The Case
A 74-year-old man with Alzheimer’s dementia presents with urinary tract infection (UTI), hypovolemia, and hypernatremia. He also has chronic dysphagia with a history of aspiration pneumonia and has been on thickened liquids at home for the past five months. As his infection is treated, he improves and requests water to drink.
Background
Dysphagia is a very common problem, particularly among elderly patients. The exact prevalence is unknown, but it is estimated to occur in up to 30% of the elderly population. Dysphagia is defined as difficulty or discomfort in swallowing and is traditionally classified as either oropharyngeal or esophageal in origin. Normal aging as well as chronic illness may lead to decreased connective tissue elasticity, muscle mass, and oral secretions, which affect swallowing performance.1 Stroke is a common predisposing condition.2 Dysphagia predisposes patients to dehydration, malnutrition, and electrolyte derangements. The most feared immediate complication is aspiration pneumonia (AP) resulting from impaired clearance of oral secretions.3
The diagnosis of dysphagia is clinical, and assessments from patients and family are often sufficient. The optimal test to assess the severity of dysphagia is a bedside swallow evaluation using small amounts of water.1 Video-assisted fluoroscopic examinations can identify problem areas within the oropharynx and esophagus and may help determine the etiology of dysphagia.
What evidence supports various treatment options for dysphagia?
Access to Water
Water is a thin liquid with low viscosity, which allows for rapid transit through the oropharynx. In debilitated and elderly patients, thin liquids easily reach the epiglottis and enter the trachea before pharyngeal muscles compensate. As such, access to water and other thin liquids is often restricted in patients suspected to have dysphagia.4
However, allowing access to water improves patient satisfaction, reduces the development of dehydration, and does not increase the incidence of AP. Bedside therapy interventions such as correct positioning and chin-tuck and sipping technique as well as attention to oral hygiene are recommended prior to more noxious options such as thickened liquids.1 The Frazier water protocol may help provide logistical guidance for facilities interested in improving access to water for patients with dysphagia.
Liquid Modification
Many clinicians manage dysphagia through restricting access to all thin liquids. In the hospital setting where video fluoroscopy and speech therapy are readily available, clinicians frequently employ the use of modified diets with thickened liquids in order to minimize the risk of aspiration despite the lack of high-quality evidence supporting liquid modification.2 Patients associate thickened liquids and restricted diets with a reduction in quality of life. Compliance studies have shown that only a minority of patients are compliant with thickened liquids at five days. In addition, thickening liquids has not been shown to decrease the risk of AP nor improve nutritional status, and it may actually cause harm by increasing the risk of dehydration and UTI.4
Tube Feeding
In patients with severe dysphagia in whom conservative management is not feasible or has failed, maintaining adequate nutrition can be a challenge. There are encouraging data with nutritionally enriching and modifying the texture of solid foods.1 Alternative methods of enteral nutrition delivery are often also considered. The most common vehicles of delivery are nasogastric tubes, post-pyloric feeding tubes, and percutaneous endoscopic gastrostomy (PEG) tubes. In theory, bypassing the pharynx and esophagus could result in fewer aspiration events and less AP.3 However, nasogastric, post-pyloric, or PEG feeding does not decrease the risk of AP. For patients with advanced dementia, there have been no randomized trials demonstrating an improvement in mortality with tube feeds.4 Tube feeding also carries with it a slight procedural risk and a high incidence of associated diarrhea, plus is associated with electrolyte derangements such as hypernatremia. The decision to pursue tube feeding should be weighed heavily in every patient and is highly influenced by the etiology and anticipated duration of dysphagia.