Short ‘n Sweet Review – Presbyphagia

This topic has completely gotten me and I know others totally entranced, so I wasn’t too entirely surprised it took the first cake (although I’ve been dying to read more about biofeedback too!!😉🤓). And, instead of 1 article, I figured let’s really start this off with a 💥bang💥 and include 2 great articles I’ve got! Since this is supposed to be a quick ‘n dirty…I mean short ‘n sweet review, let’s jump right in!!

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The first article up, McCoy & Desai (2018):

“Presbyphagia versus Dysphagia: Identifying Age-Related Changes in Swallow Function”

This article is a muust-read (honestly guys, this is one where even just the abstract will leave you a better clinician!) and made perfect sense to start us off because it gives such an awesome brief summary of everything presbyphagia, starting with, of course, the definition:

“Presbyphagia refers to characteristic changes in the swallowing mechanism of otherwise healthy older adults. It is an old, yet healthy, swallow.” p.1

 

Still confused?🤨🤔 They don’t leave ya hanging..

“Presbyphagia is not a disease in itself but contributes to a more pervasive naturally diminished functional reserve, making older adults more susceptible to dysphagia.”

“When an older healthy adult, whose functional reserve or their ability to adapt to stressors, has been naturally diminished with age, or they are faced with increased stressors, such as acute illnesses, medications, mechanical disruptions, or chronic medical conditions, they become more vulnerable, crossing the link from having a healthy aging swallow to being diagnosed with dysphagia” p.2

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(#relatableanyone?😂)

But, what exactly are these changes to be on the lookout for healthy older adults you ask🤷‍♀️?? Obviously, knowing the specific swallow pathophysiology cannot be known and understood without direct visualization of the mechanism (i.e. VFSS/FEES), and the authors do us all a huge favor by spelling it all out:

 

  1. Changes in Oropharyngeal Function
  • Diminishing management and manipulation of bolus due to reduced dentition, oral hygiene, and altered salivary flow
  • Reduced sensation for viscosity, reduced lingual pressures (isometric tongue pressures)°

“Although older individuals manage to achieve pressures necessary to affect an adequate swallow despite a reduction in overall maximum tongue strength, they achieve these pressures more slowly than young swallowers.”  p.3

  • a “slowed” swallow” >65 years old→ significantly delayed airway protection mechanisms of the larynx and pharynx (including laryngeal vestibular closure)

“Thus, in older healthy adults, it is not uncommon for the bolus to be adjacent to an open airway by pooling or pocketing in the pharyngeal recesses for more time than in younger adults, increasing the risk of adverse consequences due to ineffective deglutition.” p.3

 

2. Airway invasion/swallow safety:

    • “In older adults, penetration of the bolus into the airway occurs more often and to a deeper and more severe level than in younger adults…under stressful conditions or system perturbations, older individuals are less able to compensate due to the age-related reduction in functional reserve capacity.” p. 3

 

3. Changes in Esophageal Function

  • increased intrabolus pressure
  • increased impedance (resistance) to bolus flow at the pharyngoesophageal segment
    • “The high-pressure zone associated with the upper esophageal sphincter (UES) appears reduced in length as compared with younger subjects.” p.3

  • reduced UES resting pressures
  • reduced UES pressure during opening of the segment
  • reduced UES response to pharyngeal/laryngeal stimulation

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(I think we can all painfully agree that everything basically starts ‘relaxing’ as we get older, #amiright?😅)

 

4. Changes in Sensory Function

  • decreasing lip and tongue spatial-tactile awareness
  • decreasing recognition and response to viscosity in oral cavity
  • poor oral stereognosis°
  • reduced taste perception

“Increased use of prescription medication in the older adult and its impact on the swallow due to side effects, with xerostomia being the most common that can have a significant impact on swallowing.” p.4

At this time I wanna give a shoutout to the second article by Leslie, Drinnan, Ford, & Wilson, (2005) to point out another elderly change,

Swallow Respiratory Patterns and Aging:

Presbyphagia or Dysphagia?

 

Again, this article can also be great to just gain some preliminary info from the abstract😉 (but I’ll give you the rundown because I can’t help it😅🤓),

“Methods: 50 volunteers (aged 20–78 years) were recruited to have swallow respiration patterns recorded on a computer. Bolus volume and consistency variations were studied: 5 and 20 ml of water, and 5 ml of yogurt.” p.1 Abstract

Obviously, this isn’t the hugest sample size to go off of to be able to generalize all the results, but you can rest assured that the researchers really tried to make the situation as realistic as possible (meaning no cued swallows, done in either the hospital or a home, and keeping the participant unaware of their swallow and respiratory patterns), while also keeping some things veryImage result for yeah yeah yeah gif standardized (like measuring all bolus amounts via syringe prior to spoon application, specific measurements for swallow apnea before/during/after swallowing, and noting how many swallows occurred).

“A significant, positive correlation was found between age and duration of swallow apnea for both the 5 ml water boluses and 5 ml yogurt boluses” p.3

“Age was not correlated with airflow direction postswallow [or] multiple swallowing. [Nor was] there evidence of age affecting respiration reset patterns.” p.4 [edits]

So a healthy older person might ‘stop breathing’ for longer during a swallow, but that doesn’t mean their whole system is changed, and likely can be a good modification:

“Such a change may be a protective mechanism rather than solely a result of decreased muscle mobility or reaction times. This increased duration of apnea may enable the system to compensate for other age-related changes such as longer oropharyngeal and hypopharyngeal transit times and delayed initiation of maximum hyolaryngeal excursion.” p.4

“The lack of correlation between age and apnea duration on 20 ml of water may indicate that the bolus is approaching a size at which respiration patterns become unstable or that a larger bolus is required to maintain an age-independent swallow mechanism. This would fit with sensation decreasing as we age, and so older people need larger, more flavorsome boluses (not the opposite, as has been traditionally thought).” p.4

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Both articles actually make a great point for thinking about this in the context of specific populations we already know have differences in sensation and respiratory coordination during swallowing (think Parkinson’s, dementia) and require modifications to amounts or sensory aspects (flavor), even though this may put some more at risk in normal circumstances. Because if you can’t feel something (or it takes longer to sense something like pooling in the pharynx), how can you consciously know how to manage it?  Food for thought🙃🤤. . .


 

This refresher may seem somewhat common sense to some, and for others feel like the closet to Narnia transporting you to a whole new world of SLP-thinking, I like to think of this as the never-ending “SLP-Englightenment” journey😅. But what I think is crucial for all of us medical SLPs, who work with adults of all ages, with a vast range of diagnoses, comorbidities, different goals for care and medical risks, is that old≠impaired, as Robbins et al. (1992) eloquently and bluntly explains:

“Presbyphagia may place elderly individuals at greater risk for developing dysphagia. However, evidence suggests that the secondary effects of disease are necessary to disrupt the normal intake of food and liquid in older individuals (Robbins et al., 1992).” p.4

Just like aspiration≠pneumonia, there are always a ton of factors to consider and there needs to be some type of atypical event–be it a fall, stroke, reduced oral intake, changes in medications, infection, whathaveyou– that would need to take place in order to go from presbyphagia (see definition above), to a true dysphagia (and ultimately put the ‘host’ at risk for immunocompromisation for that scary pneumonia anyway😉).

The authors really drive the point home further about not only the risks of overmanaging (i.e. unnecessary diet restrictions or strategies) or undermanaging (i.e. dehydration, malnutrition, aspiration consequences) the assessment and intervention of this population, but also the fact that,Image result for the limit does not exist gif

“there are no standard algorithmic approaches for elderly patients with dysphagia; rather goals and plans are individualized to fit given clinical scenarios.” p.5

Sorry guys, that’s why our services are called ‘skilled‘👩‍⚕️ and we (hopefully) do the amazing, time-consuming, behind-the-scenes work we do for our patients. They instead offer some guidance as we all go into work the next day, keeping these little factoids tucked in our maxed-out SLP brain🧠:

“First, if we can differentiate expected age-related changes in swallow function from those that are atypical, our ability to diagnose dysphagia, and target specific therapies for it, is improved.”

“Second, if we understand typical changes in swallow function with aging that are also aversive, we may be able to prevent or minimize swallowing difficulty in the older adult.” p.2

 

And if that wasn’t clear enough and you’re looking for another reason not to sprint straight into that dietary closet for more thickener or ordering chin tucks for the masses, more food for thought from Article #2:

“We need to modify our current thinking on the swallow: are all of the changes we observe in the 85-year-old poststroke patient due to dysphagia or simply oropharyngeal presbyphagia? We must increase our knowledge of the effects of presbyphagia on the increasing healthy older population and the effects of dysphagia in these people as they succumb to age related illnesses.” p.5

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🤯(us talking to our colleagues/bosses after learning all this)🤯


Articles Referenced:

 

  • Leslie, P., Drinnan, M., Ford, G., & Wilson, J. (2005). Swallow Respiratory Patterns and Aging: Presbyphagia or Dysphagia?. The Journals Of Gerontology: Series A60(3), 391-395. doi: 10.1093/gerona/60.3.391

♦♦♦ I highly recommend checking out the references from the above articles for even more info and knowledge that I know I missed and couldn’t fit in something that’s supposed to be short ‘n sweet  (hopefully it was bearable and I’ll get the hang of this “shorter” writing style😅)

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