Nestle Supplement 2

DIAGNOSIS AND MANAGEMENT OF OROPHARYNGEAL DYSPHAGIA IN THE ELDERLY Pere Clavé, MD, PhD From the Hospital de Mataró, Consorci Sanitari del Maresme, Spain, and the Universitat Autonoma de Barcelona, Spain Correspondence: Pere Clavé, MD, PhD, Unitat d’Exploracions Funcionals Digestives, Department of Surgery, Hospital de Mataró C/ Cirera s/n, 08304 Mataró, Spain Phone: 34 93 741 77 00 • Fax: 34 93 741 77 33 • E-mail: pclave@teleline.es O ropharyngeal dysphagia is a major complaint among older people. Elderly patients with oropharyngeal dysphagia present a severe impairment in efficacy and safety of swallow caused by weak tongue propulsion and prolonged and delayed swallow response.The severity of oropharyngeal dysphagia varies from moderate difficulty to complete inability to swallow. Dysphagia may cause 2 groups of clinically relevant complications in the elderly: a) a decrease in the efficacy of deglutition, leading to malnutrition and dehydration and contributing to frailty and b) a decrease in deglutition safety, leading to tracheobronchial aspiration, which results in aspiration pneumonia that can lead to death. Clinical screening methods should be used to identify older people with oropharyngeal dysphagia, to identify those patients who are at risk of aspiration, and to select patients who need more comprehensive study.Videofluoroscopy (VFS) is the gold standard method to study the oral and pharyngeal mechanisms of dysphagia in the elderly. Videofluoroscopy characterizes the alterations of deglutition in terms of videofluoroscopic signs, allows accurate measurement of the oropharyngeal swallow response, and helps to select and assess specific therapeutic strategies. Up to 45% of elderly patients with dysphagia present with penetration into laryngeal vestibule, 30% present with aspiration, half present without cough (silent aspirations), and 45% present with oropharyngeal residue.Treatment with dietetic changes in bolus volume and viscosity and rehabilitation procedures can improve deglutition and prevent nutritional and respiratory complications in older patients. Diagnosis and management of oropharyngeal dysphagia require a multidisciplinary approach. Identification of functional oropharyngeal dysphagia as a geriatric syndrome will induce many changes in the provision of medical care in the near future. DEFINITION AND PREVALENCE Dysphagia is a symptom that refers to difficulty or discomfort during the progression of the alimentary bolus from the mouth to the stomach. From an anatomical standpoint, dysphagia may result from oropharyngeal or esophageal dysfunction and from a pathophysiological standpoint from structure-related or functional causes.1,2 The prevalence of oropharyngeal functional dysphagia is very high: it affects more than 30% of patients who have had a cerebrovascular accident. Its prevalence in Parkinson’s disease is 52%–82%; it affects up to 84% of patients with Alzheimer’s disease, up to 40% of adults age 65 and older, and more than 60% of elderly institutionalized patients.2,3 Aging is one of the principal demographic characteristics of the population of developed countries. In Europe, more than 17% of the citizens are now older than 65 years with a life expectancy at this age of 21 years in women and 17 years in men. In the last decade, the European population older than 65 years1 has increased 28% whereas the rest of the population has grown only 0.8%. It has been estimated that 16,500,000 US senior citizens will require care for dysphagia4 by the year 2010. Despite this enormous impact in the functional capacity, health, and quality of life of the elders who suffer from it, oropharyngeal dysphagia is underestimated and underdiagnosed as a cause of symptoms and major nutritional and respiratory complications in elderly patients. Oropharyngeal dysphagia fulfills most criteria to be recognized as a major geriatric syndrome, as its prevalence is very high in geriatrics and results from multiple diseases, risk factors, and precipitating diseases.5 The current state of the art with oropharyngeal dysphagia management in the elderly aims to identify patients at risk for dysphagia early, to DECEMBER 2007 • 7

Table of Contents Feed for the Digital Edition of Nestle Supplement 2

Nestle Supplement Table of Contents Introduction to Weight Loss in Older Persons Diagnosis and Management of Oropharyngeal Dysphagia in the Elderly The Danger of Weight Loss in the Elderly Nutrients and Frailty

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