Pharmacists have an important role in advising on routes and modes of drug administration in patients with dysphagia, but what are the key questions to ask?

All this week David G Smithard MD FRCP, consultant in elderly and stroke medicine, chair of the UK Swallowing Research Group, Hon Reader University of Kent, takes an in-depth look at dysphagia.

Join us today to find out about the neurology and causes of the condition, then come back each day to discover more about the important role pharmacists can take helping patients manage their illness.

Eating and drinking are an important part of life, both physically and socially. Where swallowing is difficult, people may become isolated, under-nourished and frail.

Dysphagia may be caused by pathology in the mouth, pharynx or oesophagus.

Neurology

Swallowing is essentially a reflex involving 55 muscles, five cranial nerves and two cervical nerve roots.

The swallowing control centre is situated in the medullary area of the brain stem.

The swallowing centre afferents from the mouth and pharynx regarding bolus characteristics and the respiratory centre to coordinate swallowing and breathing.

The cerebral hemispheres (cortical and subcortical) also receive information regarding the characteristics of the bolus, this information is integrated and afferents from the subcortical areas, feeding into the swallowing centre to alter the duration of laryngeal elevation and upper oesophageal sphincter relaxation.

Swallowing and breathing are intimately related, sharing the same path through the pharynx, air enters the larynx and food/ liquid continues to the oesophagus.

When this relationship is disturbed, swallowing problems/ dysphagia occurs.

Dysphagia

Dysphagia is always abnormal, irrespective of someone’s age.

The only difference is that the timing of the different components is more critical.  

 Dysphagia is a symptom, not a diagnosis very much like cardiac failure and falls.

Once identified the underlying aetiology needs to be sought.

 

Diagnostic group Example
Neurological Stroke

Sub arachnoid haemorrhage

Multiple sclerosis

Motor neurone disease

Brain tumour

Traumatic brain injury

Encephalitis

Post polio syndrome

Developmental problems (Cleft palate)
Musculoskeletal Cervical osteophytes

Spondylolisthis

Rheumatoid arthritis

Disc prolapse
Malignancy Tongue

Gum

Larynx

Pharynx

Oesophagus
Infection Candida

Streptococcal

 

 
Cardio respiratory Heart failure

COPD

Lung fibrosis
Latrogenic Post intubation

Post surgery
Other Pharyngeal pouch

Pharyngeal atresia/stenosis

Crico pharyngeal spasm

Oesophageal atresia

Oesophageal achalasia

Frailty
Medication Anticholinergic medication

Antibiotics

Opiates

Anti psychotics

Benzodiazepines

Calcium channel blockers

 
Self Harm Bleach

Fire

 

Table 1: Aetiological factors for dysphagia

Take home points

  1. Swallowing problems are common.
  2. Swallowing problems are under reported and under recognised.
  3. Swallowing problems occur in all age groups, but you need to be aware and look for them.

Come back tomorrow as we investigate the epidemiology of dysphagia and reveal why the condition should be categorised as a Geriatric Syndrome.