What is Dysphagia?
Some older adults have trouble swallowing food or liquids. This condition is called dysphagia in the medical world, and it’s serious as it could cause all sorts of problems such as malnutrition, dehydration, weight loss or aspiration pneumonia.
Humans have 50 pairs of muscles and nerves to help them swallow. In other words, there are lots of things that can go wrong and lead to problems swallowing. The inability to swallow foods or liquids easily isn’t always indicative of a medical condition. In fact, this condition may be temporary and can go away on its own. Although dysphagia can happen at any age, it is more common in older adults, especially those with acid reflux.
It has been estimated that 15% of seniors and up to 68% of nursing home residents are affected by dysphagia. About 1 in 25 people will experience dysphagia in their lives. Important to note is that having difficulty swallowing doesn‘t always indicate a medical condition.
Dysphagia is important to be aware of because it can cause serious health problems for seniors, including:
- Poor nutrition
- Loss of appetite
- Weight loss
- Not taking medication properly
- Aspiration pneumonia: a lung infection caused by food or liquid particles in the lungs. It is a leading cause of hospitalisation and death in nursing home residents.
In this paper, you’ll discover what dysphagia is, why it’s so serious, the common signs of dysphagia, and what causes it.
How do we swallow?
The US National Institute on Deafness and Other Communication Disorders website explains how we, as human beings, swallow food or drink:
“Swallowing is a complex process. Some 50 pairs of muscles and many nerves work to receive food into the mouth, prepare it, and move it from the mouth to the stomach. This happens in three stages. During the first stage, called the oral phase, the tongue collects the food or liquid, making it ready for swallowing. The tongue and jaw move solid food around in the mouth so it can be chewed. Chewing makes solid food the right size and texture to swallow by mixing the food with saliva. Saliva softens and moistens the food to make swallowing easier. Normally, the only solid we swallow without chewing is in the form of a pill or caplet. Everything else that we swallow is in the form of a liquid, a puree, or a chewed solid.
“The second stage begins when the tongue pushes the food or liquid to the back of the mouth. This triggers a swallowing response that passes the food through the pharynx, or throat (see figure). During this phase, called the pharyngeal phase, the larynx (voice box) closes tightly and breathing stops to prevent food or liquid from entering the airway and lungs.
“The third stage begins when food or liquid enters the oesophagus, the tube that carries food and liquid to the stomach. The passage through the oesophagus, called the oesophagal phase, usually occurs in about three seconds, depending on the texture or consistency of the food, but can take slightly longer in some cases, such as when swallowing a pill.”
What causes dysphagia?
There are many potential causes of dysphagia, so getting a swallowing problem checked out by a doctor is important.
Any condition that weakens or damages the muscles and nerves used for swallowing may cause dysphagia. For example, people with nervous system diseases, such as cerebral palsy or Parkinson’s disease often have problems swallowing. Difficulty with swallowing can occur for a variety of reasons, including multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), Parkinson’s disease (PD), stroke, and various forms of dementia. These conditions can affect the muscles and/or nerves involved in the process of swallowing.
Additionally, stroke or head injury may weaken or affect the coordination of the swallowing muscles or limit sensation in the mouth and throat.
Common causes include:
- Teeth in bad condition or having poorly fitting dentures
- Normal ageing (weakening of mouth/throat muscles)
- Acid reflux
- Cognitive disorders like Alzheimer’s or dementia
- Cancer of the mouth, throat, or oesophagus
- Taking certain medications
What causes swallowing difficulty?
According to the US National Institute on Deafness and Other Communication Disorders (NIDCD), humans have 50 pairs of muscles and nerves used to help us swallow. Some conditions related to difficulty swallowing include:
- Acid reflux and gastroesophageal reflux disease (GERD): Acid reflux symptoms are caused when stomach contents flow up from the stomach back into the oesophagus, causing symptoms like heartburn, stomach pain, and burping.
- Heartburn: Heartburn is a burning sensation in your chest that often occurs with a bitter taste in your throat or mouth.
- Epiglottitis: Epiglottitis is characterised by inflamed tissue in your epiglottis. It’s a potentially life-threatening condition. This condition is considered a medical emergency. Urgent care may be required.
- Goitre: Your thyroid is a gland found in your neck just below your Adam’s apple. A condition that increases the size of your thyroid is called a goitre.
- Esophagitis. Esophagitis is inflammation of the oesophagus that can be caused by acid reflux or certain medications.
- Oesophagal cancer: Oesophageal cancer occurs when a malignant (cancerous) tumour forms in the oesophagus lining, which can cause difficulty swallowing. Herpes esophagitis: Herpes esophagitis is caused by the herpes simplex virus type 1 (HSV-1). The infection can cause some chest pain and difficulty swallowing. Recurrent herpes simplex labialis: Recurrent herpes simplex labialis, also known as oral or orolabial herpes, is an infection of the mouth area caused by the herpes simplex virus.
- Thyroid nodule: A thyroid nodule is a lump that can develop in your thyroid gland. It can be solid or filled with fluid. You can have a single nodule or a cluster of nodules. Infectious mononucleosis: Infectious mononucleosis, or mono, refers to a group of symptoms usually caused by the Epstein-Barr virus (EBV).
- Zenker’s diverticulum: A rare instance in which a pouch-like structure forms between the pharynx and the oesophagus, making it difficult to swallow.
- Snake bites: A bite from a venomous snake should always be treated as a medical emergency. Even a bite from a harmless snake can lead to an allergic reaction or infection.
You can learn more about the diagnosis, symptoms, treatment and causes of the above on the Healthline website.
Signs and symptoms of dysphagia
Having trouble swallowing once in a while, usually because of eating too fast or not chewing well, isn’t the same as showing signs of dysphagia. But if there are frequent signs of dysphagia, it’s essential to have a doctor conduct an examination as soon as possible. Signs of dysphagia include:
- Coughing while eating or drinking
- Choking on food, liquids, or medication
- A gurgly-sounding voice, especially after eating or drinking
- Difficulty swallowing food or drinks
If someone is having a swallowing problem, these questions should be considered:
- Do you often cough or choke after eating or drinking?
- Does it sometimes feel like food is going down the “wrong way”?
- Do you often feel like food is stuck in your throat?
- How long does it take you to eat a meal?
- Is eating sometimes less enjoyable than it previously was?
- Have you lost weight recently (without trying)?
There is a useful tip list on the Daily Caring website that’s worth reading: “Get 7 tips for safely managing dysphagia.” 
Treatment usually depends on the cause and type of dysphagia. Many cases of dysphagia can be improved with careful management, but a cure isn’t always possible. The NHS offers suggestions to treat dysphagia, which include:
- speech and language therapy to learn new swallowing techniques
- changing the consistency of food and liquids to make them safer to swallow
- other forms of feeding – such as tube feeding through the nose or stomach
- surgery to widen the oesophagus by stretching it or inserting a plastic or metal tube (stent)
You can read more on the NHS website about treating dysphagia, but a summary is shown below:
Most swallowing problems can be managed, although treatment will depend on the type of dysphagia involved. Treatment will depend on whether your swallowing problem is in the mouth or throat (oropharyngeal dysphagia) or the oesophagus (oesophageal dysphagia). The cause of dysphagia is also considered when deciding on treatment or management. In some cases, treating the underlying cause can help relieve swallowing problems.
Treatment for dysphagia may be managed by a group of specialists, including a speech and language therapist (SLT), a dietitian, and a surgeon.
Treatments for oropharyngeal dysphagia
Oropharyngeal dysphagia can be difficult to treat if it’s caused by a condition that affects the nervous system, as these problems can’t usually be corrected using medication or surgery. There are three main ways oropharyngeal dysphagia is managed to make eating and drinking as safe as possible:
- Swallowing therapy: referral to a speech and language therapist (SLT) for swallowing therapy. An SLT is trained to work with people with eating or swallowing difficulties. SLTs use a range of techniques that can be tailored for your specific problem, such as teaching you swallowing exercises.
- Dietary changes: referral may be made to a dietitian for advice about changes to your diet to make sure you receive a healthy, balanced diet. The SLT can offer advice about softer foods and thickened fluids that may be easier to swallow. They may also try to ensure the person with the condition is getting the support that’s needed at mealtimes.
- Feeding tubes: feeding tubes can be used to provide nutrition while recovering the ability to swallow. They may also be required in severe cases of dysphagia where there is a risk of malnutrition and dehydration.
Feeding tubes can also make it easier to take medications needed for other conditions. There are two types of feeding tubes:
- Nasogastric tube: a tube passed through your nose and into your stomach. Nasogastric tubes are designed for short-term use and will need to be replaced and swapped to the other nostril after about a month.
- Percutaneous endoscopic gastrostomy (PEG) tube – a tube is implanted directly into your stomach. PEG tubes are designed for long-term use and last several months before they need replacing.
Most people with dysphagia prefer to use a PEG tube because it can be hidden under clothing. However, they carry a greater risk of minor complications, such as skin infection or blocked tube, compared to nasogastric tubes.
Treatments for oesophageal dysphagia
Oesophageal dysphagia is swallowing difficulties due to problems with the oesophagus. Depending on the cause, it may be possible to treat oesophageal dysphagia with medication. For example, proton pump inhibitors (PPIs) used to treat indigestion may improve symptoms caused by narrowing or scarring of the oesophagus.
Botox and Surgery
Botox can sometimes be used to treat achalasia, a condition where the muscles in the oesophagus become too stiff to allow food and liquid to enter the stomach. Botox can be used to paralyse the tightened muscles that prevent food from reaching the stomach. However, the effects only last for around six months. Other cases of oesophageal dysphagia can usually be treated with surgery.
Endoscopic dilatation is widely used to treat dysphagia caused by obstruction. It can also be used to stretch your oesophagus if it’s scarred. Endoscopic dilatation will be carried out during an internal examination of your oesophagus using an endoscopy.
There are a few different solutions to help manage dysphagia – these would depend on the type of dysphagia someone has. A texture modified diet might be recommended specifically for an individual by a Speech and Language Therapist. Eating naturally softer foods helps to make mealtimes more manageable with less risk involved.
If advised by a Healthcare Professional to change diet, it can become confusing to understand what food the person with the condition can eat. (Read the blog post ‘Foods to Avoid With Dysphagia’ for more information on certain foods that are not safe for those living with dysphagia.)
A Speech and Language Therapist will be able to provide advice and information on what texture food will be right by giving you a level of food modification to follow in line with IDDSI guidelines. These food and liquid descriptors were developed by the International Dysphagia Diet Standardisation Initiative (IDDSI) in collaboration with healthcare professionals and industry professionals.
Dysphagia Diet: Food Texture Descriptors
An article by Wiltshire Farm Foods is interesting and worth reading. When advised that you need a textured modified diet, a healthcare professional may mention a range of food texture descriptors. A patient might be recommended a texture modified diet to reduce the risk of choking and aspiration, where food travels down the windpipe into the lungs rather than the stomach, which can have severe health consequences.
In early 2019, the NHS adapted its criteria around food texture descriptors for those on a dysphagia diet. IDDSI (The International Dysphagia Diet Standardisation Initiative) was rolled out globally to ensure that terminology and food texture descriptors were applied and understood across all cultures, all ages and all settings.
IDDSI is endorsed by reputable bodies such as the British Dietetic Association and the Royal College of Speech & Language Therapists. “A global initiative to improve the lives of over 590 million people worldwide living with dysphagia” – IDDSI. Before IDDSI came into practice, food descriptors in the UK were formed on best clinical advice rather than international standards. There was an established set of national descriptors and terminology in the UK. Differences between countries were often a source of confusion internationally. This has now been addressed by IDDSI.
Foods needed by individuals who have oropharyngeal dysphagia
Descriptors detail the types and textures of foods required by individuals who have oropharyngeal dysphagia (swallowing difficulties) and who are at risk of choking or aspiration (food or liquid going into their airway to their lungs). The descriptors provide standard terminology to be used by all health professionals and food providers when communicating about an individual’s requirements for a texture modified diet. The food textures are:
B = Thin Purée Dysphagia Diet
C = Thick Purée Dysphagia Diet
D = Pre-mashed Dysphagia Diet
E = Fork Mashable Dysphagia Diet
Fluids are not currently included in these descriptors. The following guidance is suggested for information on thickened fluids: http://www.gcu.ac.uk/sndri/pdf/consistency/100505FluidThickening.pdf and http://www.speechpathologyaustralia.org.au/resources/terminology-for-modified-foods-and-fluids
The descriptors were developed in 2011 by the National Patient Safety Agency (NPSA) Dysphagia Expert Reference Group in association with Cardiff and Vale University Health Board and replaced the previous versions developed by the British Dietetic Association (BDA) and Royal College of Speech and Language Therapists (RCSLT). These replacement descriptors have been endorsed by the BDA, RCSLT, Hospital Caterers Association (HCA) and the National Nurses Nutrition Group (NNNG).
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Swallowing – explained simply by WebMD
Swallowing seems simple, but, in practice, it’s rather complicated. It takes your brain, several nerves and muscles, two muscular valves, and an open, unconstricted oesophagus (or swallowing tube) to work just right. Your swallowing tract goes from the mouth to the stomach. Swallowing normally happens in three phases.
- In the first phase, food or liquid is contained in the mouth by the tongue and palate (oral cavity). This phase is the only one we can control.
- The second phase begins when the brain decides to swallow. At this point, a complex series of reflexes start. The food is thrust from the oral cavity into the throat (pharynx). At the same time, two other things happen: A muscular valve at the bottom of the pharynx opens, allowing food to enter the oesophagus, and other muscles close the airway (trachea) to prevent food from entering the airways. This second phase takes less than half a second.
- The third phase starts when food enters the oesophagus. The oesophagus, which is about nine inches long, is a muscular tube that produces waves of coordinated contractions (peristalsis). As the oesophagus contracts, a muscular valve at the end of the oesophagus opens, and food is propelled into the stomach. The third phase of swallowing takes six to eight seconds to complete.
Sources and Further Reading
- Book: Dysphagia: Clinical Management in Adults and Children, Hardcover – 5th November 2020, by Michael E. Groher PhD (Author), Michael A. Crary PhD F-ASHA (Author), at: https://www.amazon.co.uk/Dysphagia-Clinical-Management-Adults-Children/dp/0323636489
- Book: Working with Dysphagia, Spiral-bound – 31st October 2001, Lizzy Marks (Author), Dierdre Rainbow (Author) at: https://www.amazon.co.uk/Working-Dysphagia-Lizzy-Marks/dp/0863882498/
- YouTube Video: https://youtu.be/rkGJnEr1MF0
Picture Source and acknowledgement of Rights: Screenshot from YouTube Video at: https://youtu.be/rkGJnEr1MF0
Caution: No advice is implied or given in articles published by us. This guide is for general interest only. It should never be used as a substitute for obtaining advice from your Doctor or other qualified clinician/medical practitioner. The facts are believed to be correct as at the date of publication, but there may be certain errors and omissions for which we cannot be responsible. The hyperlinks were valid at the date of publication.
- Aspiration pneumonia is a lung infection caused by food or liquid particles in the lungs – a leading cause of hospitalisation and death among residents in nursing homes. ↑
- At: https://www.nidcd.nih.gov/health/dysphagia#2 ↑
- At: http://www.nidcd.nih.gov/health/dysphagia ↑
- At: https://www.healthline.com/health/difficulty-in-swallowing ↑
- From: https://dailycaring.com/7-helpful-tips-for-seniors-and-caregivers-managing-dysphagia/ ↑
- At: https://www.nhs.uk/conditions/swallowing-problems-dysphagia/ © Crown copyright acknowledged ↑
- See at: https://www.nhs.uk/conditions/swallowing-problems-dysphagia/treatment/ © Crown copyright acknowledged ↑
- Source: https://www.specialistnutrition.com/swallowing-difficulties/what-is-dysphagia/ ↑
- See: https://www.specialistnutrition.com/blog/2020/october/iddsi-levels-and-framework/ ↑
- Article dated 17th December 2020 at: https://www.specialistnutrition.com/healthcare-professionals/healthcare-articles/2020/december/dysphagia-diet-food-texture-descriptors/ ↑
- Source: https://www.independentliving.co.uk/Dysphagia-food-texture-descriptors.pdf ↑
- Source: https://www.webmd.com/digestive-disorders/swallowing-problems ↑