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Understanding dysphagia

Dysphagia is described as a difficulty or discomfort in swallowing. It is not a disease, but a symptom of an underlying condition. While it can occur at any age, it is more common in older patients.

From a healthcare perspective, swallowing difficulties are associated with increased hospital admissions, antibiotic cover, feeding tube insertions and prolonged inpatient stays. Dysphagia is also associated with high cost for medical facilities. Despite its prevalence and the impact it has on so many aspects of daily life as well as on health and wellbeing, dysphagia remains under-diagnosed and untreated in many medical centres worldwide, according to the Department of Clinical Speech and Language Studies in Trinity College Dublin (TCD), which hosted an Interdisciplinary Swallowing and Voice Conference earlier this month. The treatment of swallowing difficulties is advancing internationally but high-quality research is urgently required in this area, the conference heard.

Classification

There are two classifications of dysphagia: oropharyngeal dysphagia refers to difficulty in the passage of liquids or food from the mouth to the oesophagus, while oesophageal dysphagia refers to difficulty with the passage of food through the oesophagus.

Aetiology

While in some cases it is difficult to identify the cause of dysphagia, certain conditions are associated with it, including eosinophilic oesophagitis, gastro-oesophageal reflux disease, multiple sclerosis, muscular dystrophy, Parkinson’s disease, injuries, certain cancers, stroke and scleroderma. Certain treatments, including radiation therapy, may result in dysphagia.

Prevalence

It is difficult to estimate the true prevalence of dysphagia, as the condition affects both adult and paediatric populations across a range of conditions. Overall, an estimated 5 per cent of the general population have dysphagia but this percentage is much higher among the elderly and in people with conditions such as stroke, Parkinson’s disease, dementia and head and neck cancer. According to US estimates, dysphagia may be as high as “22 per cent in adults over 50 years of age, as high as 30 per cent in elderly populations receiving inpatient medical treatment and up to 68 per cent for residents in long-term care settings”.

Signs and symptoms

These are varied and can include, but are not limited to:

  • Difficulty swallowing foods on the first attempt.
  • Feeling of food or liquids being ‘stuck’ in the throat.
  • Drooling.
  • Recurring respiratory infections/pneumonia.
  • Weight loss.
  • Coughing/choking during or after meals.
  • Food or liquids travelling back up through the throat or nose after swallowing.
  • Pain while swallowing.
  • Feeling of heartburn.
  • Dehydration.

Diagnosis

Diagnosis of dysphagia usually follows persistent difficulties swallowing. If the cause is not apparent, the patient will be referred to a specialist, dependant on the suspected cause, to assess them for dysphagia. Tests can include, but are not limited to, videofluoroscopy or gastroscopy.

Treatment

Swallowing disorders are treated in a number of different ways, depending on the classification of the disease. Medication may be useful among some patients, for example, to reduce stomach acid production. Swallowing therapy or intervention by a speech and language therapist may be recommended. A dietitian may help a patient find a more appropriate diet and advise on any necessary supplementation, or alternative methods of feeding. In some cases, such as if there is narrowing in the throat or oesophagus, surgery may be recommended.

Clinical impact of dysphagia

Dysphagia has a number of clinical impacts on the patient.

It can lead to serious choking episodes, recurrent pneumonias, malnutrition and dehydration. Overall mortality rate ranges from 20-to-50 per cent, with rates as high as 80 per cent reported in some groups. 

Swallowing difficulties can also have a major impact on the quality of life for individuals and their carers, interfering with routines of eating and drinking and leading to anxiety and embarrassment about eating outside the home.

Administration of medicine

A recent study found that 37.4 per cent of patients from a general practice population reported having had difficulties in swallowing tablets and capsules.

One US study found that up to 4 per cent of participants gave up on treatments because they could not swallow the prescribed pills, while 7 per cent categorically rejected taking pills that are hard to swallow.

The administration of medicines to patients with dysphagia can be complex. In such instances, clinicians should first establish whether the patient has difficulty swallowing foods or liquids. It should be noted that some thinner liquid medicines can increase the risk of coughing and aspiration in a patient with dysphagia.

Patients with known swallowing difficulties should be advised whether or not certain medications can be crushed, or their capsules opened, and of any possible drug-food interactions with their medicine. This is because some patients may modify the medications prescribed to them to make them easier to swallow. A recent study found people who take more than four doses of medicine a day appear more likely to crush tablets or open capsules, potentially reducing their effectiveness.

For more information on dysphagia and World Swallowing Day, see the European Society for Swallowing Disorders website at www.myessd.org.

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