Dysphagia in Elderly

Posted by e-Medical PPT Friday, September 28, 2012
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 Zenker’s diverticulum, cervical osteophytes, and dysphagia aortica.
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.
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

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%.

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

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

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

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

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

DIAGNOSTIC AND THERAPEUTIC APPROACHES
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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