DR' Akanis Srisukwattana

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Geriatric Review
Dysphagia in Elderly

• DR. Akanis Srisukwattana

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SCOPE

• PREVALENCE
• CHANGES IN ESOPHAGEAL PHYSIOLOGY WITH AGING
• CAUSES OF DYSPHAGIA
• DIAGNOSTIC AND THERAPEUTIC APPROACHES

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Introduction

• Dysphagia is a very common problem in older
  individuals.
• In a survey from the Netherlands, 16 of a cohort
  of residents older than 87 years described
  symptoms of swallowing dysfunction
• Some esophageal diseases are much more common in
  older patients, including Zenkers diverticulum,
  cervical osteophytes, and dysphagia aortica.

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Introduction

• Other disorders may have special diagnostic
  considerations, in older patient with achalasia,
  the possibility of secondary achalasia due to a
  distal esophageal malignancy is more likely than
  in a young
• They are also more likely to be on multiple
  medications, which may have unwanted side effects
  and drug-drug interactions.

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Introduction

• Eating problem are relate with gastrointestinal
  tract, including cognitive or psychiatric
  problems, physical disability of the upper limbs,
  deterioration of the muscles of mastication,
  dental disease, and osteoporosis affecting the
  mandible.

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PREVALENCE

• In studies from Europe, dysphagia occurs in 8 to
  10 of persons over age 50 years,
• Studies of patients in general medical wards have
  noted prevalence rates of 10 to 30
• One study reported that, even in older patients
  without dysphagia, video fluoroscopy shows
  abnormalities in up to 63.

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PHYSIOLOGY OF SWALLOWING

• Oral preparatory phase
• Under voluntary control and involves use of
  cranial nerves V , VII , and XII.
• Pharyngeal phase
• Esophageal phase

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Pharyngeal phase

• Pharyngeal peristalsis. occurs by advance of soft
  palate to posterior nasopharyngeal wall, which
  narrows upper pharynx, and contraction of the
  superior constrictor muscles.
• Simultaneously, larynx and hyoid are pulled
  upward and forward, causing relaxation of the
  cricopharyngeus muscle, which makes up much of
  the upper esophageal sphincter
• Controlled reflexively and involves CN V , X , XI
  and XII.
• During swallowing, respiration is inhibited
  centrally

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Esophageal phase

• Peristaltic contractions in body of esophagus
  combined with simultaneous relaxation of the
  lower esophageal sphincter propel the bolus into
  the stomach.

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CHANGES IN ESOPHAGEAL PHYSIOLOGY WITH AGING

• Motility of the Upper Esophageal Sphincter
  (UES)/Pharynx
• Motility of the Esophageal Body
• Motility of the Lower Esophageal Sphincter
• Changes in Sensory Function

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Motility of the Upper Esophageal
sphincter(UES)/Pharynx

• Dysfunction of the proximal aspects of swallowing
  (UES and pharynx)
• Pharyngeal muscle weakness and abnormal
  cricopharyngeal relaxation
• Abnormal of the coordination of muscle
• Lower resting UES pressure and delayed UES
  relaxation after swallowing.

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Motility of the Upper Esophageal
sphincter(UES)/Pharynx

• longer in duration of oropharyngeal swallowing,
  
• Increase the sensory threshold for initiating a
  swallow result in a increased risk of pharyngeal
  stasis and potential for aspiration

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Motility of the Esophageal Body

• Decrease in myenteric neurons, which result in
  dysmotility
• Impaired secondary peristalsis
• Increased frequency of failed primary peristalsis
  (possibly reflux related)
• More patients with ineffective esophageal
  motility (IEM)

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Motility of the Lower Esophageal Sphincter

• Abnormal LES responses to deglutition, including
  a reduced amplitude after contraction,
• Hiatal hernias seem to increase in aging

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Changes in Sensory Function

• Secondary peristalsis decrease with aging
• Impaired sensation with balloon distention
• Impaired sensation with acid perfusion (Berstein
  test)
• Impaired pharyngeal sensation (decreases swallow
  initiation)

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CAUSES OF DYSPHAGIA

• Devided into two categories
• Oropharyngeal dysphagia (OPD) Abnormalities
  affecting the neuromuscular mechanisms
  controlling movements of the tongue, pharynx, and
  UES
• Esophageal dysphagia (ED)
• Abnormal affecting the esophagus itself

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Oropharyngeal Dysphagia (OPD)
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Stroke

• Affects the swallowing center in the brainstem or
  the nerves that modulate the swallowing process,
  including the fifth, seventh, ninth, tenth, and
  twelfth cranial nerves
• Evidence of a swallowing disorder was noted in
  51 in patient with acute stroke
• Increased rate of complications such as
  aspiration pneumonia, dehydration, malnutrition,
  and depression.

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Parkinsons Disease

• Dysphagia develops in approximately 50 of
  patients
• Due to damage to both the central and enteric
  nervous system
• Tremor of the tongue or hesitancy in swallowing
• Dysfunction of the pharyngeal phase of swallowing

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Myasthenia Gravis (MG)

• Nasal regurgitation ,jaw claudication
• Bulbar muscle weakness causes dysphagia and
  dysarthria labeled
• Atrophy of the tongue with paresis and atrophy of
  other muscle of the palate and uvula

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Multiple Sclerosis (MS)

• 34 reported dysphagia.
• Dysphagia in MS from bulbar involvement and
  severity of the illness.

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Idiopathic Upper Esophageal Sphincter Dysfunction

• Cricopharyngeal dysfunction
• Inability of muscle to function in synchrony
  with other components of swallowing mechanism

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Local Structural Lesions

• Head and neck tumors.
• Abscess, congenital web, prior surgical resection
  
• Enlarged thyroid gland
• Cervical hypertrophic osteoarthropathy and
  cervical osteoarthritis

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Zenkers Diverticulum

• Outpouching in the posterior pharyngeal wall
  above the UES
• More common in males than females
• Present with classic symptoms of cough, fullness
  and gurgling in the neck, postprandial
  regurgitation, and aspiration.
• If become large will produce visible mass, which
  may gurgle on palpation (Boyces sign) or
  obstruct esophagus thereby contributing to
  esophageal dysphagia

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DIAGNOSTIC AND THERAPEUTIC APPROACHES

• Oropharyngeal Dysphagia (OPD)

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• Careful history and physical examination may
  provide clues to the diagnosis.
• Evidence of a systemic neurologic disorder should
  be sought.
• Careful examination of the head and neck for a
  neoplasm.

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• The major diagnostic study in the evaluation of
  OPD is a barium x-ray of the pharynx and UES with
  videofluoroscopy
• a) dysfunction or inability to initiate the
  pharyngeal swallow,
• b) aspiration
• c) nasal regurgitation
• d) obstruction to the normal barium flow
• e) residual bolus in the pharynx after
  swallowing.

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• Treatment depends on the underlying cause.
• Parkinsonism, myasthenia gravis, polymyositis,
  and thyroid dysfunction
• Neoplasms require resection and chemotherapy or
  radiotherapy
• Rehabilitation ,trained in swallowing therapy
• Type of food -thickened liquids (honey-like
  consistency).
• In permanent dysphagia gastrostomy or jejunostomy
  may be the only option and should not be delayed

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Esophageal Dysphagia
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Three most important questions

• 1) Is the dysphagia with solids alone or also
  with liquids?
• 2) Is the dysphagia intermittent or progressive?
  
• 3) Is there any symptom associated?

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Achalasia

• Slowly progressive dysphagia for solids and
  liquids and gradual weight loss.
• Associated with a significant increase risk for
  pulmonary complications, malnutrition, and
  gastroesophageal cancer
• Secondary achalasia should suspected in a patient
  with clinical triad of age greater than 50
  years, dysphagia of less than 1 years duration,
  and weight loss of greater than 15 lb.

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Achalasia

• The principal treatment options are pneumatic
  dilatation, surgical myotomy, and injection of
  botulinum toxin.
• Pneumatic dilation is a safe procedure in the
  elderly.
• Injection of botulinum toxin into the LES
  provides effective short-term symptomatic relief
  in patient that have serious medical illness.

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Diffuse Esophageal Spasm and Related Disorders

• Present by intermittent dysphagia for both solids
  and liquids, association with chest pain
• Esophageal manometry shows normal peristalsis
  interrupted by simultaneous (nonperistaltic)
  contractions

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Scleroderma

• Esophageal involvement occurs more than 80 of
  patients.
• Slowly progressive dysphagia for both solids and
  liquids, as in achalasia.
• Heartburn is prominent symptom of severe
  gastroesophageal reflux, gt40 develop a peptic
  esophageal stricture that increased risk for
  Barretts esophagus and esophageal
  adenocarcinoma.

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Esophageal Cancer

• Progressive dysphagia associated with
• weight loss.
• History of tobacco and alcohol use.
• Gastroesophageal reflux may risk for Barretts
  esophagus to adenocarcinoma
• Investigation- Barium X ray study and Endscope
  with biopsy.

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Peptic Stricture

• Occur in 7-23 of patients with untreated reflux
  disease, especially older men.
• Present with progressive dysphagia for solids
  food with history of heartburn and other symptoms
  of gastroesophageal reflux.

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Rings or Webs

• Present with nonprogressive intermittent
  dysphagia for solids food
• Most symptomatic rings present after 50 years
• Has been called Steakhouse syndrome.
• Diagnosis by Barium swallow with a solid bolus
  and endoscopy is indicated if question about the
  diagnosis and to facilitate dilation.

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Vascular Compression

• Dysphagia aortica is a disorder of hypertensive
  elderly, more often female.
• Caused by external compression from an ecstatic,
  tortuous, or aneurysmal aorta
• Radiographic findings include a prominent
  indentation of aortic arch on plain chest
  radiograph.
• On barium swallow show partial esophageal
  obstruction at aortic arch area, pulsatile
  movement of barium synchronous with aortic
  pulsation
• Endoscopic findings include stenosis, band-like
  pulsatile extrinsic compression, or kinking of
  the esophagus.

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Medication-Induced Esophageal Injury

• Occur when caustic medicinal preparations
  dissolve in the esophagus termed pill esophagitis
  or pill-induced esophageal injury.
• Elderly are risk for several reasons
• Take more medications
• Have anatomic or motility disorders
• Spend more time in a recumbent position
• Reduced salivary production and/or impaired
  esophageal motility.

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Medication-Induced Esophageal Injury

• Factor that relate injury
• Sustained-release preparations
• Large pills or those with sticky surfaces
• Patients position at the time of ingested
• Volume of fluid ingested with the drug.

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DIAGNOSTIC AND THERAPEUTIC APPROACHES

• Esophageal Dysphagia (ED)

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Esophageal Dysphagia (ED)

• Characterized according to
• Predominant type of material involved (solids
  only or liquids and solids)
• Intermittent, stable, or progressive.
• Associated symptoms including heartburn,
  regurgitation and weight loss.
• Diagnostic procedure are barium studies,
  manometry, and endoscopy.

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Thank You