Diseases of the Esophagus (2011) 24, 476–480

DOI: 10.1111/j.1442-2050.2011.01182.x

Original article dote_1182 476..480

Prevalence and symptom profiling of oropharyngeal dysphagia in a community

dwelling of an elderly population: a self-reporting questionnaire survey

G. Holland,1 V. Jayasekeran,1 N. Pendleton,2 M. Horan,2 M. Jones,2 S. Hamdy1

1
Gastroenterology, School of Translational Medicine, and 2Age and Cognitive Performance Research Centre
(ACPRC), Community Based Medicine, University of Manchester, Manchester, UK

SUMMARY. Symptomatic dysphagia is believed to be more common in the older population; however, the factors
that predict age-related dysphagia are less well-understood. Here, we describe a questionnaire-based survey of
swallowing dysfunction in a large, otherwise ‘healthy’ community dwelling older population in the UK in whom
additional cognitive and depression related scores were evaluated. A postal survey using Sydney oropharyngeal
dysphagia questionnaire was sent to 800 residences in the North of England that formed part of the University of
Manchester Age and Cognitive Performance Longitudinal Study. This cohort was composed of older individuals
(mean age 81 [range 69–98 years]) who are otherwise healthy with no history of previous neurological disease. The
postal questionnaire is a validated self-report inventory measuring symptoms of oropharyngeal dysphagia covering
a total of 17 domains of swallowing function. The maximal score obtainable is 1700, with a score of ⱖ200
arbitrarily considered to indicate swallowing difficulty. Cognitive performance and depression scores utilized the
telephone interview cognitive screen and the Geriatric Depression Scale. All data were analyzed in SPSS. Of the
800 questionnaires sent out, 637 where returned. Three were later discarded as unusable after follow-up telephone
interviews of incomplete forms, giving a completed response rate of 79%. Females made up 77% of the total
respondents. Of the population, 11.4% reported symptoms indicative of significant dysphagia. Unsurprisingly,
dysphagia severity was directly correlated with subject age (r = 0.11, P = 0.007). When cognitive factors were taken
into account, there was no correlation between memory, recall, and mental performance and dysphagia; however,
depression was strongly and independently associated (P = 0.002) with dysphagia symptoms. Dysphagia symptoms
are prevalent in older people, affecting nearly one in nine people who are otherwise living independently in the
community. While cognitive factors such as memory recall do not seem to influence dysphagia symptoms, depres-
sion is associated with dysphagia, suggesting a potential interaction. This could relate to associations with quality
of life or psychological factors.
KEY WORDS: community, dysphagia, elderly, questionnaire, swallowing.

INTRODUCTION is associated with significant morbidity.1,2 While neu-

Swallowing problems or dysphagia is considered a
substantial problem among the older population and
Address correspondence to: Professor Shaheen Hamdy, PhD,
FRCP, School of Translational Medicine – Inflammation
Sciences, Faculty of Medicine and Health Sciences, University of
Manchester (part of the Manchester Academic Health Sciences
Centre, MAHSC), Salford Royal Hospital, Eccles Old Road,
Salford M6 8HD, UK. Email: shaheen.hamdy@manchester.
ac.uk
Contributions: GH collected the data, analyzed the data, and
helped write the article. VJ collected data, analyzed data, and
was involved in conceptualizing in the study. NP and MH helped
in conceptualizing the study, data interpretation, and writing the
article. MJ helped to collect and analyze data. SH conceptualized
the study, helped analyze the data, and helped write the article.
476 Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
romuscular disorders, degenerative neurological syn-
dromes such as dementia, and upper digestive tract
cancer are common causes of dysphagia in this popu-
lation, the aging process may also cause a variety of
physiological changes that can impair swallow func-
tion.2,3 Despite these observations, little is known
about the prevalence of dysphagia in the healthy
older population. Previous studies have suggested
that dysphagia may be found in up to 16% of the
‘frail’ elderly.4,5 The prevalence of dysphagia in
nursing home and inpatient populations is sub-
stantially higher, reflecting disease comorbidity.6
Neuromyogenic dysphagia is most commonly caused
by stroke.2 Other associated conditions include
© 2011 Copyright the Authors

parkinsonism, bulbar/pseudobulbar palsy, multiple
sclerosis, dementia, and myopathies. The general
elderly population is at increased risk of dysphagia
because of the increasing incidence of conditions such
as stroke along with age-related impairment of swal-
lowing function.7 Delays in the transfer of the bolus
through the oropharynx, laryngeal closure, and
opening of the upper esophageal sphincter (UES)
have been reported with aging.7,8 Muscular degenera-
tion can produce resistance at the UES, and this
increases the chance of food passing into the larynx.8,9
However, the symptomatic basis for oropharyn-
geal dysphagia in the ‘disease-free’ elderly remains
unclear.
Another factor relevant to old age is cognitive
capacity. Many studies have demonstrated that rates
of cognitive decline and variability in cognitive func-
tion increases with age.10 Moreover, loss of brain
volume due to ageing appears to predict decline in
processing speed but not memory.11 Furthermore, the
prevalence of depression in elderly populations has
been reported to be as high as 16%.12 Depression is
associated with a number of comorbidities and an
increased mortality rate. Neurological conditions are
more prevalent in elderly depressed individuals and
depression is associated with increased cognitive
impairment following stroke. Given the multiple
health issues associated with aging,13 the aims of
this study are to assess the prevalence of swallowing
symptoms in a healthy community dwelling elderly
population and describe the association between
cognitive function and depression with swallowing
dysfunction.
METHODS
Study population
The study population was composed of 800
community-dwelling individuals from Manchester
and Newcastle who represented the surviving
members of the University of Manchester Longitudi-
nal Study of Cognition in Normal Healthy Old Age.10
This population was established in 1983 to enable a
longitudinal study examining the nature, time course,
extent, and etiology of changes in cognitive function
of over 6000 normal healthy individuals aged 50
years and over. On entry to the study, all volunteers
achieved the maximum score on the mini-mental state
examination and at the time, of reassessment in 1998,
cognitive tests indicated no sign of dementia.
The validated Sydney oropharyngeal dysphagia
questionnaire was sent to 800 members of the study
cohort.14 A total of 637 patients returned the ques-
tionnaire (80% response rate); however, 24 question-
naires were incomplete or incorrectly completed.
Twenty-one out of 24 individuals were able to
complete the questionnaire via telephone interview
© 2011 Copyright the Authors
Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
Swallowing difficulty in the elderwell 477
resulting in a final number of 634 completed forms
(23.5% men, 76.5% women; mean age 81 ⫾ 5 years;
range 69–98 years) and giving a completed response
rate of 79%.
Swallow questionnaire
The questionnaire itself was composed of 17 ques-
tions about swallowing function with responses
entered onto a visual analog scale for 16 questions.14
On these questions, it was possible to obtain a score
of 0–100. The visual analog scale was composed of
105 mm continuous line that followed each question.
On the left-hand side of the line, a statement such as
‘No difficulty at all’ or ‘Never occurs’ was printed; an
opposing statement was printed on the right-hand
side of the line such as ‘Unable to swallow at all’
or ‘Occurs every time I swallow.’ The participants
placed an X at a certain distance along the line to
indicate the magnitude of their response. The dis-
tance to the centre of the mark was measured to the
nearest millimeter and converted to a score out of
100 for each question. A mark placed within the first
5 mm of the line was scored as zero for that question.
On one question, it was possible to score 0, 20, 40, 60,
80, or 100 depending upon which category the par-
ticipant placed a mark. The maximum possible total
score was thus 1700, with a higher score indicating
greater swallowing dysfunction. Instructions explain-
ing how to complete the questionnaire were printed at
the start of the questionnaire.
Cognitive tests
A variety of cognitive tests was performed on the
study population. The main test constituted the
Telephone Interview Cognitive Screen (TICS-m),
which is a short screening tool for measuring cogni-
tive performance that includes a word list learning
task. The version used in our study was composed
of 13 items with a maximum score of 39 points.15 It
tests orientation, concentration, immediate and
delayed memory, naming, calculation, compre-
hension, and reasoning. The test of immediate and
delayed memory is a 10-word list-learning exercise
that can be scored separately. Participants are read a
list of 10 words and then asked to repeat as many as
possible immediately at the end of the TICS-m inter-
view, which may be several minutes later. A score out
of 10 was produced for immediate and delayed recall
for each participant, with a higher score indicating
greater recall ability. Three scores are therefore gen-
erated: the total TICS-m score, an immediate learn-
ing score, and a delayed learning score. The cutoff
that was used to define ‘cognitive impairment’ was a
TICS-m score below 21 (out of a possible 39).15,16
Depression was quantified using the validated Geri-
atric Depression Scale (GDS) questionnaire.17,18 The
478 Diseases of the Esophagus

Table 1 Question topics used in the Sydney Swallow 1700 was taken to indicate dysphagia. This cutoff
Questionnaire14
value was estimated using results obtained from a
previous validation of the swallow questionnaire.14
Question
number Question topic

1 Any difficulty swallowing at present. RESULTS

2 Difficulty swallowing: thin liquids.
3 Thick liquids
4 Soft foods Table 1 shows the categories of questions included in
5 Hard foods the survey. The mean swallow scores for each question
6 Dry foods across all subjects are shown in Figure 1. The mean
7 Saliva
8 Difficulty starting a swallow. total swallow score across all participants was 86/1700
9 Feeling of food getting stuck in your throat when (⫾standard deviation [SD] [120], range 0–894).
swallowing.
10 Coughing or choking when swallowing solid foods.
11 Coughing or choking when swallowing liquids.
12 Eating time for an average meal. Symptom profiles
13 Food or liquid going behind or up the nose when
swallowing. Based on the dysphagia score cutoff of 200 to indicate
14 Swallowing more than once for food to go down.
15 Coughing up or spitting out food or liquids during symptomatic dysphagia, the prevalence of dysphagia
a meal. in this older population was 11.4%. The three com-
16 Severity of swallowing problem today. monest symptoms in the subjects with dysphagia
17 How much the swallowing problem interferes with
enjoyment or quality of life? scores >200 were the following:
1 A feeling of food getting stuck in the throat (Q9).
2 A sensation of choking/coughing on swallowing
maximum possible score on the questionnaire was 15, (Q10).
with a score above 5 considered to indicate more 3 Difficulty swallowing hard foods (Q5).
severe depression. The participants could answer yes
or no to each question. TICS-m and GDS
The mean TICS-m score assessing cognitive perfor-
Statistical analysis
mance was 32 (⫾0.5 standard error of the mean
All data were analyzed using SPSS version 15.0 soft- [SEM]). Only 1.2% of the population had a score of
ware (SPSS Inc., Chicago, IL, USA). Spearman’s <21, indicating mild cognitive impairment; however,
nonparametric correlation was used to identify a sig- no subjects scored <17, implying that across the
nificant correlation between total swallow score and group, the levels of cognitive performance were
cognitive scores or age. Linear regression models were outside of the dementia range. Mean immediate
then calculated with total swallow score as the depen- learning score was 6.5 (⫾0.1 SEM), while the mean
dent variable. A total swallow score greater than 200/ delayed memory score was 5.2 (⫾0.1 SEM). By

Fig. 1 Histogram showing the range of responses (mean ⫾ SEM) across all participants (n = 637) to swallowing specific questions
using the Sydney Swallow Questionnaire.14 The highest score (Q9) related to a sensation of food sticking in the throat, although across
subjects, the question with the highest abnormal response rate was question 12 (eating times for an average meal).
© 2011 Copyright the Authors
Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus

Table 2 Correlation between total swallow scores, cognitive/
depression scores and age
Correlation coefficient
Variables (Spearman’s)
Total swallow score and age 0.107
Total swallow score and 0.133
GDS score
Total swallow score and -0.043
immediate recall
Total swallow score and -0.014
delayed recall
GDS score and age 0.200
Immediate recall and age -0.162
Delayed recall and age -0.159
contrast, the mean depression score across the
population was 3.2 (⫾0.5 SEM), with only 7% of the
respondents giving a score >5, indicative of more
severe depression/unhappiness.
Associations with dysphagia score
Total dysphagia scores were not significantly affected
by gender (P = 0.987). However, the dysphagia score
correlated positively with age (P = 0.007) and depres-
sion symptoms (P = 0.001) but not with immediate/
delayed recall (Table 2). Immediate recall, delayed
recall, and depression symptoms also significantly
correlated with age (Table 2). However, following
regression analysis, only age (F = 7.9; P = 0.005) and
depression symptoms (F = 9.5; P = 0.002) were shown
to significantly affect the dysphagia score.
DISCUSSION
The prevalence of oropharyngeal dysphagia follow-
ing neurologic diseases has been well-described.
However, much less is known about dysphagia in the
‘healthy’ elderly population; indeed, few studies have
determined the prevalence of dysphagia in European
populations. The self-report postal questionnaire
used in this study demonstrated a high completion
rate and used visual analog scales to assess a variety
of symptoms associated with oropharyngeal dys-
phagia. The Sydney oropharyngeal dysphagia ques-
tionnaire was first tested and validated in a group of
neuromyogenic dysphagic patients and compared
against a global dysphagia score that used instru-
mental examination and other clinical indicators.14
Against this standard, the questionnaire was found to
have a high level of reliability and has since been
further validated in patients with head and neck can-
cer.19 Thus, this tool seems to have the appropriate
attributes to screen a community for oropharyngeal
problems, albeit without any clinical examination
data to corroborate the findings.
The prevalence of dysphagia in this ‘healthy’ older
population was found to be 11.4%, which is sub-
© 2011 Copyright the Authors
Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
Swallowing difficulty in the elderwell 479
stantial given the population demographic. This
prevalence is similar, although slightly lower, to that
described in comparable studies from Japan, the
P-value Netherlands, and the USA (14–16% prevalence).4,5,20
The lower value found in this study may be related to
0.007
0.001
the cutoff score used to indicate dysphagia or that the
population studied here were healthier than frail and
0.295 more elderly populations used in the previous studies.
0.731
Alternatively, the result may represent a genuinely
lower prevalence of dysphagia in the UK. However,
<0.001 the prevalence of dysphagia in our study is surprising
<0.001
<0.001
and confirms that swallowing problems are underre-
ported in the elderly, possibly because of the assump-
tion that dysphagia is a normal consequence of
ageing. The latter argument is supported by a recent
study that found that 23% of an elderly community-
dwelling population thought that swallowing diffi-
culty is or could be a normal consequence of aging.20
Nonetheless, dysphagia will have a significant impact
on quality of life and health. Therefore, it may be
beneficial to screen elderly patients for dysphagia
and provide education regarding its significance,
especially as dysphagia can also be associated with
serious underlying pathology and complications such
as aspiration.
A significant positive correlation was found
between total swallow score and age, and this was
maintained following linear regression analysis,
suggesting that increasing age is associated with
increased severity and prevalence of dysphagia in a
healthy elderly population. A proportion of the age-
related increase in dysphagia is likely to result from
the increased incidence of comorbidity, such as
stroke, which is known to occur with aging. However,
given the healthy nature of the study population, the
biological determinants of age-related decline in
swallowing function remain uncertain and require
further exploration. We also found a clear association
between total swallow score and quantitative assess-
ment of depression using the GDS. Moreover, this
association remained significant following linear
regression analysis. Previously published literature in
this cohort using the Beck Depression Inventory21
found that the vast majority of participants scored
<15, which would be subdiagnostic for clinical
depression and would thus imply that the GDS
assessment was identifying more ‘unhappiness’ than
‘state’ levels of depression. Furthermore, an assess-
ment of depression scales in this population over
time showed remarkable stability,10 suggesting that
the correlation with dysphagia is not likely to be
explained by the effects of swallowing dysfunction on
mood but rather that low mood symptoms and swal-
lowing function are linked, possibly through other
central nervous system degenerative processes. A
number of studies have linked depression and anxiety
with functional gastrointestinal disorders including
dyspepsia and feeding disorders.22,23 Gastroeso-
480 Diseases of the Esophagus
phageal reflux symptoms and esophageal dysphagia
symptoms have also been correlated with anxiety and
depression independently.24 The results thus empha-
size the importance of awareness by clinicians that
depression is common in patients with dysphagia and
that this should be taken into consideration when
managing depression in the elderly.25
In conclusion, our study found that one in nine
older healthy people living in the community will
have symptoms that amount to dysphagia, which are
likely to be underreported and underrecognized.
These data support the contention that dysphagia in
the elderly is clinically important and while correlated
with ageing and depression, needs to be managed
appropriately by aware clinicians.
Acknowledgment
The authors would also like to thank Annie Herbert
for advice on statistical analysis.
References
1 Altman K W, Yu G P, Schaefer S D. Consequence of dys-
phagia in the hospitalized patient: impact on prognosis and
hospital resources. Arch Otolaryngol Head Neck Surg 2010;
136: 784–9.
2 Mistry S, Hamdy S. Neural control of feeding and swallowing.
Phys Med Rehabil Clin N Am 2008; 19: 709–28.
3 Miller A J. The neurobiology of swallowing and dysphagia.
Dev Disabil Res Rev 2008; 14: 77–86.
4 Kawashima K, Motohashi Y, Fujishima I. Prevalence of
dysphagia among community-dwelling elderly individuals
as estimated using a questionnaire for dysphagia screening.
Dysphagia 2004; 19: 266–71.
5 Bloem B R, Lagaay A M, van Beek W, Haan J, Roos R A C,
Wintzen A R. Prevalence of subjective dysphagia in community
residents aged over 87. BMJ 1990; 300: 721–2.
6 Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P.
Social and psychological burden of dysphagia: its impact on
diagnosis and treatment. Dysphagia 2002; 17: 139–46.
7 Achem S R, Devault K R. Dysphagia in aging. J Clin Gastro-
enterol 2005; 39: 357–71.
8 Cook I J. Diagnostic evaluation of dysphagia. Nat Clin Pract
Gastroenterol Hepatol 2008; 5: 393–403.
9 Hall K E. Aging and neural control of the GI tract II. Neural
control of the aging gut: can an old dog learn new tricks? Am J
Physiol Gastrointest Liver Physiol 2002; 283: 827–32.
Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
10 Rabbitt P M A, McInnes L, Diggle P et al. The University of
Manchester longitudinal study of cognition in normal healthy
old age, 1983 through 2003. Aging Neuropsychol Cogn 2004;
11: 245–79.
11 Rabbitt P, Ibrahim S, Lunn M et al. Age-associated losses of
brain volume predict longitudinal cognitive declines over 8 to
20 years. Neuropsychology 2008; 22: 3–9.
12 Takeda M, Tanaka T. Depression in the elderly. Geriatr
Gerontol Int 2010; 10: 277–9.
13 Yanker B A, Lu T, Loerch P. The aging brain. Annu Rev
Pathol Mech Dis 2008; 3: 41–66.
14 Wallace K L, Middleton S, Cook I J. Development and vali-
dation of a self report symptom inventory to assess the severity
of oral-pharyngeal dysphagia. Gastroenterology 2000; 118:
678–87.
15 Plassman B L, Welsh K A, Helms M, Brandt J, Page W F,
Breitner J C. Intelligence and education as predictors of cogni-
tive state in late life: a 50-year follow-up. Neurology 1995; 45:
1446–50.
16 Welsh K A, Breitner J C S, Magruder-Habib K M. Detection of
dementia in the elderly using telephone screening of cognitive
status. Neuropsychiatry Neuropsychol Behav Neurol 1993; 6:
103–10.
17 Yesavage J A, Brink T L. Development and validation of a
geriatric depression screening scale: a preliminary report.
J Psychiatr Res 1983; 17: 37–49.
18 Wancata J, Alexandrowicz R, Marquart B, Weiss M, Friedrich
F. The criterion validity of the Geriatric Depression Scale: a
systematic review. Acta Psychiatr Scand 2006; 114: 398–410.
19 Dwivedi R C, St Rose S, Roe J W et al. Validation of the
Sydney Swallow Questionnaire (SSQ) in a cohort of head and
neck cancer patients. Oral Oncol 2010; 46: e10–4.
20 Chen P, Golub J S, Hapner E R. Prevalence of perceived dys-
phagia and quality of life impairment in a geriatric population.
Dysphagia 2009; 24: 1–6.
21 Beck A T, Ward C H, Mendelson Mock M J, Erbaugh J. An
inventory for measuring depression. Arch Gen Psychiatry
1961; 4: 561–71.
22 Boyd C, Abraham S, Kellow J. Appearance and disappearance
of functional gastrointestinal disorders in patients with eating
disorders. Neurogastroenterol Motil 2010; 22: 1279–83.
23 Van Oudenhove L, Vandenberghe J, Geeraerts B et al.
Determinants of symptoms in functional dyspepsia: gastric
sensorimotor function, psychosocial factors or somatisation?
Gut 2008; 57: 1666–73.
24 Eslick G D, Talley N J. Dysphagia: epidemiology, risk factors
and impact on quality of life – a population-based study.
Aliment Pharmacol Ther 2008; 27: 971–9.
25 Beyer J L. Managing depression in geriatric populations. Ann
Clin Psychiatry 2007; 19: 221–38.
© 2011 Copyright the Authors
Copyright of Diseases of the Esophagus is the property of Wiley-Blackwell and its content may not be copied or
emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.