Makindo Medical Notes Comprehensive Medical Encyclopedia | Education for Healthcare Professionals

Dysphagia = difficulty in swallowing. It is common in older adults and carries risks of malnutrition, aspiration pneumonia, dehydration, and reduced quality of life. 👉 Always distinguish between oropharyngeal vs oesophageal dysphagia.

📌 Basic Physiology of Swallowing

👅 Oral phase – bolus formation and voluntary transfer to pharynx.
🧠 Pharyngeal phase – reflex, coordinated by brainstem; larynx elevates, epiglottis closes, pharyngeal muscles propel food.
🫀 Oesophageal phase – peristaltic waves move bolus to stomach via lower oesophageal sphincter.
👂 Requires intact cranial nerves (V, VII, IX, X, XII), muscles, and coordination.

🔎 Causes in Older Adults

Category	Examples	Clues
🧠 Neurological	Stroke, Parkinson’s disease, dementia, motor neuron disease, myasthenia gravis	Difficulty initiating swallow, coughing, choking, nasal regurgitation, aspiration
🦠 Structural (Oropharyngeal)	Head/neck cancer, Zenker’s diverticulum, pharyngeal pouch, goitre	Lump sensation, regurgitation, halitosis, neck mass
🩻 Oesophageal Mechanical	Oesophageal stricture (reflux, caustic), carcinoma, Schatzki ring	Progressive difficulty with solids → later liquids, weight loss
⚡ Oesophageal Motility	Achalasia, oesophageal spasm, scleroderma	Intermittent dysphagia with solids + liquids, chest pain, regurgitation
💊 Iatrogenic/Other	Drugs (anticholinergics, sedatives), poor dentition, xerostomia, frailty	History of polypharmacy, dry mouth, difficulty chewing

🚩 Red Flags

Unintentional weight loss 📉
Progressive dysphagia (esp. solids → liquids) 🍞➡️🥤
Haematemesis, anaemia, melaena 🩸
Neck lump, hoarseness, or odynophagia
Recurrent aspiration pneumonia 🤒

🧪 Clinical Assessment

📚 History: Onset (sudden vs gradual), intermittent vs progressive, solids vs liquids, aspiration episodes, associated pain/weight loss.
👀 Examination: Cranial nerves, gag reflex, tongue movements, oral cavity inspection, cervical lymph nodes.
⚠️ Bedside swallow assessment (water swallow test).

📊 Investigations

🦻 ENT referral if oropharyngeal suspicion.
📈 Videofluoroscopic swallow study (gold standard for aspiration).
📸 Endoscopy (OGD) for suspected oesophageal pathology.
📡 Barium swallow or manometry for motility disorders.
🧪 Bloods: FBC, U&E, iron studies if anaemia present.

🛠️ Management Principles

🍽️ Dietary modification: Thickened fluids, soft/pureed diet.
🧑‍⚕️ Speech & Language Therapy (SALT): swallow rehabilitation, safe feeding techniques.
💊 Treat cause: PPIs for reflux strictures, dilatation/stenting for oesophageal obstruction, botulinum toxin for achalasia.
🧠 Neurological causes: posture, swallow training, NG or PEG feeding if high aspiration risk.
🚫 Aspiration prevention: Sit upright during meals, oral hygiene, avoid sedating drugs.

🎯 Teaching Pearls

Solids then liquids dysphagia → mechanical obstruction 🚧.
Solids + liquids from onset → motility disorder ⚡.
Choking/coughing at start → oropharyngeal cause 🧠.
Always check SALT assessment before prescribing “nil by mouth”.

🥣 Food Consistencies in Dysphagia

The safest diet for swallowing problems depends on the underlying cause (neurological vs mechanical). The IDDSI framework (Levels 0–7) standardises fluids and food textures worldwide.

📊 IDDSI Levels (Simplified)

Level	Description	Examples
0️⃣ Thin	Normal fluids, fast flow → highest aspiration risk.	Water, tea, coffee, juice
1–3️⃣ Slightly–Moderately Thick	Slower flow, easier to control.	Nectar-thick juice, smoothies, thickened soups
4️⃣ Extremely Thick / Pureed	Cannot be poured easily, but no chewing needed. Safest for severe oropharyngeal dysphagia.	Puréed vegetables, mashed potato with no lumps
5️⃣ Minced & Moist	Small, soft pieces (<4 mm for adults), minimal chewing.	Finely minced meat in thick sauce, soft scrambled egg
6️⃣ Soft & Bite-Sized	Easy to chew, bite-sized (≤15 mm), moist texture.	Stewed meat, soft fruit (banana), well-cooked veg
7️⃣ Regular	Normal diet, no restriction.	All standard foods

🧠 Matching Food Texture to Diagnosis

🧠 Stroke / Parkinson’s / Dementia → often need pureed (Level 4) meals or thickened fluids (Levels 1–3) due to aspiration risk.
🩻 Oesophageal stricture / cancer → soft & bite-sized (Level 6); avoid dry solids. May tolerate thin fluids if lumen not completely obstructed.
🔥 Acute painful swallowing (e.g. severe tonsillitis, oesophagitis, mucositis from chemo/radiotherapy) → prefer liquidised (Level 3) or pureed (Level 4) foods to reduce pain, plus cool/thickened fluids.
🔄 Achalasia → often struggle more with liquids than solids; better with soft & bite-sized (Level 6) and may need slightly thick (Level 1–2) fluids.
🧬 Myasthenia gravis / Motor Neurone Disease (MND) → progressive weakness leads to fatigue with chewing; may require minced & moist (Level 5) or pureed (Level 4), plus thickened drinks as bulbar symptoms worsen.
👶 Paediatrics with congenital dysphagia / cerebral palsy → textures depend on individual swallow study, but often liquidised (Level 3) or pureed (Level 4), with close SALT supervision.

🧑‍⚕️ Clinical Cases

Case 1: 82-year-old with sudden-onset dysphagia after stroke. 👉 Likely oropharyngeal dysphagia. Needs urgent SALT swallow assessment, NG feeding, aspiration precautions.

Case 2: 76-year-old with progressive dysphagia (solids → liquids), weight loss, anaemia. 👉 Suspect oesophageal carcinoma. Arrange OGD + biopsy, urgent 2WW referral.

Case 3: 70-year-old with intermittent dysphagia to solids + liquids, chest pain, regurgitation. 👉 Achalasia. Confirm with manometry, treat with balloon dilatation or Heller’s myotomy.

Older Patient with Swallowing Problems