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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.

The purpose of our study was to prospectively determine pneumonia frequency and correlate it with prandial liquid aspiration and feeding status in frail elderly nursing home residents. Initially, 152 patients had video swallowing examinations (81 oropharyngeal dysphagia, 19 thoracic dysphagia, 52 without dysphagia). Those diagnosed with oropharyngeal impairment were subsequently managed with swallowing therapy or artificial feeding modalities. Patients were followed for 3 years (unless they expired earlier) and clinical courses were categorized according to the degree of prandial aspiration and feeding (PAF) status. Subjects with new lung infiltrates persisting for at least 5 days with appropriate clinical findings were diagnosed as having pneumonia and were classified according to the PAF status months in which these findings occurred. Fifty-six pneumonias were diagnosed during 4,280 months with the following frequencies: no aspiration months 0.6%; minor aspiration months 0.9%; major aspiration/oral feeding months 1.3%; major aspiration/artificial feeding months 4.4%, p < 0.001. Our results indicate that there is not a simple and obvious relation between prandial liquid aspiration and pneumonia. Artificial feeding does not seem to be a satisfactory solution for preventing pneumonia in elderly prandial aspirators.

Oral and pharyngeal function in 131 institutionalized elderly patients with advanced dementia was evaluated by means of videofluoroscopic deglutition examination (VDE). Findings were normal in only nine (7%) patients. Oral-stage dysfunction was observed in 93 (71%) patients, pharyngeal dysfunction in 56 (43%), and pharyngoesophageal-segment abnormalities in 43 (33%). Multiple-stage dysfunction was noted in 55 (42%) patients. Major aspiration of contrast medium was present in 31 patients, and minor aspiration in 66. Evaluation of VDE findings prompted a change in clinical staging (degree of impairment) in 40 patients and substantial alteration in treatment planning in 28. At clinical bedside evaluation, the degree of bolus misdirection was overestimated in 19 patients with minor aspiration and underestimated in seven with major aspiration. Dementia is often associated with oral and pharyngeal impairment, and VDE can be important in diagnosis and treatment.

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The radiologic evaluation of oropharyngeal dysfunction requires interpretation of observed morphodynamics and bolus movements. This can be facilitated if a simplified biomechanical approach is used to understand basic physiology. Oral stage activity can be described as a lingual delivery pump and pharyngeal stage activity as a glossopharyngeal propulsion pump. Bolus misdirection into the airway is more often due to oral rather than pharyngeal abnormalities and is frequently inconsistent with regard to timing and degree. The video-deglutition examination is still a relatively new diagnostic study and its purpose, indications, and criteria for patient selection should be clearly understood.

The clinical background and circumstances of 75 patients who had survived a near-fatal choking episode, i.e., had undergone a Heimlich maneuver, oropharyngeal suctioning, or intubation, is reported. Sixty had choked on a solid bolus (often of a complex texture like sandwiches and chicken soup). Four patients had choked on mashed banana. In 30 patients neurologic disease (such as cerebrovascular disease, Parkinson disease, or dementia) was present. Choking occurred during breakfast (16 patients), lunch (21), dinner (26), and snacks (12). Twenty-five choked at home, 18 in nursing homes, 14 in hospitals, nine in restaurants, and nine in drinking establishments. Twelve were being fed at the time of choking. Fifty-eight of the individuals had oral, pharyngeal, or esophageal abnormalities on radiographic examination that could explain the choking episode. Fourteen patients who were able to vocalize during the choking episode had probably suffered from esophageal impaction. Our study indicates that elderly individuals and those with neurogenic dysphagia are at risk for choking. Dysphagia diet (semisolids) may actually contribute to the risk in these patients. Young adults may also be at risk during episodes of consumption of alcohol and snacks.

Acute airway obstruction during oral intake is a relatively common event that may be fetal if not relieved immediately. Deglutition was studied in 75 individuals who had experienced a near-fatal choking episode (NFCE) or sudden inability to breathe during food intake that was promptly relieved by means of a Heimlich maneuver, suctioning, or intubation. Videofluoroscopy supplemented by static imaging revealed abnormal stages of deglutition in 58 individuals: oral, 32; pharyngeal, 19; pharyngoesophageal segment (PES), 28; and esophageal, 23. Forty individuals aspirated a liquid bolus; this was more often due to oral dysfunction (bolus leakage, n = 17; delayed initiation, n = 18) than pharyngeal abnormality (defective closure, n = 13; incomplete transport, n = 9). Oral-stage dysfunction was common in those with neurologic disease, a history of dysphagia, and structural or motor abnormalities of the PES or esophagus. Fourteen patients were able to vocalize during the NFCE, and each demonstrated an abnormality of the PES or esophagus that could obstruct a solid bolus, suggesting that symptoms were not due to airway obstruction. A variety of unsuspected deglutition abnormalities were documented, indicating the usefulness of radiographic evaluation after NFCE.