Research Proposal on "Dysphagia in the Elderly"

Research Proposal 10 pages (2606 words) Sources: 1+

[EXCERPT] . . . .

Dysphagia in the Elderly

The work of Michael R. Spieker (2000) entitled: "Evaluating Dysphagia" published in the journal of the 'American Family Physician' states that dysphagia is a problem "that commonly affects patients cared for by family physicians in the office, as hospital inpatients and as nursing home residents." Problems that are known to lead to complaints of dysphagia include:

Cerebrovascular accidents;

Gastoresophageal reflux disease; and 3) Medication-related side-effects. (Spieker, 2000)

Spieker states that stroke patients "are at particular risk of aspiration because of dysphagia." (2000) Approximately seven to ten percent of adults over the age of fifty years of age have dysphagia although according to Spieker (2000) this number "may be artificially low because many patients with this problem may never seek medical care."

Approximately 25% of patients who are hospitalized and 30 to 40% of patients in nursing homes "experience swallowing problems." (Spieker, 2000) Spieker states that "diseases of the esophagus are among the top 50 reasons that patients seek medical care, and in frequency, rank alongside problems such as pneumonia, bronchitis and otitis media." (2000) Conditions that cause dysphagia can "produce esophageal rupture, nutritional deficits and aspiration pneumonia." (Spieker, 2000) the following figure lists the differential diagnoses of Dysphasia which has been adapted from the work of Spieker (2000)

Differential Diagnoses of Dysphagia

Oropharyngeal dysphagia

Esophageal dysphagia

Neuromuscular disease

Diseases of the central nervous system

Cerebrovascular accident

Parkinson's disease

Brain stem tumors

Degenerative diseases

Amyotrophic lateral sclerosis

Multiple sclerosis

Huntington's disease

Postinfectious

Poliomyelitis

Syphilis

Peripheral nervous system

Peripheral neuropathy

Motor end-plate dysfunction

Myasthenia gravis

Skeletal muscle disease (myopathies)

Polymyositis

Dermatomyositis

Muscular dystrophy (myotonic dystrophy, oculopharyngeal dystrophy)

Cricopharyngeal (upper esophageal sphincter), achalasia

Obstructive lesions

Tumors

Inflammatory masses

Trauma/surgical resection

Zenker's diverticulum

Esophageal webs

Extrinsic structural lesions

Anterior mediastinal masses

Cervical spondylosis

Neuromuscular disorders

Achalasia

Spastic motor disorders

Diffuse esophageal spasm

Hypertensive lower esophageal sphincter

Nutcracker esophagus

Scleroderma

Obstructive lesions

Intrinsic structural lesions

Tumors

Strictures

Peptic

Radiation-induced

Chemical-induced

Medication-induced

Lower esophageal rings (Schatzki's ring)

Esophageal webs

Foreign bodies

Extrinsic structural lesions

Vascular compression

Enlarged aorta or left atrium

Aberrant vessels

Mediastinal masses

Lymphadenopathy

Substernal thyro

Source: Spieker (2000)

II. DIFFERENTIAL DIAGNOSIS of DYSPHAGIA in the ELDERLY

Spieker states that the patients who have dysphagia "may present with a variety of complaints, but they usually report coughing or choking, or the abnormal sensation of food sticking in the back of the throat or upper chest when they are trying to swallow." (2000) it is necessary that the physician conduct the patient history carefully in order to identify the causes of the dysphagia and this involves asking specific questions about the "onset, duration and severity of the dysphagia, and a variety of associated symptoms." (Spieker, 2000) a patient history that conducted carefully will answer two general questions as follows:

Is the dysphagia oropharyngeal or esophageal in nature; and Is it caused by mechanical obstruction or a neuromuscular motility disorder? (Spieker, 2000)

III. TYPES of DYSPHAGIA IDENTIFIED

The following descriptions are assigned to each of the types of dysphagia as noted in the work of Spieker (2000):

1) Oropharyngeal Localization - Patients with this condition present "with difficulty in initiating swallowing and also may have associated coughing, choking or nasal regurgitation. The patient's speech quality may have a nasal tone. This type of dysphagia is most often associated with stroke, Parkinson's disease or other long-term neuromuscular disorders. (Spieker, 2000)

2) Esophageal Localization - "Patients with esophageal dysphagia present with the sensation of food sticking in their throat or chest. Motility disorders and mechanical obstructions are common. Several medications have been associated with direct esophageal mucosal injury while others can decrease lower esophageal sphincter pressures and cause reflux." (Spieker, 2000)

3) Neuromuscular Motility Disorders - "Patients with neuromuscular dysphagia experience gradually progressive difficulty in swallowing solid food and liquids. Cold foods often aggravate the problem. Patients may succeed in passing the food bolus by repeated swallowing, by performing the Valsalva maneuver or by making a positional change. They are more likely to experience pain when swallowing than patients with simple obstruction. Achalasia, scleroderma and diffuse esophageal spasm are the most common causes of neuromuscular motility disorders." (Spieker, 2000)

4) Mechanical Obstruction - "Obstructive pathology is typically associated with dysphagia of solid food but not liquids. Patients may be able to force food through the esophagus by performing a Valsalva maneuver, or they may regurgitate undigested food. Close questioning of the patient may reveal a change in diet to one of predominantly soft foods. Rapidly progressive dysphagia of a few months' duration suggests esophageal carcinoma. Weight loss is more predictive of a mechanical obstructive lesion. Peptic stricture, carcinoma and Schatzki's ring are the predominant obstructive lesions." (Spieker, 2000)

The following chart illustrates the process of evaluation of Dysphagia as set out in the work of Spieker (2000).

Evaluation of Dysphagia

Source: Spieker (2000)

IV. TYPES of TESTING in DYSPHAGIA

Testing types that may be used in assessing dysphagia include those as follows:

Barium swallow studies;

Double-contrast upper gastrointestinal evaluation;

Gastoesophageal endoscopy;

Manometry;

pH monitoring; and Videoradiography. (Spieker, 2000)

V. RECENT STUDY FINDINGS

The work of Paul E. Marik and Danielle Kaplan (2003) entitled: "Aspiration Pneumonia and Dysphagia in the Elderly" published in the 'Chest' journal states that community-acquired pneumonia (CAP) "is a major cause of morbidity and mortality in the elderly and the leading cause of death among residents of nursing homes." (Marik, 2003) the most important factor leading to pneumonia in the elderly is stated by Marik to be that of "oropharyngeal aspiration." (2003) This is because "the incidence of cerebrovascular and degenerative neurological diseases increase with aging and these disorders are associated with dysphagia and an impaired cough reflex with the increased likelihood of oropharyngeal aspiration." (Marik, 2003) According to Marik, elderly patients who present with "clinical signs suggestive of dysphagia and/or who have CAP should be referred for a swallow evaluation. Patients with dysphagia require a multidisciplinary approach to swallowing management." (2003) This may be inclusive of "swallow therapy, dietary modification, aggressive oral care, and consideration for treatment with an angiotensin-converting enzyme inhibitor. (Marik, 2003)

The work of Bautmans, et al. (2008) entitled: "Dysphagia in Elderly Nursing Home Residents with Severe Cognitive Impairment Can be Attenuated by Cervical Spine Mobilization" published in the 'Journal of Rehabilitative Medicine' reports a study which investigated the "feasibility of cervical spine mobilization in elderly dementia patients with dysphagia, and its effects on swallowing capacity." (Bautmans, et al., 2008) the method used in this study of fifteen nursing home residents (9 women, 6 men, age range 77-98 years) with severe dementia (median Mini Mental State Examination score=8/30, percentile (P)25-75=4-13) and known dysphagia participated in a randomized controlled trial with cross-over design involved the administration of cervical spine mobilization by trained physiotherapists. The study reports "...Control sessions consisted of socializing visits. Feasibility (attendance, hostility, complications) and maximal swallowing volume (water bolus 1-20 ml) were assessed following one session and one week (3 sessions) of treatment and control." (Bautmans, et al., 2008) Study results report "...ninety percent of cervical spine mobilization sessions were completed successfully (3 sessions could not be carried out due to the patient's hostility and 2 due to illness) and no complications were observed. Swallowing capacity improved significantly after cervical spine mobilization (from 3 ml (P25-75=1-10) to 5 ml (P25-75=3-15) after one session p=0.01 and to 10 ml (P25-75=5-20) (+230%) after one week treatment p=0.03) compared with control (no significant changes, difference in evolution after one session between treatment and control, p=0.03)." (Bautmans, et al., 2008) Conclusions stated by Bautmans et al. (2008) include that cervical spine mobilization "...is feasible and can improve swallowing capacity in cognitively impaired residents in nursing homes. Given the acute improvements following treatment, it is probably best provided before meals." (Bautmans, et al., 2008)

The work of Rebecca S. Stone (2006) entitled: "Dysphagia in the Elderly" published in 'Inpatient Times' reports that dysphagia is "a remarkably prevalent disorder in the aging population. In independently living populations of > 65-year-olds, up to 15% may have dysphagia. In facility-based populations, the prevalence is as high as 40%. Normal effects of the aging process, such as deterioration in salivary gland function or decreased reflexive opening of the upper esophageal sphincter, can be contributing factors to dysphagia, as can stroke or dementia. Finally, medications, including diuretics, anti-cholinergics, anti-histamines, and beta-blockers can lead to or worsen dysphagia due to xerostomia." (Stone, 2006) Stone additionally states that when a patient has a stroke or other event that has the ability to cause an impairment to swallowing it is critical to look "for signs that swallowing is impaired" including:

cough after swallow; voice change after swallow; abnormal volitional cough; abnormal gag reflex; dysphonia; and dysarthria. (Stone, 2006)

Stone states that the patient should be observed carefully "during spontaneous swallowing. If no signs of swallowing impairment are noted then the patient may be tested under direct observation using small amounts of clear liquid. If no swallowing dysfunction is noted, the diet may be carefully advanced." (Stone, 2006) However, in the event that difficulty in swallowing or any of… READ MORE

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