DYSPHAGIA IN THE ELDERLY

HEATHER MORRIS, SPECIALIST NURSE CONSULTANT
KILLINGWORTH HEALTH CENTRE, CITADEL EAST, KILLINGWORTH,                                             NEWCASTLE NE12 6HS

Dysphagia (difficulty swallowing) is common among elderly people in nursing homes [1] and can cause several clinical problems, including compromising nutritional status, complicating administration of oral solid medications and undermining quality of life [2; 3]. There is, however, relatively little information about dysphagia’s prevalence and characteristics among older people living in the community. This feature introduces this pervasive problem and presents the results of a survey that aimed to gain an insight into dysphagia’s impact on patients’ ability to take solid oral medications.

A common, complex condition

Older people are particularly prone to develop dysphagia for several reasons. Firstly, the prevalence of several diseases linked to dysphagia - such as advanced Alzheimer's disease [4] and stroke [5] – is higher among the elderly than in younger people. Secondly, the laryngo-upper oesophageal sphincter contractile reflex and salivary gland function, which contribute to swallowing, often deteriorate with advancing age [6; 7]. Thirdly, several drugs can induce xerostomia (dry mouth), including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids and diuretics [7].

Dysphagia’s clinical presentation can vary markedly. Dysphagia might be painless or cause considerable discomfort. Patients may experience swallowing problems continuously or intermittently. Solids alone can trigger dysphagia. Other patients find swallowing solids and liquids difficult [8].

Dysphagia seems relatively common. For example, between 15% [9] and 33% [1] of patients in nursing homes report having trouble swallowing solid oral medications. Moreover, between 29% and 77% of cancer patients suffer xerostomia [7], while 48% of patients undergoing palliative care in the community or hospital for conditions other than cancer experience dysphagia [1]. As a final example, six months after an acute stroke, only 34% of survivors are able to eat properly [10]. Nevertheless, we were unable to identify any studies examining the epidemiology, characteristics or management of dysphagia in a typical primary care population.

Surveying dysphagia

Against this background, we conducted a survey to pose an insight into the issues arising from dysphagia when patients take solid oral medications. We devised a nine-point questionnaire to assess whether dysphagia caused difficulties when administering solid medications (Table 1). As dysphagia seems particularly common among elderly subjects, we performed a computer search to identify patients over the age of 75 years. In addition, the computer search identified patients with one or more risk factors for dysphagia, such as history of stroke or transient ischemic attacks; oesophageal stricture or stenosis; and percutaneous endoscopic gastrostomy tubes. As we were interested in patients having trouble administering drugs, we included only subjects currently receiving medications. The search identified 182 suitable patients.

We asked patients or their carers to return the questionnaire within two weeks. Where appropriate, a nurse contacted patients by phone. We received 154 replies and telephoned a further 17 patients, giving an overall response rate of 94%. One questionnaire was unusable. Seventy-five of those interviewed were male, 17 responses came from carers and 109 patients were at least 75 years.

To summarise the results (see table 1): 11% of those surveyed reported problems swallowing medications. Six per cent found that some medication remains in their mouth for a time before they swallowed the drug properly. Nine per cent reported that, at some point, they crushed tablets or opened capsules to make the medicine easier to swallow. A similar proportion (8%) put the drug in food or drink, while 5% reported either chewing or sucking the medication. Twenty medicines from a diverse range of therapeutic classes caused swallowing problems. At least two patients reported experiencing problems swallowing paracetamol, levetiracetam, antibiotics, furosemide or amiloride. In some cases, the problem may arise because of side effects (eg xerostomia). In other cases, patients may find swallowing a particular shape or formulation (eg galantine) difficult.

Four per cent of those surveyed reported not taking a medication because they experience difficulties swallowing. In most cases, the primary healthcare team will be unaware that there is a problem: only 22% of patients said that their doctor or nurse asked them if they experienced difficulty swallowing before issuing a prescription. Furthermore, 80% of patients said that did not inform their doctor or pharmacist if they could not take their medication. In retrospect, this question could be ambiguous. Most people had not experienced problems, which might account for some of the negative responses. We believe that “Would you let your doctor or pharmacist know if you have to miss a tablet or capsule because you find it hard to swallow?” is a better phrasing.

A cause for concern

These results raise several causes for concern. Firstly, chewing or sucking medications as well as opening or crushing tablets or capsules alter pharmacokinetics or pharmacodynamics [11]. In our audit, 87% of patients or carers questioned seemed unaware that opening or crushing a tablet or capsule could influence efficacy or tolerability, suggesting that we need to improve patient education. Simple measures such as advising that the patient sits upright and takes the medicine with plenty of water may ease discomfort.

In most cases, however, primary healthcare professionals will be unaware that patients experience problems swallowing medications. Our audit suggested that 80% of patients did not inform a healthcare professional if they could not take their medication. Upon reflection, we recognised that this question could be ambiguous: we asked, “did” rather than “would”. Most people had not experienced problems, which might account for some negative responses. Nevertheless, the figure is high enough to raise concerns over adherence and warrant further investigations.

Furthermore, healthcare professionals tend not to proactively enquire about dysphagia, which further reduces the number of cases that come to GPs’ attention. Only 22% of those interviewed said that their doctor or nurse asked if they have problems swallowing before issuing a prescription. This may be subject to recollection bias. Nevertheless, it suggests that, at the very least, the frequency of enquiry was not sufficient for patients to recall. Worryingly, dysphagia is a well-established alarm symptom for strictures and some cancers [12; 13] and simple questioning can reveal swallowing problems. Open questions that may help identify patients with dysphagia include: “Do you cough after drinking or eating”; and “How long does it normally take you to eat” [14].

In many cases, changing formulation may help overcome the problems of administering medicines to people suffering from dysphagia. For example, there is now a liquid alternative with an acceptable shelf life in almost all therapeutic groups. Specialist manufacturers can supply those not listed in MIMS and the British National Formulary. In other cases, prescribing oval-shaped tablets, which many people find easier to swallow than round ones, could help [1].

In conclusion, dysphagia is relatively among elderly people. Nevertheless, swallowing problems should always act as an alarm symptom and clinicians should proactively ask about dysphagia. Liquid formulations offer an alternative in patients in whom dysphagia makes swallowing solid medications difficult. The results of our preliminary survey raise several concerns, which we plan to address with audits and service development. There is clearly a need for further studies into the prevalence, characteristics and management of dysphagia in elderly people in the community.

References

1.                  Stevenson J (2002) Meeting the challenge of dysphagia management Nurse 2 Nurse 3:2-3

2.                  Gillespie MB, Brodsky MB, Day TA, Lee FS and Martin-Harris B (2004) Swallowing-related quality of life after head and neck cancer treatment Laryngoscope  114:1362-7

3.                  Radford K, Woods H, Lowe D and Rogers SN (2004) A UK multi-centre pilot study of speech and swallowing outcomes following head and neck cancer. Clin Otolaryngol 29:376-81

4.                  Eggenberger SK and Nelms TP (2004) Artificial hydration and nutrition in advanced Alzheimer's disease: facilitating family decision-making J Clin Nurs 13:661-7

5.                  Finestone HM and Greene-Finestone LS (2003) Rehabilitation medicine: 2. Diagnosis of dysphagia and its nutritional management for stroke patients CMAJ 169:1041-4

6.                  Kawamura O, Easterling C, Aslam M, Rittmann T, Hofmann C and Shaker R  (2004) Laryngo-upper esophageal sphincter contractile reflex in humans deteriorates with age Gastroenterology 127:57-64

7.                  Mercadante S (2002) Dry mouth and palliative care Euro J Pall Care 9:182-5

8.                  Gaze MN and Wilson IM (2003) Handbook of Community Cancer Care GMM Press  1^st edition London : 252-3

9.                  Perry L and McLaren S (2003) Eating difficulties after stroke J Adv Nurs 43:360-9

10.              Wright D (2002) Medication administration in nursing homes Nursing Standard 16:33-38

11.              Bending A (2001) Hiding medicines or hiding problems? Nursing & Residential Care 3:439-40

12.              Ferguson DD and DeVault KR (2004) Dysphagia Curr Treat Options Gastroenterol 7:251-258

13.              Vakil NB , Traxler B and Levine D (2004) Dysphagia in patients with erosive esophagitis: prevalence, severity, and response to proton pump inhibitor treatment Clin Gastroenterol Hepatol 2:665-8

14.              Mathieu J (2000) Dieticians can play an active role in screening for dysphagia J Am Dietetic Assoc 100:1101

(9/5/05)