What is the diagnosis and treatment for Dysphagia (Difficulty Swallowing)?

From the Guidelines

Dysphagia, or difficulty swallowing, should be diagnosed and treated with a comprehensive approach that includes screening, assessment, and management by a multidisciplinary team, including a speech-language pathologist (SLP), to reduce the risk of aspiration pneumonia, malnutrition, and mortality, as recommended by the most recent and highest quality study 1.

Diagnosis of Dysphagia

The diagnosis of dysphagia involves a step-by-step approach, starting with:

• Screening for swallowing deficits using a valid screening tool by an expert in dysphagia, ideally an SLP, as soon as the patient is alert and ready for trialing oral intake 1
• Bedside swallowing assessment and management of swallowing, feeding, nutritional, and hydration status by a trained dysphagia clinician, including an SLP, occupational therapist, or dietitian 1
• Videofluoroscopic swallow study (VSS) or fiberoptic endoscopic examination of swallowing (FEES) for patients at risk for pharyngeal dysphagia or poor airway protection 1

Treatment of Dysphagia

The treatment of dysphagia should focus on:

• Restorative swallowing therapy and/or compensatory techniques to optimize the efficiency and safety of the swallow, with reassessment as required 1
• Individualized management plans to address therapy for dysphagia, dietary needs, and specialized nutrition plans 1
• Education on swallowing and feeding recommendations for patients, families, and caregivers 1
• Meticulous mouth and dental care to reduce the risk of pneumonia 1
• Consideration of enteral nutrition, such as percutaneous endoscopic gastrostomy (PEG), for patients who are unable to take food orally 1

Key Considerations

• Dysphagia is a common and life-threatening symptom of neurological disorders, affecting respiratory safety and swallowing efficacy, and leading to aspiration pneumonia, dehydration, and malnutrition 1
• The prevalence of dysphagia increases with age, affecting 16% of independently living older persons in the 70-79 year old group and 33% in the 80 year old group 1
• Dysphagia is associated with poorer outcomes, including higher mortality rates, poorer ability to complete activities of daily living (ADLs), greater caregiver burden, and more frequent nursing home placement 1

From the Research

Diagnosis of Dysphagia

• Dysphagia is a common problem that may be underreported, and its diagnosis should be guided by specific symptoms rather than their perceived location 2.
• The diagnosis of dysphagia involves evaluating the patient's symptoms, medical history, and physical examination, as well as using diagnostic procedures such as radiological esophagogram, videofluoroscopy, flexible endoscopic examination, ultrasound examination, manometry, electromyography, scintigraphy, and 24-hour pH monitoring 3.
• Flexible endoscopic evaluation of swallowing (FEES) is a useful tool in determining the oral diet of neurological intensive care patients suspected of dysphagia 4.
• Assessing esophageal dysphagia requires an understanding of deglutition, in particular the oropharyngeal versus esophageal stages, and the differential diagnosis of dysphagia should consider both benign and malignant disease processes 5.

Treatment of Dysphagia

• The treatment of dysphagia depends on the underlying cause and may involve surgical, pharmacological, or rehabilitative approaches 3.
• Non-invasive methods of dysphagia treatment may be divided into reconstitution, compensatory, and adaptive techniques, and the most effective way to regain efficiency is the regeneration of lost function 3.
• Dysphagia rehabilitation is difficult and long-lasting, and primary treatment should include addressing the underlying neurologic cause if possible 3.
• Dietary modifications, such as avoiding sustenances that strengthen dysphagia and ensuring adequate dietary intake, are important components of dysphagia treatment 3, 4.
• Early diagnosis and intervention are critical in preventing complications such as aspiration pneumonia, malnutrition, and death, and healthcare providers should be knowledgeable in assessing and diagnosing individuals with or at risk for dysphagia 6.

Types of Dysphagia

• Oropharyngeal dysphagia manifests as difficulty initiating swallowing, coughing, choking, or aspiration, and is most commonly caused by chronic neurologic conditions such as stroke, Parkinson disease, or dementia 2.
• Esophageal dysphagia may be caused by gastroesophageal reflux disease, functional esophageal disorders, eosinophilic esophagitis, or esophageal motility disorders such as achalasia 2.
• Neurogenic dysphagia may be caused by a disruption in different parts of the central nervous system or neuromuscular and muscular disorders, and its diagnosis and treatment require an interdisciplinary approach 3.