When you sit down to dinner with your mother, do you wonder why she constantly clears her throat? 
 
Are you puzzled as to why her nose runs after nearly     every meal?
 
When you give your father juice, do you hold your  breath waiting to see if it goes down the right tube?
 
When he eats a sandwich, are you on the edge of your     seat ready to perform the Heimlich maneuver?
 
Are you forever looking at the kitchen clock when you     eat with your mother because meals take so long and   you’ve got a million things to do?
 
Do you wonder how your loved one can possibly be   getting enough food or liquid to survive?
 
If you’ve had any of these concerns, your loved one may have a significant, potentially serious, swallowing problem.

COMMON AND OFTEN OVERLOOKED

Many people these days know about the dangers of falling in the elderly. Did you know that swallowing problems are another major threat to the elderly? They, too, account for tens of thousands of deaths in the United States every year. More, perhaps, than falls.

• Choking, a blockage of the airway, takes nearly four thousand lives.
  

• Aspiration of food, liquid, or bacteria-laden material from the mouth into the lungs causes fatal pneumonia in tens of thousands. 
  

• Malnutrition resulting from swallowing problems causes weakness and susceptibility to infection that hasten the death of thousands more.

Nearly 40 million Americans in a total U.S. population of just over 300 million are elderly (65 years of age and older). From 15 to 50 percent of the elderly are estimatedsix and 20 million people and growing.
 
As common as these problems are, they are often overlooked. The symptoms and situations listed above – frequent throat-clearing, a runny nose while eating, and meals that take forever – are but some of the clues that suggest your loved one has a swallowing problem that could be life-threatening. 

IT’S NOT JUST THE ELDERLY

You don’t have to be 65 or older to have a swallowing problem. Persons with a wide variety of medical and neurologic disorders are vulnerable. These disorders include stroke, multiple sclerosis, cancer, ALS, myasthenia gravis, head injury, congestive heart failure, and COPD.

Here are some typical scenarios: 

• A 49-year-old man with multiple sclerosis was able to chew. But after he swallowed, some food remained in his throat. It was sucked into his airway; and, because his cough was so weak, the material made its way to his lungs to cause pneumonia.

• A 56-year-old woman treated for salivary gland cancer had an extremely dry mouth and exquisitely painful sores inside her cheeks. Chewing was painful and made eating unpleasant, leaving her feeling drained physically and emotionally.
  

• A 64-year-old woman with a recent stroke had difficulty drinking liquids. They caused fits of coughing that brought tears to her eyes. A bout of pneumonia put her back into the hospital and delayed her neurologic recovery.

AS FOR THE ELDERLY:

A 72-year-old man with Parkinson’s disease did everything slowly. That included swallowing. Food often got stuck in his throat and caused him to cough and gag.

An 82-year-old man with Alzheimer’s was extremely distractible and could no longer use a fork or spoon. He had also “forgotten” what to do with food once it was in his mouth. A single swallow could take three minutes or longer. Not surprisingly, he frequently became dehydrated. 

WHAT PEOPLE COMPLAIN OF

These are some of these things people complain of when they have a swallowing problem:

• “The food doesn’t go down.”
  

• “I have to swallow more than once.”
  

• “My nose runs at mealtimes.”
  

• “Pills get stuck in my throat.”
  

• “I cough when I drink water.”
  

• “The food falls out of my mouth.” 
  

• “I have a hard time eating steak.”
  

• “When I swallow, juice goes up my nose.”
  

• “It hurts when I swallow.”
  

• “I’m afraid I’m going to choke.”
  

• “My voice sounds funny after I eat.”
  

• “I get so tired, I can’t finish a meal.”
  

• “What do you expect? I’m old.”

Sometimes, however, a person has no complaint at all – but a very real problem with swallowing.

WHERE SWALLOWING BREAKS DOWN

To understand how things can go wrong with swallowing, let’s look briefly at normal swallowing. 
 
Swallowing is a process – a set of steps that takes food (or liquid or pills) from mouth to stomach. 

1. CHEWING (which, of course, does not apply to liquids). The tongue, lips, cheeks, jaw, and teeth work together to reduce food to a pasty ball. Saliva plays a key role. It glues together the ground-up food, gathering up flaky bits so they don’t tickle your throat or get sucked into your lungs. 
 
When jaw muscles are weak, teeth are missing, or dentures are loose or painful, chewing will be impaired. That can set the stage for a choking emergency. 
 
2. TRANSPORTING the food from mouth to throat. The tongue acts like a bucket without a handle. Cancer surgery, neurologic disorders (such as stroke, MS, ALS, or Parkinson’s disease), or dehydration can interfere with moving the food along.
 
3. SWALLOWING itself. This is a reflex triggered by food or liquid getting to where the tonsils are (or used to be).  Several things happen pretty much at once to make sure food goes into the esophagus, not into the windpipe. 
 
When muscles are weak (as with muscular dystrophy or myasthenia gravis) or nerve signals are scrambled or absent (as with stroke, MS, or ALS), the reflex cannot provide for safe swallowing.
 
4. THE ESOPHAGUS. Muscles at its beginning and end act like traffic cops. One-way travel only! Otherwise, you pay the price with heartburn, bad breath, or worse.

Connective tissue disorders like scleroderma can constrict the esophagus and prevent proper movement of food or liquid. Chronic reflux of acidic stomach contents (as with GERD) can irritate the lining of the esophagus and cause it to stick together, preventing food from getting to the stomach.   

WATCH OUT FOR DEHYDRATION  AND MEDICATION

Dehydration can cause swallowing problems by reducing the supply of saliva. Food sticks to the throat so leftover material can get sucked into the lungs after the swallow. Pills can attach to the esophagus and burn its lining. 

Diuretic medications can cause or contribute to dehydration. Anticholinergic drugs (such as diphenhydramine, amitriptyline, or ipratropium) cut down on saliva formation to interfere with swallowing at any phase of the process.

WHAT’S YOUR NEXT STEP?

Gather together your observations, questions, and concerns and get them to your loved one’s primary medical provider. 

If things worsen at any time – if she has increased difficulty swallowing, threatened dehydration, labored breathing, or progressive weakness, for example–seek medical attention at once.  

IN CONCLUSION

Give yourself a pat on the back for learning about an important subject that receives little attention and which can be life-threatening. Ignoring a swallowing problem can be disastrous. Now that you have a plan, don’t hesitate to use it.

Roya Sayadi, Ph.D., CCC-SLP, is a speech-language pathologist with the Natick (Massachusetts) Visiting Nurse Association. She has had extensive experience in diagnosing and treating patients with swallowing disorders, working with families, the elderly, and the chronically ill in a variety of settings. Joel Herskowitz, M.D., Dr. Sayadi’s husband, is a pediatric neurologist on the faculty of the Boston University School of Medicine.  They are authors of SWALLOW SAFELY: How Swallowing Problems Threaten the Elderly and Others. A Caregiver’s Guide to Recognition, Treatment, and Prevention (available through Amazon.com and www.swallowsafely.com). For further information, contact swallowsafely@aol.com.

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