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Communication Facts: Special Populations: Dysphagia - 2008 Edition

Swallowing is one of the most complex neuromuscular interactions in the human body. Swallowing problems (dysphagia) may be classified as oropharyngeal or esophageal. Oropharyngeal dysphagia refers to difficulty in the passage from the mouth to the esophagus. In esophageal dysphagia, there is a disordered passage of food through the esophagus (1). These problems should be distinguished from feeding disorders, which are difficulties in presenting food to the mouth (2). Swallowing problems are related to neuromotor speech disorders in that they frequently (though not necessarily always) accompany disturbances in speech movement (3).

General Demographics

  • The exact prevalence of dysphagia is unknown. Epidemiologic studies, however, indicate that the prevalence may be as high as 22% in those over 50 years of age (1).
  • Approximately 10 million Americans are evaluated each year with swallowing difficulties (2).
  • Swallowing difficulties negatively impact quality of life functioning (4). Impaired swallowing can cause significant morbidity and mortality (5).

Disorders Causing Dysphagia

Neurogenic Dysphagia

  • Neurologic disorders include stroke, Parkinson's disease, multiple sclerosis, and amyotrophic lateral sclerosis. These disorders may produce oropharyngeal dysphagia (1). It is found in both pediatric and adult populations (2, 6, 7).
  • Several studies conclude that between 300,000 and 600,000 individuals in the United States are affected by neurogenic dysphagia each year (6, 8).

Stroke

  • Studies on the prevalence of dysphagia range from 25%-70% in patients who have experienced stroke. These estimates vary because of the method of assessing swallowing function, the timing of swallowing assessment after stroke, and the number of and type of stroke patients studied (1, 6, 9-12).
  • There is a consistently high incidence of dysphagia and pneumonia in patients with stroke (12).
  • Although dysphagia improves in most patients following a stroke, in many of them the swallowing difficulties follow a fluctuating course, with 10%-30% of individuals continuing to have dysphagia with aspiration (6).
  • Dysphagia, and speech and language disturbances are common consequences of the high incidence of stroke (10, 11).

Traumatic Brain Injury

Established incidence figures for dysphagia in individuals with traumatic brain injury vary greatly depending on whether the population studied is comprised of severe TBI patients, consecutive brain injury admissions, acute TBI patients, or patients in the rehabilitation phase of recovery (13).

Huntington's Disease

  • Although dysphagia is not an obvious symptom of Huntington's disease, it is a common symptom that may be associated with fatal complications (14).
  • Dysphagia hinders nutritional intake and places the patient at risk for aspiration (15).

Multiple Sclerosis

  • Patients with multiple sclerosis (particularly those with brainstem involvement) are reported to have swallowing difficulties. Dysphagia may develop early or late in the disease's process. Among the difficulties are choking and a "sticking" of food in the throat (16, 17).
  • There is a high prevalence of clinical symptoms of oropharyngeal dysphagia in patients with multiple sclerosis (18).
  • Over 30% of individuals with multiple sclerosis experience swallowing problems, a higher rate than previously assumed (19).

Parkinson's Disease

  • Patients with Parkinson's disease not only experience dysfunction of the various phases of swallowing, but they also have great difficulty in their ability to feed themselves (20).
  • Dysphagia is a symptom reported by 20%-40% of patients with idiopathic (i.e., of unknown cause) Parkinson's disease (21).

Amyotrophic Lateral Sclerosis (ALS)

  • Oropharyngeal dysphagia is highly prevalent in individuals with ALS (22).
  • Individuals with ALS usually die of respiratory complications within five years of diagnosis. Patients may benefit from swallowing therapy early on in the course of the disease (2).

Cerebral Palsy

  • Swallowing and sucking problems are commonly encountered within the first 12 months of life (23).
  • Most cerebral palsy patients have visible drooling (24).

Psychogenic Dysphagia

Psychogenic dysphagia is characterized by oral apraxia, but with intact speech, pharyngeal, and neurologic function. These patients undergo a detailed neurologic evaluation to rule out other forms of neurogenic dysphagia. Clinical symptoms in patients with psychogenic dysphagia may include anxiety, depression, and hypochondriasis (2).

Obstructive Lesions and Dysphagia

Dysphagia is one of the most frequent syndromes in patients with tumors of the head and neck, and esophagus (25).

Tumors

  • Tumors that affect swallowing are usually located in the skull base or brainstem. The degree of dysphagia and treatment depend on the size and type of tumor (2).
  • Depending on their location, benign or malignant tumors may cause oral or pharyngeal dysphagia (26).

Age and Dysphagia

…in the elderly

  • Dysphagia prevalence increases with age and poses particular problems in the older patients, potentially compromising nutritional status, increasing the risk of aspiration pneumonia and undermining the quality of life (27, 28).
  • Approximately 7%-10% of adults older than 50 years have dysphagia, although this number may be artificially low because many patients with this problem may never seek medical care (29). Of those over age 60, approximately 14% of individuals are affected by dysphagia (30).
  • The consequences of dysphagia include dehydration, starvation, aspiration pneumonia, and airway obstruction (5).

…in children

  • Gastroesophageal reflux is common in children and is associated with morbidity rates that justify increasing interest in early diagnosis and appropriate medical or surgical treatment. In children, ENT manifestations of GERD mainly affect the larynx, ears, nose, paranasal sinuses and oral cavity. Main manifestations are laryngotracheal stenosis, laryngomalacia, otitis media with effusion, and rhinosinusitis (31).
  • Aspiration can be a problem in newborn infants, especially those born prematurely with the inability to coordinate their suck, swallow, and breathing. By 34 weeks of gestational age, however, most infants are able to perform these functions to begin bottle-feeding or breast-feeding (32).
  • When the process of sucking falters, children may develop gagging, regurgitating, or choking during feeding and may fail to thrive. Neurologically impaired children are at high risk for aspiration because of a lack of maturation of neuromuscular coordination of the oral and pharyngeal muscles, which is complicated by the increased prevalence of gastroesophageal reflux in this group (32).
  • Gastroesophageal reflux occurs frequently in infants and children and is complicated as a trigger for reactive airways disease (33).
  • Data are unavailable on the prevalence of dysphagia in the pediatric population after traumatic brain injury, despite the knowledge that recovery can be severely compromised by a swallowing impairment (13).

Setting

  • The literature varies greatly concerning the incidence and prevalence of dysphagia in different health care settings. Several studies report that dysphagia is present in:
    • 61% of adults admitted to acute trauma centers (13)
    • 41% of individuals admitted to rehab settings (13)
    • 30%-75% of patients in nursing homes (1, 2, 29, 34)
    • 25%-30% of patients admitted to hospitals (29, 35)
  • One study estimates that 10% of deaths within 30 days of admission among hospitalized patients with stroke are attributable to pneumonia, and that one death could be averted for every 11 patients in whom stroke-related pneumonia is prevented (36).

References

  1. Howden, C.W. (2004, September 6). Management of acid-related disorders in patients with dysphagia. American Journal of Medicine, 117 (5A): 44S-48S.
  2. Domench, E., & Kelly, J. (1999, January). Swallowing disorders. Medical Clinics of North America, 83 (1): 97-113.
  3. Minifie, D. (1994). Introduction to communication sciences and disorders. San Diego, CA: Singular Publishing Co.
  4. Lovell, S.J., Wong, H.B., Loh, K.S., et. al. (2005, October). Impact of dysphagia on quality of life in nasopharyngeal carcinoma. Head & Neck, 27 (10): 864-872.
  5. Palmer, J.B., Drennan, J.C., & Baba, M. (2000, April 15). Evaluation and treatment of swallowing impairments. American Family Physician, 61, 2453-2462.
  6. Marik, P.E., & Kaplan, D. (2003, July). Aspiration pneumonia and dysphagia in the elderly. Chest, 124 (1): 328-336.
  7. Mayer, V. (2004, February). The challenges of managing dysphagia in brain-injured patients. British Journal of Community Nursing, 9 (2): 67-73.
  8. Terrado, M., Russell, C., & Bowman, J.B. (2001, October). Dysphagia: An overview. MedSurg Nursing, 10 (5): 233-248.
  9. Mann, G., Hankey, G.J., & Cameron, D. (2000). Swallowing disorders following acute stroke: Prevalence and diagnostic accuracy. Cerebrovascular Disease, 10, 380-386.
  10. Schlep, A.O., Cola, P.C., Gatto, A.R., et. al. (2004, June). Incidence of oropharyngeal dysphagia associated with stroke in a regional hospital in Sao Paulo State-Brazil. [article in Portuguese]. Arquivos de Neuro-Psiquiatria, 62 (2B): 503-506.
  11. Paciaroni, M. Mazzotta, G., Corea, F., et. al. (2004). Dysphagia following stroke. European Neurology, 51 (3): 162-167.
  12. Martino, R., Foley, N., Bhogal, S., et. al. (2005, December). Dysphagia after stroke: Incidence, diagnosis, and pulmonary complications. Stroke: A Journal of Cerebral Circulation, 36 (12): 2756-2763.
  13. Morgan, A., Ward, E., Murdoch, B., et. al. (2003). Incidence, characteristics, and predictive factors for dysphagia after pediatric traumatic brain injury. Journal of Head Trauma & Rehabilitation, 18 (3): 239-251.
  14. Hunt, V.P., & Walker, F.O. (1989, April). Dysphagia in Huntington's disease. Journal of Neuroscience Nursing, 21 (2): 92-95.
  15. Cangemi, C.F. Jr., & Miller, R.J. (1998, Fall). Huntington's disease: Review and anesthetic case management. Anesthesia Progress, 45 (4): 150-153.
  16. Hartelius, L., & Svensson, P. (1994). Speech and swallowing symptoms associated with Parkinson's disease and multiple sclerosis: A survey. Folia Phoniatrica et Logopedica, 46, 9-17.
  17. Boucher, R.M., & Hendrix, R.A. (1991, April). The otolaryngic manifestation of multiple sclerosis. Ear Nose & Throat Journal, 70 (4): 224-226.
  18. Terre-Boliart, R., Orient-Lopez, F., Guevera-Espinosa, D., et. al. (2004, December). Oropharyngeal dysphagia in patients with multiple sclerosis. [article in Spanish]. Revista de Neurologia, 39 (8) : 707-710.
  19. Prosiegel, M., Schelling, A., & Wagner-Sonntag, E. (2004, April). Dysphagia and multiple sclerosis. International MS Journal, 11 (1) : 22-31.
  20. Nilsson, H., Ekberg, O., Olsson, R., et. al. '(1996, Spring). Quantitative assessment of oral and pharyngeal function in Parkinson's disease. Dysphagia, 11 (2): 144-150.
  21. Volonte, M.A., Porta, M., & Comi, G. (2002). Clinical assessment of dysphagia in early phases of Parkinson's disease. Neurological Sciences, 23, S121-S122.
  22. Kidney, D., Alexander, M., Corr, B. et. al. (2004, September). Oropharyngeal dysphagia in amyotrophic lateral sclerosis: Neurological and dysphagia specific rating scales. Amyotrophic Lateral Sclerosis and Other Neuron Disorders, 5 (3): 150-153.
  23. Reilly, S., Skuse, D., & Poblete, X. (1996, December). Prevalence of feeding problems and oral motor dysfunction in children with cerebral palsy: A community survey. Journal of Pediatrics, 129, 877-882.
  24. Waterman, E.T., Koltai, P.J., Dowaney, J.C., et. al. (1992). Swallowing disorders in a population of children with cerebral palsy. International Journal of Pediatric Otorhinolaryngology, 24, 63-71.
  25. Arias, F., Manterola, A., Dominguez, M.A., et. al.(2004). Acute dysphagia of oncological origin. Therapeutic management. [article in Spanish]. Anales del Sistema Sanitario de Navarra, 27 (Suppl.3): 109-115.
  26. Newton, H.B., Newton, C., Pearl, D., et. al. (1994, October). Swallowing assessment in primary brain tumor patients with dysphagia. Neurology, 44 (10): 1927-1932.
  27. Morris, H. (2006, May 25-June 7). Dysphagia in the elderly - a management challenge for nurses. British Journal of Nursing, 15 (10): 558-562.
  28. Wilkins, T., et. al. (2007, March-April). The prevalence of dysphagia in primary care patients: a HamesNet Research Network study. The Journal of the American Board of Family Medicine, 20 (2): 144-150.
  29. Spieker, M.R. (2000, June 15). Evaluating dysphagia. American Family Physician, 61, 3639-3648.
  30. Agency for Health Care Policy and Research. (1999). Diagnosis and treatment of swallowing disorders (dysphagia) in acute-care stroke patients. Evidence Report/Technology Assessment No. 8 (AHCPR Pub. No. 99-E024). Rockville, MD: Author.
  31. Caruso, G., & Passali, F.M. (2006, October). ENT manifestations of gastroesophageal reflux in children. Acta Otorhinolaryngolica Italica, 26 (5): 252-255.
  32. Sheikh, S., Allen, E., Shell, R., et. al. (2001). Chronic aspiration without gastroesophageal reflux as a cause of chronic respiratory symptoms in neurologically normal infants. Chest, 12, 1190-1195.
  33. Mercado-Deane, M.G., Burton, E.M., Harlow, S.A., et. al. (2001, June). Swallowing dysfunction in infants less than 1 year of age. Pediatric Radiology, 31 (6): 423-428.
  34. Rosenvinge, S.K., & Starke, I.D. (2005, November). Improving care for patients with dysphagia. Age and Ageing, 34 (6): 587-593.
  35. Leslie, P., Carding, P.N., & Wilson, J.A. (2003, February 22). Investigation and management of chronic dysphagia. British Medical Journal, 326, 433-434.
  36. Katzan, I.L., Cebul, R.D., Husak, S.H., et. al. (2003, February 25). The effect of pneumonia on mortality among patients hospitalized for acute stroke. Neurology, 60 (4): 620-625.

Compiled by Andrea Castrogiovanni * American Speech-Language-Hearing Association * 2200 Research Boulevard, Rockville, MD 20850 * acastrogiovanni@asha.org

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