An Overview of Dysphagia

Because many things can cause it, dysphagia is experienced in different ways. For some, it may be problems managing food and drink in the mouth. For others, the throat does not function effectively. And in some cases, the oesophagus causes swallowing difficulties. There are also people who cannot eat and drink because of cognitive problems. Or, it could be a mixture of these.

It might be difficult to eat and drink at any one of the stages of swallowing. It’s quite a complicated business that people don’t think about until it goes wrong. Swallowing requires a conscious effort, but most of it is subconscious or ‘reflexive’ . Approximately 50 pairs of muscles and nerves are involved in the whole swallow process.

The stages of swallowing are;

Oral preparatory stage; anticipating food, drink and how it’s taken
Oral propulsive or transit stage; managing the food or drink in the mouth and getting it to the throat
Pharyngeal stage; food and drink entering and passing through the throat
Osophageal stage – food and drink entering and passing through the gullet (to the stomach)

Depending what and how a person eats and drinks, some of these stages are happening all at the same time. It usually happens fast when there are no difficulties. For example, a drink takes 1 second to pass through the throat and 5 to 6 seconds through the gullet .

There are many chances for something to go wrong. It happens to us all from time to time.

When it happens persistently, it could be dysphagia.

The signs and symptoms of dysphagia include;

Recurrent chest infections / pneumonias
Choking
Persistent or prolonged bouts of coughing during or after swallowing
Unintentional weight loss
Malnutrition or risk of malnutrition
Feeling full sooner than is normal or expected
Fatigue perhaps managing half a meal before swallow problems occur
Regurgitation of food or drink
Food or drink coming out of the nose
Reflux
A feeling of food sticking in the throat or oesophagus
Avoidance of ‘difficult’ foods such as crunchy or dry food or meat
Difficulty chewing food
Dribbling
Pocketing or pouching of food or drink in mouth
Food or drink residue left in the mouth
A change in taste or smell sensation
Persistent wet/gurgly voice after swallowing
Significantly faster or more effortful breathing after swallowing
A drop in oxygen saturations during eating or drinking
Anxiety when eating or drinking
Excessive gulping of air (aerophagia)
Pain on swallowing (odynophagia)

Across the world, 590 million people are living with dysphagia and 40 million of them are in Europe.

There is no known exact number of people living with dysphagia in the UK but we have a broad idea depending on the cause of the dysphagia¹.

Who?	How many?
Nursing Home Residents	50-75%
Head and Neck Cancer Survivors	50-60%
Stroke Survivors	40-78%
People with MS	31-33%
People with Parkinson’s Disease	32%
People with COPD	27%
People with Dementia	13-57%
Adults with a Learning Disability	5%

Causes of Dysphagia

Dysphagia is a symptom caused by another condition.

In adults, it may occur as a result of;

Stroke
Brain or spinal injury
Neurodegenerative diseases
Head and Neck cancer and other cancers
Respiratory diseases
Gastro problems
Dementia
Mental health difficulties
Learning Disability
Frailty
Infection
Medications, surgery or radiation therapy
Rare syndromes and diseases

Because there are so many causes, people with dysphagia will be assessed by a speech and language therapist who specialises in understanding the underlying condition such as stroke or head and neck cancer. This means they know what kind of things to look out for and how dysphagia might resolve, or progress.

As different conditions can cause dysphagia, this means that different treatments might be needed. Some exercises or strategies that work well for someone with a brain injury might not be the right treatment for someone with a respiratory condition.

The speech and language therapist will not only advise on how to help when first meeting the person with dysphagia but also what to expect in future and work together to ensure a safe and comfortable swallow when possible.

Treating People with Dysphagia

In the UK, speech and language therapists play a key role in supporting people with dysphagia. They assess, provide a diagnosis and come up with a treatment plan.

There is a number of ways to provide person-centred support for the individual with dysphagia.

These include;

Exercises
Sensory stimulation
Manoeuvres, strategies and compensatory measures
Protocols
Personal and environmental support

NEVER try to carry out any swallow therapy without first consulting a speech and language therapist.

If muscles required for safe and effective swallowing are weak, are reduced in their range of motion, or move inaccurately then exercises can help. The speech and language therapist will work out which exercises are most effective, along with the intensity, repetition and frequency required.

Sensory stimulation of the swallow is becoming better understood and used more in swallow therapy.

This involves;

Flavour
Temperature
Pressure
Carbonation

Trying out various flavours of salty, bitter, sweet, sour and umami can help some people work out which flavours help them swallow better. Similarly, experimenting with hot, cold, warm and cool can also bring about different results. Sometimes, pressing down on the tongue with a spoon can aid the swallow. It is also helpful to assess the effect of carbonated drinks such as ginger ale.

Sometimes manoeuvres and strategies can help; they involve ways of swallowing that require extra effort or changing movement to overcome the difficulties and risks and improve swallow function.

Adapting food and drink using the IDDSI Framework is a way to compensate for the dysphagia. The texture, size and way food or drink moves through the mouth, throat and oesophagus can be adapted to make swallowing safer and more comfortable.

In a healthcare context, a protocol is a set of instructions describing a process or method to follow. Some swallow protocols require the use of equipment. Many combine some elements of exercise, sensory input, manoeuvres and strategies.

It is also important to understand the person with dysphagia, what is important to them, and how they live. Lots of factors affect how we eat and drink and these need to be considered to ensure safe and enjoyable mealtimes.

Complications of Dysphagia

The inability to swallow well or safely can result in significant complications.

Some people with dysphagia experience frightening choking episodes and require slaps on the back or abdominal thrusts to clear the food (or even drink) that is in the airway.

For others, when food or drink enters the airway, it results in coughing. How much, how often and how well the cough works is important. There are even people with dysphagia who do not feel it go the wrong way and do not cough. Food or drink entering the airway is called ‘aspiration’. If the cough reflex does not kick in, this is called ‘silent aspiration’. This can make dysphagia hard to detect.

If enough food or drink enters the airway, it can cause one or more chest infections. It depends on how strong the person’s immune system is as to how well chest infections can be prevented despite aspiration, and how well they can recover. Another serious chest complication is ‘aspiration pneumonia’. The bacteria in the lungs from the food or drink is not cleared by the lungs and pneumonia can make people acutely unwell. Chest infections and pneumonia caused by aspiration are usually treated with antibiotics.

Fear, anxiety and other psychological difficulties can arise from dysphagia. If a person has choked in the past or no longer enjoys their food or cannot eat or drink at all and becomes socially isolated, this significantly changes their quality of life.

Other complications are malnutrition and unintentional weight loss. Some people with dysphagia become very frail as a result or cannot heal from injury very well. They are then supported by dietitians to gain weight including muscle mass and to aid recovery.

If a person has dysphagia, they may remain nil by mouth and receive nutrition enterally through a PEG (a tube into the stomach). A PEG insertion is usually carried out in an endoscopy clinic but sometimes in an operating theatre.

If someone is nil by mouth or does not eat or drink very much, they can experience oral hygiene complications; this includes bacterial growth, which can also cause aspiration pneumonia, as well as discomfort from dryness and sometimes sore or cracked lips or tongue.

Managing Dysphagia at Home

There are thousands of people living with dysphagia at home. A speech and language therapist will provide advice on how to eat and drink safely and comfortably in one’s own home and to keep people as independent as possible.

Some of the dysphagia treatment options may be needed at home and this could include adapted food and drink textures using the IDDSI Framework. It could be that some new equipment is needed such as a hand blender or dysphagia cups and adapted utensils.

If possible, enjoying food and drink at a table is preferable to in bed as an upright position is usually safer. However, this is not always possible and the speech and language therapist will bear this in mind when providing the safer swallow recommendations.

These might also include environmental and personal factors; reducing too many distractions, enhancing the mealtime experience by eating and drinking with others, and being physically comfortable before eating and drinking.

Changing from three square meals a day to smaller amounts over the whole day could also be recommended. Some people need help to eat and drink safely from family members or carers. The speech and language therapist will provide advice that works for the person with dysphagia. They may also refer to a dietitian if the change in food texture or volume means there is a risk of malnutrition or weight loss.

The use of pre-prepared meals such as the Made For You range , which meet the IDDSI Framework standards and include valuable nutrition can be a practical time-saver and bring peace of mind to the person with dysphagia. They can form an integral part of living with dysphagia at home.