Mealtime Partners, Inc.

The Impact of Aging upon Swallowing

The vast majority of people have no difficulties with swallowing until they become elderly. As we age we are more likely to become ill and this can negatively affect our ability to eat and drink. Additionally, with age our muscles lose mass as well as elasticity. These changes impact our ability to chew and swallow and as we grow older we may find that our chewing takes more time (is slower) and that the swallow process is also slower. Along with these changes, reduction in saliva production, our ability to smell, and to taste food, may also be reduced. Elderly people can make adjustments to their mealtimes to accommodate the age related changes in their eating abilities. However, illness and disease can cause significant sudden degradation in our eating and drinking abilities that are more difficult to accommodate. Problems with swallowing are called dysphagia.

There are a wide range of conditions that can cause dysphagia, and the risk of acquiring any of them increases with age. However, the two most prevalent dysphagia triggering disorders in the elderly are stroke and dementia. The impact of dysphagia, caused by these conditions, includes, but is not limited to, malnutrition, dehydration, and pneumonia. Additionally, they contribute to increased length of hospital and rehabilitation stays, and the need for long term help when they return home. This all contributes to an increase in healthcare costs.

It is not uncommon for people to be identified as under nourished when they are admitted to the hospital because of a stroke. Unfortunately, the condition is likely to worsen during their hospitalization and also during the time they spend in a rehabilitation facility¹. Difficulties experienced with swallowing contribute to this problem as the individual finds eating and drinking difficult. This results in them consuming less.

Pneumonia occurs in approximately one third of those individuals who have a stroke and who are also identified as having dysphagia. Pneumonia is responsible for as many as 35% of the deaths that occur after a stroke. Pneumonia in stroke patients commonly occurs as a result of aspiration. The stroke causes swallowing difficulties and as a result food or liquid are aspirated into the airway below the true vocal cords. The aspirated material causes an infection in the lungs (aspiration pneumonia). The likelihood of having a stroke increases with age. The likelihood of developing dysphagia dramatically increases if a stroke occurs. The likelihood of aspirating increases with dysphagia, and the likelihood of pneumonia occurring increases with aspiration, so the relationship between aging, stroke, dysphagia, aspiration, and pneumonia are compelling.

A great number of elderly people who live in institutional settings are affected by dementia, and as many as 45% of those affected by dementia are impacted by some degree of dysphagia. Depending upon how the dementia is manifested will influence how their swallow difficulties occur. In most cases their chewing and swallowing process is slowed and meals take much longer to consume than they did in the past. Additionally, many people with dementia may lose the ability to feed themselves. This may be because of cognitive difficulties or decline in motor abilities. Combining the increased time requirement for eating and the need for feeding assistance, as well as a decrease in appetite, increases the risk of these individuals not getting enough to eat. Over time this frequently leads to under nutrition or malnutrition. The resulting weight loss can cause a weakened health status, which increases the likelihood of the development of infections like pneumonia.

Because of the high incidence of dysphagia in the elderly population who has dementia, dysphagia management programs are commonly implemented to improve the health outcomes for this population. Strategies that are used include changes to the individual’s positioning during eating and drinking. Lowering the head so that the chin is close to the neck during swallowing is a frequent positioning change used to improve swallowing safety. Swallowing maneuvers are also used. Depending upon the swallowing problem, different maneuvers are used. For example, in some instances the individual consciously holds their breath prior and during swallowing, rather than depending upon their body’s natural apneic event that happens during swallowing. Also, an effortful swallow, or hard swallow, is used to increase the force at which food is propelled during a swallow.

Lastly, and the most commonly used intervention is texture modification of both food and liquid. Liquids are thickened so that they become a more viscous consistency which provides more control over the liquid during the swallowing process. A complication that is associated with thickening liquids is the risk of dehydration. Thickened liquids are not well accepted by those for who they are prescribed, and therefore, individuals often do not consume enough liquid and dehydration results.

The consistency of food, and the ease with which it can be chewed and swallowed, is changed by chopping it into tiny pieces, blending it, or pureeing it, depending upon the level of difficulty that the individual is experiencing when swallowing food. Tough, or dry, food is very hard for someone who has chewing and swallowing difficulties to eat. Meat that is chewy, or stringy, can be a special problem because even when it is chewed, and chewed, it does not break down into soft particles and, therefore, is difficult to swallow as it remains a lump even after being ground by the teeth. Of course, for those who do not have teeth, or have ill-fitting dentures, the problem is amplified.

Dry food creates an entirely different problem. Imagine eating a cracker. The cracker breaks up easily when ground by the teeth, however, the particles that result need to be mixed with a significant amount of saliva to make them into a moist mixture to form a bolus that can easily be swallowed. For many people who have swallowing difficulties, the production of an adequate volume of saliva to moisten the particles of a cracker is difficult, or impossible, and thus dry cracker crumbs distribute throughout the mouth rather than binding together. Flakes can easily be breathed to the back of the throat and sucked into the windpipe resulting in choking or aspiration.

Regardless of the cause of dysphagia, for those who are affected by it, it is important that they eat slowly and are offered foods that have the appropriate texture for the individual to eat without choking or aspiration. In many instances, it is helpful to use assistive technology to facilitate eating and drinking in a safe manner. Mealtime Partners offers cups that are designed to help drink both thin and thick liquids safely.

1. Foley, N. C., Martin, R. E., Salter, K. L., Teasell, R. W. “A Review of the Relationship Between Dysphagia and Malnutrition Following Stroke. Journal of Rehab Med. 2009; 41:707-713.