Dysphagia in the elderly.

Abstract

Difficulty with swallowing, or dysphagia, is a relatively unusual symptom produced by a number of rather specific etiologies. In the elderly population, however, dysphagia can become a much more frequent clinical disorder and can result in severe defects in eating and nutrition. Attention to this frequent association has been brought to mind by the article by Siebens et al. in this month's issue of the Journal. They have identified a fairly high incidence of swallowing problems involving the mouth, pharynx, and upper esophageal sphincter (UES) in an elderly population. It has been traditional for esophagologists to divide dysphagia into those lesions causing abnormal movement of food through the mouth, pharynx, and UES, so-called oropharyngeal dysphagia; and those abnormalities producing difficulty with the passage of ingested material through the smooth muscle portion of the esophagus, so-called esophageal dysphagia. Oropharyngeal dysphagia is characterized clinically by difficulty initiating the process of swallowing and physically by impaired ability to transfer food from the mouth into the upper portion of the esophagus. This process involves a closely coordinated central mechanism between the sensory nerves from afferent receptors (cranial nerves V, IX, and X) and the efferent nerves (V, VII, IX, X, and XII), supplying the striated muscles in this area. Thus, it should be apparent that many lesions of the central nervous system and muscle apparatus of the mouth and UES can produce oropharyngeal dysphagia. Common symptoms in these patients are an awareness of food moving in the wrong direction with associated coughing or sneezing or actual regurgitation through the nose. The specific defects more likely to cause oropharyngeal dysphagia in the aging population are listed in Table 1. Not to be forgotten in the elderly patient, however, is the potential for true esophageal dysphagia. This group of abnormalities was not reported upon in the paper by Siebens et al. because it was not sought in the evaluation of their patients. It is important to remember that lesions of this kind can, and do, occur in the elderly, some of them being particularly likely in this segment of the population (Table 2). Esophageal dysphagia usually presents to the patient as a sensation of food “sticking” or stopping behind the sternum after it has been swallowed. That is to say, the transfer of food from mouth to esophagus is readily accomplished but the transport of the ingested material down the esophagus is impaired. In an elderly subject complaining of esophageal dysphagia, particulary of recent onset, the diagnosis of esophageal cancer must be high on the differential list. This lesion is fairly common in our population and the most serious abnormality in the differential diagnosis of these patients. It is important to recall, however, that achalasia can initially present in the elderly patient, and that other motility disorders such as diffuse esophageal spasm and scleroderma do occur in these individuals. Another cause of esophageal dysphagia that is unique to the elderly population is so-called dysphagia aortica, in which the transport of material down the esophagus is impaired by a markedly tortuous and enlarged aorta and/or heart. A critical differentiation of more serious causes of dysphagia, such as that produced by esophageal cancer, from some of the other more likely lesions in the elderly begins with a careful history. By its nature, esophageal cancer should produce primarily solid food dysphagia. It should be truly esophageal in nature with the patient noting stopping of food behind the sternum after a swallow. Initially, liquids should pass the obstructing lesion without any difficulty. Only as the carcinoma becomes more advanced, is the potential for liquid dysphagia also a possibility. This symptoms complex is in contrast with that produced by oropharyngeal dysphagia discussed above and also with that seen with an esophageal motility disorder like achalasia. These patients will usually have dysphagia for all kinds of foods, both solid and liquid, from the beginning of their symptomatic phase. It is important to keep in mind that an achalasia-like syndrome has been seen in some patients with various malignancies, including adenocarcinoma at the esophagogastric junction, oat cell carcinoma of the lung, pancreatic carcinoma, and lymphoma. The clinical radiographic, and even manometric features may mimic those of idiopathic achalasia. A clinical triad that should arouse the suspicion of possible secondary achalasia of this type has been suggested. It includes the following: a patient in an older age group (greater than 50 years), significant weight loss (greater than 15 lb), and short total duration of symptoms (less than one year). Dysphagia in the elderly, like dysphagia in any age group, represents a challenging, yet satisfying, clinical problem. A thorough understanding of the lesions that may potentially be present and the important historical features, should help lead to the proper diagnosis in the vast majority of cases.