, 20% had oropharyngeal dysphagia, 20% had pharyngeal dysphagia, and 20% had a normal study. In addition, 41.5% of the patients showed laryngeal penetration and 18.4% showed aspiration. Surgical intervention was employed in 29.2% of the patients in the form of botulinum toxin injection, esophageal dilatation, cricopharyngeal myotomy, vocal fold injection, diverticulectomy, and percutaneous endoscopic gastrostomy. Whereas 21.5% of the patients received swallowing therapy, 61.5% underwent diet modification. As a result, 80% of the patients needed some type of treatment. Conclusions: Swallowing problems in older patients are not uncommon. The clinician needs to be diligent to inquire about dysphagia because a large number of these patients will require treatment. Key Words: Dysphagia, geriatric, videofluoroscopic swallowing study, laryngoscopy, treatment, swallowing therapy. Level of Evidence: 4. Laryngoscope, 125: , 2015 INTRODUCTION According to U.S. Department of Health and Human Services, persons over the age of 65 years old currently represent 12.9% of the U.S. population. As the fastest growing segment of the population, this age group is expected to expand to 30% by Dysphagia is a growing health concern in the aging population. Age-related changes in swallowing physiology, as well as age-related diseases, are predisposing factors for dysphagia in older adults. Although the exact prevalence of dysphagia across different settings is unclear, conservative estimates suggest that 15% of the geriatric population is affected by dysphagia. 2 From the Department of Otolaryngology Head and Neck Surgery (P.K., R.G., O.E.T-U.); and the Department of Biostatistics (E.R.S.), University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A. Editor s Note: This Manuscript was accepted for publication August 11, Presented at the American Bronchoesophagological Association Meeting, Orlando, Florida, U.S.A., April 10 11, The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Ozlem E. Tulunay-Ugur, MD, Associate Professor, Director Division of Laryngology, University of Arkansas for Medical Sciences, Department of Otolaryngology Head and Neck Surgery, 4301 W Markham, Slot 543, Little Rock, AR oetulunayugur@uams.edu DOI: /lary Patients with dysphagia are often at increased risk of developing other medical conditions. If left unmanaged, dysphagia can lead to dehydration, malnutrition, respiratory infections, and death. 3 To our knowledge, studies defining the exact characteristics of this group are still lacking. Therefore, we aimed to review the details of videofluoroscopic swallowing study (VFSS) and laryngoscopic findings in a group of older patients with dysphagia complaints who were without a history of neurological disease or head and neck cancer, as well as their management and outcomes. MATERIALS AND METHODS This study was approved by the institutional review board of the University of Arkansas for Medical Sciences (UAMS). A retrospective review of 1,843 patients with dysphagia seen at the laryngology clinic between the years of 2003 and 2012 was performed. Patients with dysphagia due to head and neck cancer, stroke, and neurodegenerative disorders were excluded from the study. Of this group of patients, patients under 65 years old and patients without a swallowing study were excluded as well. Although used in our clinical practice, the MD Anderson Swallowing Inventory 4 is a retrospective study; therefore, not all patients had a questionnaire that evaluated for dysphagia. In order to define dysphagia, indices on eating assessment tool (EAT-10) and globus sensation were also reviewed and recorded from patients charts. Sixty-five patients were identified and reviewed. Demographics, comorbidities, laryngostroboscopic findings, swallowing study findings, and treatment modalities that

2 TABLE I. Swallowing Performance Status Scale Description. 5 1 Normal 2 Within functional limits Abnormal oral or pharyngeal stage Able to eat regular diet without modifications or swallowing precautions 3 Mild impairment Mild dysfunction in oral or pharyngeal stage Requires modified diet without need for therapeutic swallowing precautions 4 Mild moderate impairment with need for therapeutic precautions Mild dysfunction in oral and pharyngeal stage Requires modified diet and therapeutic precautions to minimize aspiration risk 5 Moderate impairment Moderate dysfunction in oral or pharyngeal stage Aspiration noted on examination Requires modified diet and swallowing precautions to minimize risk of aspiration 6 Moderate severe dysfunction and requires supplemental enteral feeding support Moderate dysfunction in oral or pharyngeal stage Aspiration noted on examination Requires modified diet and swallowing precautions to minimize risk of aspiration Needs supplemental feeding support 7 Severe impairment Severe dysfunction with significant aspiration or inadequate oropharyngeal transit to esophagus Requires primary enteral feeding support were employed were noted. In addition, in order to define improvement and satisfaction, complaints after treatment were reviewed and recorded. A patient was regarded as 100% improved if all pretreatment symptoms were relieved, 75% improved if three of four were improved, and so on. During this study period, VFSS was utilized more frequently compared to the fiberoptic endoscopic evaluation of swallowing (FEES).In our routine practice,all patients complaining of dysphagia undergo videolaryngostroboscopy in order to rule out anatomical and organic pathologies. Generally, if we are mainly aiming to rule out penetration or aspiration, patients will undergo FEES; however, a VFSS is performed if a more detailed evaluation is needed. Swallowing performance status scales (SPSS) were performed on all patients 5 (Table I). All of the VFSS were performed at UAMS by the same speech pathology team using the same protocol each time. During the VFSS, 18- to 40-mL Varibar thin liquid (E-Z-EM, Inc., Melville, NY), 1 1/2 teaspoon Varibar paste, 8- to 20-mL Varibar nectar, and 1/2 to 1/4 of a graham cracker mixed with Varibar paste were used for each patient. Thin, nectar-like, and honey-like liquid; dysphagia-pureed textured foods, and regular textured foods were the tested consistencies. Oral bolus control, swallow initiation, tongue-base retraction, pharyngeal stripping wave, epiglottic inversion, hyolaryngeal excursion, upper esophageal sphincter (UES) opening, laryngeal penetration, aspiration, preswallow pooling in vallecula and pyriform sinus, postswallow residue in vallecula, and pyriform sinus and upper esophageal residue were recorded. In the final part of the study, postural adjustment techniques and swallowing maneuvers are tested in order to plan for swallowing therapy. Fisher s exact test, Cochran-Armitage Trend test, and Kruskal-Wallis test were used for the statistical analysis. RESULTS A total of 65 patients were included in this study (demographics listed in Table II). The mean age of the patients was 75 years-old (range years-old). There was a female predominance with 44 patients (67.6%). Thirty-four patients (52.3%) had difficulty swallowing solids, 35 (53.8%) were choking/coughing on food, 27 (41.5%) complained of food sticking in their throat, 12 (18.4%) had difficulty swallowing pills, 11 (16.9%) had difficulty swallowing liquids, 10 (15.3%) had globus sensation, six (9%) had weight loss, and five (7.6%) had odynophagia (Table II). Also, four patients had a history of aspiration pneumonia, one of them requiring hospitalization. Forty-seven patients (72.3%) were on reflux medication; in addition, one patient underwent Nissen fundoplication for gastroesophageal reflux disease (GERD). The diagnosis of GERD was made clinically. Prior to being seen at our center, primary care doctors had already placed most of the patients on therapy. Only five patients (3%) were put on reflux medication at our center. The leading comorbidity following GERD was hypertension, which was reported in 34 (52.3%) patients. On indirect flexible laryngostroboscopy, 10 patients (15.3%) had pooling in the pyriform sinuses, 20 (30.7%) had a glottic gap during phonation, 12 (18.4%) had vocal fold immobility, two (3%) had vocal fold hypomobility, and 30 (45.16%) had a normal laryngoscopy. These patients did not undergo electromyography. The etiologies of vocal immobility were carotid endarterectomy in two patients, thoracic surgery in one patient, aortic aneurysm in one patient, intubation in two patients, hemithyroidectomy in one patient, and idiopathic in five patients. Eight patients (12.3%) showed significant vocal fold atrophy (Table III). VFSS was performed on all patients. Twenty-five (38.4%) patients had pharyngoesophageal dysphagia, 13 TABLE II. Patient Demographics. No (%) Sex Male 21 (32.3%) Female 44 (67.6%) Age Average 75 Range Dysphagia complaint Difficulty with swallowing solids 34 (52.3%) Choking on food 35 (53.8%) Food getting stuck in throat 27 (41.5%) Difficulty with swallowing pills 12 (18.4%) Difficulty with swallowing liquids 11 (16.9%) Globus sensation 10 (15.3%) Weight loss 6 (9%) Pain with swallowing 5 (7.6%) 401

3 TABLE III. Flexible Laryngoscopic Findings and Treatment Modalities Employed. No. (%) Flexible Laryngoscopy Findings Pooling in pyriform sinus 10 (15.3%) Glottic gap 20 (30.7%) Vocal fold paralysis 12 (18.4%) Vocal fold paresis 2 (3%) Treatment Surgical intervention 19 (29.2%) Swallowing therapy 14 (21.5%) Diet modification 40 (61.5%) (20%) oropharyngeal dysphagia, 13 (20%) pharyngeal dysphagia, and 13 (20%) patients had a normal study. Type of dysphagia was defined according to the levels of abnormal findings on VFSS. Whereas 27 patients (41.5%) had laryngeal penetration, 12 (18.4%) aspirated. There was post-swallow vallecular and pyriform sinus residue in 25 (38.4%) and 23 patients (35.3%), respectively (with liquid, solid, or both). None of these residues caused post-swallow aspiration. Swallowing performance status scale reviews revealed that all patients except three had a score between 4 and 7 and continued oral intake (Table IV). Two patients with SPSS 2 underwent percutaneous endoscopic gastrostomy (PEG) and feeding tube placement. Nineteen patients (29.2%) underwent a surgical intervention in the form of botulinum toxin injection, cricopharyngeal dilatation, myotomy, vocal fold injection, Zenker s diverticulectomy, Nissen fundoplication, PEG, or a combination of any of these procedures. Fourteen patients (21.5%) received swallowing therapy. and 40 (61.5%) underwent diet modification. In addition, 13 patients (20%) received speech therapy. Twenty-five patients had more than one intervention. Therefore, a total of 52 (80%) patients needed some type of treatment. Of these 52 patients, the complaints of 20 patients (30%) resolved completely; 10 (20%) patients had an improvement ranging between 25% to 80%; 12 patients (18.4%) had no change and remained on their presenting diet (nectar-like liquid or dysphagia-mechanically altered textured foods); and 10 patients were lost to follow-up after treatments. The majority of the patients lost to follow-up were patients referred for swallowing therapy close to home. Because we are a tertiary referral center, patients are seen from the entire state and commonly receive therapy locally. Despite these appointments being arranged by our clinic staff, there still are no-shows. Seven patients underwent vocal fold injections (6 underwent calcium hydroxylapatite; 1 underwent fat injection). Two patients with unilateral immobility and one with presbylarynx (bilateral injections) had no residual complaints of dysphagia following injections. Whereas two patients had mild to moderate improvement, two patients with unilateral vocal fold immobility had no improvement in dysphagia following vocal fold injections and remained on nectar-like liquid and regular textured food. Five patients underwent cricopharyngeal dilation, botulinum toxin injection, myotomy, or a combination of these procedures. All but one patient had improvement in their symptoms; swallowing therapy was added to the management as necessary. Two patients had Zenker s diverticulectomy with complete resolution of symptoms. Two patients had esophageal pathologies and needed dilatations, two with SPSS scores of 2 required feedingtube placements; one remained without oral intake; and one was lost to follow-up. Each complaint was compared with VFSS findings by using Fisher s exact test. Four patients of six (67%) who had weight loss had reduced UES opening, compared to 14 of 59 (23%) patients who did not (P ). Five patients of five (100%) who had weight loss had laryngeal penetration on VFSS, compared to 22 of 59 (37%) who did not (P ). The sixth patient with weight loss had missing information. There was a significant relationship between weight loss and aspiration as well. Five patients of six (83%) with weight loss had aspiration compared to only seven of 59 (12%) without weight loss (P ). All six patients (100%) with weight loss had mild, moderate, or severe postswallow pyriform sinus residue on VFSS, compared to 29% (17 of 59) without weight loss (P ) (Fig. 1). All four patients (100%) who had an aspiration pneumonia history, but only 31% (19 of 61) who did not, had mild or moderate postswallow sinus residue on VFSS (P ). Nine patients of 11 who had difficulty with swallowing liquids had laryngeal penetration on VFSS, compared to 18 of 53 (34%) who did not (P ). Of these, seven TABLE IV. Details of VFSS Findings. No (%) Oral dysphagia 1 (1.5%) Poor oral bolus control 3 (4.6%) Delayed swallow initiation 15 (23.0%) Oropharyngeal dysphagia 13 (20.0%) Reduced tongue base retraction 16 (24.6%) Pre-swallow pooling at the vallecula 8 (12.3%) Post-swallow vallecular residue 25 (38.5%) Pharyngeal dysphagia 13 (20.0%) Reduced pharyngeal stripping wave 8 (12.3%) Reduced epiglottic inversion 16 (24.6%) Reduced hyolaryngeal excursion 17 (26.1%) Laryngeal penetration 27 (41.5%) Aspiration 12 (18.4%) Pharyngoesohageal dysphagia 25 (38.5%) Reduced UES opening 18 (27.6%) Pre-swallow pooling at pyriform sinus 8 (12.3%) Post-swallow pyriform sinus residue 23 (35.3%) Normal 13 (20.0%) UES 5 upper esophageal sphincter; VFSS 5 videofluoroscopic swallowing study. 402

4 Fig. 1. Percentage of subjects with abnormal videofluoroscopic swallowing study finding. *Statistically significant. UES 5 upper esophageal sphincter. [Color figure can be viewed in the online issue, which is available at patients of 11 had pyriform sinus residue (64%), compared to 16 of 54 (30%) who did not have this complaint (P ). Fifteen patients of 34 (44%) who had difficulty swallowing solids had reduced UES opening on VFSS, compared to three of 31 (10%) who did not have this complaint (P ). In addition, 17 patients of 34 (50%) had pyriform sinus residue compared to six of 31 (19%) without solid food dysphagia (P ). Treatment methods were compared with satisfaction percentage; and each complaint was also compared with the number of comorbidities as well as the number of medications by using the Kruskal-Wallis test. These comparisons did not reveal any statistically significant relationships. DISCUSSION Dysphagia is an important and sometimes dismissed symptom in the geriatric population. The prevalence of dysphagia is higher in selected populations, such as patients residing in nursing homes with reported rates as high as 30% to 40%. 6 Aging of elastic fibers in connective tissues of the neck, sensory endorgan deterioration, and muscular weakness affecting oropharyngeal structures have all been presumed to interfere with swallowing function of the pharynx. 7 Due to the complexity of the swallowing process, other comorbidities such as neurologic diseases can influence swallowing function. 2 This study focused on the older patients without a history of neurological disease or head and neck cancer, both of which have been studied more comprehensively. Health care professionals tend to anticipate swallowing problems in these patient populations; but it is underestimated in patients without these ailments. Additionally, older patients commonly do not communicate their symptoms adequately. Unrecognized dysphagia may cause recurrent aspiration pneumonia or impaired nutritional status. Patients with dysphagia can become isolated, feel excluded by others, and become anxious and distressed at mealtimes. 3 Furthermore, dysphagia affects a patient s dignity, self-esteem, and the regard of others. 3,8 Laryngeal penetration and aspiration are important findings on VFSS. In our study, older patients with a complaint of dysphagia were evaluated; thus, 41.5% showed penetration and 18.4% had aspiration. There was a statistically significant relationship between weight loss and penetration and aspiration (P , P , respectively), as well as aspiration pneumonia and post-swallow pyriform sinus residue (P ). Post-swallow pyriform sinus residue on VFSS can be a helpful finding in assessing the risk of future aspiration pneumonias. Interestingly, none of the patients (14 patients) in the current series complaining of coughing while they eat showed aspiration; only two patients of 14 had laryngeal penetration. Whereas this data indicates that cough is not a reliable predictor of the presence of penetration or aspiration on a VFSS, an alternative explanation may be that these findings simply missed during the VFSS. The VFSS does not replicate a normal meal; all effort should be made to perform it as close to a normal meal as possible, such as asking the patient about particular foods they are having trouble with or increasing the amount of boluses used. A negative VFSS does not entirely rule out aspiration, and attention should be given to the patient history and complaints. Similarly, a patient who is not complaining of any coughing could be aspirating silently, and either a VFSS or FEES should be performed in the event of any clinical suspicion. On the other hand, there was a significant correlation with liquid dysphagia and penetration, as well as pyriform sinus residue. As expected, patients with solid dysphagia showed more pyriform sinus residue and decreased UES opening. Evaluation of larynx with laryngoscopy is critical for assessing dysphagia. Aspiration may be due to vocal fold adductor dysfunction, which causes an incompetent glottic valve, eliminating this level of mechanical protection of the lower airway during deglutition. 9 It is not clear if this dysfunction is specific to the geriatric population; however, decreased upper esophageal sphincter tone, as well as impaired opening of the upper esophageal sphincter, have been associated with older age. 10 Oliven et al. showed a decrease in type IIa and an increase in type IIb fibers in mice over 18 months. 403

5 Oxidative capacity of the muscles declined with aging in rats as well, especially that of the genioglossus. This suggests that normal age-related physiologic changes in pharyngeal tone may be contributory in geriatric patients with no other identified cause of neurologic impairment. 11 In the current study, delayed swallowing initiation, reduced tongue-base retraction, reduced epiglottic inversion, and hyolaryngeal excursion were the most common findings. Most patients had multilevel impairment. Twenty-eight percent of the patients showed decreased UES opening. The study by Oliven et al. corroborates a study performed by Rofes et al., which showed impaired deglutition due to delayed laryngeal vestibule closure, as well as weak tongue bolus propulsion and slowed hyoid motion, in frail older patients. 11,12 In that study, a video swallow study with rigorous measurements via bolus kinematics was used to create a validated index to compare findings in older adults to those of healthy volunteers and patients with neurodegenerative diseases. Frail older patients had similar swallow study findings to patients with known neurodegenerative disease. With this knowledge, a practitioner should suspect dysphagia in presumably neurologically intact older patients who may be at greater risk for respiratory and nutritional compromise. 12 Other than obvious factors increasing risk such as history of stroke, head and neck cancer, dementia, or cardiopulmonary pathology, factors such as dependency, depression, and educational level should be considered. 13 In a prospective study by Roy et al., the lifetime risk of dysphagia has been reported as 38%, with 33% of the participants complaining of current swallowing problems. On the other hand, few were noted to seek treatment. 8 Of note, some of the older patients at highest risk may not be able to communicate symptoms to caregivers. Similarly, swallowing problems in the older patients may be dismissed as a normal part of aging by the patients, family members, and even practitioners. There is increasing pressure to improve outcomes in facilities caring for the aging population; therefore, physicians should be motivated to question whether a patient may have presbyphagia and treat it appropriately. Bhattacharyya et al. have reported an improved penetration aspiration scale score in their patients after undergoing vocal fold medialization. 14 In this series, laryngoscopy revealed that 20 (30.7%) patients had a glottic gap, 12 (18.4%) had vocal fold immobility, and two (3%) had hypomobility. Seven patients underwent vocal fold injection. This is a small number from which to be able to draw strong conclusions, but our experience suggests that, although you can guarantee good voice outcomes with these types of procedures, they may not yield the desired outcomes in terms of dysphagia. Swallowing is a complex system and involves more than just laryngeal closure, which is improved by an injection laryngoplasty. There is continued controversy with regard to this in the literature. 14,15 Successful swallowing interventions not only benefit individuals with reference to oral intake of food/liquid, but also have extended benefit to nutritional status and prevention of related morbidities such as pneumonia. A variety of management tools are available pending the characteristics of the swallowing impairment of the individual patient. Compensatory strategies include, but are not limited to, postural adjustments of the patient, swallow maneuvers, and diet modifications. 2 Fourteen patients (21.5%) received swallowing therapy, which included sessions for teaching patients the required maneuvers (e.g., postural maneuvers, muscle training); another 40 patients (61.5%) received diet modification instructions. Patients current diets were changed to the recommended diets such as thin liquids or thicken liquids and puree foods according to the patients requirements. Speech pathologists also suggested patient-specific modifications such as avoiding specific food items (e.g., popcorn), sipping liquids after solid foods, and small frequent meals. Additional surgical interventions such as cricopharyngeal myotomy, botulinum toxin injection, and dilation improve the outcomes obtained by swallowing therapy and diet modification. In this series, 52 (80%) patients needed some type of treatment; 20 (38.4%) had 100% improvement; and 20 (38.4%) had improvement ranging between 25% to 80% after their treatments. To our knowledge, this is the first study that examines the characteristics of dysphagia in older patients presenting to a tertiary care center without a history of neurological disease or head and neck cancer. Additional prospective studies are needed to address and compare different treatment modalities. This study does have the limitations of a retrospective study, such a missing data points and lack of patient questionnaires. CONCLUSION Swallowing problems in older patients are not uncommon and can present with vague symptoms. Weight loss is a significant finding and should prompt a thorough workup; these patients are at risk of complications. The clinician needs to be diligent because a vast number of older patients with dysphagia will require an intervention in the form of surgery, swallowing therapy, or diet modification. With diligent follow-up, meaningful improvement in symptoms may be seen, thus improving oral intake. BIBLIOGRAPHY 1. Davids T, Klein AM, Johns MM. Current dysphonia trends in patients over the age of 65: is vocal atrophy becoming more prevalent? Laryngoscope 2012;122: Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging 2012;7: Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P. Social and psychological burden of dysphagia: its impact on diagnosis and treatment. 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