• Dysphagia means difficulty in swallowing.
• It also includes the feeling that the food is stuck in the throat or between the throat and the stomach.
• Difficulty in swallowing is more common among older people. About 5% to 10% of older people who live independently have difficulty in swallowing.
• Swallowing becomes difficult when food does not pass normally from the mouth to the stomach.
• The swallowing difficulty may be temporary and disappear on its own, or it may be caused by a disorder.
• The swallowing process is partly under a person’s control (voluntary) and partly without conscious effort by the person (involuntary).

Causes of Dysphagia

• Simple problem e.g. eating too fast, taking bites that are too big, poorly fitting dentures or having loose or missing teeth, not drinking enough water when eating or eating while lying down can cause swallowing difficulty.
• Older people with dementia may not know how to chew their food adequately or may forget to swallow it.
• Food and foreign bodies may block the esophagus.
• Noncancerous (benign) or cancerous (malignant) tumor in the esophagus can partially or completely blocked the esophagus.
• Any disorders that may damage the muscles, nerves or brain which involved in swallowing can cause difficulty in swallowing, for example:
  1. Stroke is the most common example among older people. About 30% of people who have had a stroke have difficulty in swallowing.
  2. Other neurological diseases such as Parkinson’s disease, myasthenia gravis can also cause difficulty in swallowing.
  3. Some drugs such as phenothiazines (a type of antipsychotic drug) can cause difficulty in swallowing because they affect the throat muscles.
• Some disorders can block the esophagus by putting pressure on it from outside, for example:
  1. A heart disorder may cause part of the heart to enlarge and press on the esophagus
  2. Cancer, most commonly lung cancer and
  3. Enlargement of the thyroid gland can put pressure on the esophagus.

Sign and Symptoms

• Most people who have difficulty in swallowing have difficulty in swallowing solid food, e.g. bread and meat. After eating, they may feel as if they have a lump in their throat and they may have to swallow several times before the food feels as if it has gone down.
• Much later, swallowing liquids may become difficult.
• However, some people have difficulty swallowing solids and liquids from the beginning.
• People with difficulty in swallowing may regurgitate food through the mouth or nose. When they lie down at night, they may cough or spit up food swallowed many hours before.
• They may inhale (aspirate) food into the windpipe (trachea), then develop cough. Aspirating food can lead to lung infections i.e. a form of pneumonia called aspiration pneumonia.
• Depending on the cause of dysphagia, older people may have different symptoms.

Complications

If older people continue to have difficulty in swallowing, they may lose weight, become undernourished and dehydrated. Aspirating food into the lungs will lead to infections which may be severe if treatment is not given early.

Diagnosis

• If difficulty in swallowing lasts more than a few days, the older person should see a doctor promptly.
• The doctor will try to identify the underlying cause. Symptoms provide some clues to the cause. The doctor usually asks whether the person has difficulty swallowing both solids and liquids, whether pain is felt and whether the person has vomited blood or seen blood in stool. The throat is examined, and the person is asked to swallow to see if the throat is working normally.
• Usually, tests are needed to identify the cause. Most often, the esophagus is examined with a flexible viewing tube (endoscope) that is passed down the throat. The doctors may need to take a sample of tissue in order to rule out cancer,
• A barium study may be done before endoscopy or it may be done afterward if endoscopy does not provide enough information. It can detect any blockages, tumors, ulcers and evidence of spasm. This study also helps doctors assess the function of the nerves and muscles involved in swallowing.

Treatment

• Treatment focuses on helping the older person to swallow safely including how to avoid aspiration and on treating the disorder causing the problem if possible.
• Effective treatment enables a person to eat enough types of foods in order to get a well-balanced and adequate diet.
• Sometimes, simple measures are the only treatment required, e.g. chewing food thoroughly and then sipping water can help prevent symptoms, sitting upright while eating can help foods with certain textures such as thick creamed soups or pureed fruits may be easier to swallow. Using appropriate eating utensils may help, for example, using a small straw or small spoon can limit the amount of food put in the mouth and a smaller amount is easier to swallow.
• If the cause is a disorder that impairs the muscles or nerves involved in swallowing, speech therapists may suggest exercises to strengthen the muscles or improve coordination and techniques to use when eating.
• Occasionally, surgery may be indicated e.g. when the cause is due to blockages by tumors or external compression by enlarged thyroid gland etc.