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The Prevalence of Dysphagia among Adults in the United States Neil Bhattacharyya Otolaryngology -- Head and Neck Surgery published online 5 September 2014 DOI: 10.1177/0194599814549156 The online version of this article can be found at: http://oto.sagepub.com/content/early/2014/09/04/0194599814549156
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Original Research
The Prevalence of Dysphagia among Adults in the United States Neil Bhattacharyya, MD1
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Abstract Objective. To determine the prevalence of dysphagia, reported etiologies, and impact among adults in the United States. Study Design. Cross-sectional analysis of a national health care survey. Subjects and Methods. The 2012 National Health Interview Survey was analyzed, identifying adult cases reporting a swallowing problem in the preceding 12 months. In addition to demographic data, specific data regarding visits to health care professionals for swallowing problems, diagnoses given, and severity of the swallowing problem were analyzed. The relationship between swallowing problems and lost workdays was assessed. Results. An estimated 9.44 6 0.33 million adults (raw N = 1554; mean age, 52.1 years; 60.2% 6 1.6% female) reported a swallowing problem (4.0% 6 0.1%). Overall, 22.7% 6 1.7% saw a health care professional for their swallowing problem, and 36.9% 6 0.1.7% were given a diagnosis. Women were more likely than men to report a swallowing problem (4.7% 6 0.2% versus 3.3% 6 0.2%, P \ .001). Of the patients, 31.7% and 24.8% reported their swallowing problem to be a moderate or a big/very big problem, respectively. Stroke was the most commonly reported etiology (422,000 6 77,000; 11.2% 6 1.9%), followed by other neurologic cause (269,000 6 57,000; 7.2% 6 1.5%) and head and neck cancer (185,000 6 40,000; 4.9% 6 1.1%). The mean number of days affected by the swallowing problem was 139 6 7. Respondents with a swallowing problem reported 11.6 6 2.0 lost workdays in the past year versus 3.4 6 0.1 lost workdays for those without a swallowing problem (contrast, 18.1 lost workdays, P \.001). Conclusion. Swallowing problems affect 1 in 25 adults, annually. A relative minority seek health care for their swallowing problem, even though the subjective impact and associated workdays lost with the swallowing problem are significant.
Keywords dysphagia, swallowing, prevalence, epidemiology, stroke
Otolaryngology– Head and Neck Surgery 1–5 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814549156 http://otojournal.org
Received May 12, 2014; revised July 17, 2014; accepted August 7, 2014.
D
eglutition is an essential survival function of the human species. Because of the anatomical complexities in the human in which airway structures, swallowing structures, and speech structures are positioned in such close proximity and share multiple functions, human deglutition is an extremely complex mechanical and neurological process. Because it is such a complex process, deglutition is subject to a wide variety of functional derangements and may be negatively affected by many disease conditions. Despite many published reports on specific dysphagia diagnoses and dysphagia arising in different disease conditions in defined cohorts, a truly representative epidemiologic national estimate of the prevalence of adult swallowing problems across the United States has not been determined. The National Health Interview Survey (NHIS), conducted by the National Center for Healthcare Statistics of the Centers for Disease Control, is a household-based, yearly survey evaluating and quantifying the self-reported health status of US residents.1 This survey has been used to determine the basic prevalence of many health problems on a national basis, including several in otolaryngology, such as sinusitis and balance disorders.2–5 In the 2012 cycle of the NHIS, a supplement was contained within the survey specifically pertaining to swallowing and speech disorders in adults. We have previously reported on the prevalence of voice problems and other diagnoses in the US adult population with this national survey.6 Herein, we sought to analyze this survey to determine, at the national population level, the basic contemporary prevalence of swallowing problems among adults in the United States.
1
Department of Otology & Laryngology, Harvard Medical School, Boston, Massachusetts, USA This article was presented at the 2014 AAO-HNS/F Annual Meeting & OTO EXPO; September 21-24, 2014; Orlando, Florida. Corresponding Author: Neil Bhattacharyya, MD, Division of Otolaryngology, Department of Otology & Laryngology, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA. Email: [email protected]
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Methods The household-based NHIS for calendar year 2012 maintained by the National Center for Healthcare Statistics served as the data source for this study.7 This study was reviewed by our hospital’s committee on clinical investigation and was deemed exempt from review. Within the 2012 NHIS survey, a specific supplement was contained titled the ‘‘Adult Swallowing, Speech and Language Supplement: Adult Communication Disorders.’’ The supplement focused on the domains of speech and swallowing for adults aged 18 years and older, gathering data about the causes, age of onset, severity, and health care utilization in these areas. From the sample adult NHIS, file standard demographic information was extracted along with study design elements for sample weights, strata, and clustering to account for the survey study design of the NHIS, which allows derivation of national estimates from survey responses. In addition, data components that pertain to swallowing function were extracted from the speech and swallowing supplement. These data include information on adults reporting a swallowing problem in the previous 12 months, visits to a health care professional specifically for a swallowing problem in the preceding 12 months, and whether or not a diagnosis was given for the reported swallowing problem. Data were collected by trained census bureau interviewers via face-toface interviews with swallowing-specific questions such as, ‘‘DURING THE PAST 12 MONTHS, have you had a SWALLOWING problem, such as difficulty eating solid food, taking pills, or drinking beverages?’’ Additional questions included, for example, ‘‘How many days in the past year did you have problems swallowing?’’ and ‘‘DURING THE PAST 12 MONTHS, have you received treatments, therapy, or other rehabilitation services for your problems swallowing?’’ Respondents were also asked about the individual diagnoses for the swallowing problem, the subjective severity of the swallowing problem, and the source of swallowing-related health services. Finally, subjective response treatment with respect to social life and work/ school life and the current status of the swallowing problem were also determined. Data for lost workdays in the previous 12 months were also extracted. Data were imported into IBM SPSS Statistics, version 22. The estimated national annual prevalence of selfreported swallowing disorders along with associated swallowing-related diagnoses and subjective severity and impact were determined using sample weights and survey design variables based on a raw sample size of 34,525 adults. Data are presented as estimate 6 standard error of the estimate. Estimates were considered reliable according to criteria established by the National Center for Healthcare Statistics.7 Comparisons were conducted to determine differences in gender-related prevalence of the swallowing problem and the influence of age on the likelihood of having a swallowing disorder, with statistical significance set at P = .05. Finally, comparisons were conducted for lost workdays in the prior 12 months between those reporting
Figure 1. Age distribution of adults reporting a swallowing problem in the United States.
and not reporting a swallowing problem in the prior 12 months.
Results Among 234.9 1 2.3 million adults (raw N = 34,525), 9.44 6 0.33 million adults (raw N = 1554; mean age, 52.1 years; 60.2% 6 1.6% female) reported a swallowing problem in the preceding 12 months, equivalent to 4.0% 6 0.1% of the adult US population. Among these adults, 22.7% 6 1.7% saw a health care professional for their swallowing problem in the preceding 12 months. Of these, 36.9% 6 0.1.7% were given a diagnosis for their swallowing problem. Figure 1 presents the histogram distribution by age for respondents reporting swallowing problems. Women were more likely than men to report a swallowing problem (4.7% 6 0.2% versus 3.3% 6 0.2%, P \ .001). Increasing age was also associated with a greater likelihood of swallowing problems in the past 12 months (increased odds ratio per decade, 1.19 [95% confidence interval, 1.15-1.24]; P \ .001). Table 1 lists the prescribed diagnoses for the swallowing problems among respondents. Stroke and neurologic causes together accounted for almost 700,000 cases (18.4%) of the swallowing problems. Among those reporting a swallowing problem in the previous 12 months, the mean number of days with a swallowing problem in the past year was 139.4 6 7.1. When asked subjectively, respondents rated their swallowing problem severity as distributed in Figure 2. Respondents with a swallowing problem in the 12 months prior reported 11.6 6 2.0 lost workdays in the past 12 months versus 3.4 6 0.1 lost workdays for those without a swallowing problem (contrast, 18.1 lost workdays, P \ .001). Among those respondents who received swallowing services, 12.5% 6 3.6%, 28.0% 6 4.1%, and 19.6% 6 3.7% received them from a speech-language pathologist, family physician/general practitioner, or otolaryngologist, respectively. With respect to treatment, 56.5% 6 4.8% of respondents
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Table 1. Reported Diagnoses Received as the Cause of the Voice Problem among United States Adults.a n
SE
%b
SE
422,431 269,630 184,815 98,249 97,642 72,794 33,139 31,986 26,685 2,654,197
77,423 57,290 40,854 24,723 30,723 21,970 15,993 13,959 12,269 169,657
11.2 7.2 4.9 2.6 2.6 1.9 0.9 0.9 0.7 70.6
1.9 1.5 1.1 0.6 0.8 0.6 0.4 0.4 0.3 2.4
Cause of the Swallowing Problem Stroke Neurologic disease (Alzheimer’s, Parkinson’s, etc) Cancer anywhere in the head and neck Advancing age Head/neck injury Prescription medication or drugs Congestive heart failure Arthritic changes in the neck Chronic obstructive pulmonary disease Something else a
Weighted values representing the US population. Column may add up to .100% because more than 1 diagnosis may be mentioned per case.
b
Figure 2. Self-reported severity of the swallowing problem.
reported that treatments for swallowing problems made their personal or social life better, and 66.2% 6 6.2% reported that treatment made their school or work life better. When asked about the status of swallowing problems (better or worse compared with 12 months ago), 31.9% 6 2.1% reported it ‘‘better,’’ 16.4% 6 1.6% reported it ‘‘worse,’’ and 51.8% 6 2.3% reported it ‘‘about the same.’’
Discussion In this population-based, nationally representative, household sample investigation, we found an annualized prevalence of swallowing problems among adults of 4.0%; this represents swallowing problems occurring annually among 1 in 25 adults. We also found that a relative minority sought medical care for their swallowing problem, despite the fact that having a swallowing problem was associated with an additional 8 days of lost work per year, and 48% of adults felt their swallowing problem to be of moderate severity or greater. Otolaryngologists were
involved in the medical care of only 1 in 5 of those respondents with a swallowing problem. Contemporary data regarding the prevalence of dysphagia in the United States are sparse, especially outside of elderly cohorts or outside of specific disease-selected populations. Previous investigations have quantified the epidemiology of dysphagia among the elderly population. In a non–treatmentseeking elderly cohort (N = 117), Roy and associates8 identified a lifetime prevalence and current prevalence of dysphagia of 38% and 33%, respectively. Stroke, esophageal reflux, chronic obstructive pulmonary disease, and chronic pain or medical conditions were associated with a history of dysphagia.8 Turley and Cohen9 identified a prevalence of dysphagia of 19.7% among an elderly population (N = 248), with only 20.6% seeking treatment for their dysphagia. Other studies have identified a prevalence of swallowing disorders in older individuals ranging from 7% to 22%, increasing to 40% to 50% in older individuals residing in long-term care facilities.10 This cumulative influence of age on dysphagia is further highlighted by the fact that a significant portion of respondents herein identified ‘‘advancing age’’ as an etiology for their swallowing problem (Table 1). The current data are not restricted to only elderly patients, hence the lower overall prevalence of dysphagia. To our knowledge, these data are the first nationally representative statistics on the prevalence of swallowing disorders across the United States spanning the adult age spectrum. Although dysphagia can range from a minor affliction to a severe problem, when attached to certain comorbid diagnoses, especially neurologic ones, dysphagia can increase the risk of hospitalization and mortality. We found that stroke and neurologic diseases were the most commonly reported causes of the swallowing problem. Recently, in an analysis of a treatment-seeking population, Mahboubi and Verma11 found that neuropsychiatric diagnoses were present in 9.1% of outpatient dysphagia visits. Of note, dysphagia occurring in the setting of these diagnoses may be more dangerous and prove fatal. Aspiration pneumonia and malnutrition are particularly serious consequences of dysphagia
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occurring with an underlying neurologic diagnosis. For example, the prevalence of dysphagia in Parkinson’s disease is estimated at 35%, and the prevalence of dysphagia and multiple sclerosis approaches 30% to 40%.12,13 Head and neck cancer, as might be expected, accounted for a significant portion of the underlying etiologies associated with dysphagia, after neurologic causes. Posttreatment dysphagia is a common complaint among survivors of head and neck cancer, with reported rates ranging from 40% to 85%, dependent in part on duration of follow-up.14,15 Head and neck injury was also a prominent underlying etiology for the swallowing problem. This category would likely include the significant incidence of dysphagia that occurs, for example, after anterior approaches to the cervical spine, which may be as high as 79% in the early postoperative period, declining to 13% to 21% at 1 year.16,17 The current findings are also consistent with a recent systematic review of the literature regarding causes of dysphagia with respect to different age groups.18 One of the remarkable features of the data is that for more than two-thirds of the patients, respondents identified ‘‘something else’’ as the underlying cause of the dysphagia. This might be expected since a relatively small portion of patients actually sought medical care for their dysphagia and therefore were less likely to receive a formal diagnosis from a health care provider for their dysphagia. This highlights a significant health care void: many patients with dysphagia may not seek treatment and thereby likely fail to receive a diagnosis for their dysphagia. This then leads to a lack of treatment address for this patient population, with potential consequences of their untreated dysphagia. For example, only 19.6% of adults with dysphagia consulted with an otolaryngologist. Aside from the medical morbidities that may arise in the setting of dysphagia, the data herein would suggest a strong association between dysphagia and functional impact on workdays lost. We actually found more associated lost workdays with dysphagia (11.6 workdays lost) than dysphonia (7.4 workdays lost) or sinusitis (5.7 days lost).2,6 This is not to say that the dysphagia was the sole cause for the workdays lost; the dysphagia itself may be a marker for an associated medical condition contributing to the workdays lost. Nonetheless, given the comorbidities and consequences of dysphagia, its functional impact deserves further investigation. This may be made more salient by the average number of days respondents suffered with the swallowing problem at 139 days in the prior 12 months. This suggests that the reported dysphagia is not episodic but rather a more chronic problem (on average, greater than 4 months in duration). Several limitations of the current methodology merit mention. The NHIS is a multipurpose health survey conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention, and is the principal source of information on the health of the civilian, noninstitutionalized household population of the United States.7 Therefore, certain populations are excluded from this analysis (eg, homeless and institutionalized adults). In addition,
although the survey design is subjected to field testing, cognitive testing, and reliability testing, the adult communications supplement is not in and of itself a validated survey instrument. Another potential limitation is that the survey had specific items queried for the cause of the swallowing problem. One potential missing diagnosis (not queried) that could be related to a significant proportion of the dysphagia symptoms is gastroesophageal reflux disease. Future studies should include assessment of this correlated diagnosis as well as others (eg, cricopharyngeal muscle dysfunction, Zenker’s diverticulum).
Conclusion Approximately 1 in 25 adults in the United States will have a swallowing problem, annually. Despite a significant selfreported impact of the swallowing problem, a commonly extended length of time with dysphagia, and an association with a significant number of workdays lost, a relative minority of affected adults seek treatment. Further efforts should be directed at screening for swallowing health and diagnoses in the United States based on this epidemiology and future projections of an aging population. Author Contributions Neil Bhattacharyya, collected data, analyzed data, drafted article, reviewed article for publication.
Disclosures Competing interests: Neil Bhattacharyya, IntersectENT, Inc and Entellus, Inc.
consultant
for
Sponsorships: None. Funding source: None.
References 1. Pleis JR, Lethbridge-Cejku M. Summary health statistics for U.S. adults: National Health Interview Survey, 2005. Vital Health Stat. 2006;10:1-153. 2. Bhattacharyya N. Contemporary assessment of the disease burden of sinusitis. Am J Rhinol Allergy. 2009;23:392-395. 3. Vakharia KT, Shapiro NL, Bhattacharyya N. Demographic disparities among children with frequent ear infections in the United States. Laryngoscope. 2010;120:1667-1670. 4. Lin HW, Bhattacharyya N. Balance disorders in the elderly: epidemiology and functional impact. Laryngoscope. 2012;122: 1858-1861. 5. Roberts DS, Lin HW, Bhattacharyya N. Health care practice patterns for balance disorders in the elderly. Laryngoscope. 2013;123:2539-2543. 6. Bhattacharyya N. The prevalence of voice problems among adults in the United States [published online April 29, 2014]. Laryngoscope. doi:10.1002/lary.24740. 7. National Center for Health Statistics. Data File Documentation NHIS, 2014 (machine readable data file and documentation). Hyattsville, MD: National Center for Health, National Center for Health Statistics, Centers for Disease Control and Prevention;2012.
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8. Roy N, Stemple J, Merrill RM, Thomas L. Dysphagia in the elderly: preliminary evidence of prevalence, risk factors, and socioemotional effects. Ann Otol Rhinol Laryngol. 2007;116: 858-865. 9. Turley R, Cohen S. Impact of voice and swallowing problems in the elderly. Otolaryngol Head Neck Surg. 2009;140:33-36. 10. Easterling CS, Robbins E. Dementia and dysphagia. Geriatr Nurs. 2008;29:275-285. 11. Mahboubi H, Verma SP. Swallowing disorders in the ambulatory medical setting. Otolaryngol Head Neck Surg. 2014;150: 563-567. 12. Kalf JG, de Swart BJM, Bloem BR, Munneke M. Prevalence of oropharyngeal dysphagia in Parkinson’s disease: a metaanalysis. Parkinsonism Relat Disord. 2012;18:311-315. 13. Restivo DA, Marchese-Ragona R, Patti F. Management of swallowing disorders in multiple sclerosis. Neurol Sci. 2006; 27:s338-s340.
14. Francis DO, Weymuller EA Jr, Parvathaneni U, Merati AL, Yueh B. Dysphagia, stricture, and pneumonia in head and neck cancer patients: does treatment modality matter? Ann Otol Rhinol Laryngol. 2010;119:391-397. 15. Wilson JA, Carding PN, Patterson JM. Dysphagia after nonsurgical head and neck cancer treatment: patients’ perspectives. Otolaryngol Head Neck Surg. 2011;145:767-771. 16. Anderson KK, Arnold PM. Oropharyngeal dysphagia after anterior cervical spine surgery: a review. Global Spine J. 2013;3:273-286. 17. Riley LH III, Vaccaro AR, Dettori JR, Hashimoto R. Postoperative dysphagia in anterior cervical spine surgery. Spine. 2010;35:S76-S85. 18. Roden DF, Altman KW. Causes of dysphagia among different age groups: a systematic review of the literature. Otolaryngol Clin North Am. 2013;46:965-987.
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The Prevalence of Dysphagia among Adults in the United States Neil Bhattacharyya Otolaryngology -- Head and Neck Surgery published online 5 September 2014 DOI: 10.1177/0194599814549156 The online version of this article can be found at: http://oto.sagepub.com/content/early/2014/09/04/0194599814549156
Published by: http://www.sagepublications.com
On behalf of:
American Academy of Otolaryngology- Head and Neck Surgery
Additional services and information for Otolaryngology -- Head and Neck Surgery can be found at:
P> OnlineFirst Version of Record - Sep 5, 2014 What is This?
Downloaded from oto.sagepub.com at UNIV OF CO HEALTH SCIENCE CTR on September 28, 2014
Original Research
The Prevalence of Dysphagia among Adults in the United States Neil Bhattacharyya, MD1
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Abstract Objective. To determine the prevalence of dysphagia, reported etiologies, and impact among adults in the United States. Study Design. Cross-sectional analysis of a national health care survey. Subjects and Methods. The 2012 National Health Interview Survey was analyzed, identifying adult cases reporting a swallowing problem in the preceding 12 months. In addition to demographic data, specific data regarding visits to health care professionals for swallowing problems, diagnoses given, and severity of the swallowing problem were analyzed. The relationship between swallowing problems and lost workdays was assessed. Results. An estimated 9.44 6 0.33 million adults (raw N = 1554; mean age, 52.1 years; 60.2% 6 1.6% female) reported a swallowing problem (4.0% 6 0.1%). Overall, 22.7% 6 1.7% saw a health care professional for their swallowing problem, and 36.9% 6 0.1.7% were given a diagnosis. Women were more likely than men to report a swallowing problem (4.7% 6 0.2% versus 3.3% 6 0.2%, P \ .001). Of the patients, 31.7% and 24.8% reported their swallowing problem to be a moderate or a big/very big problem, respectively. Stroke was the most commonly reported etiology (422,000 6 77,000; 11.2% 6 1.9%), followed by other neurologic cause (269,000 6 57,000; 7.2% 6 1.5%) and head and neck cancer (185,000 6 40,000; 4.9% 6 1.1%). The mean number of days affected by the swallowing problem was 139 6 7. Respondents with a swallowing problem reported 11.6 6 2.0 lost workdays in the past year versus 3.4 6 0.1 lost workdays for those without a swallowing problem (contrast, 18.1 lost workdays, P \.001). Conclusion. Swallowing problems affect 1 in 25 adults, annually. A relative minority seek health care for their swallowing problem, even though the subjective impact and associated workdays lost with the swallowing problem are significant.
Keywords dysphagia, swallowing, prevalence, epidemiology, stroke
Otolaryngology– Head and Neck Surgery 1–5 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814549156 http://otojournal.org
Received May 12, 2014; revised July 17, 2014; accepted August 7, 2014.
D
eglutition is an essential survival function of the human species. Because of the anatomical complexities in the human in which airway structures, swallowing structures, and speech structures are positioned in such close proximity and share multiple functions, human deglutition is an extremely complex mechanical and neurological process. Because it is such a complex process, deglutition is subject to a wide variety of functional derangements and may be negatively affected by many disease conditions. Despite many published reports on specific dysphagia diagnoses and dysphagia arising in different disease conditions in defined cohorts, a truly representative epidemiologic national estimate of the prevalence of adult swallowing problems across the United States has not been determined. The National Health Interview Survey (NHIS), conducted by the National Center for Healthcare Statistics of the Centers for Disease Control, is a household-based, yearly survey evaluating and quantifying the self-reported health status of US residents.1 This survey has been used to determine the basic prevalence of many health problems on a national basis, including several in otolaryngology, such as sinusitis and balance disorders.2–5 In the 2012 cycle of the NHIS, a supplement was contained within the survey specifically pertaining to swallowing and speech disorders in adults. We have previously reported on the prevalence of voice problems and other diagnoses in the US adult population with this national survey.6 Herein, we sought to analyze this survey to determine, at the national population level, the basic contemporary prevalence of swallowing problems among adults in the United States.
1
Department of Otology & Laryngology, Harvard Medical School, Boston, Massachusetts, USA This article was presented at the 2014 AAO-HNS/F Annual Meeting & OTO EXPO; September 21-24, 2014; Orlando, Florida. Corresponding Author: Neil Bhattacharyya, MD, Division of Otolaryngology, Department of Otology & Laryngology, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA. Email: [email protected]
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Methods The household-based NHIS for calendar year 2012 maintained by the National Center for Healthcare Statistics served as the data source for this study.7 This study was reviewed by our hospital’s committee on clinical investigation and was deemed exempt from review. Within the 2012 NHIS survey, a specific supplement was contained titled the ‘‘Adult Swallowing, Speech and Language Supplement: Adult Communication Disorders.’’ The supplement focused on the domains of speech and swallowing for adults aged 18 years and older, gathering data about the causes, age of onset, severity, and health care utilization in these areas. From the sample adult NHIS, file standard demographic information was extracted along with study design elements for sample weights, strata, and clustering to account for the survey study design of the NHIS, which allows derivation of national estimates from survey responses. In addition, data components that pertain to swallowing function were extracted from the speech and swallowing supplement. These data include information on adults reporting a swallowing problem in the previous 12 months, visits to a health care professional specifically for a swallowing problem in the preceding 12 months, and whether or not a diagnosis was given for the reported swallowing problem. Data were collected by trained census bureau interviewers via face-toface interviews with swallowing-specific questions such as, ‘‘DURING THE PAST 12 MONTHS, have you had a SWALLOWING problem, such as difficulty eating solid food, taking pills, or drinking beverages?’’ Additional questions included, for example, ‘‘How many days in the past year did you have problems swallowing?’’ and ‘‘DURING THE PAST 12 MONTHS, have you received treatments, therapy, or other rehabilitation services for your problems swallowing?’’ Respondents were also asked about the individual diagnoses for the swallowing problem, the subjective severity of the swallowing problem, and the source of swallowing-related health services. Finally, subjective response treatment with respect to social life and work/ school life and the current status of the swallowing problem were also determined. Data for lost workdays in the previous 12 months were also extracted. Data were imported into IBM SPSS Statistics, version 22. The estimated national annual prevalence of selfreported swallowing disorders along with associated swallowing-related diagnoses and subjective severity and impact were determined using sample weights and survey design variables based on a raw sample size of 34,525 adults. Data are presented as estimate 6 standard error of the estimate. Estimates were considered reliable according to criteria established by the National Center for Healthcare Statistics.7 Comparisons were conducted to determine differences in gender-related prevalence of the swallowing problem and the influence of age on the likelihood of having a swallowing disorder, with statistical significance set at P = .05. Finally, comparisons were conducted for lost workdays in the prior 12 months between those reporting
Figure 1. Age distribution of adults reporting a swallowing problem in the United States.
and not reporting a swallowing problem in the prior 12 months.
Results Among 234.9 1 2.3 million adults (raw N = 34,525), 9.44 6 0.33 million adults (raw N = 1554; mean age, 52.1 years; 60.2% 6 1.6% female) reported a swallowing problem in the preceding 12 months, equivalent to 4.0% 6 0.1% of the adult US population. Among these adults, 22.7% 6 1.7% saw a health care professional for their swallowing problem in the preceding 12 months. Of these, 36.9% 6 0.1.7% were given a diagnosis for their swallowing problem. Figure 1 presents the histogram distribution by age for respondents reporting swallowing problems. Women were more likely than men to report a swallowing problem (4.7% 6 0.2% versus 3.3% 6 0.2%, P \ .001). Increasing age was also associated with a greater likelihood of swallowing problems in the past 12 months (increased odds ratio per decade, 1.19 [95% confidence interval, 1.15-1.24]; P \ .001). Table 1 lists the prescribed diagnoses for the swallowing problems among respondents. Stroke and neurologic causes together accounted for almost 700,000 cases (18.4%) of the swallowing problems. Among those reporting a swallowing problem in the previous 12 months, the mean number of days with a swallowing problem in the past year was 139.4 6 7.1. When asked subjectively, respondents rated their swallowing problem severity as distributed in Figure 2. Respondents with a swallowing problem in the 12 months prior reported 11.6 6 2.0 lost workdays in the past 12 months versus 3.4 6 0.1 lost workdays for those without a swallowing problem (contrast, 18.1 lost workdays, P \ .001). Among those respondents who received swallowing services, 12.5% 6 3.6%, 28.0% 6 4.1%, and 19.6% 6 3.7% received them from a speech-language pathologist, family physician/general practitioner, or otolaryngologist, respectively. With respect to treatment, 56.5% 6 4.8% of respondents
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Table 1. Reported Diagnoses Received as the Cause of the Voice Problem among United States Adults.a n
SE
%b
SE
422,431 269,630 184,815 98,249 97,642 72,794 33,139 31,986 26,685 2,654,197
77,423 57,290 40,854 24,723 30,723 21,970 15,993 13,959 12,269 169,657
11.2 7.2 4.9 2.6 2.6 1.9 0.9 0.9 0.7 70.6
1.9 1.5 1.1 0.6 0.8 0.6 0.4 0.4 0.3 2.4
Cause of the Swallowing Problem Stroke Neurologic disease (Alzheimer’s, Parkinson’s, etc) Cancer anywhere in the head and neck Advancing age Head/neck injury Prescription medication or drugs Congestive heart failure Arthritic changes in the neck Chronic obstructive pulmonary disease Something else a
Weighted values representing the US population. Column may add up to .100% because more than 1 diagnosis may be mentioned per case.
b
Figure 2. Self-reported severity of the swallowing problem.
reported that treatments for swallowing problems made their personal or social life better, and 66.2% 6 6.2% reported that treatment made their school or work life better. When asked about the status of swallowing problems (better or worse compared with 12 months ago), 31.9% 6 2.1% reported it ‘‘better,’’ 16.4% 6 1.6% reported it ‘‘worse,’’ and 51.8% 6 2.3% reported it ‘‘about the same.’’
Discussion In this population-based, nationally representative, household sample investigation, we found an annualized prevalence of swallowing problems among adults of 4.0%; this represents swallowing problems occurring annually among 1 in 25 adults. We also found that a relative minority sought medical care for their swallowing problem, despite the fact that having a swallowing problem was associated with an additional 8 days of lost work per year, and 48% of adults felt their swallowing problem to be of moderate severity or greater. Otolaryngologists were
involved in the medical care of only 1 in 5 of those respondents with a swallowing problem. Contemporary data regarding the prevalence of dysphagia in the United States are sparse, especially outside of elderly cohorts or outside of specific disease-selected populations. Previous investigations have quantified the epidemiology of dysphagia among the elderly population. In a non–treatmentseeking elderly cohort (N = 117), Roy and associates8 identified a lifetime prevalence and current prevalence of dysphagia of 38% and 33%, respectively. Stroke, esophageal reflux, chronic obstructive pulmonary disease, and chronic pain or medical conditions were associated with a history of dysphagia.8 Turley and Cohen9 identified a prevalence of dysphagia of 19.7% among an elderly population (N = 248), with only 20.6% seeking treatment for their dysphagia. Other studies have identified a prevalence of swallowing disorders in older individuals ranging from 7% to 22%, increasing to 40% to 50% in older individuals residing in long-term care facilities.10 This cumulative influence of age on dysphagia is further highlighted by the fact that a significant portion of respondents herein identified ‘‘advancing age’’ as an etiology for their swallowing problem (Table 1). The current data are not restricted to only elderly patients, hence the lower overall prevalence of dysphagia. To our knowledge, these data are the first nationally representative statistics on the prevalence of swallowing disorders across the United States spanning the adult age spectrum. Although dysphagia can range from a minor affliction to a severe problem, when attached to certain comorbid diagnoses, especially neurologic ones, dysphagia can increase the risk of hospitalization and mortality. We found that stroke and neurologic diseases were the most commonly reported causes of the swallowing problem. Recently, in an analysis of a treatment-seeking population, Mahboubi and Verma11 found that neuropsychiatric diagnoses were present in 9.1% of outpatient dysphagia visits. Of note, dysphagia occurring in the setting of these diagnoses may be more dangerous and prove fatal. Aspiration pneumonia and malnutrition are particularly serious consequences of dysphagia
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Otolaryngology–Head and Neck Surgery
occurring with an underlying neurologic diagnosis. For example, the prevalence of dysphagia in Parkinson’s disease is estimated at 35%, and the prevalence of dysphagia and multiple sclerosis approaches 30% to 40%.12,13 Head and neck cancer, as might be expected, accounted for a significant portion of the underlying etiologies associated with dysphagia, after neurologic causes. Posttreatment dysphagia is a common complaint among survivors of head and neck cancer, with reported rates ranging from 40% to 85%, dependent in part on duration of follow-up.14,15 Head and neck injury was also a prominent underlying etiology for the swallowing problem. This category would likely include the significant incidence of dysphagia that occurs, for example, after anterior approaches to the cervical spine, which may be as high as 79% in the early postoperative period, declining to 13% to 21% at 1 year.16,17 The current findings are also consistent with a recent systematic review of the literature regarding causes of dysphagia with respect to different age groups.18 One of the remarkable features of the data is that for more than two-thirds of the patients, respondents identified ‘‘something else’’ as the underlying cause of the dysphagia. This might be expected since a relatively small portion of patients actually sought medical care for their dysphagia and therefore were less likely to receive a formal diagnosis from a health care provider for their dysphagia. This highlights a significant health care void: many patients with dysphagia may not seek treatment and thereby likely fail to receive a diagnosis for their dysphagia. This then leads to a lack of treatment address for this patient population, with potential consequences of their untreated dysphagia. For example, only 19.6% of adults with dysphagia consulted with an otolaryngologist. Aside from the medical morbidities that may arise in the setting of dysphagia, the data herein would suggest a strong association between dysphagia and functional impact on workdays lost. We actually found more associated lost workdays with dysphagia (11.6 workdays lost) than dysphonia (7.4 workdays lost) or sinusitis (5.7 days lost).2,6 This is not to say that the dysphagia was the sole cause for the workdays lost; the dysphagia itself may be a marker for an associated medical condition contributing to the workdays lost. Nonetheless, given the comorbidities and consequences of dysphagia, its functional impact deserves further investigation. This may be made more salient by the average number of days respondents suffered with the swallowing problem at 139 days in the prior 12 months. This suggests that the reported dysphagia is not episodic but rather a more chronic problem (on average, greater than 4 months in duration). Several limitations of the current methodology merit mention. The NHIS is a multipurpose health survey conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention, and is the principal source of information on the health of the civilian, noninstitutionalized household population of the United States.7 Therefore, certain populations are excluded from this analysis (eg, homeless and institutionalized adults). In addition,
although the survey design is subjected to field testing, cognitive testing, and reliability testing, the adult communications supplement is not in and of itself a validated survey instrument. Another potential limitation is that the survey had specific items queried for the cause of the swallowing problem. One potential missing diagnosis (not queried) that could be related to a significant proportion of the dysphagia symptoms is gastroesophageal reflux disease. Future studies should include assessment of this correlated diagnosis as well as others (eg, cricopharyngeal muscle dysfunction, Zenker’s diverticulum).
Conclusion Approximately 1 in 25 adults in the United States will have a swallowing problem, annually. Despite a significant selfreported impact of the swallowing problem, a commonly extended length of time with dysphagia, and an association with a significant number of workdays lost, a relative minority of affected adults seek treatment. Further efforts should be directed at screening for swallowing health and diagnoses in the United States based on this epidemiology and future projections of an aging population. Author Contributions Neil Bhattacharyya, collected data, analyzed data, drafted article, reviewed article for publication.
Disclosures Competing interests: Neil Bhattacharyya, IntersectENT, Inc and Entellus, Inc.
consultant
for
Sponsorships: None. Funding source: None.
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