Research progress in the risk factors and screening assessment of dysphagia in the elderly
Kerong Chen1† Liwei Xing2† 
Bonan Xu3† 
Yi Li1 Tianyun Liu1 Tingjuan Zhang1 Hongping Shi1 Hanmei Lu1 Wengang Zhou4 Jianhong Hou5* Hongling Shi1* Dongdong Qin3*- 1Department of Rehabilitation Medicine, The Third People’s Hospital of Yunnan Province, Kunming, China
- 2The First School of Clinical Medicine, Yunnan University of Chinese Medicine, Kunming, China
- 3School of Basic Medical Sciences, Yunnan University of Chinese Medicine, Kunming, China
- 4Department of Medical, The Third People’s Hospital of Yunnan Province, Kunming, China
- 5Department of Orthopedics, The Third People’s Hospital of Yunnan Province, Kunming, China
With the aging of the population, the incidence of dysphagia has gradually increased and become a major clinical and public health issue. Early screening of dysphagia in high-risk populations is crucial to identify the risk factors of dysphagia and carry out effective interventions and health management in advance. In this study, the current epidemiology, hazards, risk factors, preventive, and therapeutic measures of dysphagia were comprehensively reviewed, and a literature review of screening instruments commonly used globally was conducted, focusing on their intended populations, main indicators, descriptions, and characteristics. According to analysis and research in the current study, previous studies of dysphagia were predominantly conducted in inpatients, and there are few investigations and screenings on the incidence and influencing factors of dysphagia in the community-dwelling elderly and of dysphagia developing in the natural aging process. Moreover, there are no unified, simple, economical, practical, safe, and easy-to-administer screening tools and evaluation standards for dysphagia in the elderly. It is imperative to focus on dysphagia in the community-dwelling elderly, develop unified screening and assessment tools, and establish an early warning model of risks and a dietary structure model for dysphagia in the community-dwelling elderly.
Introduction
Dysphagia is a process in which food is not delivered safely and efficiently into the stomach due to structural and/or functional impairment of the organs such as the jaw, lips, tongue, soft palate, throat, and esophagus (1). Aging, degradation of physiological function, tumor, stroke, and other nervous system diseases, as well as other underlying diseases make the elderly population susceptible to dysphagia (2). Approximately 8% of the global population suffer from swallowing problems (3), and research shows that the lifetime prevalence rate of dysphagia is 17.10% in the community-dwelling elderly, rising to 52.60% in high-risk populations (4).
At present, research on dysphagia in the elderly has predominantly focused on populations with a high incidence of dysphagia such as inpatients and those that have had a stroke, and the subjects are mostly elderly inpatients. There are limited surveys on the incidence of dysphagia in the community-dwelling elderly, and few studies on the influencing factors of dysphagia in the naturally aging, community-dwelling population. Early screening of populations at high risk of dysphagia is crucial to identify the risk factors of dysphagia, and perform effective interventions and health management in advance, which may reduce the incidence of dysphagia, prevent complications, lower medical burdens, and save medical resources. In the current study, a literature review was conducted on the research progress in the risk factors, screening assessment, preventive, and therapeutic measures of dysphagia in the elderly with the aim providing a reference for the screening and research of dysphagia in the elderly.
Current epidemiology and hazards of dysphagia
As a syndrome in the elderly, dysphagia has been listed by the World Health Organization (WHO) in the International Classification of Diseases-10 (ICD-10) and the International Classification of Functioning, Health and Disability (ICF) (5), and is a major public health issue worldwide. In the United States, more than half of people older than 60 years have dysphagia, and 60% of residents of nursing homes have experienced dysphagia (5, 6). Nine percent of residents of nursing homes in the Netherlands (7) and 11.4% of people in British communities complained of symptoms of dysphagia (8). In a geriatric Korean community, 33.7% of the population reported symptoms of dysphagia (9). The prevalence of dysphagia is 5.5–12.9% in the elderly in Chinese communities (10), rising to 31.1% in the institutionalized elderly (11). According to one epidemiological survey of 5,943 patients, 2,341 patients (39.4%) had dysphagia, including 51.14% of stroke patients, 34.4% of patients with head and neck cancer, 48.3% of patients with nervous degenerative diseases, and 19.2% of healthy elderly people (12).
Dysphagia hinders the intake of nutrients required by elderly patients, which leads to serious complications such as weight loss, malnutrition, dehydration, aspiration pneumonia, asphyxia, anxiety, and sociopsychological disorders. These complications directly or indirectly influence the long-term prognosis and quality of life (13), prolong hospital stays, and increase hospital readmissions and the risk of death in elderly patients (14). It was reported that over 60,000 people die each year from complications of dysphagia, of which aspiration pneumonia is the most serious complication and the leading cause of death (15). Dysphagia and its complications and sequelae increase the overall utilization of healthcare services and result in a huge consumption of medical resources. It is estimated that annual costs of dysphagia in the US medical care system are between $4 billion and $7 billion US dollars. Moreover, this estimate does not consider indirect costs, such as the economic impact of a patient’s inability to work due to dysphagia symptoms. In addition to medical costs, there are emotional and mental-health-related costs, which seriously impact the quality of life of patients and simultaneously place a heavy burden on the patient’s family, hospitals, and society (16, 17).
Risk factors for dysphagia in the elderly
Identifying the risk factors of dysphagia in the elderly is the premise and basis for the identification, assessment, and control of these risks. The main risk factors for dysphagia in the elderly are as follows.
Age
Anatomic and physiological changes in elderly patients are believed to be likely to cause dysphagia (18). The incidence of postoperative dysphagia in patients older than 60 years of age was significantly higher compared with that in patients younger than 60 years, suggesting that age is a risk factor for the development of dysphagia. Another study suggests that although the incidence of diseases that are likely to cause dysphagia, such as stroke, increases with age, the physiological changes, and functional decline that occur in natural aging are associated with the occurrence of dysphagia. With aging, factors such as tooth damage, dull neuroreceptors, decrease in salivary secretion and the elasticity of swallowing organs, and weakening of swallowing muscle strength all increase the risk of dysphagia (3, 19). Thus, even in the absence of underlying diseases, natural aging itself affects swallowing which is supported by the findings of Byeon (4) and Holland et al. (8). Therefore, it is recommended that early screening and assessment of dysphagia is performed to facilitate early intervention in the elderly population older than 60 years.
Illnesses
The prevalence of dysphagia is 27–64% in stroke patients, and approximately 50% in the acute phase (20). The figure is over 80% in patients with Parkinson’s disease (21) and 38% in those with multiple sclerosis (22). While, it is 34.4% in those with head and neck cancer (23). The incidence of dysphagia in patients with ossification of the anterior longitudinal ligament (OALL) in the neck is influenced by the thickness of osteophytes, the range of cervical motion, and craniocervical alignment, and OALL occasionally leads to dysphagia due to the anterior osteophytes (20). Skeletal muscle loss is also thought to be a possible cause of dysphagia (21).
Surgical and therapeutic factors
The incidence of dysphagia was reported to be 1–80% following anterior cervical surgery (20, 24). Furthermore, Baron et al. (25–27) found the incidence of transient dysphagia was up to 80% after anterior cervical fusion, and even higher in patients older than 60 years. Dysphagia is one of the most common complications after anterior cervical surgery (28). Severe paralysis and tracheotomy may also be risk factors for dysphagia (29). Oropharyngeal dysphagia (OD) is common in elderly patients with hip fractures and is easily overlooked, predisposing patients to life-threatening postoperative pneumonia. Hip fractures often occur in elderly patients with comorbidities such as stroke or dementia. In addition, the incidence of dysphagia is particularly high in patients with hip fractures due to intraoperative intubation. The prevalence of dysphagia was reported to be 7% in patients with hip fractures but 34% after surgery. These findings suggest that the effects of the disease itself, hospitalization, surgery, and intubation on swallowing function may be temporary, but identification of dysphagia after surgery is necessary to prevent consequences such as pneumonia. These data can help clinicians to manage patients with advanced dysphagia.
Other factors
Pharmacological factors like opioid and topical steroid (24), psychological factor such as depression (22), as well as mealtime (30), and serum albumin levels (31) are all additional influencing factors of dysphagia.
Dysphagia screening instruments
There are no unified standards of screening and assessment tools for dysphagia in elderly individuals worldwide, and multiple screening and assessment tools for dysphagia have been developed according to individual situations. Screening and assessment tools are reviewed in the current study. Table 1 details the name of the assessment tool, the country and intended populations, main indicators, methods and characteristics.
Table 1. Common screening and assessment tools for dysphagia.
In general, there are pros and cons to the various screening tools, and a widely accepted, perfect assessment tool is currently lacking. Munich Dysphagia Test–Parkinson Disease (MDT-PD) includes difficulty in swallowing general food, dysphagia unrelated to food, burden related to dysphagia, and health problems caused by dysphagia. There are 4 major parts, 26 items, and a score of < 3.65 indicates no symptoms of dysphagia. A score of 3.65–4.78 indicates early oropharyngeal dysphagia, and a score of ≥ 4.79 indicates that the patient is at risk of aspiration. In addition, 3-ounce water swallow test, repeated salivary swallowing test, simple swallowing provocation test (S-SPT) and other tests are also applied. The water swallowing test WST (32) is the most classical and most commonly used assessment methods in clinical practice, but the specificity is low, and latent aspirations cannot be effectively predicted for it could only identify the inability of safety concerns when swallowing water in patients with stroke. In addition, the risk of aspiration pneumonia from the use of these methods may adversely affect patient prognosis (33). Videofluoroscopic swallowing study (VFSS) allows real-time visual observation of the swallowing process and qualitative and quantitative analysis, which is regarded as an ideal method and gold standard for diagnosis of dysphagia (34). However, VFSS has drawbacks such as being time-consuming and complicated and causing exposure to radiation, consequently VFSS is unsuitable for early screenings.
In addition, currently available screening instruments for dysphagia are mainly aimed at inpatients with certain diseases or other unique conditions, especially elderly patients, and these tools cannot meet the screening needs of elderly people dwelling in nursing homes and communities.
Preventive and therapeutic measures
Due to increased risk of dysphagia in the elderly which is probably the result of complicated risk factors as forementioned, there is clearly a need for preventive and therapeutic measures for dysphagia in the elderly which are individualized according to their specific risk factors.
Preventive measures
Prophylactic swallowing exercises can avoid periods of nothing per oral (NPO) which is the commonest preventive measure based on the rule of “use it or lose it” (35). Study has shown that prophylactic exercises may result in maintenance of oral and oropharyngeal musculature, improved swallowing function, and less dysphagia-related aspiration pneumonia (36). Interventions to prevent dysphagia in older adults living in nursing homes included more bedside evaluation, modification of dietary, creating an appropriate environment for swallowing, providing appropriate feeding assistance, appropriate posture or maneuver for swallowing, appropriate rehabilitation program, medication treatment, and stimulation treatment. Among them, modification of dietary was the most frequently used intervention to prevent or reduce aspiration (37). Saliva aspiration prevention like oral anticholinergics, transdermal anticholinergics, intravenous anticholinergics, and salivary gland irradiation, as well as active dysphagia revalidation including bedside swallow exercises, swallow training with electrical stimulation and swallow training with surface electromyographic biofeedback were proven to be effective preventive measures for dysphagia (38).
Therapeutic measures
The primary goal of therapy is an adequate diet without any risk of aspiration, such as utilizing fluid adaptation with thickeners to avoid impaired safety, and postures and maneuvers to compensate biomechanical alterations are also generic protocols (39). Fluid and nutritional adaptation was proven to be therapeutic in older patients with dysphagia by reducing the prevalence of laryngeal vestibule penetrations and tracheobronchial aspirations (40). Due to its unpleasant taste, however, which many patients find problematic to swallow on a daily basis, thus results in low compliance (41). The minimally massive intervention (MMI) was developed to reduce nutritional and respiratory complications in older hospitalized patients with dysphagia (42). The MMI consists of the following steps: (1) dysphagia evaluation with a clinical tool and adaptation of fluids to avoid impaired safety of swallow, (2) nutritional evaluation and a triple adaptation of food with high-calorie, high-protein and high-vitamin to improve patient nutritional status, and (3) oral health and hygiene evaluation and treatment to avoid respiratory pathogen colonization of the oral cavity (43). Preliminary results suggest that the MMI might become a simple and cost-effective strategy to reduce dysphagia complications in the geriatric population with an acute disease admitted to a general hospital (44).
New treatments based on stimulation of sensorial and motor neural pathways promote swallowing function recovery rather than compensating it. Intrapharyngeal or transcutaneous neuromuscular electrical stimulation, as well as chemical or pharmacological stimulation using TRPV1 (transient receptor potential vanilloid 1) agonists like capsaicin and piperine, which heighten sensory stimuli to the afferent pathway of deglutition, are the peripheral stimulation techniques that have got the most attention (45, 46). Because there are few studies and small patient samples, there is minimal scientific evidence for these therapy approaches, but initial findings are intriguing and promising. As a result, therapies for dysphagia in elderly patients are quickly transitioning from compensatory to therapeutic approaches that encourage the restoration of swallow function.
Summary
Considering the hazards of dysphagia, screening of dysphagia is crucial for elderly patients. Risk factors including age, illnesses, surgical, and therapeutic factors are the premise and basis for the diagnosis, assessment, and control of dysphagia in the elderly. Screening and assessment tools reported in the last two decades indicated that a widely accepted, perfect assessment tool is yet currently lacking. Some compensatory measures and new treatments based on stimulation of sensorial and motor neural pathways can promote swallowing function recovery. More efforts should be focused on early identification and effective prevention and rehabilitation. Reduced morbidity in elderly populations may be achieved by addressing issues like the most efficient and effective ways to detect malnutrition and dysphagia in high-risk patients and community-dwelling elderly persons.
Perspectives
With the increasing incidence of dysphagia, there is an urgent need to explore barriers and facilitators of different risk factors, screening tools and therapeutic strategies in detail. Limitations still exist throughout the available research including short duration of many interventions, variations in types of participants, differences in the methods used to diagnose dysphagia, poor design, and poor interpretation of results. Many trials that were identified had small sample sizes and lacked the ability to be generalized to a wider population. Dropout rates and lack of true randomization of trials also weaken the available research. To further clarify different risk factors, screening tools and therapeutic strategies underlying dysphagia in the elderly, a need remains for future large-scale multi-center randomized controlled trials, risk prediction model of dysphagia in elderly patients and in-depth mechanism studies, with the aim of minimizing the occurrence of dysphagia in elderly populations.
Author contributions
All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.
Funding
This study was supported by the National Natural Science Foundation of China (31960178 and 82160923); Applied Basic Research Programs of Science and Technology Commission Foundation of Yunnan Province (2019FA007); Key Laboratory of Traditional Chinese Medicine for Prevention and Treatment of Neuropsychiatric Diseases, Yunnan Provincial Department of Education; Scientific Research Projects for High-level Talents of Yunnan University of Chinese Medicine (2019YZG01); Young Top-Notch Talent in 10,000 Talent Program of Yunnan Province (YNWR-QNBJ-2019-235); National Science and Technology Innovation 2030 Major Program (2021ZD0200900); Yunnan Key Research and Development Program (202103AC100005); and Yunnan Province Fabao Gao Expert Workstation Construction Project (202105AF150037).
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
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Keywords: community-dwelling elderly, dysphagia, screening tool, preventive and therapeutic measures, research progress
Citation: Chen K, Xing L, Xu B, Li Y, Liu T, Zhang T, Shi H, Lu H, Zhou W, Hou J, Shi H and Qin D (2022) Research progress in the risk factors and screening assessment of dysphagia in the elderly. Front. Med. 9:1021763. doi: 10.3389/fmed.2022.1021763
Received: 21 August 2022; Accepted: 21 October 2022;
Published: 07 November 2022.
Edited by:
Esther-Lee Marcus, Herzog Hospital, IsraelReviewed by:
Edvard Ehler, Eldis Pardubice, CzechiaCopyright © 2022 Chen, Xing, Xu, Li, Liu, Zhang, Shi, Lu, Zhou, Hou, Shi and Qin. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Dongdong Qin, qindong108@163.com; Jianhong Hou, hjhjyy@126.com; Hongling Shi, kmshl1@126.com
†These authors have contributed equally to this work