Deglutition (the act of swallowing) is the result of a complex and coordinated motor function, where several nerves and muscles of the mouth and neck are involved. Generally it can separated into 3 phases; one voluntary, oral phase and 2 involuntary phases, pharyngeal and esophageal. The oral phase is subdivided into two sub-phases, one preparatory and another of transit. The healthy elderly population do not generally present significant changes in deglutition nor esophagus function, however, those residing in old people´s homes or presenting a neurodegenerative disease (i.e. Alzheimer´s or Parkinson) can present a condition known as dysphagia.
Dysphagia is the subjective sensation of difficulty or blockage of food during the act of deglutition. Epidemiological studies reveal a prevalence of 16-22% in individuals over 50 years of age. This percentage increases in old people´s homes, where over 60% of the patients have eating difficulties. A high percentage of these cases is due to oropharyngeal dysphagia, in other words, anomalies in the neuromuscular coordination of the pharynges and superior esophagus sphincter. Esophagus dysphagia is less common, where the esophagus is affected due to a motor dysfunction or mechanic obstruction. In the elderly, 20-40% with common disorders such as cerebral vascular disease and other degenerative disorders (i.e. Parkinson´s disease) also suffer from oropharyngeal dysphagia.
Generally, oropharyngeal dysphagia occurs 1-2 seconds after initiating deglutition. The individual feels that food has been retained in the throat, forcing to swallow repeatedly. Frequently, it is accompanied by regurgitation of the food through the nasopharynges (sometimes exiting through the nose) or by laryngeal aspiration, which can cause respiratory infections. In the most severe cases, the individual cannot swallow saliva, causing sialorrhea (drooling).
As for the consistence of the food that causes the symptoms, functional or motor alterations that cause dysphagia can occur with both solid and liquid foods, with liquids being even more severe under certain cases (paradoxical dysphagia). On the other hand, mechanical obstructions initially cause dysphagia with solid foods, and as the esophagus narrows, begins to difficult the passage of semisolid and ultimately liquid foods As for the evolution and duration of the symptoms, the episodic and non-progressive dysphagia without weight loss is a common characteristic of the presence of a esophagus membrane or ring, that stretches the pathway and hampers food passage.
The first episode usually occurs with a fast meal, where the individual notices how a piece of solid food is blocked in the esophagus and needs to ingest liquid to force the food to advance. However, when the dysphagia to solid foods is progressively more difficult, the differential diagnosis is esophagus narrowing or carcinoma.
Approximately 10% of individuals with esophageal reflux develop a benign esophageal narrowing, with previous cases of heartburn. As for patients with esophageal carcinoma, they are generally over 50 years of age, do not have a clinical history of heartburn, and the evolution is rapid.
NUTRITIONAL TREATMENT FOR DYSPHAGIA
The treatment should be oriented to obtain and maintain an adequate nutritional state in the individual, so that his/her health is not compromised. If the individual´s health is affected, they must follow certain guidelines to improve their state. Finally, in the individuals with dysphagia as a secondary complication of a certain disease, nutrition may help his/her pharmacological, psychiatric and overall clinical treatment. Considering that the elderly are at risk for malnutrition, the early detection and treatment of dysphagia will help reduce or eliminate this risk. Generally, the individuals with dysphagia do not require different nutritional guidelines than the rest of the population. In other words, the nutritional requirements in carbohydrates, proteins, fatty acids, vitamins and minerals, as well as liquid needs, are the same as any other individual with similar age, gender and physical activity, with only personal adjustments to consider. In these patients, the difference appears in the method of consuming the food, modifying and adapting it so that the individual can easily consume it.
Dietetic Objectives for Patients with Dysphagia
– Facilitate deglutition with dietetic and posture changes.
– Ensure an adequate hydration.
– Avoid or decrease problems that affect an adequate eating habit, such as posture problems, change meal hours…
– If despite these changes, a correct nutritional state cannot be achieved, it may be necessary to add nutritional supplements.
DIETETIC STRATEGIES TO HELP DEGLUTITION.
When dysphagia is diagnosed and its cause known, different guidelines must be followed:
Problem: Weak mouth muscular control, poor coordination.
– Include foods with strong flavors
– Control the temperature of the food (avoiding possible burns)
– Offer frequent meals, being small and semi-solid
– Avoid large-sized foods (make them “bite-sized”)
Justification: Stimulate deglutition. Reduce at a minimum fatigue. Avoid obstruction of the respiratory pathways.
Problem: Reduced mouth sensations
– Place the food in the most sensitive part of the mouth
– Include foods with strong flavors
– Eat cold foods
Justification: Increase sensations, avoid burns.
Problem: Decreased larynx elevation
Avoid foods that crumble and those that are viscous
Justification: Reduce the risk of respiratory obstruction.
It is important for a doctor to diagnose the disorder properly so that an adequate nutritional intervention can be performed.