Short ‘n Sweet – Preclinical Dysphagia

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Over the last few decades, prevention has been a key role in health more than ever. From preventing wrinkles to preventing heart disease, taking steps to prevent, at times, inevitable outcomes can have an influential impact down the road. 

But what if we don’t think there’s a problem or anything to be changed?🤔 That’s just what this viewpoint type of article starts to explore, and let me tell you, the insights learned may stick in your SLP mind longer than extra-thickened molasses…

The author single-handedly shares an all-too-common story to really ensure the topic at hand actually relates to a clinician’s life. For a moment, just try to remember any independently living older patient that has ended up in the hospital for something as seemingly innocent as a fall or dehydration. Easy enough, right? Fast forward a couple days later and before any clinical bedside evaluation, and this patient might be found to be not only malnourished, but also inadvertently making natural changes to their diet even before this instance such as avoiding super moist foods like rice or never chugging liquids down to avoid any “discomfort or difficulty.” This “dysphagia of unknown etiology” according to the author is what would be known as ”“preclinical dysphagia:”

“CDOA [community dwelling older adults] who live independently in their home may underreport swallowing difficulties. In fact, CDOA view swallowing problems as a natural part of aging..they independently apply compensations like diet modification and avoid food/reduce intake, all without ever considering their swallowing difficulties and subsequent compensations may be pathologic.” p.1

Just how many CDOA might we be talking about here? Madhavan et al.’s 2016 systematic review reference shares a wide range from “5-72% with a mean prevalence of 15% among high-quality research studies.” And if you think that number’s gonna stay the same or shrink, you’ll be knocked off your feet to learn quite the opposite😳:

Older adults aging in place, combined with their underreporting of swallowing difficulties, puts an estimate of 5 million CDOA at risk for dysphagia in the United States alone. Consequently, a deeper understanding of this subset of CDOA at risk for preclinical dysphagia is essential to help with early identification and prevention of dysphagia-related morbidities.” p.2

If we really stop to think deep and hard about the above existential phenomenon, this will only grow as those in the “baby boomer” generation (1940s-1960s) continue to naturally age into the geriatric category (absolutely no shame in the age game though folks!😉). The real question remains:

Dr. Madhavan (and her lab)’s first step from their 2016 systematic review was to identify “risk factors associated with dysphagia in CDOA,” and now are proposing a framework to help not only understand this phenomenon, but also to identify preclinical dysphagia early and intervene as appropriate!

Risk factors for dysphagia in CDOA:

  • History of multiple medical diagnoses (unrelated to causing dysphagia)
  • Age >70 years
  • Cognitive decline
  • Physical frailty (including difficulty independently performing ADLs)

The author also includes other related concepts and the parallels such as a “dysphagic-related geriatric syndrome” and “geriatric giant” to help us finally understand this continually evolving framework:

“A geriatric syndrome is defined as ‘clinical conditions in older persons that do not fit into disease categories but are highly prevalent in old age, multifactorial, associated with multiple co-morbidities and poor outcomes, and are only treatable when a multi-dimensional approach is used’ ” p.2 (Baijens et al. 2016)

“Smithard described dysphagia as a “geriatric giant,” that is, not a diagnosis by itself, but symptoms that require a multidisciplinary approach to management.” p.2 (Smithard, 2016)

Meanwhile, preclinical dysphagia is hanging out there like:

If you’re anything like me, likely sitting at the edge of your seat reading and waiting for the almighty words to tell us what to do when it comes to this ongoing and fascinating aging-anomaly…

As so many beginning Facebook statuses awkwardly declared long-ago:

Dr. Madhavan does serve some great food for thought when describing why it’s hard to know for sure given the fact that many of the tools we turn to when trying to diagnose (or screen) swallowing impairment, while validated for older populations, are often not applicable to this special subgroup because they rely on either self-reported or symptomatic factors:

“given that CDOA accept swallowing difficulties as a natural part of aging, this approach may underidentify dysphagia..because these tools were designed to assess dysphagia as a result of a known etiology, these tools may not consider that observed functional declines may have presented in the reverse, that is, the swallowing decline preceded the functional decline in absence of a known underlying etiology. Yet, understanding that this reverse presentation is possible may be essential to our understanding of dysphagia in CDOA.” p.2

Think about it, if you don’t consider something an actual “problem” (like me not thinking twice of a “clinking” sound my car door makes or older adults simply avoiding a certain texture) but more as a “way of life” or typical “wear and tear” that can be easily remedied without major inconvenience (like turning my radio louder so I don’t hear the clink😅), then would you be as apt to bring it up to your doctor or mark “yes” to a question like, “Do you have difficulty with swallowing foods/liquids?

More of the author’s previous work has already started on developing a more appropriate, patient-reported outcome screening tool for the early identification of dysphagia risk in CDOA:

“Psychometric validation resulted in a 17-question PRO tool…Emergent factors represented swallowing effort, physical function, and cognitive function.”

“The results revealed strong construct validity and internal consistency. A novel, simple PRO incorporating multiple function domains associated with aging demonstrated strong preliminary psychometric properties. This tool is more comprehensive and aging-focused than existing dysphagia screening tools.” (Abstract; Madhavan et al., 2018)

Until we get our hands on this following validation and all the other required assurances, here are different areas to consider from this proposed multidimensial framework of preclinical dysphagia in CDOA, based off the varying levels of evidence compiled thus far:

Factors with Causative Evidence

(“it is known” that these are factors to have an influence on preclinical dysphagia in CDOA)

  • Advanced Age+Swallowing Difficulties
    • Obviously the umbrella cause of a myriad of issues, with decreased muscle mass, elasticity, strength, and range of motion all leading to a functional decline which can pose a threat to airway protection and inefficiency during meals
    • Increased age=higher susceptibility of illnesses/diseases/injuries etc. “that may not cause dysphagia, but can still exacerbate declines in a functional aging swallowing, pushing the individual over the threshold to dysphagia (Namasivayam-MacDonald & Riquelme, 2019)
  • Medical Diagnoses
    • Obviously a wide array of neurological, pulmonary, cardiac, or other related conditions (e.g. reflux or cancers, etc.) are known to influence swallowing difficulties
    • “Associations with health conditions like diabetes, depression, and chronic pain may be significant and merit further investigation, because (a) these diagnoses are not typically thought to be associated with dysphagia and (b) prevalence of these diagnoses increase with increasing age”
    • “Moreover, multiple medications may be required to manage these conditions, and these medications may have an impact on swallowing and oral intake. If symptoms of swallowing difficulty are not routinely reported to medical professionals, they are likely to be ‘missed’ or underdiagnosed until further systemic decline occurs as a result of dysphagia” p.4

Factors with Associative Evidence:

(more like, “it can be said that these factors can influence clinical dysphagia in CDOA”)

  • Reduced Physical Function & Frailty
    • Reduced tongue strength can lead to sarcopenia/dysphagia sarcopenia, which can be associated with increased aspiration in older adults (Butler et al., 2011)
    • Molfenter et al. (2019) demonstrated atrophied larger pharyngeal volumes found in older adults related to reduced constrictiona and inefficient swallows
    • Needless to say, in addition to acute hospital-associated debilitation not even related to specific neurological or known diagnoses influencing dysphagia, “there is strong preliminary evidence to suggest that aging is a risk factor for declining physical function, frailty, and resulting sarcopenia that can predispose older adults to dysphagia and all of its negative consequences
  • Cognitive Decline
    • Even an acute decline or delirium (remember why we consider orientation/cognition for Yale Swallow Protocol?) along with general declines with age can impact the “cognitive awareness, visual recognition of food, physiologic response, motor planning, and execution of sensorimotor responses” that the act of swallowing requires (Rogus-Pulia et al., 2015)
  • Undernutrition/Malnutrition
    • Loads of evidence all pointing to the fact that changes in an individual’s diet (e.g. texture, amount, duration, etc.) can impact overall nutritional health and increase risks in many other factors (falls, frailty, oral healt, etc.), and “suggest that older adults living in the community who have dysphagia may present with an elevated risk for malnutrition that is likely underrecognized or undertreated
  • Oral Health
    • From missing/removed teeth, to xerostomia and reduced salivary flow, along with medication side effects (see above*cough*😉), denture discomfort, and Langmore’s long-live revelations that dysphagia alone≠pneumonia, all can contribute to various swallowing difficulties

“Although the evidence is growing, much of it is associative…Limited evidence is available to describe the direct impact of reduced cognition on dysphagia in the CDOA. However, the strong relationships between frailty, cognition, and reduced nutrition cannot be ignored, as deficits in one area can significantly impact the others and further affect swallowing.” p.6

Factors with Speculative Evidence

(you might think it could have an impact, but no known evidence)

  • Social Support
    • Think along the lines of lack of assistance/support can lead to increased falling and decreased ability to complete ADLs, which can eventually impact swallowing (brushing teeth etc.)
    • More social support = better accessibility for medical/dental care, obtaining meals/nutrition, and a variety of food selections for comprehensive nutrition/health
  • Sensory Loss
    • Obviously sensation, especially oropharyngeal sensory pathways, (along with sight, smell, and taste) dampen with age, which can lead to attempts to alter foods or decrease overall PO intake and “may be an early symptom of preclinical dysphagia” and could further lead to frailty, malnutrition, overall functional decline, and eventually contribute to dysphagia

“Despite this theoretical and clinical knowledge, there is no direct evidence that demonstrates the relationship between dysphagia, sensory loss, and social support.” p.7

Since I’m not nearly as gifted as Dr. Madhavan in visually depicting the complexity of all those factors, I have to beg you to check out the actual article (or at least the supplemental material!!🤩😍) to really better understand how it all connects and more details, I promise it’ll help way better than I ever could!

So, while many of those factors are things we as SLPs already have permanently glued in our minds🤓, when considered collectively in this multifactorial way where “a decline in any single factor can likely contribute to declines in other factors, subsequently leading to overall decline,” for SLPs working with the geriatric population, it’s going to continue to be important to “ask about swallowing difficulties even when obvious signs do not exist, especially in the face of factors that may relate to initiating or exacerbating decline in swallowing function.”

The author even brings it back to the initial example, suggesting something unrelated like chronic pain could potentially impact an independently-living gentleman’s ability to complete ADLs or lead to frailty, potentially resulting in changes in mealtime behaviors and malnutrition/dehydration, and ultimately end with a hospital admission outcome such as a fall.

“This multidimensional framework was developed to initiate the conversation regarding improved management of dysphagia in CDOA…and can help inform improved screening and identification.” p.8

Until we know more about the how, where, or when of any type of screening measure, what it comes down to is instead of the asking the obvious “Have you been having any issues swallowing?” we need to keep trying to investigte a bit further into many other areas mentioned above even when some older patients may insist “Everything’s fine” and chalk it all up to “just normal aging.“🧐

Article Referenced :[FREE ASHA ACCESS]

Madhavan, A. (2021). Preclinical Dysphagia in Community Dwelling Older Adults: What Should We Look For?. American Journal Of Speech-Language Pathology30(2), 833-843. doi: 10.1044/2020_ajslp-20-00014

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