Fast Facts: Neurogenic Dysphagia

By A. Sabry, K. Kyriakou and M. Moerman

Dysphagia refers to any difficulty or problem with deglutition or bolus movement from the time the bolus is placed in the mouth until the time it enters the stomach. It affects around 16 million individuals in the USA and over 40 million individuals in Europe. Evaluation of dysphagia by a phoniatrician/speech-language pathologist (SLP) may consist of a clinical swallow evaluation and an instrumental assessment, such as a videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic valuation of swallow (FEES). This resource is designed to benefit a broad audience, including phoniatricians, SLPs, trainee SLPs, physicians, nurses, dietitians, and occupational and physical therapists who work with populations who have dysphagia, as well as researchers in the field of swallowing disorders. Table of Contents: • Definition, etiology, epidemiology, symptoms and consequences • Normal swallowing and pathophysiology of dysphagia • Screening and clinical swallowing examination • Instrumental assessment • Management • Recent advances and future directions

• Language: English
• Publisher: S. Karger
• Release date: Dec 6, 2022
• ISBN: 9783318072167

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Introduction

Dysphagia refers to any difficulty or problem with deglutition or bolus movement from the time the bolus is placed in the mouth until the time it enters the stomach. It affects around 16 million individuals in the USA and over 40 million individuals in Europe. Symptoms of dysphagia, which include difficulty feeding and swallowing, coughing and vomiting, may lead to medical complications, including aspiration, dehydration, undernutrition, weight loss, choking and death. Other important consequences are psychological problems, such as social isolation and depression, and economic issues, such as lost days of work and high healthcare costs.

Evaluation of dysphagia by a phoniatrician/speech-language pathologist (SLP) may consist of a clinical swallow evaluation and an instrumental assessment, such as a videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallow (FEES). Treatment includes food and liquid modifications (for example, texture-modified diets), as well as direct and indirect swallow therapy, which involves the use of various swallowing maneuvers with or without food or liquid, respectively.

This resource is designed to benefit a broad audience, including phoniatricians, SLPs, trainee SLPs, physicians, nurses, dietitians, and occupational and physical therapists who work with populations who have dysphagia, as well as researchers in the field of swallowing disorders. We hope it will increase readers’ knowledge about dysphagia, resulting in more accurate identification of the condition and prompt referral for specialist care. Ultimately, it is hoped that this will improve the quality of life of individuals with dysphagia and reduce the medical, economic and psychological consequences of the condition.

1Definition, etiology, epidemiology, symptoms and consequences

Definition of dysphagia

The term ‘swallowing’ signifies the entire act of deglutition from the placement of food in the mouth until the food arrives in the stomach.¹ Any difficulty or problem with deglutition or bolus movement from the time the bolus is placed in the mouth until the time it enters the stomach is defined as dysphagia. Problems with deglutition may include slow movement, incomplete passage or misdirection of a bolus.² Here, we focus on oropharyngeal swallowing problems caused by neurological problems, so the esophageal phase (from the moment the bolus has passed the upper esophageal sphincter [UES]) falls out of the scope of this resource.

Etiology

Neurogenic dysphagia is caused by a neuromuscular disorder. There are numerous possible etiologies of neurogenic dysphagia secondary to damage to the CNS and/or cranial nerves (CNs), and unilateral cortical and subcortical lesions (Table 1.1).

TABLE 1.1

Causes of neurogenic dysphagia

Epidemiology

Prevalence. Dysphagia, particularly oropharyngeal dysphagia, affects around 16 million individuals in the USA and over 40 million individuals in Europe.³ In 2014, a US national health interview survey reported that 9.44 million (1 in 25; 4%) adults had a swallowing problem.⁴ In a 2020 population-based survey of more than 31 000 adults in the USA, 1 in 6 participants (16.1%) reported experiencing dysphagia.⁵

Incidence of neurogenic dysphagia varies widely depending on its etiology and method of diagnosis. For example, a systematic review of 33 studies reported the incidence of dysphagia in patients with stroke, Parkinson’s disease and traumatic brain injury to be 8.1–80%, 11–81% and 27–30%, respectively.⁶ In patients with strokes, the incidence of dysphagia was found to be 51–55% with clinical testing and 64–78% with instrumental testing.⁷ In patients with multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS) and cervical dystonia, the incidence of dysphagia was reported to be 24–34%, 86% and 2–36%, respectively.⁸

Symptoms

Symptoms of dysphagia are shown in Table 1.2.

Consequences

Dysphagia may lead to medical, psychological and economic consequences.

Medical consequences

Aspiration occurs when materials (for example, food, liquids, pills or secretions) descend below the vocal cords and enter the trachea;¹⁰ it is one of the main complications of dysphagia. Intense or chronic aspiration of swallowed material or material that regurgitates from the stomach into the airway can result in aspiration pneumonia: 55.2% of patients diagnosed with oropharyngeal dysphagia and aspiration have been shown to also have pneumonia.¹¹

Dehydration is a situation in which there is not enough water in the body to maintain a normal level of liquids in the body tissues.¹⁰ Patients with dysphagia who need to be on thickened liquids but do not like to drink them may become dehydrated. In one study, 53% of patients with dysphagia secondary to a stroke demonstrated evidence of dehydration.¹²

TABLE 1.2

Symptoms of dysphagia

Undernutrition and weight loss. Undernutrition occurs when the body does not receive adequate quantities of nutrients.¹⁰ It may occur in patients who are unable to swallow safely or who are unwilling or afraid to eat or drink because of previous swallowing problems. This can affect the patient’s energy levels and compromise their immune system.¹³ In one study, 17% of nursing home residents with oropharyngeal dysphagia were malnourished compared with residents without oropharyngeal dysphagia.¹⁴

Weight loss may occur when the individual does not eat or eats less because of swallowing difficulties. Extensive weight loss may result in a loss of muscle mass, which can lead to significant weakness that may affect daily activities.¹⁰

Choking occurs when a solid bolus physically blocks the airway.¹³ It may stop the individual from breathing properly and can be life threatening.

Death may occur as a result of choking, dehydration, undernutrition and/or aspiration pneumonia. Mortality has been shown to increase in patients with oropharyngeal dysphagia compared with individuals without the condition 30 days (22.9% vs 8.3%) and 1 year (55.4% vs 26.7%) after they are diagnosed with dysphagia.¹¹

Psychological consequences. Individuals with dysphagia may experience social isolation and depression. Social interactions often involve sharing meals with others either in or outside the home. People with dysphagia who have choking or coughing episodes may not want to share meals with others and as a result can become socially isolated from friends, colleagues and family members.¹³ Other psychological consequences of dysphagia include stress and unhappiness. For example, a person with dysphagia who needs to be on a modified diet, such as puréed food, may be reliant on a family member or hired carer to prepare their meals, which can be a cause of stress. Additionally, a person with dysphagia who needs to be on a modified diet who does not like the texture may be unhappy.¹³

Economic consequences. Adults with a swallowing problem reported 11.6 lost workdays over 1 year versus 3.4 lost workdays for those without a swallowing problem.⁴ In addition, patients may need specialized feeding equipment (for example, a G-tube or nasogastric tube) or nutritional formulas, blenders, thickeners or prethickened liquids, which are all extra expenses. Patients may also need to hire someone to help with food preparation and feeding. Speech therapy services, clinical or instrumental swallowing evaluations, psychological therapy and hospitalization for pneumonia and other complications may also be required, all of which can be costly.

Healthcare costs. Dysphagia significantly increases healthcare costs. Reports in several countries have shown increased costs per person (compared with patients without dysphagia) of $4510 (USA, Medicare costs),¹⁵ $6243 (USA, inpatient costs),¹⁶ $4282 (Denmark, hospitalization costs),¹⁷ €3000 (France)¹⁸ and CHF14 000 (Switzerland).¹⁸ Healthcare costs in patients with dysphagia have been reported to be 40–60% higher than in patients without dysphagia.¹⁵,¹⁶,¹⁹

Key points – definition, etiology, epidemiology, symptoms and consequences

Oropharygeal dysphagia is any difficulty or problem with the act of deglutition or bolus movement from the time the bolus is placed in the mouth until it passes the UES.

Neurogenic dysphagia may result from various etiologies, including cerebral vascular