Perspectives of the ASHA Special Interest Groups

SIG 15, Vol. 3(Part 1), 2018, Copyright © 2018 American Speech-Language-Hearing Association

Presbyphagia Versus Dysphagia: Identifying Age-Related

Changes in Swallow Function
Yvette M. McCoy
Speak Well Solutions, LLC, Speech Pathology
Leonardtown, MD
MedStar NRH Rehabilitation Network
Brandywine, MD

Rinki Varindani Desai

HealthPRO–Heritage
Dallas, TX
Disclosures
Financial: Portions of this information have been presented in the form of a webinar for Northern
Speech Services.
Nonfinancial: Portions of this information have been presented at the 2015 Annual Convention
of the American Speech and Hearing Association.

Presbyphagia refers to the characteristic changes in the swallowing mechanism of healthy

older adults that result from the normal aging process. These changes have an impact on
each stage of deglutition. Presbyphagia can lead to impaired bolus control and transport,
the slowing of pharyngeal swallow initiation, ineffective pharyngeal clearance, impaired
cricopharyngeal opening, and reduced secondary esophageal peristalsis, with serious
consequences for independence and quality of life.
Misattributing healthy age-related changes to impairments affects patient care and the
optimum use of health care resources. In order to effectively identify and distinguish
between presbyphagic and dysphagic symptoms in the older adult and to subsequently
manage these individuals successfully, clinicians must have a clear understanding of how
aging affects the anatomy, physiology, and functioning of the swallowing mechanism. This
article explores prebysphagia, that is, changes in the aging swallow in otherwise healthy
older adults, in further detail, and clinician’s perceptions of their readiness to treat such
disorders.

With numerous advances and changes in health care, the scope of practice of speech-
language pathologists (SLPs) has changed considerably in the past 20 years, particularly their
role in the assessment and treatment of swallowing disorders (Coyle, 2015). The management
of dysphagia has become the largest recognized subspecialty in the field of speech-language
pathology (Scholten & Russell, 2000).
An SLP Health Care Survey report states the following:
• SLPs in medical settings spent 39% of their adult clinical services time on swallowing.
• More adult service time was provided by SLPs in the area of swallowing disorders than
any other area of intervention.
• Adults made up 60% of the caseload for SLPs in all health care settings, ranging from
25% in outpatient clinics to 98% in skilled nursing facilities.
These results suggest that the assessment and treatment of dysphagia in adults has become
central to the practice of the medical SLP (American Speech-Language-Hearing Association, 2017).

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 Adults over the age of 65 years represent one of the fastest growing segments of the U.S.
population. The U.S. Census Bureau indicates that, in 2015, the population of persons above the
age of 65 years was 44 million. This number is expected to grow to over 72 million, or 19% of the
population, by 2030 (He, Goodkind, & Kowal, 2016).
Dysphagia is a growing health concern in our aging population. It is estimated that
6–10 million individuals in the United States are evaluated each year for dysphagia (Domench
& Kelly, 1999). The number of evaluations performed on patients whose dysphagia is in some
way related to aging is not clear; however, epidemiological studies suggest that dysphagia affects
22% of adults over the age of 50 years (Howden, 2004). Seventy-five percent of nursing home
residents experience some degree of dysphagia. Dysphagia is linked to malnutrition (Serra-Prat
et al., 2011), dehydration (Leibovitz et al., 2007), and aspiration pneumonia (Almirall et al.,
2013). It also drastically lowers the enjoyment of food and social interactions that accompany
mealtimes (Ekberg, Hamdy, Woisard, Wuttge–Hannig, & Ortega, 2002). The combined physical
and psychosocial impacts of dysphagia can lead to negative effects on the overall quality of life.
Referrals for dysphagia evaluation in medical settings have been rising for those aged
60 years and older, with referrals between 2002 and 2007 double for those in their 80s and
triple for those who were at least in their 90s (Leder & Suiter, 2009). Dysphagia is a significant risk
factor for hospital readmissions for patients aged 65 years and older (Cabré et al., 2014). These
figures are hardly surprising as the list of etiologies that can lead to dysphagia only grows
with increasing age (Roden & Altman, 2013). A number of variables in the domains of demographics,
functional status, and medical conditions have been linked to dysphagia in older adults. Of these,
only a few have been identified as independent risk factors, including candidiasis (Poisson,
Laffond, Campos, Dupuis, & Bourdel-Marchasson, 2016), sarcopenia (Maeda & Akagi, 2016),
and age (Humbert & Robbins, 2008).
Given our rapidly growing aging population and growing evidence that dysphagia affects
a significant number of elderly individuals, our need to understand associations between aging
and swallowing is clear. First, if we can differentiate expected age-related changes in swallow
function from those that are atypical, our ability to diagnose dysphagia, and target specific therapies
for it, is improved. Second, if we understand typical changes in swallow function with aging that
are also aversive, we may be able to prevent or minimize swallowing difficulty in the older adult.

What is Presbypahgia?
Presbyphagia refers to characteristic changes in the swallowing mechanism of otherwise
healthy older adults (Robbins, Hamilton, Lof, & Kempster, 1992). It is an old, yet healthy,
swallow. Presbyphagia is not a disease in itself but contributes to a more pervasive naturally
diminished functional reserve, making older adults more susceptible to dysphagia. When an
older healthy adult, whose functional reserve or their ability to adapt to stressors, has been
naturally diminished with age, or they are faced with increased stressors, such as acute illnesses,
medications, mechanical disruptions, or chronic medical conditions, they become more vulnerable,
crossing the link from having a healthy aging swallow to being diagnosed with dysphagia. If the
effects of age on the biomechanics of normal swallow function are understood, then clinicians
would have a better chance of appropriately differentiating normal from abnormal and managing
the resulting symptoms of disease (McCullough, Rosenbek, Wertz, Suiter, & McCoy, 2007).
To distinguish between healthy aging (presbypahgia) and the onset of swallowing impairment
(dysphagia), clinicians should first understand swallow function changes as a result of aging.
Some of these changes have been summarized below.

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 Senescent Swallowing Changes
Changes in Oropharyngeal Function
Loss of dentition, poor oral hygiene, and reduced and altered salivary flow can all affect
bolus management and swallowing in the older adult (Astor, Hanft, & Ciocon, 1999; Cassolato &
Turnbull, 2003; Langmore et al., 1998). Alterations in viscosity sensation and increased difficulty
with some bolus textures, as well as altered lingual pressures during swallow, may also impede
bolus clearance (Smith, Logemann, Burghardt, Zecker, & Rademaker, 2006; Tamine et al., 2010).
Healthy older individuals demonstrate significantly reduced isometric tongue pressures compared
with younger counterparts (Nicosia et al., 2000). Although older individuals manage to achieve
pressures necessary to affect an adequate swallow despite a reduction in overall maximum tongue
strength, they achieve these pressures more slowly than young swallowers.
The healthy older swallow is slow (Robbins et al., 1992). In those over age 65, the initiation
of laryngeal and pharyngeal events, including laryngeal vestibule closure (and airway protection)
are delayed significantly longer than in adults younger than 45 (Logemann, Kahrilas, Kobara, &
Vakil, 1989). Thus, in older healthy adults, it is not uncommon for the bolus to be adjacent to
an open airway by pooling or pocketing in the pharyngeal recesses for more time than in younger
adults, increasing the risk of adverse consequences due to ineffective deglutition.
In older adults, penetration of the bolus into the airway occurs more often and to a deeper
and more severe level than in younger adults. When the swallowing mechanism is functionally
altered, airway penetration can be even more pronounced. A study examining this issue found
that, when a nasogastric tube was in place in men and women older than 70 years, liquid penetrated
the airway significantly more frequently (Robbins et al., 1992), indicating that, under stressful
conditions or system perturbations, older individuals are less able to compensate due to the
age-related reduction in functional reserve capacity.
Changes in Esophageal Function
In the esophagus, changes with possible implications for food management in the older
adult include both increased intrabolus pressure and increased impedance to bolus flow at
the pharyngoesophageal segment (Shaker, 1993; Shaw et al., 1995). The high-pressure zone
associated with the upper esophageal sphincter (UES) appears reduced in length as compared
with younger subjects (Bardan et al., 2000). Reduced UES resting pressures and reduced drops
in pressure with opening of the UES have been described, as well as reduced UES response to
both pharyngeal and laryngeal stimulation (Kawamura et al., 2004).
Changes in Sensory Function
Swallow safety and swallow efficiency not only imply an adequate motor function but also
a preserved sensory system. Sensory function changes with age and is influenced by declining
perception of spatial–tactile recognition on the lips and tongue, diminished perception of viscosity
in the oral cavity, poor oral stereognosis, and reductions in taste perception (Humbert & Robbins,
2008). This disruption of sensory–cortical–motor feedback loops may interfere with proper bolus
formation and the timely response of the swallowing motor sequence, as well as detract from the
pleasure of eating. Thus, reduced sensation may explain the failure of some older adults, such
as those with dementia or Parkinson’s disease, to spontaneously swallow when food, liquid, or
saliva is pooling in the pharynx.
The aforementioned changes are the most common, but there are others changes that
occur in the older adult that will affect swallowing such as the following:
• Changes in neurophysiology of swallowing (Humbert et al., 2009).
• Changes in coordination of respiration and swallowing (Leslie, Drinnan, Ford, & Wilson,
2005) and increased fatigue during meal consumption (Hiramatsu, Kataoka, Osaki, &
Hagino, 2015).
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 • Disease processes more common in the older adult associated with dysphagia
(Baijens et al., 2016).
• Increased use of prescription medication in the older adult and its impact on the
swallow due to side effects, with xerostomia being the most common that can have
a significant impact on swallowing (Leal et al., 2010).
Although certain parameters change significantly with aging, swallow safety and swallow
efficiency are still adequately preserved in normal aging. Dysphagia cannot be attributed to normal
aging alone, and its presence suggests the need for further investigation to identify potentially
treatable causes.

Presbyphagia and Clinical Competence

The majority of speech-language pathology service is provided in medical settings, and
the topic of competency is an area of significant discussion within the profession. Beyond the
entry level, there is no clarity about what it takes to demonstrate competence. Initial entry-level
competencies do not imply the ability to independently perform in every area of speech-language
pathology, particularly dysphagia.
In 2015, a survey was conducted (McCoy & Desai, 2016) for currently practicing SLPs
and dysphagia clinicians to assess their perceptions regarding the adequacy of dysphagia
preparation provided by current graduate SLP programs in the United States. Seven hundred
fifteen clinicians responded to our survey. Thirty percent of the respondents reported that they
worked in skilled nursing facilities—the highest percentage of all clinical settings. The results of
our survey indicated that a majority (61%) of respondents did not feel adequately prepared in
the practice area of dysphagia after completion of their graduate program. Only 5.5% of respondents
reported feeling “very competent” in dysphagia upon graduation in this survey.
With the shift in health care toward pay-for-performance, reimbursement is primarily
based on the value of services provided. Value will likely be measured as a ratio of patient
outcomes to cost. If clinicians are educated and trained in a more focused manner to provide
high-quality services to patients with dysphagia, then they are going to deliver more value to
those patients and medical teams, and SLPs will continue to be in high demand in medical
settings (Spencer & Rogers, 2015).
New mechanisms are needed to measure and ensure broad competence of those providing
clinical services in dysphagia. Looking toward the future, it is time to focus our attention on
dysphagia clinical training processes with specialized populations, particularly older adults, and
to consider a variety of options and opportunities for improvements. Collaboratively, employers
and academia must work together to ensure adequate training, clinical supervision, mentoring,
and continuing education (Wisely, 2015) to create a strong foundation for the next generation
of clinicians working with swallowing and swallowing disorders in the older adult.

Conclusion
In summary, several neurophysiological changes associated with aging may adversely
affect all components of swallowing function. Clinicians need to increase their awareness of what
is normal as the patient gets older to identify problems earlier and to prevent decline. Presbyphagia
may place elderly individuals at greater risk for developing dysphagia. However, evidence suggests
that the secondary effects of disease are necessary to disrupt the normal intake of food and liquid in
older individuals (Robbins et al., 1992). Furthermore, although decreased sensations of taste, smell,
and vision, among others, may not contribute significantly to an increased risk of dysphagia, the use
of quality-of-life measures in future research may highlight important implications of such deficits
for the overall nutritional and psychosocial well-being of the increasing numbers of elderly individuals
in our society. Overmanaging older adult (i.e., restricting diet or implementing compensatory

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 strategies that may not be needed) on the basis of false assumptions could lead to unnecessary
restrictions on nutritional intake and quality of life. Likewise, undermanagement could lead to
negative consequences, such as aspiration, dehydration, and malnutrition.
Dysphagia evaluation and management are usually a multidisciplinary team effort and
are based on careful history, differentiating presbyphagia from oropharyngeal and esophageal
dysphagia, identifying the underlying cause, ascertaining the degree of risk or presence of silent
or overt aspiration, defining the patient’s abilities and impairments, and the degree to which the
impairments can be improved with therapy. There are no standard algorithmic approaches for
managing elderly patients with dysphagia; rather, goals and plans are individualized to fit given
clinical scenarios.
Oropharyngeal dysphagia may be life-threatening, but so are some of the alternatives,
particularly for frail elderly patients. Therefore, contributions by all team members are valuable
in this challenging decision-making process, with the patient’s family or care provider’s point
of view, perhaps, being the most critical. The state of the evidence calls for better training and
preparation in identifying presbyphagia and in assessing and treating dysphagia in the older
adult.

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History:
Received September 28, 2017
Revised February 03, 2018
Accepted February 18, 2018
https://doi.org/10.1044/persp3.SIG15.15

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