Annals of Otology, Rhinoiogy & Laryngology 116(n):858-865.

© 2007 Atinals Publishitig Cotnpatiy. All rights reserved.

Dysphagia in the Elderly: Preliminary Evidence of Prevalence,

Risk Factors, and Socioemotional Effects
Nelson Roy, PhD; Joseph Stemple, PhD; Ray M. Merrill, PhD, MPH; Lisa Thomas, MA

Objectives: Epidemiological studies of dysphagia in the elderly are rare. A non-treatment-seeking, elderly cohort was
surveyed to provide preliminary evidence regarding the prevalence, risks, and socioemotional effects of swallowing dis-
orders.
Methods: Using a prospective, cross-sectional survey design, we interviewed 117 seniors living independently in Utah
and Kentucky (39 men and 78 women; mean age, 76.1 years; SD, 8.5 years; range, 65 to 94 years) regarding 4 primary
areas related to swallowing disorders: lifetime and current prevalence, symptoms and signs, risk and protective factors,
and socioemotional consequences.
Results: The lifetime prevalence of a swallowing disorder was 38%, and 33% of the participants reported a current prob-
lem. Most seniors with dysphagia described a sudden onset with chronic problems that had persisted for at least 4 weeks.
Stepwise logistic regression identified 3 primary symptoms uniquely associated with a history of swallowing disorders:
taking a longer time to eat (odds ratio [OR], 9.5; 95% confidence interval [Cl], 2.3 to 40.2); coughing, throat clearing, or
choking before, during, or after eating (OR, 3.4; 95% Cl, 1.1 to 10.2); and a sensation of food stuck in the throat (OR, 5.2;
95% Cl, 1.8 to 10.0). Stroke (p = .02), esophageal reflux (p = .003), chronic obstructive pulmonary disease (p - .05), and
chronic pain (p = .03) were medical conditions associated with a history of dysphagia. Furthermore, dysphagia produced
numerous adverse socioemotional effects.
Conclusions: This study provides preliminary evidence to suggest that chronic swallowing disorders are common among
the elderly, and highlights the need for larger epidemiological studies of these disorders.
Key Words: prevalence, quality of life, risk, swallowing disorder.

INTRODUCTION elderly are associated with dysphagia, such as cen-

tral nervous system disorders (eg, stroke, Parkin-
The human aerodigestive tract undergoes a num- son's disease, Alzheimer's disease), diabetes, use of
jer of structural and functional changes with aging. certain medications, and lack of adequate dentition,
In the elderly, these changes are sometimes suffi- to mention only a few.'^'i*'"'^ The ensuing swallow-
cient to alter both voice and swallowing function. In ing disorder is understood to contribute to a variety
this regard, dysphagia is believed to represent a sig- of untoward effects such as pneumonia, malnutri-
nificant health care problem among older adults.^"^ tion, dehydration, and reduced mobility,''^ as well
It has been estimated that 13% to 35% of elderly as adverse socioemotional effects (eg, anxiety with
individuals who live independently report dyspha- meals, avoidance of public eating).^''^-'^ At present,
gic symptoms,"^"^ and that the vast majority fail to however, most epidemiological studies of swallow-
seek treatment.^'^ Age-related changes in degluti- ing disorders in the elderly are based almost exclu-
tion can lead to impaired bolus control and trans- sively on clinical populations (ie, patients visiting
port, slowing of pharyngeal swallow initiation, in- specialized clinics and/or residing in hospitals, re-
effective pharyngeal clearance, impaired cricopha- habilitation centers, or skilled nursing or long-term
ryngeal opening, and reduced secondary esopha- care facilities).'^'^ Studies examining dysphagia in
geal peristalsis.^ However, some dysphagic symp- community-dwelling elderly have been conducted
toms reflect acute or chronic underlying disease outside the United States.'*"^'^^ However, because of
processes, and manifest as oral residue, vallecular distinct differences in culture, lifestyle habits, diet,
and pyriform stasis, and laryngeal penetration and health care services, and practices, it is impossible
aspiration.^ Indeed, numerous disease states in the to generalize these results to the elderly residing in
From the Department of Communication Sciences and Disorders, The University of Utah, Salt Lake City (Roy), and the Department of
Health Science, Brigham Young University, Provo (Merrill), Utah, and the Department of Rehabilitation Sciences, The University of
Kentucky, Lexington, Kentucky (Stemple, Thomas).
Correspondence: Nelson Roy, PhD, Dept of Communication Sciences and Disorders, The University of Utah, 390 South 1530 East,
Room 1219, Salt Lake City, UT 84112-0252.
858
 Roy et al, Dysphagia in Elderly
the United States.
At present, there are 36 million elderly (at least
65 years of age) living in the United States, and this
number is estimated to double by the year 2030. The
"2030 problem" refers to the challenge of ensur-
ing that sufficient resources and an effective service
system are available when the elderly population is
twice what it is today. Therefore, epidemiological
data are essential to estimate and meet the long-term
voice and swallowing-related needs of this expand-
ing elderly population. To date, however, almost no
information exists regarding 1) the prevalence of
voice and swallowing disorders in the general (non-
institutionalized) elderly population; 2) patterns of
voice and swallowing decline with age; 3) risk fac-
tors associated with this decline; and 4) consequenc-
es of voice and swallowing disorders on social and
emotional functioning in the elderly. This investiga-
tion was designed to provide preliminary evidence
of the epidemiology of swallowing disorders in el-
derly individuals (at least 65 years of age) living in-
dependently in the United States. The prevalence of
self-reported swallowing disorders and symptoms;
the key risk factors, including the comorbidity of
voice and swallowing disorders; and the socioemo-
tional consequences of swallowing disorders are re-
ported.
METHODS
Sampling Procedures. Data related to swallowing
disorders were acquired during face-to-face inter-
views of elderly individuals in Utah and Kentucky
who were recruited through senior citizen centers or
personal contacts. After university and state Institu-
tional Review Board approval, a total of 16 senior
centers in the Salt Lake City, Utah, area and in the
Lexington, Kentucky, area agreed to permit recruit-
ment of participants. Recruitment advertisements
were posted, and research assistants visited senior
centers periodically to recruit and schedule eligible
participants. Seniors were deemed eligible to par-
ticipate if they 1) were living independently (ie, not
living in a hospital, rehabilitation center, or residen-
tial facility such as an assisted living or skilled nurs-
ing facility; 2) were free of dementia as assessed by
the ]VIiniCog,'5 a brief screening test of cognitive
performance with proven psychometric properties
(ie, pass cutoff score of at least 3 of 5 points); and 3)
had no significant hearing loss sufficient to interfere
with completion of the oral questionnaire. In both
states, all participants were interviewed by the in-
vestigators or research assistants who were trained
in the administration of the questionnaire. The in-
terview required approximately 50 minutes to com-
plete.
859
Description of Interview Questionnaire. The sur-
vey tool was developed from a model instrument
originally used in a previous epidemiology study
aimed at the prevalence of voice disorders in a va-
riety of nonelderly populations (less than 65 years
of age).'^"^^ The original survey was subsequent-
ly modified and expanded to target both voice and
swallowing disorders in the elderly, including cur-
rent and past problems, as well as possible risk and
protective factors, familial trends, and disease-spe-
cific functional consequences. For this study, we
considered a swallowing disorder to be "any time
the individual experienced difficulty moving food
or liquid from mouth to stomach, or experienced
choking or throat clearing during or following meal-
time." In addition, we considered a voice disorder
to be any time the voice did not work, perform, or
sound as it normally should, so that it interfered with
communication. Thus, the survey probed the do-
mains of both voice and swallowing history to iden-
tify symptoms, signs, practices, and patterns, and to
relate these findings to medical, psychosocial, oc-
cupational, and social and lifestyle factors. To as-
sess the effects of swallowing dysfunction on qual-
ity of life, we also administered the M. D. Anderson
Dysphagia Inventory (MDADI) as part of the inter-
view process. ^^ The IVIDADI is a psychometrical-
ly validated, dysphagia-specific instrument that as-
sesses psychosocial aspects of dysphagia. Although
information regarding both voice and swallowing
function was acquired, in this article we emphasize
the results from the swallowing portion of the inter-
view, and report data on the comorbidity of voice
and swallowing disorders only. Details surrounding
the epidemiology of voice disorders in the elderly
are reported elsewhere.^o
Statistical Analyses. The prevalence of ever hav-
ing had a swallowing disorder and selected patterns,
dysphagic symptoms, general health conditions,
diet, and use of tobacco and alcohol were evalu-
ated with contingency tables, analysis of variance,
and logistic regression. Bivariate analyses of asso-
ciations were evaluated for statistical significance
with the x^ test and the /-test. IMultiple logistic re-
gression allowed us to estimate odds ratios (ORs)
and corresponding 95% confidence intervals (CIs).
Note that odds ratios can range from 0 to infinity.
An OR of less than 1 indicates a negative associ-
ation, an OR of 1 indicates no association, and an
OR of more than 1 indicates a positive association
between two variables. If both the lower and upper
limits of the Cl are less than 1, there is a signifi-
cant negative association, whereas if both the lower
and upper limits of the Cl are greater than 1, there
is a significant positive association. Two-tailed tests
860 Roy et al, Dysphagia in Elderly
of significance and confidence intervals were based
on the .05 level. Analyses were performed with the
Statistical Analysis System (SAS), version 9.0 (SAS
Institute Inc, Cary, North Carolina). The procedure
statements used in SAS for assessing the data were
PROC GLIVI, PROC FEQ, PROC LOGISTIC, and
PROC UNIVARIATE.
RESULTS
Demographics and Swallowing Disorders. We
surveyed 117 participants, including 66 from Utah
(56.4%) and 51 from Kentucky (43.6%). The partic-
ipants ranged in age from 65 to 94 years (mean, 76.1;
SD, 8.5). There were 39 men (33.3%) and 78 wom-
en (66.7%); 14 (12.0%) had less than a high school
education, 48 (41%) had a high school diploma, 18
(15.4%) had an associate's degree, 19 (16.2%) had
a bachelor's degree, and 18 (15.4%) had a master's
degree; 113 (96.6%) were white, non-Hispanic; 37
(34.6%) had an annual income of less than $20,000,
44 (41.1%) had an income of $20,000 to $40,000,13
(12.2%) had an income of $40,000 to $60,000, and
13 (12.2%) had an income of more than $60,000.
Prevalence of Swallowing Disorders. A swallow-
ing disorder had occurred in 44 (37.6%) of the par-
ticipants during their lifetime, and 38 (32.5%) in-
dicated that they currently had a swallowing disor-
der. Of the participants who currently had a swal-
lowing disorder, 30 (79.0%) said it began suddenly
and 8 (21.0%) reported that it began gradually; 28
(73.7%) reported it as a chronic problem (ie, dura-
tion of at least 4 weeks), and 10 (26.3%) reported
it as an acute problem (ie, duration of less than 4
weeks). Of the 28 participants who currently had
a chronic swallowing disorder, 3 (10.7%) said the
problem began as a reaction to medicine, 2 (7.1%)
said the problem began after an illness, and 2 (7.1%)
said the problem began after surgery. There were 18
(15.6%) with a family history of swallowing disor-
ders. The relation between family history of swal-
lowing disorders and having ever had a swallow-
ing disorder was not statistically significant, how-
ever. Of those who had ever had a voice disorder,
47.3% had also had a swallowing disorder. On the
other hand, of those who had ever had a swallowing
disorder, 59.1% had also had a voice disorder. The
higher percentage of swallowing disorders among
those who had ever had a voice disorder was sta-
tistically significant (x^ (1) = 4.13; p = .0421). In
addition, there were 6 (5.2%) who had ever had a
feeding tube and 15 (12.9%) who had needed to use
nutritional supplements to make sure that they con-
sumed sufficient calories each day. These variables
were not significantly associated with ever having
had a swallowing disorder.
Using a stepwise procedure with logistic regres-
sion, we regressed "ever having had a swallowing
disorder" (yes versus no) on sex, age, income, ed-
ucation, family history of swallowing problems,
"have you ever had a feeding tube," need for the
use of nutritional supplements to get enough calo-
ries each day, and site. The selected entry and exit
level of significance was 0.2. Site (Utah versus Ken-
tucky) was significant (OR, 2.5; Cl, 1.1 to 5.6), with
the IJtah site reporting more swallowing disorders.
This "site" variable was included, and adjusted for,
in the remaining logistic regression models that are
reported below.
Signs and Symptoms of Dysphagia. A wide variety
of symptoms of dysphagia are listed in Table 1. As
expected, individuals with a history of swallowing
disorders reported numerous dysphagic symptoms.
Interestingly, the majority of subjects with dys-
phagia reported more frequent difficulty swallow-
ing solids than swallowing liquids. To identify the
symptoms that uniquely distinguished the swallow-
ing-disordered participants from the nondisordered
group, we used a stepwise procedure with logistic
regression. "Ever having had a swallowing disor-
der" (yes versus no) was regressed on the variables
shown in Table 1. The selected entry and exit level
of significance was 0.2. Although all symptoms list-
ed in Table 1 occurred more frequently within the
swallowing-disordered group, variables that were
significant in the model and uniquely distinguished
the dysphagia group were 1) taking a longer time to
eat because of swallowing problems (OR, 9.5; Cl,
2.3 to 40.2); 2) coughing, throat clearing, or choking
before, during, or after eating (OR, 3.4; Cl, 1.1 to
10.2); and 3) a sensation of food stuck in the throat
(OR, 5.2;CL 1.8 to 10.0).
Risk Factors and Dysphagia. Table 2 lists a num-
ber of medical conditions and their relation with sub-
jects ever having had a swallowing disorder. A num-
ber of medical conditions were observed more fre-
quently among those elderly participants with a his-
tory of swallowing disorders, including esophageal
reflux (p = .003), stroke (p = .02), chronic obstruc-
tive pulmonary disease (COPD; p = .045), chronic
pain (p = .03), severe neck, back, or head injury (p
= .069), and arthritis (p = .099). Using the stepwise
procedure with logistic regression, we regressed
"ever having had a swallowing disorder" (yes ver-
sus no) on all ofthe variables shown in Table 2. The
selected entry and exit level of significance was
0.2. Only esophageal reflux entered and remained
in the model (OR, 3.1; Cl, 1.5 to 6.9). In addition
to the medical conditions listed above, individuals
with swallowing disorders tended to experience ten-
 Roy et al, Dysphagia in Elderly 861

TABLE 1. FREQUENCY OF SPECIFIC SWALLOWING SIGNS AND SYMPTOMS ACCORDING TO WHETHER

SWALLOWING DISORDER HAD BEEN PREVIOUSLY IDENTIFIED
Swallowing No Swallowing
Disorder Disorder
(N = 44) (N-.= 73)
Symptom No % No. % P(X')
Long time to eat because of swallowing problem 24 54.6 3 4.1 <.OOO1*
Difficulty swallowing liquids 16 36.4 6 8.2 .0002*
Difficulty swallowing solids 27 61.4 5 6.8 <.OOO1*
Difficulty swallowing medication 20 45.4 9 12.3 <.OOO1*
Gurgly or wet voice 0 1
Coughing, throat clearing, or choking before, during, or after eating 28 63.6 11 15.1 <.OOO1*
Inability to control food, liquid, or saliva in mouth 4 9.1 3 4.1 .2711
Sneezing during or after meal 9 20.4 5 6.8 .0281*
Pain or pressure in throat or chest during swallowing 16 36.4 4 5.4 <.OOO1*
Wheezing after eating 4 9.1 1 1.4 .0455*
Food coming out of nose during eating 7 15.9 3 4.1 .0270*
Need to chew excessively in order to swallow safely 20 45.4 5 6.8 <.OOO1*
Dry mouth 21 47.7 24 32.9 .1097
Difficulty placing food in mouth 1 0
Sensation of food sticking in throat 30 68.2 11 15.1 <.OOO1*
Forcibly regurgitating food that is stuck in throat 17 38.6 4 5.5 <.OOO1*
Avoidance of certain foods because of swallowing problems 13 29.6 3 4.1 .0001*
Increased mucous or phlegm in throat before, during, or after eating 10 22.7 8 11.0 .0875
Taking smaller bites of food in order to swallow safely 21 47.7 5 6.8 <.OOO1*
*Significant difference (p < .05).

sion within the neck and throat, jaw, and shoulder
region more frequently than did those without swal-
lowing disorders (Table 3). Interestingly, diet and
lifestyle factors did not appear to influence report-
ing of dysphagia. There were no statistical associa-
tions between ever having had a swallowing disor-
der and frequent use of foods or liquids believed to
be refluxogenic, such as coffee, tea, colas, choco-
late, mint products, acidic foods, or spicy foods. The
responses were also added for each of these items.
The average response did not differ significantly be-
tween those who had ever had a swallowing disor-
der and those who had never had a swallowing dis-
order. Finally, there were no significant associations
between having ever used any tobacco products for
a year or longer and having ever had a swallowing
disorder, or between drinking an average of 1 or
more alcoholic beverages a week and having ever
had a swallowing disorder. Furthermore, inspection
of Table 4 confirms that participants with a history
of swallowing disorders did not differ significantly
from those without a history of dysphagia on self-
assessed activity or exercise levels, or on overall
physical or mental health or personality.
Socioemotional Effects of Dysphagia. To assess
the effects of swallowing dysfunction on quality of
life, we analyzed the results from the MDADI.^o Ta-
ble 5 confirms that swallowing disorders are asso-
ciated with significant and multiple adverse effects
on quality of life. The scores of participants were
summed across the items listed in Table 5 and divid-
ed by the number of items. The mean score for those
with a current swallowing disorder was 4.1 (SD,
0.7), and that for those without a swallowing disor-
der was 4.8 (SD, 0.4). The means were significantly
different (f(59.4) = 5.63; p < .0001, with the Satter-
thwaite method used because of unequal variances).
It should be noted that each of the variables in the
Table were highly correlated (Spearman's correla-
tion p < .0001 for each pairwise comparison). When
we used stepwise logistic regression (selection entry
and exit equal to 2.0 and adjusted for survey loca-
tion) with "ever having had a swallowing disorder"
as the dependent variable and each of the trouble-
with-swallowing variables as the independent vari-
ables, only "takes longer to eat" was retained in the
model.
DISCUSSION
Epidemiological studies of swallowing disorders
of non-treatment-seeking elderly populations are
exceedingly rare. In only 2 community-based stud-
ies have swallowing problems been examined in the
noninstitutionalized elderly. Bloem et al'^ surveyed
a group of 130 individuals over 87 years of age and
identified swallowing complaints in 16% of those
surveyed. Furthermore, the results suggested that a
862 Roy et al, Dysphagia in Elderly

TABLE 2. FREQUENCY OF SPECIFIC MEDICAL CONDITIONS (EVER HAD) ACCORDING TO WHETHER

SWALLOWING DISORDER HAD BEEN PREVIOUSLY IDENTIFIED
Swallowing No Swallowing
Disorder Disorder
(N = 44) (N=73)
Medical Condition No. % No. % P(X')
Arthritis 32 72.7 42 57.5 .0987
Immune disorder 3 6.8 3 4.1 .5200
Heart disease 16 36.4 25 34.2 .8162
Hypertension 27 61.4 50 68.5 .4310
Circulatory problems 11 25.0 17 23.3 .8335
Kidney problems 4 9.1 9 12.5 .5722
Thyroid problems 12 27.3 19 26.0 .8825
Stomach or duodenal ulcers 7 15.9 14 19.2 .6554
Esophageal reflux 27 61.4 24 32.9 .0026*
Stroke 9 20.4 5 6.8 .0281*
Respiratory allergies 9 20.4 14 19.2 .8664
Pneumonia 21 47.7 36 49.3 .8678
Emphysema 3 6.8 1 1.4 .1162
Chronic obstructive pulmonary disease 4 9.1 1 1.4 .0455*
Bronchitis 16 36.4 21 28.8 .3920
Asthma 4 9.1 9 12.3 .5893
Severe neck, back, or head injury 12 27.3 10 13.7 .0687
Chronic pain 22 50.0 22 30.1 .0317*
Cancer 12 27.3 17 23.6 .6586
Depression or anxiety 13 29.6 23 31.5 .8238
Sleep disorder 10 22.7 10 13.7 .2089
*Significant difference (p < .05).

number of participants had not reported swallowing pling procedures, and survey techniques, our results
concems before participating in the study, suggest- do suggest that swallowing disorders were more
ing that the prevalence of dysphagia in the elderly common among our cohort of elderly surveyed, with
may be greater than clinically reported. Kawashima 33% of respondents reporting a current swallow-
et al^ conducted a cross-sectional study to deter- ing disorder and almost 40% reporting a previous
mine the prevalence of dysphagia in 1,313 elderly history of swallowing dysfunction. Most of the re-
persons, 65 years and older, living at home in the spondents with dysphagia described a sudden onset
same Northern Japanese community. Results from with chronic problems persisting at least 4 weeks,
the screening questionnaire indicated that 13.8% re- and 60% of swallowing-disordered participants re-
ported symptoms of dysphagia. Our preliminary in- ported previous voice problems, perhaps highlight-
vestigation represents the first attempt to establish ing the shared role of the larynx in deglutition and
epidemiological data of swallowing disorders in a voice production.
nonclinical, elderly population in the United States.
Although direct comparison between our study and Although numerous symptoms of dysphagia were
the other community-based studies is inherently reported, stepwise logistic regression identified 3
problematic because of differences in samples, sam- primary symptoms uniquely associated with a his-
TABLE 3. FREQUENCY AND LOCATION OF TENSION ACCORDING TO WHETHER SWALLOWING DISORDER
HAD BEEN PREVIOUSLY IDENTIFIED
Mean ±SD
% of Participants Swallowing No Swallowing
Tension Never (1) Rarely (2) Occasionally (3) Often (4) Disorder (N = 44) Disorder (N = 73) p (t Statistic)
Neck and throat 44.4 18.0 19.7 18.0 2.5 ±1.2 1.9±1.1 .0078*
Jaw 73.5 16.2 6.0 4.3 1.6 ±0.9 1.3 ±0.7 .0299*
Shoulders 41.9 12.8 28.2 17.1 2.5 ± 1.2 2.0 ±1.1 .0212*
Abdomen 71.8 17.1 8.6 2.6 1.5 ±0.7 1.3 ±0.8 .1610
*Significant difference (p < .05).
 Roy et al, Dysphagia in Elderly 863

TABLE 4. LEVELS OF ACTIVITY, EXERCISE, HEALTH, plex contributes to accumulation of food around the
AND WELL-BEING AND THEIR RELATION WITH arytenoids and airway entrance, with aspiration fol-
HISTORY OF SWALLOWING DISORDER
lowing a swallow.23-26 Chronic obstructive pulmo-
% Ever Had nary disease is also an interesting risk factor iden-
Swallowing
tified in the present study. As respiration and swal-
Self-Appraisal No. Disorder P(X')
lowing are closely integrated and coordinated, it is
Active or inactive
possible that changes in respiratory function that oc-
Active 105 37.1 .7592
cur with COPD may produce swallowing problems.
Inactive 12 41.7
However, few studies have examined the nature of
Do you exercise? the swallowing problems in patients with COPD,
Yes 93 37.6 .9903 and the frequency of swallowing disorders in this
No 24 37.5 population is not well known. Difficulty with air-
How often do you exercise? way closure and aspiration during the swallow has
1-2 times per week 18 55.6 .3422 been reported in COPD, as well as gastroesophage-
3-4 times per week 27 33.3 al reflux.2'7'28 Whether the airway closure problem
5+ times per week 48 35.4 results from the COPD or is a contributing factor
Overall health in the pulmonary disease is unknown.^?" In addition
Excellent 25 28.0 .2973 to COPD, swallowing disorders were frequently as-
Good 68 36.8 sociated with severe neck, back, and head injury,
Fair 23 52.2 chronic pain, and increased tension in the head, jaw,
Poor 1 0.0 and neck region. The apparent interplay between
Easy-going or worrier trauma or injury, pain, regional tension, and dyspha-
Easy-going 83 34.9 .3521 gia is an enticing finding worthy of further study.
Worrier 34 44.1
Happy or sad Another interesting finding is the apparent lack
Happy 109 36.7 .4534 of increased frequency of swallowing disorders with
Sad 8 50.0 increasing age. Age was not a significant risk fac-
tor in this cohort of elderly. This may be explained
tory of swallowing disorders: 1) taking a longer time in part by the uneven distribution of participants
to eat; 2) coughing, throat clearing, or choking be- in each age stratum. In this preliminary investiga-
fore, during, or after eating; and 3) a sensation of tion, we did not intentionally sample to create equal
food stuck in the throat. These symptoms appeared numbers of seniors in each age group. Although we
to uniquely distinguish the swallowing-disordered sampled across the 65-plus age spectrum, and our
participants from the nondisordered group, and median age was 77 years, the "very old" (ie, at least
speak to the salience and uniqueness of these symp- 90 years of age) were underrepresented. Thus, while
toms in dysphagia reporting. advancing age intuitively represents a general risk
Of the medical conditions surveyed, stroke, ar- factor for dysphagia, a larger epidemiological study
thritis, esophageal reflux, severe neck, back, or head using stratified block sampling procedures is war-
injury, COPD, and chronic pain were frequently as- ranted to evaluate the effects of age on swallowing
sociated with a history of dysphagia. However, the function, by ensuring adequate sampling across age
stepwise regression analysis identified esophageal categories, including the very old. Furthermore, the
reflux as the most potent variable that discrimi- sample surveyed in this study was predominant-
nated the swallowing-disordered respondents from ly white (96.6%). There is a clear need to obtain a
the nondisordered group. Dysphagia associated larger, more ethnically and racially diverse sample
with esophageal reflux is a known clinical entity, in the future, to explore the influence of such factors
and poor esophageal body motility is considered a on rates of dysphagia in the elderly.
major pathomechanism of gastroesophageal reflux
disease-induced dysphagia.2i'22 -pj^e identification CONCLUSIONS
of arthritis, COPD, chronic pain, and severe neck, These preliminary data not only provide compel-
back, and head injury, however, as additional risk ling evidence regarding the prevalence of past and
factors is intriguing. Rheumatoid arthritis can affect present swallowing disorders among the elderly, but
several structures involved in swallowing, and can also confirm the adverse effects of dysphagia on
affect the cricoarytenoid joint, causing restricted ar- quality of life. These socioemotional effects were
ytenoid movement during swallowing, and perhaps numerous and varied, and ranged from limiting food
reduced airway protection, or alternatively, swell- intake, to embarrassment, to social withdrawal. In
ing of the cricoarytenoid joint and arytenoid com- the future, a large random sample of seniors should
864 Roy et al, Dysphagia in Elderly

TABLE 5. ITEMS FROM M. D. ANDERSON DYSPHAGIA INVENTORY SHOWING SOCIOEMOTIONAL EFFECTS OF

DYSPHAGIA ACCORDING TO WHETHER CURRENT SWALLOWING DISORDER WAS REPORTED
Mean ±SD
Current No Current
% of Participants Swallowing Swallowing
SA A A^ D SD Disorder Disorder p
Trouble With Swallowing (1) (2) (3) (4) (.5) (N = 34) (N = 83) ft Statistic)
Limits activities 0.0 2.6 1.7 31.6 64.1 4.2 ±0.7 4.8 ±0.5 <.OOO1*
Embarrassed 1.7 4.3 0.0 27.4 66.7 4.1 ±1.1 4.7 ±0.5 .0008*
Difficulty cooking for 0.0 0.0 2.6 24.8 72.6 4.5 ±0.6 4.8 ±0.4 .0011*
Swallowing more difficult at end of day 3.4 1.7 2.6 29.1 63.2 4.1 ±1.1 4.7 ± 0.7 .0007*
Not self-conscious when eatingt 2.6 6.0 0.8 26.5 64.1 3.9 ±1.2 4.8 ±0.6 <.OOO1*
Upset by swallowing problem 1.7 13.7 0.8 23.1 60.7 3.5 ±1.3 4.7 ± 0.6 <.OOO1*
Takes great effort 0.8 8.6 1.7 27.4 61.5 3.8 ±1.2 4.8 ±0.5 <.OOO1*
Do not go out because of 0.8 0.8 0.0 29.1 69.2 4.3 ±0.8 4.8 ±0.4 .0003*
Caused loss of income 0.8 0.8 0.0 20.5 11.?, 4.5 ± 0.7 4.8 ±0.5 .0332*
Takes longer to eat 6.8 10.3 1.7 17.1 64.1 3.3 ±1.6 4.8 ±0.6 <.OOO1*
People ask why you can't eat certain foods 1.7 0.0 5.1 25.6 67.5 4.2 ± 0.9 4.8 ±0.5 .0014*
Others irritated by your problem 0.0 1.7 2.6 24.8 70.9 4.4 ± 0.7 4.8 ±0.5 .0010*
Cough when drink liquids 2.6 6.0 2.6 26.5 62.4 3.9 ±1.2 4.7 ±0.6 .0001*
Limits social life 0.0 0.8 0.8 23.9 74.4 4.5 ±0.7 4.9 ±0.3 .0007*
Comfortable eating with friendst 0.8 0.8 0.0 23.9 74.4 4.4 ±0.8 4.9 ± 0.3 .0016*
Limit food intake 3.4 4.3 1.7 25.6 65.0 3.9 ±1.3 4.8 ±0.5 .0001*
Cannot maintain weight 0.0 0.0 1.7 29.9 68.4 4.4 ±0.6 4.8 ±0.4 .0003*
Low self-esteem 1.7 0.8 0.0 29.1 68.4 4.3 ±0.9 4.8 ±0.4 .0013*
Feels like swallowing huge amount of food 1.7 7.7 0.8 30.8 59.0 3.9 ±1.1 4.6 ±0.7 .0005*
Feel excluded 1.7 0.8 0.0 29.1 68.4 4.3 ±1.0 4.8 ±0.4 .0013*
Rows may not sum to 100 because of rounding.
SA — strongly agree; A — agree; N — no opinion; D — disagree; SD -- strongly disagree.
*Significant difference (p < .05).
tReverse coded.

be surveyed to ensure proportionate representation ity strata, and to assess additional risk factors that
across age and sex, as well as race and/or ethnic- might contribute to vulnerability.
Acknowledgments: We gratefully acknowledge the contributions of Rebekah Barlow, Kassi Harris, and Camilya Siever, who served
as research assistants on this project. The authors also acknowledge the contribution of Elaine Smith, PhD, of The University of Iowa,
whose voice disorder questionnaire served as the basis for this study.

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