Dysphagia 5 : 61-71 (1990)

Dysphagia 9 Springcr-VerlagNewYork Ino. 1990

Aspiration and the Elderly Michael J. Feinberg, M.D., 1 Janice Knebl, DO, z Joann Tully, MA, 3 and Linda Segall, MS, 3 1 Departmentof Radiology, Albert Einstein MedicalCenter, Philadelphia, Pennsylvania; 2 Departmentof Medicine, Fort Worth Osteopathic Hospital, Fort Worth, Texas; and 3 Departmentof Physical Medicineand Rehabilitation, Philadelphia Geriatric Center, Philadelphia, Pennsylvania,USA

Abstract. Aspiration is prevalent in the elderly but its association with impairment of oral intake and gastroesophageal reflux is often misunderstood. This paper describes the causes, pathophysiology, and consequences of aspiration and their unique features in aged persons. It also explains how videofluoroscopic evaluation can assess current function while limiting factors that result in misinformation. The management of aspiration is discussed, emphasizing the importance and difficulties in maintaining functional well-being and possible complications of therapy. Key words: Aspiration - Aspiration pneumonia Swallowing, geriatrics - Deglutition - Deglutition disorders.

Feeding and swallowing problems can occur at any age but are particularly prevalent in the elderly. The morbidity and mortality as well as the costly disability and dependence that result from an impairment in oral intake are now being recognized as major geriatric health problems. Functioning as a multidisciplinary team, we have had the opportunity to diagnose and manage such impairment in over 1000 elderly individuals in a number of outpatient, hospital, and nursing home settings. Our current approach to oral intake dysfunction has developed from retrospective and prospective analyses of our patients. It has been our experience that the term aspiration is universally recognized by health-care professionals who deal with the elderly but is often misunderstood. This paper will first attempt to clarify definitions and then discuss Address reprint requests to: Michael J. Feinberg, MD, Department of Radiology, Albert Einstein Medical Center, Philadelphia, PA 19141, USA

the causes, pathophysiology, consequences, diagnosis, and management of aspiration in elderly patients.

Aspiration Aspiration can be broadly defined as the misdirection of oropharyngeal contents into the larynx. It may occur during oral intake (prandial) or may not be associated with food or fluid consumption (nonprandial). Most individuals aspirate small amounts of oropharyngeal contents during sleep [1]. However, ingested food, fluids, and secretions are aspirated infrequently by normal, awake adults. Materials that enter the larynx may pass further into the trachea and lungs, depending on their physical or rheologic characteristics, the functional status of the cough reflex, and the efficiency of the mucociliary action of the respiratory epithelium. The more liquid or fluid a substance, the more likely it will be aspirated and travel further into the respiratory system. Temporal and anatomical descriptions of bolus misdirection have led to conflicting radiographic definitions. Logemann [2] describes aspiration as material penetrating the larynx and entering the airway below the true cords. Linden [3] uses the term penetration instead of aspiration and describes supraglottic and subglottic extent. Groher [4] defines penetration as oral spillage into the larynx without swallowing being initiated, and aspiration as inspiration of pharyngeal residual following an attempted swallow. Kramer [5] describes penetration as a bolus entering below the cords during pharyngeal swallow and aspiration as airway encroachment before or after pharyngeal swallow. To avoid this confusion, it is preferable to equate aspiration and penetration and define them as bolus misdirection into

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the airway (larynx, trachea, bronchi) regardless of when the event occurs. Aspiration pneumonia This refers to two pathophysiologically distinct conditions that may occur more frequently in those with an impairment in oral intake, but may not be directly related to prandial aspiration. C o m m o n medical usage equates aspiration pneumonia with Mendelson's syndrome [6], or the acute aspiration of gastric contents [7, 8]. This condition occurs when depressed levels of consciousness or laryngopharyngeal impairment allow refluxed or vomited gastric contents to be aspirated into the lungs. The respiratory and cardiovascular deterioration that results is variable, but often leads to considerable morbidity and mortality. Aspiration pneumonia is also used to describe the bacterial infection of the lungs that results from aspiration of bacteria contained in oropharyngeal [9, 10] or gastric secretions [11]. Gram-negative enteric rods ( G N E R ) and anaerobes are the most common organisms that cause such pneumonias. Causes Involutional and degenerative changes of aging often result in marginally compensated deglutition [12]. When common neuromuscular diseases affect the elderly, oral intake impairment may present and progress differently than in younger individuals. Dysphagia secondary to acute stroke is less common than progressive dysfunction due to multiple prior strokes. Parkinson's disease may continue to affect deglutition adversely even when other motor symptoms are well controlled with medication. In our experience, aspiration is more commonly associated with debilitation, dementia, and depression than specific neuromuscular disorders. Decreased levels of alertness, psychomotor retardation, anorexia, and psychosocial isolation considerably reduce oral intake and may result in disuse deconditioning. In patients with these conditions, the voluntary and automatic aspects of oropharyngeal deglutition may deteriorate or be lost when not practiced for even relatively brief periods. Psychoactive medications may also contribute to or cause such impairment, as may food and fluid restrictions due to serious medical illness. These deconditioned patients often become incontinent and lose locomotion ability as part of global functional deterioration. Although hypoxic and metabolic encephalopathy may contribute to this syndrome, focal neurologic changes are not pres-

M.J. Feinberg et al. : Aspiration a n d the Elderl!

ent. Gastroesophageal reflux (GER) probably oc. curs more often because of the patient's bedridden state and vomiting may be more frequent, addint to the risk of aspiration pneumonia (gastric). El. derly patients frequently have deglutition problern~ and aspirate during the postoperative period 01 when removed from ventilators. Hypoxia and small strokes are potential causes, but we believe that most cases are secondary to the adverse effects of endotracheal intubation and disuse decondition. ing. Tumors that affect deglutition are uncomm0~ causes of aspiration in the elderly. Large cervical osteophytes or hyperostosis are common structural abnormalities associated with aging. Such bon) masses may prevent inversion of the cpiglottis or displace the laryngopharynx and alter biomechani. cal forces [13]. Zenker's diverticula are more corn. mon in the elderly [14] and may cause aspiration either by obstruction or reflux of contents back into the pharynx. Cricopharyngeal impressions of varying sizes and configurations arc more frequently found wit~ advancing age [15], but we have found no correla. tion with dysfunction or aspiration. Esophageal dysmotility is frequently observed in the elderly although it is not clear if presbyesophagus is the result of senescent motor changes [1 6], nervous system diseases [17], or GER. Compression of the esophagus by an atherosclerotic aorta [18], en. larged heart, or left pleural effusion is also corn. mon and may be exaggerated by a senile kyphosis in the sitting position. These motor and structural abnormalities result in aspiration if there is a dela! in esophageal emptying and return of contents into the pharynx. G E R appears to occur more frequently in the elderly due to many factors [191 Aspiration of gastric contents occurs if the reflex. ive laryngopharyngeal response is delayed or in. complete. Pathophysiology Abnormal function and structure during the oral pharyngeal, and esophageal stages of deglutiti0~ cause aspiration. Multiple stage dysfunction i~ common in the elderly and sometimes results iz complex pathophysiological interactions. Loss 0t bolus control, improper timing or sequencing, in. adequate propulsion or peristalsis, faulty valving~ and luminal compromise can all cause bolus mis. direction. When we consider its voluntary and somatic nature, it is not surprising that oral-stage dysfunc. tion is the most common cause of aspiration i~

M.J. Feinberg et al. : Aspiration and the Elderly

elderly persons. Primary sensorimotor abnormalities or alterations in cognition, affect, or alertness can cause loss of bolus control during oral-stage pretransport and delivery. Inappropriately large boluses or rapid ingestion rates frequently cause aspiration in elderly individuals, often in the presence of otherwise normal oropharyngeal function. This abnormal behavior seems to reflect an acquired habit, learned preference, or willful response. It results in a disruption of sequencing between bolus ingestion, delivery, propulsion, and laryngeal closure. Failure of containment during pretransport (bolus ingestion, alteration, sizing, and sampling) results in leakage into the pharynx during the oral stage. Weak or uncoordinated lingual delivery or a delay in initiation of swallowing (considered an oral stage dysfunction because of its voluntary nature in prandial deglutition) results in early entry of the bolus into the pharynx. A leaked or prematurely delivered bolus can directly enter the open laryngeal vestibule. In the elderly, the epiglottis frequently assumes a straight or curled configuration and the valleculae may be obliterated or covered (Fig. 1). Cartilage degeneration, muscle atrophy, and loss of resting tone result in formation of a " c h u t e " that directs the bolus into the larynx. In these cases, bolus misdirection can occur during oral pretransport activity or lingual delivery. Alternatively, the leaked or prematurely delivered bolus is mispositioned for pharyngeal ejection and aspiration can occur after initiation. It must be remembered that vestibular closure is not complete until early in the pharyngeal stage, and in such cases aspiration may occur despite normal laryngeal dynamics. Once triggered, the pharyngeal stage represents a series of visceral events that occurs in a fair!y predictable fashion. Lingual propulsion, constrictor activity, laryngopharyngeal excursion, epiglottal inversion, and upper esophageal sphincter (UES) opening result in efficient bolus transport. Dysfunction of one or more of these events results in incomplete bolus transport, with residual remaining in the valleculae or pyriform sinuses after the pharynx relaxes. The retained bolus may be aspirated when the larynx reopens or shortly after initiation of the next pharnygeal stage. Intrinsic closure of the larynx is also a major event of the pharyngeal stage. If the closure mechanism is defective, bolus misdirection occurs after initiation of swallowing. On radiographic examination, the most common observation is failure of the arytenold masses to appose the base of the epiglottis during maximal laryngeal contraction. The arytenoid

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Fig. I. Obliteration o f valleculae. The free portion o f the epiglottis (arrows) is adjacent to the lingual base and no valleculae can be identified.

masses may also fail to appose each other and contrast can enter between them. Aspiration occurs more frequently during or after the pharyngeal stage than during the oral stage, in our experience. However, oral dysfunction (leak, large bolus ingestion, initiation delay/ uncoordination) is at least as prevalent as pharyngeal dysfunction (defective closure, incomplete transport) in the elderly [20]. Esophageal stage abnormalities that result in the return of bolus to the pharynx after it has been swallowed can result in aspiration even if oropharyngeal function is unimpaired. Reduced gag or cough reflexes are the rule in the elderly and the sensescent laryngopharynx often cannot respond appropriately to retrograde bolus flow. Any structural esophageal abnormality (stricture, tumor) or dysmotility that causes arrest or obstruction can result in a bolus refluxing into the pharynx. Gastroesophageal reflux due to lower esophageal sphincter (LES) incompetence or vomiting frequently results in aspiration of stomach contents

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in the elderly. Decreased levels of consciousness and specific oropharyngeal impairment add to the likelihood that esophageal or gastric contents will be aspirated if they are returned to the pharynx.

Consequences of Aspiration Rational diagnostic and management strategies depend on an understanding of the consequences of aspiration. The respiratory sequelae that may develop depend on the nature of the aspirate (chemical, physical, bacteriologic), the amount and frequency of aspiration, and the status of the host's defenses [21, 22]. As previously described, aspiration pneumonia due to significant amounts of gastric contents acutely entering the lungs is a well-described entity. Obtundation or fluctuating levels of consciousness due to medications and neuropsychiatric disorders particularly predispose the elderly to gastric aspiration, Confinement to bed, debilitation, esophageal abnormalities, and conditions that promote G E R and vomiting are also added risk factors in the geriatric population. The acute pathologic process is chemically induced inflammation of the lungs and obstruction of the airways. Manifestations depend on pH, volume, enzyme concentration, and solid content of the aspirate [6, 23-25]. Apnea and death due to asyphxia may be the immediate consequences of gastric aspiration. More commonly, respiratory distress and fever develop within 2 h of a witnessed event [26]. The progression of this type of aspiration penumonia is variable in its severity and duration. If adult respiratory distress syndrome develops, a high mortality rate can be expected clue to hypoxemia and shock [27]_ Bacterial pneumonia and pulmonary embolism are also possible complications. In the institutionalized elderly, the actual aspiration may not be witnessed and a high index of suspicion is required to make the initial diagnosis. Chrome aspiration of small amounts of gastrointestinal contents has long been thought to cause pulmonary disease [28, 29]. Conditions that delay or obstruct bolus flow or cause reflux are again predisposing factors. Gastroesophageal reflux has been implicated as a cause of asthma, bronchiectasis, atelectasis, bronchitis, and chronic fibrosis [30]. Although the obvious pathophysiological mechanism is direct toxicity to respiratory structures after aspiration, a neurally mediated mechanism has also been suggested in cases of bronchospasm. Aspiration pneumonia secondary to G N E R is one of the most serious health threats to the institutionalized [31] and hospitalized elderly [32]. Oro-

M.J. Feinberg et al.: Aspiration and lhe Elderly

pharyngeal overgrowth of G N E R is associated with chronic illness, debilitation, incontinence, functional decline, and administration of broadspectrum antibiotics [33]. This pathologic colonization appears to represent a translocation of indigenous fecal bacteria and not an acquisition of flora native to a particular environment [34]. Age-related decline in the cough reflex [35] and possible deterioration of pulmonary host defenses allow the development of pneumonia when these virulent bacteria are aspirated into the lungs in sufficient nmnbers [36]. In the elderly with gingival inflammation or dentures, anaerobic bacteria may colonize oropharyngeal secretions [37] and also cause aspiration pneumonia. It is often presumed that prandial aspiration of ingested materials directly causes pneumonia. However, objective verification of the respiratory consequences of such aspiration is limited. Vegetable oils and vegetal particulate matter can cause granulomatous changes [38-40], animal fats can cause necrotizing lesions [411, and acid [6, 24, 251 can incite a severe inflammation in the lungs_ The actual amounts of aspirate and the length of exposure necessary to cause clinically significant acute or chronic disease in humans are unknown. Pathologic changes in the lungs due to exposure to dietary materials may occur after aspiration of gastroesophageal contents and not as a result of prandial aspiration [41]. Secretions containing bacteria probably enter the airway more often when ingested materials are aspirated, but it has not been proven if this significantly adds to the risk of infection. The diagnosis of penumonia may be very difficult in the elderly {43]. The typical clinical findings are frequently lacking [44] and chest x-rays are often suboptimal or difficult to interpret due to coexisting conditions [45]. Congestive heart Failure and bronchitis can cause respiratory symptoms that mimic pneumonia. Fever may be due to decubitus ulcers or urinary tract infections. However, the high morbidity and mortality associated with pneumonia in the elderly usually prompt aggressive antimicrobial treatment, even if the diagnosis is not firmly established. In chronic prandial aspirators, suspected or proven lung infections are invariably referred to as "aspiration pneumonias". A direct cause and effect relationship is implied but may not be necessarily correct, and caution is needed when making management decisions in such cases. Transitory abnormalities on chest x-rays of patients who aspirate have been previously noted [22, 46] and almost certainly add to the difficulty in

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Fig. 2. ~ Fleeting" infiltrate. A Chest xray from an asymptomatic 89-year-old aspirator demonstrates left lower lobe infiltrate (arrows). B Twenty-four hour follow-up shows clearing of infiltrate.

pneumonia diagnosis in this population. "Fleeting" infiltrates in the gravity-dependent lungs have been detected in our population of patients who aspirate and follow-up chest x-rays and clinical correlation have been required to exclude significant disease (Fig. 2). We have found that prandial aspirators sometimes develop febrile illnesses that last 24~72 h. They may or may not have associated respiratory symptoms or "fleeting" infiltrates. This condition causes only minimal morbidity and should not be confused with pneumonia, which invariably has a much more serious and protracted clinical course. Although it is possible that such an illness is due to prandial aspiration, we have also observed such findings in those who are artificially fed. Food asphyxia [47, 48] and near-fatal choking episodes are very serious consequences of prandial aspiration in our population. Even in patients without oropharnygeal impairment, advancing age should be considered a predisposing factor for such events. Solids, (hot dogs, hamburgers), cohesive boluses (bananas, mashed potatoes), and complex consistencies (sandwiches, noodles) have all been removed from the airways of patients who were witnessed choking during ingestion. Patients with known impairment have experienced fatal and near-fatal choking episodes [49] while on dysphagia diets (purees, puddings, cereals, soups with small solids). Rarely have these individuals demonstrated aspiration of semisolid consistency on prior radiographic or clinical examinations in our experience. Reflexive coughing episodes should be considered a consequence of prandial aspiration. In most

healthy adults, even a trace amount of contrast entering the laryngeal ventricle will elicit coughing. We have observed that in many elderly individuals reflexive coughing does not begin until barium enters the tracheal bifurcation or main bronchi. We postulate that with advancing age, a significant decrease in irritant receptor response occurs in the larynx. A bolus may need to contact these next most sensitive [50] or receptor-intense [51] regions before coughing is elicited. Infrequently, severe and persistent coughing episodes due to prandial aspiration result in significant compromise of cardiopulmonary function. Chronic coughing during oral intake can also inducc vomiting, cause generalized fatigue, prolong feeding time, and result in sitophobia (fear of eating). Any one of these sequelae may contribute to malnutrition by reducing a patient's total oral intake.

Diagnostic Considerations The videofluorographic swallowing examination is the most accurate technique for detecting aspiration and determining its causes. However, the limitations of this study must be appreciated. Numerous methods have been described [52-55] and many variations are probably currently used. Our protocol reflects our belief that routine oral intake function should be observed in each patient. Factors that might invalidate the results should be recognized and kept to a minimum. Studies are performed only when a patient's level of alertness and cooperation approximates their usual clinical state. All individuals are examined while seated in a specially designed chair that allows the maintenance

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Fig. 3. Videofluoroscopy chair. Moldcd plastic seat is affixed to mobile chair lYame.

of adequate body posture and head positioning (Fig. 3). Patients who routinely feed themselves are encouraged to do so during the radiographic assessment. The examination begins by recording the administration of 30-60 ml cold water either from a cup or straw; the patient is permitted to determine the bolus size and ingestion rate. This allows us first to observe the oral and pharyngeal stages as the patient controls the ingestion of a familiar substance. With some experience, a fairly accurate assessment of function and morphodynamics can be made using water and air as contrast agents. Barium mixtures are often considered noxious and unpalatable by many normal adults; this response is even more prevalent in the elderly with an impairment in their oral intake. Inappropriate oral processing and delay in swallowing initiation simply due to a distaste for barium can be appreciated by comparing water and barium administrations. It is frequently not possible to visualize bolus misdirection using water as a contrast agent, but aspiration can be assumed if coughing or coughingequivalent gesturing is observed immediately or

M.J. Feinberg et al. : Aspiration and the Elderly

within 2-3 min following ingestion. When this technique is used at the bedside and is combined with examination of voice quality [56] and auscul. rated airway sounds, the number of "silent" aspi. rators can be minimized. Except for coughing epi. sodes, we have found that aspiration during water drinking trials is a benign event. Water is rapidly absorbed by the lungs and even massive entry may cause only transient respiratory changes in cases of near drowning [59]. Patients with rare aerodiges. tive tract fistulas may also cough while drinking water. We depend on the observations made during both controlled and uncontrolled high-density liquid barium administration to diagnose oropharyngeal dysfunction. If patients are capable, they are initially allowed to take three or four swallows of barium from a cup or straw in their usual pattern. A 10-20 ml bolus is most often ingested using this technique and we routinely use this range for controlled administrations. Volumes as small as 6 ml are used, especially when patients are spoon-fed. Exclusive use of such amounts may not reliably determine if improvement in oropharyngeal function is required or possible. We have found that volumes smaller than 6 ml can create or exaggerate dysfunction by not providing adequate oral-stage stimulation. Often such small boluses are unfamiliar to patients and are " l o s t " in the mouth. In addition, larger volumes optimize oropharyngeal morphodynamics such as hyoid excursion and UES opening [58, 59]. However, ingestion of volumes that are too large plus rapid impulsive drinking is a very common cause of minor aspiration in our population. In this country, barium is the only oral contrast agent available for ingestion when aspiration is suspected. Iodinated ionic contrast agents are contraindicated due to their proven toxicity to the lungs [60]. Barium (the sulfate salt and additives) is a relatively inert mixture that is not inherently toxic to the lungs [61]. In fact, barium has been safely used as a contrast agent for bronchography [62]. Compared to environmental, nutritional, and gastrointestinal substances that are frequently aspirated by those with oral intake impairment, barium is a fairly benign substance. The physical presence of large volumes of liquid barium can cause acute respiratory problems, but such "drowning" can be readily prevented using good judgment and fluoroscopic monitoring of the airways. Except for reflexive coughing, we have found no clinically apparent adverse effects from barium aspiration. Barium is frequently cleared from the airway and lungs within 24 h despite continued prandial aspi-

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Fig. 4. Clearing of aspirated barium in an 87-year-old outpatient who demonstrated major aspiration during videofluoroscopic examination and refused any treatment after the study. A Chest x-ray immediately after the examination demonstrates bilateral barium bronchograms. B Reexamination at 24 h shows clearing of right lung and less barium in left lung. C At 48 h, little if any barium is visible in the lungs.

ration and seemingly ineffective cough reflexes. Except when massive aspiration occurs during recumbent examination of the esophagus, pulmonary barium retention beyond 72 h is unusual in our experience (Fig. 4). We use high-density (250% wt/vol) liquid barium (E-Z HD, E-Z-EM Inc., Westbury, NY) for a number of important reasons. Because of its viscosity and cohesiveness it is easier to control during the oral stage than are thinner preparations. Its excellent contrast and coating properties allow detection of minute amounts of aspiration and evaluation of dry swallows. If aspiration occurs, the morphodynamics of laryngeal closure can be readily observed. Mucosal evaluation of the pharynx and esophagus is also enhanced, allowing better detection of structural abnormalities. It is our philosophy that the videofluorographic swallowing examination should attempt to diagnose tumors and inflammatory changes that affect all stages of deglutition. A second study using standard radiographic techniques is frequently not possible in the elderly with oropharyngeal impairment. These individuals frequently will not or cannot rapidly ingest the large volumes of barium necessary to obtain adequate distention of the esophagus. Gross aspiration may occur when an attempt is made to evaluate the esophagus in the standard prone oblique position. It has been our experience that most significant structural and functional abnormalities of deglutition can be adequately evaluated

by videofluoroscopy using high-density liquid barium with patients in the sitting position. If there is no aspiration of high-density liquid barium after six to eight swallows, thinner (40% wt/vol) liquid barium (liquid E-Z) is administered in an uncontrolled fashion for four to six swallows. One level teaspoon of pudding or applesauce mixed with an equal amount of powdered highdensity barium is administered for evaluation of the semisolid consistency. Barium paste alone is not used because of the difficulty patients have in removing this contrast from a spoon and the potential for airway occlusion if a large amount is aspirated. We currently do not routinely administer solid boluses during our examination. Even in normal individuals, oral activity is extremely variable with this consistency and we have not been able to establish criteria that allow us to diagnose dysfunction objectively. When solid bolus administration was part of our routine protocol, aspiration of this consistency was a rare event (unpublished data, 1988). It is necessary to take a cautious approach when estimating the degree of aspiration occurring during videofluorographic evaluation. Bolus volumes in complex three-dimensional structures such as the upper aerodigestive tract are inherently difficult to judge. Aspiration often varies with each bolus intake and increases as more contrast is administered. Because of these variables, objective standardization is difficult and we prefer to de-

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scribe only two degrees of aspiration. Minor aspiration is diagnosed when small amounts of contrast enter the larynx inconsistently and result in supraglottic or subglottic accumulation. Major aspiration is diagnosed when moderate or large amounts frequently enter the larynx, resulting in significant subglottic accumulation. During videofluorographic examination, dysfunction may be intermittent or variable with each bolus. Patients may aspirate only on the first liquid barium administration or appear relatively normal until a small amount is aspirated and then significantly deteriorate. The total number of bolus administrations needed for an adequate diagnostic study is difficult to standardize. After drinking water, major aspirators may only require 2 or 3 liquid barium boluses for adequate evaluation, but minor aspirators may need 10-12 administrations. The videofluorographic examination reflects function during only one brief period and may not be representative of current function or capabilities outside the radiology department. It is important that a swallowing therapist confirm that the patient's mental status and behavior are similar to those observed during clinical evaluation. Levels of alertness and conditioning are often adversely affected by fatigue, medications, social interactions, and physical surroundings. Oral intake ability can significantly change on a daily or even hourly basis in the frail elderly. It must be emphasized that the results of the radiographic study need to be correlated with multiple clinical evaluations before an overall assessment is made. The frequency, degree, and bolus specificity of aspiration as well as the status of the cough reflex, prior history of pulmonary disease, and current respiratory status are all considerations needed to stage aspiration accurately.

Management " T h e American College of Physicians believes that maintenance of patient's functional well-being is a fundamental goal of medical practice" in the elderly [63]. Our approach to aspiration management reflects this philosophy. There have been no large, well-controlled clinical studies indicating that a specific therapy for chronic aspiration reduces morbidity and/or mortality. We believe that the potential benefits of intervention must be carefully weighed against the possible medical, mental, and psychosocial burdens that such treatment may impose. When oral intake contributes substantially to functional well-being, we attempt to maximize cur-

M.J. Feinberg et al. : A s p i r a t i o n a n d the Elderly

rent abilities while using practical methods to minimize aspiration. In chronic aspirators, our first task is often to convince patients and their primary caregivers that we have diagnosed a condition that requires treatment. Reduction or elimination of thin liquids is recommended for major aspirators, but dietary preferences and habits that have developed over a lifetime are difficult to change. Individuals who have been drinking water, coffee, and tea for 80 years are not readily convinced that such beverages can be thickened or substituted for. Compliance with dietary alterations is frequently a problem even in controlled settings. Patients often cajole caregivers, friends, or family members or resort to surreptitious methods to obtain thin liquids. Radical changes in diet tend to heighten perceptions of ill-health and may cause or exacerbate depression. Maintaining adequate fluid balance is a common problem in the elderly that is frequently made more difficult when thin liquids are restricted. The liberal use of parenteral fluid replacement is re-, quired in these cases, especially when febrile illnesses intervene. Repeated hospitalizations often result because intravenous therapy and monitoring may not be available to outpatients or those in institutions. Constipation is also a c o m m o n geriatric problem that is worsened when fluid intake is altered. Dysphagia diets that rely on semisolids to replace liquids and solids may result in more choking episodes (airway occlusion), as already mentioned. Pills that require thin liquids for swallowing may have to be crushed and administered with semisolids or substituted for. Considering the numerous pills that many elderly people take daily, these changes are not inconsequential. An important part of our management approach involves educating patients and their caregivers about the signs of aspiration and optimal feeding techniques. It cannot be overly stressed how important slow and careful administration and ingestion of food and fluids can be in preventing or minimizing aspiration. If coughing or coughing-equivalent gesturing is excessive, oral intake is interrupted and the patient is allowed to recover. Caregivers are familiarized with the Heim. lich maneuver and emergency suctioning techniques. General measures to improve seating, head and trunk positioning, and attention levels are described and demonstrated. Compensatory strategies and exercise programs are difficult to implement in a geriatric-care setting. Debilitation, cognitive impairment, and lack of cooperation will obviously limit the effectiveness of such therapeutic strategies.

M.J. Feinberg et al. : Aspiration and the Elderly

Artificial feeding is considered if prandial aspiration significantly reduces oral intake or causes obvious respiratory compromise. When dysfunction is relatively acute and potentially reversible (stroke, disuse deconditi0ning), a nasoduodenal feeding tube is our first choice. Unfortunately, agitation and self-removal are common problems with feeding tubes and more invasive procedures may be required even for short-term artificial feeding. If some recovery is possible, we encourage patients to eat ice chips and drink water and allow other fluid and foods as tolerated with supervision. The use of long-term artificial feeding in the very aged raises legal and ethical issues that should be appreciated by those who recommend it [64-66]. When required, we have used percutaneous endoscopic gastrostomies (PEG), except in those with prior gastrectomies or large incarcerated hiatal hernias. Our experience is similar to others in terms of placement success rate and low procedure-related mortality [67, 68]. Minor infections and peritubular leakage occur in some patients, but these readily respond to appropriate treatment. Extubation occasionally occurs but reinsertion has been successful when performed promptly. Gastrointestinal and metabolic complications secondary to tube feeding formulas have not been a problem in our experience. When patients who have received long-term artificial feeding have been closely evaluated, it has been reported that aspiration pneumonia remains a serious problem [69-71]. We have found a higher frequency of pneumonia in artificial feeders than major aspirators treated with dietary alterations [72]. An increased incidence of GER, further decline in laryngopharyngeal function, and G N E R colonization due to increased debilitation all may contribute to this complication. We are currently recommending percutaneous endoscopic gastrojejunostomies [73, 74] because of their theoretical advantage. The interposition of the pyloric valve between the feeding portal and stomach may reduce the incidence of GER. Although we have had little experience with the various surgical procedures [75] that can eliminate aspiration, we believe they may have an important role. If their general medical condition permits, two groups of patients seem to be candidates for tracheostomy and laryngeal closure or diversion. Cognitively intact individuals whose health and overall quality of life is significantly affected by prandial or G E R aspiration may prefer aphonia to artificial feeding. In those with severe cognitive impairment and gastrostomies, such treatment could prevent recurrent aspiration pneumonia.

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Costly and burdensome hospitalizations could be reduced at no loss to communication ability, since it is already severely compromised. In conclusion, it is imortant to emphasize that aspiration management requires making decisions under conditions of uncertainty with regard to medical outcome. Standards of appropriateness may be based on physicians' and therapists' attitudes and inclinations rather than clinically based evidence. Radical dietary changes and artificial feeding are drastic measures by any standards. Health-care professionals must be informative, supportive, and flexible when managing conditions that have such a significant impact on the elderly. References 1. Huxley EJ, Viroslav J, Gray WR, Pierce AK: Pharyngeal aspiration in normal adults and patients with depressed consciousness. Am J Med 64: 564-568, 1978 2. Logemann JA: Evaluation and Treatment of Swallowing Disorders. San Diego: College-Hill Press, 1983 3. Linden PL: Another view on the evaluation and treatment of swallowing problems. Paper presented at the American Congress of Rehabilitation Medicine, Baltimore, 1986 4. Groher ME: Dysphagia : Diagnosis and Management. Stoneham MA: Butterworth, 1984 5. Kramer SS : Radiologic examination of the swallowing impaired child. Dysphagia 3:117-125, 1989 6. Mendelson CL: The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol 52:191-205, 1946 7. Cameron JL, Zuidema GD: Aspiration pneumonia: magnitude and frequency of the problem. JAMA 219:1194-1196, 1972 8. Arms RA, Dines DE, Tinstman TC: Aspiration pneumonia. Chest 65:136-139, 1974 9. Bartlett JG, Corbach SL, Feingold SM: The bacteriology of aspiration pneumonia. Am J Med 56: 202-207, 1974 10. Johanson Jr WG, Harris GD: Aspiration pneumonia, anaerobic infections, and lung abscesses. Med Clin North Am 64:385-395, 1980 11. Berk SL, Verghese AC, Holtsclaw SA, Smith JK: Enteroccal pneumonia. Am J Med 74:153-164, 1983 12. Sheth N, Diner WC: Swallowing problems in the elderly. Dysphagia 2: 209-215, 1988 13. Zerhouni EA, Bosma JF, Donner MW: Relationship of cervical spine disorders to dysphagia. Dysphagia 1 : 129-144, 1987 14. Ellis FH, Schlegel JF, Lynck VP, Olsen SA: Cricopharyngcal myotomy for pharyngo-oesophageal diverticulum. Am Surg 170: 340-349, 1969 15. Curtis D J, Cruess DF, Berg T: The cricopharyngeal muscle: a vidcofluoroscopic review. A JR 142:497-500, 1984 16. Soergel KH, Zboralski FF, Amberg JR: Presbyesophagus: esophageal motility in nonagenarians. J Clin Invest 48:1472-1478, 1964 17. Hollis JB, Castell DO: Esophageal function in elderly men: a new look at "presbyesophagus." Ann Intern Med 80:371 374, 1974 18. Mittal RK, Siskind BN, Hongo M, Flye MW, McCallum RW: Dysphagia aortico: clinical, radiological, and manometric findings. Dig Dis Sci 31:379-384, 1986

70 19. Pries JM: Coping with reflux esophagitis in the aged. Geriatrics 37:57-67, 1982 20. Feinberg M J, Ekberg O: Oral versus pharyngeal dysfunction as the cause of aspiration - analysis of 50 cases. Paper presented at the Society of Gastrointestinal Radiologists. Hawaii, 1990 21. Bartlett JG, Gorbach SL: The triple threat of aspiration pneumonia. Chest 68: 560-566, 1975 22. Newman GE, Effman EL, Putman CE: Pulmonary aspiration complexes in adults. Curt Prob Diagn Radiol 9:3-47, 1982 23. Exarhos ND, Logan WD, Abbott OA, Hatcher CR: The importance of pH and volume in tracheobronchial aspiration. Dis Chest 47:167-169, 1965 24. Teabeaut JR: Aspiration of gastric contents - an experimental study. Am J Patho128: 51-67, 1952 25. Hamelberg W, Bosomworth PP: Aspiration pneumonitis: experimental studies and clinical observations. Anesth Analg 43:669 677, 1964 26. Bynum LJ, Pierce AK: Pulmonary aspiration of gastric contents. Am Rev Respir Dis 114:1129-1136, 1976 27. Landay M J, Christensen EE, Bynum LJ: Pulmonary manifestations of acute aspiration of gastric contents. A JR 131:587-592, 1978 28. Belcher JR: The pulmonary complications of dysphagia. Thorax 4:d4-56, 1949 29. Kennedy JH: "Silent" gastroesophageai reflux: an important but little known cause of pulmonary complications. Dis Chest 42:42-45, 1962 30. Barish CF, Wu WC, Castell DO : Respiratory complications of gastroesophageal reflux. Arch Intern Med 145:1882-1888, 1985 31. Garb JL, Brown RB, Garb JR, Tuthill RW: Differences in etiology of pneumonias in nursing home and cumminity patients. JAMA 240:2169-2172, 1978 32. Ebright JR, Rytel MW: Bacterial pneumonia in the elderly. J Am Geriatr Soc 28:220-223, 1980 33. Palmer L: Bacterial colonization: pathogenesis and clinical significance. Clin Chest Med 8: 455-467, 1987 34. Valenti WM, Trudell RG, Bentley DW: Factors predisposing to oropharyngeal colonization with gram-negative bacilli in the aged. N Engl J Med 298:1108-1111, 1978 35. Pontoppidan H, Beecher HK: Progressive loss of protective reflexes in the airway with advance age. J A M A 174:2209-2213, 1960 36. Verghese A, Berk SL: Bacterial pneumonia in the elderly. Medicine 62:271-285, 1983 37. Terry PB, Fuller SD: Pulmonary consequences of aspiration. Dysphagia 3:179-183, 1989 38. Head MA: Foreign body reaction to inhalation of lentil soup: giant cell pneumonia. J Clin Pathol 9:295-299, 1956 39. Crome L, Valentine JC: Pulmonary nodular granulomatosis caused by inhaled vegetal particles. J Clin Pathol 15: 21-25, 1962 40. Vidyarthi SC: Diffuse miliary granulomatosis of the lungs due to aspirated vegetal cells. Arch Patho183: 215-218, 1967 41. Pinkerton H: The reaction to oils and fats in the lung. Arch Pathol 5:380--401, 1928 42. Crausaz FM, Favez G: Aspiration of solid food particles into lungs of patients with gastroesophageal reflux and chronic bronchial disease. Chest 93: 376--378, 1988 43. Niederman MS, Fein AM: Pneumonia in the elderly. Geriatr Clin North Am 2:241-168, 1986 44. Bentley DW: Bacterial pneumonia in the elderly. Hosp Pract 23:99-116, 1988 45. Puxty JAH, Andrews K: The role of chest radiology in

M.J. Feinberg et al. : Aspiration and the Elderly the evaluation of the "geriatric giants." Age Ageing 15:174-176, 1986 46. Kross DE, Effmann EL, Putman CE: Adult aspiration pneumonia. Am Farn Physician 22: 73-78, 1980 47. Gelperin A: Sudden death in an elderly population from aspiration of food. J Am Geriatr Soc 22:135-136, 1974 48. Irwin RS, Ashba JK, Braman SS, Lee HY, Corrao WM: Food asphyxiation in hospitalized patients. JAMA 237:2744-2745, 1977 49. Feinberg M J, Ekberg O: Radiologic evaluation of deglutition after near-fetal choking episode. Paper presented at the Radiologic Society of North America, Chicago, ~989 50. Widdicombe JG: Respiratory reflexes from trachea and bronchi of cat. J Physiol 123: 55-70, 1954 51. Braman SS, Corrao WM : Cough : differential diagnosis and treatment. Clin Chest 34ed 8:177-188, 1987 52. Logemann JA (ed): Manual for the Videofluorograph. ic Study of Swallowing. San Diego: College-Hill Press, 1988 53. Linden P: Videofluoroscopy in the rehabilitation of swallowing dysfunction. Dysphagia 3:189-191, 1989 54. Jones B, Kramer SS, Donner MW: Dynamic imaging of the pharynx. Gastrointest Radiol 10: 213-224, 1985 55. Robbins UH, Sufit R, Rosenbek J, Levine R, Hyland J: A modification of the modified barium swallow. Dysphagia 2:83-86, 1987 56. Linden P, Siebens AA: Dysphagia: predicting laryngeal penetration. Arch Phys Med Rehab 64:281-283, 1983 57. Modell JH: Biology of drowning. Annu Rev Med 29:1-39, 1978 58. Dodds WJ, Man KM, Cook IJ, Kahrilas PJ, Stewart ET, Kern MK: Influences of bolus volume on swallow-induced hyoid movement in normal subjects. A JR 150:1307-1309, 1988 59. Cook IJ, Dodds WJ, Dantes RO, Benson M, Kern MK, Lang IM, Brasseur JG, Hogan JH: Opening mechanisms of the human upper esophageal sphincter. Am J Physiol 257 (Gastrointest Liver Physio120) : G748-G759, 1989 60. Reich SB: Production of pulmonary edema by aspiration of water soluble nonabsorable contrast media. Radiology 92:367-370, 1969 61. Gelfand DW: Complications of gastrointestinal radiologic procedures: I. Complications of routine fluoroscopic studies. Gastrointest Radiol 5:295-315, 1980 62. Nelson SW, Christoridis AJ, Pratt PC: Further experience with barium sulphate as a bronchographic contrast medium. Am J Roenteno192. 595-614, 1964 63. Almy TP: Comprehensive functional assessment for elderly patients. Ann Intern Med 109: 70-72, 1988 64. Olins NJ : Feeding decisions for incompetent patients. J Am Geriatr Soc 34:317, 1986 65. Campbell-Taylor I, Fisher RH: The clinical case against tube feeding in palliative care of the elderly. J Am Geriatr Soc 35:1100-1104, 1987 66. Lo B, Dornbrand L: Guiding the hand that feeds: caring for the demented elderly. N Engl J Med 311:402-404, 1984 67. Kirby DF, Craig RM, Tsang TK, Plotnick BH: Percutaneous endoscopic gastrostomies : a prospective evaluation and review of the literature. J Parenteral Enteral Nutr 10:155-159, 1986 68. Larson DE, Burton DD, Schroeder KW, Di Magno EP: Percutaneous endoscopic gastrostomy : indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 93:48 52, 1987 69. Olivares L, Segovia A, Revuelta R : Tube feeding and lethal

M.J. Feinberg et al. : Aspiration and the Elderly aspiration in neurological patients: a review of 720 autopsy cases. Stroke 5: 645-657, 1974 70. Ciocon JO, Silverstone FA, Graver M, Foley CJ: Tube feeding in elderly patients: indications, benefits, and complications. Arch Intern Med 148:429433, 1988 71. Hassett JM, Sunby C, Flint LM : No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy. Surg Gynecol Obstet 167:383-388, 1988 72. Feinberg M, Kneble J, Tully J: Pneumonia and aspiration:

71 findings in an elderly population. Poster presented at the International Congress of Radiology, Paris, 1989 73. Ponsky JL, Aszodi A: Percutaneous endoscopic jejunostomy. Am J Gastroenterol 79:113-116, 1984 74. Alzate GD, Coons HG, Elliot J, Carey PH: Percutancous gastrostomy for jejunal feeding: a new technique. A JR 147:822-825, 1986 75. Blitzer A, Krespi YP, Oppenheimer RW, Levine TM : Surgical management of aspiration. Otolaryngol Clin North Am 21 : 743-750, 1988