**4. Implications for the clinical practice: prevention and detection of swallowing problems**

#### **a.** Detection

Also, some anatomical differences arise in the older person such as a smaller cross-sectional area of masticatory muscles (masseter and medial pterygoid) and an increased lingual atrophy [38]. Next to the anatomical changes also, functional alterations occur in the muscle activity of the masseter, orbicularis oris, the supra- and infra-hyoidal muscles [39], and the thyroaryte‐

The respiratory system undergoes some changes as well; there is a decreased cough reflex, a diminished ciliary clearing, and a weakening of the respiratory muscles. These changes in combination with a deterioration of the immune system make the elderly more prone to

As far as the digestive system is concerned, a delayed gastric emptying may lead to an earlier feeling of fullness at mealtime. Recent studies have shown a decreased sensibility and an

Another important issue is fatigue [41]. Fatigue, being a very common complaint in the elderly, is often associated with functional decline and may, as well as sleeping disturbances and depression, lead to a reduced food intake [42-44]. The elderly also often experience a declined perception of thirst and subsequently they have a low fluid intake. Tongue strength and endurance decline during a meal and this in combination with a diminished reserve may

As people get older, the slower swallowing act may actually also be a benefit as it can allow greater time to recruit the necessary number of muscle fibers to generate the necessary pressures for adequate bolus propulsion through the oropharynx. Hence, speeding up an elderly patient's swallow may induce contradictory results, as it may lead to insufficient

Cognitive changes are also considered to be part of the normal aging process and cognitive processes such as concentration, attention, and double-tasking are influenced by age. A decline in concentration and attention together with a reduced reserve may lead to aspiration. Moreover as eating is a social event, people tend to talk during mealtime further increasing

Staying physically active is associated with healthy aging, therefore elderly who are bedridden are additionally exposed to a number of important risk factors due to the sedative life style such as a diminished lung capacity and a weaker cough, a greater risk to develop a pneumonia,

Finally, medication may also negatively influence deglutition [47]. Drugs with an anticholi‐ nergic effect may cause xerostomia while some may lead to a diminished (e.g., allopurinol, carbamazepine, and penicillamine) or an altered (e.g., captopril lithium) taste perception. Sedatives can reduce the level of alertness and neuroleptics may mimic the swallowing problems encountered in Parkinson's disease. Nitrates are relatively contraindicated in gastroesophageal, reflux disease as they lower the pressure in the lower gastro-esophageal sphincter and steroids can not only induce a Candida infection orally but they can also provoke a steroid myopathy. Moreover, 40% of already weakened elderly take at least one medication that is

negatively influence deglutition especially in already weakened elderly [45].

swallow pressures and therefore may be contraindicated as a therapy technique.

noid muscle [39].

60 Seminars in Dysphagia

developing an aspiration pneumonia.

the risk of penetration and aspiration.

completely superfluous [48].

muscle weakness, and a loss of appetite [46].

increased stiffness of the esophagus in old age [40].

In view of the high prevalence of dysphagia in the elderly and its important consequences such as malnutrition, dehydration, aspiration pneumonia, acute food impaction, and a reduced quality of life, it is crucial to detect swallowing problems at an early stage. Moreover, the elderly themselves are not always aware of their deglutition problems [49]. In a study on 47 elderly women living at home a questionnaire was used to assess swallowing problems. Participants were all observed while drinking water. Only 44% of those in whom a clinical problem was observed admitted having experienced a deglutition problem [50]. The personnel in nursing homes is often not well trained to detect these problems [51], while for isolated elderly living at home this can be a challenge for their GP. When an elderly is admitted to a geriatric ward, the geriatrician as well as the nursing staff plays a key role in detecting a swallow problem.

In Table 2 some tips are given as to when presbyphagia is suspected and when there might be a pathologic condition.

**b.** Prevention

As prevention is always preferred over cure, an overview is here presented with the most common preventative measures to allow a safe oral intake in the elderly.



#### **Pay attention to a good hygiene of the mouth**

Clean your dentures adequately, make them fit well

Discard any food residue from your mouth after mealtime

Keep your mouth moist by rinsing or drinking at regular intervals

#### **Pay attention to eat and drink moments**

Avoid eating and drinking when you are extremely tired or when your concentration is diminished.

Do not speak during mealtime but start a conversation afterward.

Do not eat just prior going to sleep.

Remain in an upright position at least 5 to 10 min following a meal.

#### **Adaptations of food**

When experiencing difficulties chewing raw vegetables or some meat, you may cut it in very small pieces.

When your food tastes insufficiently, you may add some spices.

When you aspirate now and then on fluids, chilling it and adding some flavor could be a good idea.

When you aspirate now and then on your own saliva try to think to swallow it on a regular base for instance whenever you look for the

time thereby making it a habit.

#### **Medication**

Take your pills only when you are perfectly alert and sitting upright.

Remain in a prone position, at least 5 to 10 minutes.

Drink sufficient water during and after the medication.

When swallowing medication proves difficult mention it to your physician so that he can look for an alternative route of administration

(sublingual, transdermal).

#### **General advice**

Stay active

**When to consult a physician in case of deglutition problems?**

When you are worried

When you choke regularly

When you cough regularly during and between meals

When you eat a lot slower

When you stop enjoying to eat and drink

When you lose weight
