Why dysphagia can be a hard pill for patients to swallow
Published on 30 October 2023
We speak with three speech therapists to find out more about dysphagia – a condition that affects swallowing and can significantly impact a person's health and quality of life.
Imagine a life where it becomes a chore to swallow your favourite foods, where you find it hard to breathe while eating, and where every bite you take triggers a cough.
That is the unpleasant everyday reality for patients with severe dysphagia.
According to Singapore’s Ministry of Health, it is estimated that there are close to 174,000 individuals older than 65 years living with dysphagia in the community.
But what exactly is dysphagia? And how serious is this condition?
“Dysphagia refers to a swallowing disorder or impairment involving muscles of the mouth and throat,” Ms Alison Tan, Speech Therapist, Ng Teng Fong General Hospital (NTFGH) explained.
“The consequences of dysphagia include malnutrition and dehydration, chest infections, compromised general health, choking, and in serious cases, even death.”
But while dysphagia itself can be challenging to manage, it is often also an indicator of a more significant underlying medical issue.
“Dysphagia is usually a symptom of an underlying medical condition such as stroke, certain cancers, neurological disorders like dementia and Parkinson's disease, or respiratory conditions,” Ms Tan elaborated.
As such, it is important to recognise the signs of dysphagia, so that you know when to seek medical assistance for the condition.
If you have ever experienced a coughing fit after talking with food in your mouth or eating too fast, then you have had a taste of what it is like to suffer from dysphagia.
However, if you find that these coughing episodes when eating or drinking become increasingly common, it might be time for you to seek medical help.
Other common symptoms associated with dysphagia include the sensation of food and drink being stuck in the throat, and having a voice that sounds wet and gurgly – resembling the presence of phlegm – during or after meals.
Additionally, individuals with dysphagia may feel breathless or have a constant urge to clear their throat when eating or drinking.
Describing how dysphagia is usually diagnosed, Ms Tan shared, “Firstly, we will ask the patient or caregiver some questions to better understand the history and description of the patient’s swallowing difficulties.
“We will then proceed to conduct a swallowing assessment for the patient. This typically involves examining the patient’s structure and function of muscles around the lips, mouth, and throat, as well as trialling food and drinks of varying textures and consistencies.
“If further evaluation is needed, we may conduct more in-depth tests – this can include a swallowing x-ray called videofluoroscopic swallowing study (VFSS), or a procedure known as fibreoptic endoscopic evaluation of swallowing (FEES), which involves using a special camera and endoscope to examine the patient’s throat as they attempt to swallow.”
The tests will also help to diagnose the severity and determine the dysphagia as oral and/or pharyngeal, depending on which phase of the swallowing process is affected.
The specific goals of dysphagia treatment often depend on the condition and needs of the patient.
Nonetheless, the common primary objectives of dysphagia treatment are to ensure that the patient can swallow safely and efficiently, while also maintaining proper nutrition and hydration.
“Ensuring safe swallowing is essential in preventing food or drinks from entering the airway or lungs, which is known as aspiration” Ms Rosabel Tay, Speech Therapist, Rehabilitation, Alexandra Hospital (AH), emphasised.
“Dysphagia treatment also focuses on maintaining proper nutrition, while making mealtimes enjoyable and comfortable for the patient.”
The treatment of dysphagia often involves two main approaches: rehabilitation exercises and compensatory strategies. Where appropriate, however, intervention approaches may also include surgery.
“Rehabilitation exercises include exercises to target and strengthen the muscles involved in swallowing…it seeks to strengthen the swallowing system and improve one’s swallowing form.” Ms Tay said.
“Compensatory strategies would include dietary modifications such as changing the consistencies of one’s diet and fluids to match the patient’s swallowing capabilities, or changing the individual’s posture and positioning to minimise the risk of aspiration during meals.”
Ms Tay also stressed the importance of working closely with other healthcare professionals, like doctors, nurses, dietitians, and other therapists. This ensures a “holistic approach” to managing dysphagia that considers all aspects of a patient's well-being.
The dangers of poorly managed dysphagia
Untreated or poorly managed dysphagia can result in numerous complications and risks, affecting both the patient's well-being and their overall quality of life.
Older individuals grappling with this condition are especially vulnerable to experiencing more severe complications.
"Frequent aspiration of food, drinks, or saliva can lead to aspiration pneumonia, a severe lung infection that can be life-threatening, especially for vulnerable populations like our elderly patients," Ms Tay noted.
She continued, “Dysphagia can also weaken the immune system and give rise to additional issues, including kidney problems, urinary tract infections, and electrolyte imbalances. These complications may lead to frequent hospital readmissions, placing a heavier caregiving burden on both the patient and their families.”
Apart from impacting a patient's health, dysphagia could also potentially affect their emotional well-being.
Ms Tay therefore stressed that it was important that individuals with dysphagia seek medical help as soon as possible.
“Dysphagia can limit one's ability to enjoy meals during social activities, leading to patients isolating themselves and experiencing a reduced quality of life," Ms. Tay said.
“It is crucial to seek prompt medical attention and follow the recommendations of the speech therapist or other healthcare professionals to address dysphagia effectively and minimise the associated risks and complications.”
Dysphagia in children
Though dysphagia is more commonly associated with older adults, it can affect individuals of all ages, including children.
According to Ms Phua Quan Quan, Senior Speech Therapist at National University Hospital (NUH), diagnosing dysphagia in children poses several unique challenges.
“The biggest challenge is catching the child at the right time. Typically, the best time to assess a child is when they are well rested and hungry – which means we avoid nap times and also check in on when the child last ate,” Ms Phua said.
Another challenge would be the child’s personality – some children are more cautious and fretful in unfamiliar places or with unfamiliar people, so the speech therapist may have to observe them unobtrusively.
The child’s sensory and food preferences are also a challenge, given that some children are pickier and will only eat certain foods. Speech therapists will therefore have to manage this by having a variety of food options in their clinics so they can offer something that the child will accept. Alternatively, parents are sometimes advised to bring food for their child.
However, the treatment fundamentals for paediatric dysphagia remain similar to that of adults, with the ultimate goal to be for the child to eat safely and efficiently.
Despite that, speech therapists will still take a slightly different approach when it comes to treating children with dysphagia.
Ms Phua explained, “Depending on the age of the child, they may not understand what is going on or why they need to do certain things that they may not like. So, the speech therapist has to understand the child’s personality and interests, food preferences, and find ways to motivate the child to participate in therapy.
“We also take into consideration the child’s family – how many caregivers there are, and what their preferences and constraints are. Parents also usually have more inputs in the therapeutic journey.”
With more complex cases, a multidisciplinary team comprising a paediatrician, dietitian, and psychologist will come together to manage the child’s feeding difficulties holistically.
The most common approach to managing dysphagia in children involves modifying the consistency of their food and drink. This typically entails recommending a texture that is easy for the child to chew and swallow.
Ms Phua added that positional strategies can also help improve a child’s feeding. She said, “For children with weak muscles and difficulty sitting upright, we might use towels or cushions to support their necks or the sides of their bodies to help them sit straight.
“We also collaborate with physiotherapists to improve seating, as good posture significantly enhances feeding skills.”
Other strategies that speech therapists might employ in treating dysphagia in children include using specialised milk bottles with one-way valves, as well as and incorporating specific exercises to assist children in their food intake.
Ultimately, though, for successful dysphagia management, Ms Phua encouraged parents to establish a close partnership with their child's speech therapist.
She said, “I suggest working closely with your speech therapist, and sharing openly your goals and concerns. You should always let us know what works for you, but also what isn’t working, so that we can truly help you and your child.
“As dysphagia results from another medical condition, it is not possible to prevent dysphagia directly. However, when a child has dysphagia, it is possible to minimise the impact with safe feeding strategies recommended by the speech therapist.”