Swallowing Assessment in Comprehensive Geriatric Assessment
While swallowing assessment is not universally mandated as a core component of comprehensive geriatric assessment, it should be systematically included given that dysphagia is a prevalent geriatric syndrome affecting 10-33% of older adults and is associated with significant morbidity and mortality. 1, 2
Why Swallowing Assessment Matters in Geriatric Populations
Dysphagia in older adults directly impacts the three critical outcomes that should guide all geriatric care:
- Mortality: Dysphagia is highly associated with reduced survival in patients with stroke and dementia, and increases rates of aspiration pneumonia 3, 4
- Morbidity: It causes malnutrition (98.7% nutritional risk in hospitalized elderly), dehydration (75.3% in one study), aspiration pneumonia, and increased hospitalizations 5, 3
- Quality of Life: Dysphagia significantly reduces quality of life for patients and caregivers, causes discomfort with eating, and leads to weight loss and debility 3
The Case for Systematic Screening
The European Society for Swallowing Disorders and European Union Geriatric Medicine Society recommend that oropharyngeal dysphagia should be included in all standard screening protocols for older patients. 1
Key supporting evidence:
- Dysphagia prevalence ranges from 25% in independently living elderly to over 50% in nursing home residents 6
- Despite its prevalence and severity, dysphagia remains underdiagnosed and untreated in many medical centers 1
- Up to 55% of patients who aspirate have silent aspiration without protective cough reflex, making clinical detection difficult without formal assessment 7
- Older adults have higher rates of silent aspiration than younger adults, further necessitating proactive screening 3, 7
When to Perform Swallowing Assessment
Screen for dysphagia when any of these red flags are present:
- Coughing or choking during swallowing 7, 8
- Nasal regurgitation of food 7
- Wet vocal quality after swallowing 7, 4
- Poor secretion management 7, 4
- Weak cough 7
- Feeling of food getting stuck 7
- History of stroke, dementia, Parkinson's disease, or other neurodegenerative conditions 2, 3
- Recurrent pneumonia or unexplained weight loss 3
Practical Implementation
Use the EAT-10 questionnaire as a validated screening tool (sensitivity 86%, specificity 76% for identifying aspiration) in the initial geriatric assessment. 7
If screening is positive or clinical suspicion exists:
- Refer to a speech-language pathologist for clinical evaluation including medical history review, patient/caregiver interview, and cranial nerve examination 7, 3
- Proceed to instrumental assessment (videofluoroscopic swallowing study or fiberoptic endoscopic evaluation) when signs of dysphagia are present, as bedside evaluations alone are insufficient to determine treatment interventions 7, 3
Critical Caveat
Do not perform swallowing assessments on delirious patients, as they cannot participate meaningfully in the evaluation. 7 Wait until delirium resolves before conducting formal assessment.
The Geriatric Syndrome Framework
Dysphagia meets all criteria for a geriatric syndrome: it is highly prevalent among older people, caused by multiple factors, associated with several comorbidities and poor prognosis, and requires a multidimensional approach to treatment 1. This framework supports its inclusion in comprehensive geriatric assessment alongside other recognized geriatric syndromes like falls, frailty, and cognitive impairment.