Clinical Geriatrics

CASE PRESENTATION
Mr. G, a 90-year-old practicing attorney, was admitted to a subacute rehabilitation facility following a motor vehicle accident (MVA). Mr. G was involved in a rollover MVA, resulting in C1 fracture, C2 dislocation, T1-2 fracture, and left eye trauma. Surgical pins were placed via an anterior approach prior to surgical fusion of C1-2 via a posterior approach. Complications followed the surgical fusion, resulting in respiratory distress, placement of a tracheotomy tube, and use of a ventilator. A percutaneous endoscopic gastrostomy (PEG) tube was placed at this time, as Mr. G had lost his ability to safely swallow. He remained in an acute care facility for 5 weeks before discharge to an acute rehabilitation facility in New York, where he remained for an additional 4 weeks. At the rehabilitation facility, swallowing therapy was initiated but was unsuccessful. He arrived at a subacute rehabilitation facility NPO [nothing by mouth], with a PEG tube still in place for swallowing therapy due to a diagnosis of severe dysphagia (swallowing disorder).

DISCUSSION
Dysphagia has been found to occur in approximately 40-50% of all patients in nursing homes and approximately 33% of the patients in rehabilitation centers. The population of the United States is aging. Between 2010 and 2030, the number of Americans over the age of 65 years will double when compared to the year 2000.1 Approximately 15 million persons in the United States have dysphagia. This relatively large number reflects the significant number of medical problems that can cause abnormalities in the swallow mechanism. Swallowing problems can result from neurologic disease, multiple sclerosis, head and neck tumors, motor neuron disease, and other medical problems, such as rheumatoid arthritis and pulmonary disease (Table I). A person who has dysphagia may experience pain when trying to swallow. Others may have difficulty swallowing food, liquid, or saliva, and some may be unable to swallow at all (Table II).

Swallowing is a complex process that moves food and liquids from the mouth to the stomach, which involves the use of many nerves and muscles in the lips, tongue, mouth, throat, and esophagus. Swallowing occurs in four stages: oral preparatory stage—the food is chewed and prepared for swallowing; oral stage—the tongue pushes the food or liquid to the back of the mouth; pharyngeal stage—the swallow is triggered and the food or liquid is moved into the pharynx; and esophageal stage—food or liquid enters the esophagus and is carried into the stomach (Table III).

Dysphagia is a serious problem affecting about one-third of all patients with cervical spinal cord injury. Spinal cord injury can affect the oral or the pharyngeal phases of swallowing, or a combination of both. This situation must be treated seriously because of the risk for pneumonia.2

OUTCOME OF THE CASE PATIENT
A clinical bedside evaluation was conducted that also determines any cognitive, linguistic, or behavioral problems, as well as medical readiness to eat. The pharyngeal physiology cannot be determined at the bedside. Patients with suspected pharyngeal swallow problems require an instrumental assessment of the oropharyngeal swallow. At the bedside, Mr. G was observed wiping his saliva with a towel because he was unable to swallow his own saliva.

Initially, a fiberoptic endoscopic evaluation of swallowing (FEES) was performed, which involves passing an endoscope through the nose and down into the pharynx. Endoscopy images the pharynx from above. The swallow can be seen as the food, liquid, or ice chip comes over the tongue base until the pharyngeal swallow is triggered. The pharynx reappears after the swallow, and residue can be located. The vocal folds and larynx can be visualized before and after the swallow.3 We determined as a result of this procedure that Mr. G was not a candidate for oral intake at that time.