Recognizing the Importance of Dysphagia: Stumbling Blocks and Stepping Stones in the Twenty-First Century

The oropharyngeal swallow involves a rapid, highly coordinated set of neuromuscular actions beginning with lip closure and terminating with opening of the upper esophageal sphincter. The central coordination of this complex sensorimotor task uses a widespread network of cortical, subcortical, and brainstem structures. Many diseases and disorders affecting the central swallowing network or downstream peripheral nerves, muscles, and structures may result in an impaired oropharyngeal swallow. In addition, aging is also associated with multifactorial changes of swallowing physiology for which the term presbyphagia has been coined. Oropharyngeal dysphagia broadly affects respiratory safety due to the increased risk of aspiration, and swallowing efficacy leading to the impeding danger of insufficient nutrition and hydration.

Both from the epidemiological and the individual patient perspective, the impact of dysphagia is considerable, and should be seen as a matter of serious concern. The true prevalence of oropharyngeal dysphagia is difficult to determine. Studies have presented prevalence figures in the context of the patient’s setting, the disease state, and country of interest. Specifically, in a large survey, swallowing problems were reported in approximately 1 % of children with nearly 18 % of them rating this impairment as “big” or “very big” [1]. At the other end of the age spectrum oropharyngeal dysphagia has been reported in about 10–27 % of older community dwelling residents [2, 3, 4, 5]. In the nursing home, setting numbers are significantly higher and cross the 50 % margin, which is similar to figures reported for older individuals admitted to hospital with a diagnosis of pneumonia [6].

Disease-specific prevalence data for oropharyngeal dysphagia are also substantial. In particular, in preterm infants but also in typically developing children-feeding problems, otherwise unexplained respiratory symptoms and a failure to thrive are frequently caused by dysphagia and its sequelae [7, 8]. Furthermore, oropharyngeal dysphagia is reported in more than half of acute stroke patients and patients with traumatic brain injury, at least one-third of patients with Parkinson’s disease and dementia and a significant number of patients with neuromuscular disorders, such as amyotrophic lateral sclerosis and myasthenia gravis [9, 10, 11, 12, 13, 14]. In view of the demographic shift, especially with increasing numbers of very old people, i.e., those aged ≥85 years, these already alarming figures will further increase in the coming years since many underlying pathologies, particularly stroke, dementia and Parkinson’s disease, are age related. In light of the increasing incidence of children with prematurity and medically complex conditions, this problem is also critically augmented at the other side of the age spectrum.

The clinical consequences of dysphagia are directly linked to the patient’s overall prognosis, and may include aspiration pneumonia, malnutrition, and dehydration. In the presence of disordered swallowing, mortality is increased and elevated rates of infectious complications have been reported for several medical conditions, such as stroke or Parkinson’s disease, but are also present in other patient populations [15]. Older patients discharged from general hospitals with both dysphagia and malnutrition presented a mortality rate of 65.8 % at 1-year follow-up [16]. In children, consequences of dysphagia may be particularly severe, since unlike adults they have rapidly developing physiological systems. In this changing state, even short-term problems with swallowing can interrupt normal development and cause serious long-term sequelae [17].

Apart from these hazardous physical ramifications, dysphagia has a significant impact on the psychological well-being of affected individuals and has been linked to low mood and depression [2]. Particularly in the elderly, social isolation is propagated by dysphagia, since individuals embarrassed by their swallowing difficulties and experiencing anxiety or panic during mealtimes tend to avoid eating in public [18].

Last but not least, dysphagia also puts a heavy burden on healthcare resources. It has been shown that stroke-related dysphagia increases post-stroke medical expenses by nearly 25 % [19]. In patients with Parkinson’s disease, the presence of gastrointestinal disorders—with dysphagia being one of the most prominent symptoms—caused an excess of healthcare costs of more than 10 % [20]. Well above both these numbers, dysphagia in Alzheimer disease has been linked to a 40 % increase in total healthcare expenditures [21]. Reasons for these dysphagia-driven cost increases are probably multifactorial. They may relate to an extended length of stay in hospital, higher rate of infectious complications, more frequent emergency room visits, larger proportion of patients discharged to rehabilitations settings and nursing homes, and higher costs for medical equipment and treatment [19].

Taken together, oropharyngeal dysphagia is a highly relevant multi-etiological symptom slipping through the net of most healthcare systems worldwide. Knowledge and diagnostic methods have never been as good as today. The need for better patient care and scientific evidence is therefore a priority for the health care sector. Let us use this momentum through a greater collective and collaborative multidisciplinary effort to close the gap and achieve better treatment efficacy and quality of life for our patients.