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Otolaryngol Head Neck Surg.. 2009; 140:33-36 https://doi.org/10.1016/j.otohns.2008.10.010 Walker RW, Dunn JR, Gray WK. Self-reported dysphagia and its correlates within a prevalent population of people with Parkinson's disease. Dysphagia. 2011; 26:(1)92-96 https://doi.org/10.1007/s00455-010-9317-x Older people’s health Gastrointestinal health Dysphagia: a guide for nurses in general practice 02 April 2020 Dysphagia Linda Nazarko Linda Nazarko West London NHS Trust, London, UK View articles · Email Linda 02 April 2020  Volume 31 · Issue 4 ISSN (print): 0964-9271 ISSN (online): 2052-2940 References AbstractDysphagia is common in older adults. Linda Nazarko gives an overview of how practice nurses can support individuals living with dysphagia The practice nurse may encounter people who present with a variety of medical problems that are ultimately caused by swallowing difficulties. These difficulties may be acute or longstanding, severe or mild. The number of adults living with swallowing difficulties is set to rise in line with population ageing and the increasing levels of frailty and comorbidities that occur in older adults. This article aims to provide a guide to why dysphagia develops, how dysphagia is diagnosed and how the practice nurse can support individuals who are living with dysphagia. The UK population is ageing and the number of people aged 85 years and over is rising rapidly (; ). Dysphagia becomes more common in older age and is associated with neurological problems and frailty (). Older people may consider that swallowing difficulties are part of ageing and may not visit the GP practice until they develop complications such as weight loss or a chest infection. The practice nurse should be alert to the clinical features of dysphagia and should check if the older person is experiencing swallowing difficulties when an older person seeks treatment (). Certain older people have greater risks of dysphagia than others ().
What is dysphagia?Dysphagia literally means difficulty eating or swallowing. Intact motor and nervous systems are essential to enable normal swallowing (). There are four phases in a normal swallow ().
Around 11% of adults living in the community have dysphagia (). It is more common in older people, and 10–27% of older people living at home have dysphagia (; ; ; ). Why does it occur?Dysphagia is a symptom that may occur because of a number of conditions. It is more common in older adults but may also occur in younger adults and in children. Common causes include (; ):
PresentationThe person with dysphagia may present with a number of symptoms and if the practice nurse is not alert to the possibility of dysphagia these may not be immediately identified. Clinicians can fail to recognise dysphagia or its possible significance (). outlines the clinical features of dysphagia ().
When dysphagia is suspectedWhen the practice nurse suspects dysphagia the nurse should check for red flags that indicate the need for urgent medical attention, and in other cases determine if further investigations and treatment are required. The practice nurse should also advise the person on how to manage their dysphagia. Red flagsThe term ‘red flags’ was introduced in the 1980s and is used to signal that the person requires urgent medical attention. In terms of dysphagia, there are three major red flags. These are rapidly progressing dysphagia, suspected aspiration pneumonia or recurrent pneumonia, and inability to maintain nutrition and hydration. If a red flag is present then the nurse should escalate the case using local protocols. Steadily worsening dysphagia over a few weeks in an older person is suggestive of malignancy and patients should be urgently referred under the 2-week rule in England. Most (90%) of people referred under the two-week rule do not have cancer (). People with dysphagia are at increased risk of pneumonia and aspiration pneumonia (). Dysphagia increases the risk of developing aspiration pneumonia by 700% (). Aspiration is the term used when foods or fluid passes through the vocal folds and enters the airway. Aspiration can be caused by impaired laryngeal closure or because of the overflow of food or liquids retained in the pharynx. Aspiration increases the risk of choking and aspiration pneumonia. The larger the volume of fluid or food aspirated the greater the problem. Food and fluids can be aspirated into the trachea or more deeply. Deep aspiration is more dangerous than shallow aspiration. The properties of the aspirate are also important. Acid material (such as orange juice) can set up an inflammatory reaction in the lungs and cause serious damage. When a person has a normal swallow, the person will cough on aspiration and this helps to clear food or fluid from the lungs. Aspiration that is not accompanied by a cough is known as ‘silent aspiration’. This is much more dangerous than aspiration accompanied by a cough, because food or fluids penetrate the airway and move deep into the lungs. Silent aspiration is more likely to cause major respiratory problems. The practice nurse should consider dysphagia if a person has a history of recurrent chest infections and should carry out a dysphagia screen. If the person has an active chest infection this should be treated. Dysphagia can affect the ability to eat and drink and affect health and quality of life (). The person is at risk of malnutrition and dehydration. An estimated 3 million people in the UK are malnourished and older people are at greatest risk (). The Malnutrition Universal Screening Tool (MUST) can be used to work out malnutrition risk and provides guidance on actions to be taken (). New or deteriorating dysphagiaDysphagia can be a transient, persistent or deteriorating symptom. If a person presents with new dysphagia or a deteriorating swallow the practice nurse should follow local protocols. These may involve completing a dysphagia screen and possibly carrying out an initial assessment of swallowing (; ). illustrates the components of an initial swallowing assessment (). If the person is unsafe, or possibly unsafe, to swallow, then urgent medical referral is required. Normally, when there are non-urgent concerns regarding dysphagia, the individual is referred to a speech and language therapist (SLT). The SLT will investigate, treat or manage the condition when possible and escalate if there are concerns that cannot be managed by an SLT. Treating contributory factorsOlder people are more likely to develop swallowing problems because ageing is associated with decreased gastro-intestinal motility (; ). People who suffer from a reflux of gastric acid into the oesophagus can develop oesophageal scarring and stricture and this can lead to, or worsen, dysphagia (). The use of proton pump inhibitors, such as omeprazole, can reduce acid reflux and improve swallowing. Oesophageal carcinoma may be treated surgically or palliatively according to tumour staging and patient preference. Palliative treatment may include dilatation, stenting and other treatments (). Poor oral health can contribute to problems with dysphagia: tooth loss, gum disease and infection affects the ability to bite and chew (; ). The practice nurse should check if oral health problems are contributing to dysphagia, treat any infection and advise the person to seek dental treatment. MedicationWhen an individual has difficulty swallowing tablets or capsules, all medication should be reviewed. Medication reviews can be carried out by doctors or non-medical prescribers including practice nurses and pharmacists. The medication review will consider whether a specific medicine is necessary, whether any medicines are contributing to dysphagia, if easier-to-swallow medication is available, if medication can be safely crushed, or if liquid medication or alternative routes of delivery are the best option. outlines this process. Is the medication necessary?It is important to determine if the medication is necessary. General practice is currently under great pressure, so it can be difficult for GPs to manage medication reviews (). Non-medical prescribers, by carrying out medication reviews, can make a great difference to a person's quality of life. Is medication causing or contributing to dysphagia?Certain medications have anticholinergic effects. Anticholinergics are a class of drugs that block the action of the neurotransmitter acetylcholine in the brain. This action reduces spasm of smooth muscles. They are used to treat diseases like asthma, incontinence, allergies, gastrointestinal cramps and muscular spasms, and are also prescribed for depression and insomnia. Side effects of anticholinergic medications include dry mouth and slowing of movement throughout the gastrointestinal system. As many medicines have anticholinergic effects, the side effects increase with each medicine that has anticholinergic side effects. This is known as the ‘cholinergic burden’ (). Medicines that may be contributing to dysphagia should be discontinued if at all possible. If the person has a condition that requires treatment the prescriber may consider an alternative medication that is less likely to cause swallowing difficulties. Easy-to-swallow formulationsSometimes tablets and capsules are large and difficult to swallow. It may be possible for the prescriber to prescribe an easier-to-swallow formulation. Paracetamol, for example, comes in tablets and caplets. Many people find the capsule shape of a caplet easier to swallow. The prescriber might prescribe two smaller tablets or capsules instead of one large one. Crushing, splitting, removing from capsules and mixing with foodThe practice nurse should check if the patient or his or her caregiver is crushing medications (). Crushing medication can affect the absorption (pharmacokinetics) and effects (pharmacodynamics) of medicines. Some medication should never be crushed. Medicines that are designed to be released slowly over a long period (modified release) which are crushed can result in a large amount of the medicine being released quickly. This can lead to ineffective treatment, adverse effects or, in some cases, death. Cytotoxic and hormone medication should not be crushed, as this places the person who crushes the medication at risk (). Splitting is the process of cutting or splitting a medicine in two or more pieces in order to make it easier to swallow or to provide the correct dose. Removing medicine from a capsule can render it ineffective, as the capsule is designed to protect the medication from the stomach acid and ensure it is properly absorbed. Medicines should never be removed from a capsule unless the prescriber or a pharmacist advises that this can be done. If medicine is mixed with food it can be difficult to ascertain how much, if any, of the medicine has been taken. Medicines can interact with food and drink. There is little research into how common this practice is when a caregiver gives a person medication at home. The found that in 70% of care homes surveyed, medication was being mixed with food and drink. Liquid medicines and alternative routesLiquid medicines may be helpful, but as they are not available in modified release form they may have to be given more often. Liquid medicines may require refrigeration and some require shaking before use. Prescribers may consider different routes including topical, sublingual, buccal, rectal and parenteral. Some medicines are available in oro-dispersible formulations. These are designed to dissolve quickly in the mouth. This include medicines to treat gastro-oesophageal reflux—common in those with dysphagia. Management of dysphagiaIn many cases, it is not possible to treat dysphagia and the aims of care are to maintain nutrition and hydration, reduce the risk of aspiration pneumonia and ensure that the person is able to take medication. The key to maintaining nutrition and hydration in people with dysphagia is to promote safe swallowing and to ensure that the person has food and fluids which are of the appropriate texture and thickness. provides guidance on how to advise a person on safe swallowing.
When a person has dysphagia, SLTs and dieticians may advise that fluids are thickened. They will provide expert advice on the amount of thickener to use and the consistency of fluids to be consumed. There is a risk of choking and airway obstruction if a person tries to eat thickening powder. Dysphagia is common in advanced dementia. Department of Health guidance advises staff to be aware of these risks and to store thickeners appropriately when there is a risk of ingestion (). The practice nurse may provide advice to care-givers regarding their relative who has dysphagia and may have dementia, so it is important to emphasise that care should be taken to avoid accidental ingestion of thickeners. The person with dysphagia should be advised to consume a diet of the appropriate texture. Normally dieticians and SLTs provide such advice. If the person is not able to cook or does not have someone who can prepare suitable meals, these can be purchased and delivered to the person's home for reheating. ConclusionIncreasing numbers of people living at home have dysphagia. People who are old, frail and those who have neurological disease are at particular risk of developing this symptom; however, it can occur in others who do not have the major risk factors. The practice nurse needs to be alert to the possibility that a person has dysphagia and be aware of how to assess and refer people with suspected dysphagia. In day-to-day practice, the practice nurse will support people living with dysphagia. The practice nurse may be asked for advice from patients and caregivers on ongoing management of dysphagia. Sometimes a person with dysphagia will experience a deteriorating swallow, and the person or caregivers may be unaware of the potential clinical significance of this. The practice nurse may be the first person to be consulted about these problems. Prompt intervention on the nurse's part can at times be life-saving. In other cases, the practice nurse's interventions and advice make a huge difference to the person's treatment and quality of life. Which diagnostic test is used to confirm the diagnosis of ALS?These typically include an MRI (magnetic resonance imaging) of the neck, and sometimes of the head and lower spine, an EMG (electromyography) which tests nerve conduction, and a series of blood tests. Sometimes urine tests, genetic tests, or a lumbar puncture (also called a spinal tap) are also necessary.
How is ALS disease diagnosed?There is no single test that provides a definitive diagnosis of ALS. It is primarily diagnosed based on a detailed history of the symptoms observed by a physician during physical examination, along with a review of the individual's full medical history and a series of tests to rule out other diseases.
What causes ALS symptoms?ALS causes the motor neurons to gradually deteriorate, and then die. Motor neurons extend from the brain to the spinal cord to muscles throughout the body. When motor neurons are damaged, they stop sending messages to the muscles, so the muscles can't function. ALS is inherited in 5% to 10% of people.
How to get tested for ALS?You might first consult your family doctor about signs and symptoms of ALS . Then your doctor will probably refer you to a doctor trained in nervous system conditions (neurologist) for further evaluation.
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