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Medical care of older persons in residential aged care facilities (Silver Book)

Dysphagia and aspiration

Assessment
Management

Dysphagia refers to difficulty in swallowing; there is a 40-50% prevalence among elderly people in RACFs.160 Oropharyngeal dysphagia is the most common form of dysphagia in older people, and the most common causes are neurological disorders such as stroke, Parkinson disease, and dementia. Oropharyngeal dysphagia may be characterised by difficulty in initiation of swallowing and the impaired transfer of food from the oral cavity to the oesophagus. Oropharyngeal dysphagia causes increased morbidity and mortality through dehydration, malnutrition and aspiration pneumonia, and may be associated with depression and deterioration in quality of life.

Causes of oesophageal dysphagia include motility disorders, medication, inflammatory causes (eg. reflux oesophagitis), infection (eg. candidiasis) and obstructions(eg. oesophageal cancer) and rarely Zenker's diverticulum, external pressure.

Aspiration refers to the inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract. Silent aspiration, ie. aspiration without key clinical symptoms and signs, is found in more than 50% of patients who aspirate. Older people at risk for aspiration include those with stroke, Parkinson disease, dementia, reduced level of consciousness, or any severe illness or disability. Aspirate can include food, saliva and gastric content. Sequelae of aspiration are dependent on the amount, frequency and nature of aspirated material as well as the person's immune response. Aspiration pneumonitis is a chemical reaction in the lung parenchyma caused by the inhalation of sterile gastric contents. Aspiration pneumonia is infection caused by inhalation of oropharyngeal secretions that are colonised by bacteria. Aspiration pneumonia is the most common cause of death in patients with dysphagia associated with neurological disorders.

Assessment

The usual symptoms of dysphagia include food sticking in the throat, coughing or choking, as well as nasal or oral regurgitation. There is lack of evidence to support the use of screening protocols for oropharyngeal dysphagia.161 Clinical suspicion of aspiration could be followed up by referral to a speech pathologist for swallow assessment, and a 'modified barium swallow' when indicated. In some cases, referral may be required to a gastroenterologist or an ear, nose and throat specialist for further investigations(eg. endoscopy, full barium swallow with video recording, and manometry).

Aspiration pneumonitis and aspiration pneumonia have overlapping clinical features that may include coughing or choking on food, dyspnoea, crepitations, and signs of consolidation. However, they can present with nonspecific signs such as fever or a sudden deterioration in oxygen saturation (see Respiratory infections).

Management

In residents with dysphagia, the risk of aspiration can be reduced b:162,163

  • minimising sedative and narcotic use(eg. related to dementia, cerbrovascular accident[CVA])

  • oral hygiene to reduce risk of aspiration pneumonia

  • dietary modification(eg. thickened fluids in place of thin fluids)

  • education and/or supervision of resident with respect to safe swallowing methods(eg. upright posture, chin tucked,slow swallowing)

  • education of relatives not to give inappropriate food or drink

  • manoeuvres to achieve improved swallowing (eg. supraglottic swallow)

  • speech therapy referral for more detailed clinical swallow assessment to guide therapy (if appropriate)

  • dietician referral to optimise nutritional intake(if appropriate and available).

Aspiration pneumonitis and minor degrees of aspiration pneumonia do not require antibiotic treatment. Pain relief may help patients with chest pain to cough and clear secretions.164 There is a lack of evidence to guide management of patients with recurrent aspiration pneumonia secondary to advanced neurodegenerative diseases. Enteral feeding (nasogastric or gastrostomy tubes) can provide nutritional support, but this has not been shown to improve or prevent aspiration. If enteral feeding is being considered in hospital, the patient, their GP and relatives/carers should be involved in decision making about commencement, including its purpose, type and duration. Ideally the issues would be discussed as part of advance care planning, before the time of a crisis, and consider medical indications, patient preferences, quality of life and contextual features.165 Nasogastric and gastrostomy tube feeding may be used as a relatively short term measure for nutritional support. It is important that the benefits and adverse effects of longer term gastrostomy feeding are carefully considered before insertion, and reviewed periodically, particularly when there is a significant change in health status. If aspiration pneumonia is an indication that the person is entering a terminal phase, then a palliative approach would be appropriate (see Palliative care).

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