Chest
Volume 124, Issue 1, July 2003, Pages 328-336
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Aspiration Pneumonia and Dysphagia in the Elderly

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Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in the elderly, and the leading cause of death among residents of nursing homes. Oropharyngeal aspiration is an important etiologic factor leading to pneumonia in the elderly. The incidence of cerebrovascular and degenerative neurologic diseases increase with aging, and these disorders are associated with dysphagia and an impaired cough reflex with the increased likelihood of oropharyngeal aspiration. Elderly patients with clinical signs suggestive of dysphagia and/or who have CAP should be referred for a swallow evaluation. Patients with dysphagia require a multidisciplinary approach to swallowing management. This may include swallow therapy, dietary modification, aggressive oral care, and consideration for treatment with an angiotensin-converting enzyme inhibitor.

Section snippets

Dysphagia and the Cough Reflex in Elderly Patients With Pneumonia

Aspiration is defined as the misdirection of oropharyngeal or gastric contents into the larynx and lower respiratory tract.16 Aspiration pneumonia develops after the aspiration of colonized oropharyngeal contents.16 Aspiration of pathogens from a previously colonized oropharynx is the primary pathway by which bacteria gain entrance to the lungs. Indeed, Haemophilus influenzae and Streptococcus pneumoniae first colonize the naso/oropharynx before being aspirated and causing CAP.17 However, when

Risk Factor for Dysphagia in the Elderly

Dysphagia occurs commonly following a stroke. In patients with an acute stroke, the incidence of dysphagia ranges from 40 to 70%, with neurologic dysphagia developing in approximately 500,000 patients per year in the United States.323334353637 Aspiration occurs in approximately 40 to 50% of stroke patients with dysphagia. Dysphagic patients who aspirate are at an increased risk of acquiring pneumonia.3738 Specifically, the development of pneumonia is seven times greater in stroke patients who

Factors That Increase the Risk of Pneumonia in Patients Who Aspirate

While the presence of dysphagia and the volume of the aspirate are key factors that predispose elderly patients to aspiration pneumonia, a number of other factors play an important role.52 Colonization of the oropharynx is an important step in the pathogenesis of aspiration pneumonia. The elderly have increased oropharyngeal colonization with pathogens such as Staphylococcus aureus and aerobic Gram-negative bacilli (eg, Klebsiella pneumoniae and Escherichia coli).535455 Although this increased

Assessment of Dysphagia

Swallowing is a complex and coordinated neuromuscular process, which consists of both volitional and involuntary activity. It is described as involving three anatomically and temporally distinct phases: the oral, the pharyngeal, and the esophageal.7475 Elderly patients with signs and symptoms of oropharyngeal swallowing difficulties (Table 1), particularly with a history of pneumonia, should be referred for a comprehensive swallow evaluation and for the development and implementation of a

Clinical Assessment

A clinical assessment evaluates the structure and function of the swallow impairment of the oral stage. It enables the prediction of the impairment of the pharyngeal, laryngeal, and esophageal swallow physiology. The findings from the clinical evaluation will determine appropriate management, specific treatment strategies, and the need for appropriate instrumental testing.

The clinical assessment includes a comprehensive medical and swallowing history, an oral motor and sensory evaluation, and

Instrumental Assessment

The instrumental evaluation supplements the clinical assessment.3776828384 It enables the clinician to further evaluate the structure and function of the oral, pharyngeal, laryngeal, and upper esophageal swallow physiology, as well as assess the benefit of compensatory and treatment strategies. The videofluoroscopic swallow assessment (VFSS) is the most commonly utilized instrumental assessment tool in the clinical setting to determine the nature and extent of the swallow disorder.8285

Management of Dysphagia in the Elderly and the Prevention of Pneumonia

The management of elderly patients with dysphagia requires the coordinated expertise of a number of health-care professionals, including the patientsā€™ primary care physician, pulmonologist, speech and language pathologist, clinical dietician, occupational therapist, physiotherapist, nurse, oral hygienist, dentist, as well as the primary caregivers. The goal is to optimize the safety, efficiency, and effectiveness of the oropharyngeal swallow, to maintain adequate nutrition and hydration, and to

Tube Feeding

Nutritional supplementation, as determined by the clinical dietitian, may be required. Tube feeding is not essential in all patients who aspirate. As clinicians treating patients with dysphagia, we make every attempt to encourage oral intake, considering the safety as well as the efficiency to sustain our patients. The practice of tube feeding in the end stages of degenerative illnesses in the elderly should be carefully reconsidered. Finucane et al92 found no data to suggest that tube feeding

Oral Hygiene

Occupants of residential homes have been shown to have poor oral hygiene and rarely receive treatment from dentists and oral hygienists.100101 An aggressive protocol of oral care will reduce colonization with potentially pathogenic organisms and decrease the bacterial load, measures likely to reduce the risk of pneumonia. Yoneyama and colleagues102 demonstrated that aggressive oral care lowered the risk of pneumonia in institutionalized elderly patients. Yoshino and coworkers103 demonstrated

Pharmacologic Management

The neurotransmitter, substance P, is believed to play a major role in both the cough and swallow sensory pathways. Angiotensin-converting enzyme (ACE) inhibitors prevent the breakdown of substance P and may theoretically be useful in the management of patients with aspiration pneumonia. Arai et al104 measured serum substance P levels in hypertensive patients with cerebrovascular disease and symptomless dysphagia and control patients with no dysphagia. The patients with symptomless dysphagia

Conclusion

The medical, social, and psychological impact of dysphagia is significant, with dysphagia in the elderly often being underrecognized and poorly diagnosed and managed. Dysphagia is the major pathophysiologic mechanism leading to aspiration pneumonia in the elderly. Dysphagia has a negative impact on the quality of life for those suffering from it. Awareness of dysphagia in the elderly, the diagnostic procedures, and treatment options available should be increased among the medical profession.111

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