Dysphagia as Syndrome Dysphagia refers to the difficulty in swallowing, which can manifest as discomfort or pain during the act of swallowing. This condition ranges from mild difficulty in moving food back in the mouth to a complete inability to consume nourishment. The prevalence of dysphagia among older adults is estimated to be between 16% and 22% in those over 50 years of age. In nursing homes, 17% to 43% of residents require extensive to total assistance with eating, often indicating potential swallowing problems (Centers for Medicare and Medicaid, 2001; Lindgren & Janzon, 1991).
Individuals most at risk for developing dysphagia include those with neurological impairments, such as head injuries, stroke, or conditions like Parkinson’s disease, as well as those with malignancies affecting the head and neck (Lind, 2003). Additionally, severe cognitive impairments can result in an older adult forgetting how to eat or experiencing neurological deficits that affect swallowing.
Phases of Swallowing
Swallowing consists of both voluntary and involuntary phases. The oral stage involves the conscious effort to chew food and move it back toward the pharynx. The subsequent pharyngeal and esophageal stages occur involuntarily and involve the automatic movement of food through reflexive actions.
Dysphagia can occur at any point during the swallowing process due to various health issues, including impairments in neuromuscular pathways, structural or connective tissue diseases, or mental disorders ranging from Alzheimer’s disease to psychogenic dysphagia. Although aging is sometimes cited as a risk factor for dysphagia, evidence linking healthy aging to swallowing difficulties is lacking; rather, issues such as poor oral health or medication side effects are more likely contributors.
Diagnosis of Dysphagia
Early identification of dysphagia is crucial for preventing complications and initiating effective treatment. Symptoms accompanying dysphagia may include weight loss, dehydration, a sensation of food “sticking” in the throat, changes in dietary habits, drooling, and alterations in voice. Oral and pharyngeal dysphagia may lead to coughing or choking during swallowing. Esophageal dysphagia can result in recurrent pneumonia.
In some cases, dysphagia may be reversible with aggressive rehabilitation, particularly in acute stroke patients. However, for those with progressive diseases like dementia or Parkinson’s disease, the focus of care shifts to maintaining safe and functional swallowing for as long as possible.
Ethical Issues in Dysphagia
Ethical considerations surrounding dysphagia have become increasingly prominent, particularly regarding the use of tube feeding in individuals with severe cognitive impairments. Recent studies have highlighted the medical futility of tube feeding in this population, prompting a reevaluation of treatment options.
Nurses play a crucial role in providing information and support to families and caregivers involved in end-of-life decision-making. The ethical debate often centers around the “sanctity of life” versus “quality of life.” When considering tube feeding for patients with severe cognitive impairments, healthcare providers must weigh the benefits and burdens of this intervention. Research indicates that many justifications for tube feeding—such as preventing malnutrition and improving quality of life—lack solid empirical support (Finucane, Christmas, & Travis, 1999).
Organizations like the Hospice and Palliative Nurses Association (HPNA) have developed position statements addressing the use of artificial nutrition and hydration, recommending that patients and families receive counseling about the implications of tube feeding.
Nursing Care
Nursing care for patients with dysphagia requires a comprehensive understanding of the potential causes and an assessment of the individual’s capacity for rehabilitation. It is essential to consider any advance directives regarding end-of-life care in addition to evidence-based treatment options (Amella, 2003).
Assessment can be facilitated through the use of validated screening instruments. Two such instruments developed recently are the McGill Ingressive Skills Assessment (MISA) and the Massey Bedside Swallowing Screen (MBSS). The MISA evaluates various criteria, including positioning and texture management, and has shown good inter-rater reliability. However, the MBSS has received criticism for its broad inclusion criteria and small sample size (Sasaki & Leder, 2003).
Nurses must not only assess who is at risk for dysphagia but also identify individuals who are likely to develop complications. For example, Langmore et al. (2002) used Minimum Data Set (MDS) data to identify predictors of aspiration pneumonia, a common consequence of dysphagia. The study found 18 significant predictors, including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and tube feeding.
Nurses should also be aware of the importance of patient awareness regarding their swallowing issues. A study found that only a small percentage of stroke patients were aware of their dysphagia, indicating a need for better communication and education (Parker et al., 2004).
Nursing Challenges
Assessing the quality of life for individuals with dysphagia is critical. Research has shown that dysphagia can be a source of pain and a barrier to enjoying meals and social interactions among older adults, particularly those with stroke or progressive conditions (Perry & McLaren, 2003; Mercadante et al., 2000; Sjostrom et al., 2002).
Nursing interventions should aim to facilitate not only the nutritional aspects of eating but also the social enjoyment of meals. This holistic approach can help maintain the dignity and autonomy of older adults facing dysphagia, ensuring that they retain the pleasure associated with shared meals and companionship.
Conclusion
In summary, dysphagia in older adults is a complex and multifaceted condition that requires careful assessment, ethical consideration, and collaborative nursing care. Understanding the phases of swallowing, recognizing the signs and symptoms of dysphagia, and utilizing effective assessment tools are essential for providing high-quality care to this vulnerable population.
Addressing the challenges posed by dysphagia involves not only focusing on medical and rehabilitative interventions but also considering the emotional and social aspects of eating and swallowing. Nurses are in a unique position to advocate for their patients, ensuring that both their physical and psychosocial needs are met. Future research should continue to explore effective interventions and strategies to enhance the quality of life for older adults living with dysphagia.