Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Swallowing disorders and aspiration in palliative care: Definition, consequences, pathophysiology, and etiology

Tessa Goldsmith, MA, CCC-SLP
Audrey Kurash Cohen, MS, CCC-SLP
Section Editors
Kenneth E Schmader, MD
Daniel G Deschler, MD, FACS
Deputy Editor
Diane MF Savarese, MD


Difficulty swallowing is a disturbing symptom that occurs frequently in terminal illness, especially with malignancies of the upper aerodigestive tract; progressive neurologic disorders such as amyotrophic lateral sclerosis (ALS), Parkinson disease, and multiple sclerosis; dementia; and the general debility that develops in patients near the end of life. In the final weeks to months of life functional decline can impair the desire or ability to eat or drink; furthermore, dysphagia to solids and liquids is one of the most frequent symptoms that tends to worsen during the last days of life [1]. Swallowing dysfunction can impact the essence of pleasurable activities, compromise quality of life (eg, social interaction, communication), and impair nutrition and hydration. Swallowing disorders are also a major predisposing condition for aspiration, and can lead to several pulmonary syndromes, including pneumonia, and, in some cases, even asphyxiation or death.

Given the place of food and nutrition as a central focus of social interaction and the common concerns about adequate nutrition for well-being, swallowing disorders can also cause frustration and distress for families and caregivers. In addition, for many patients with a terminal illness, the inability to swallow and/or disinterest in food may represent a pivotal symptom that prompts the decision to consider end-of-life or hospice care. Management of patients with an advanced, life-threatening illness who are experiencing swallowing difficulty should focus on the following palliative care principles: the primary goals are prevention and relief of suffering with an emphasis on ensuring comfort, rather than optimal nutrition and hydration; the care plan should reflect the underlying life-threatening disease and be consistent with the overall goals of treatment; care is optimized by involving an interdisciplinary team whereby each specialist contributes his/her expert knowledge; and the patient and family are the unit of care and their wishes and preferences should guide collaborative decision making.

This topic review will cover the definitions, consequences, and etiology of swallowing disorders in patients receiving palliative care. Assessment and management of swallowing disorders in this patient population; overview of the causes and treatment of aspiration pneumonia in adults; issues related to swallowing problems in patients with head and neck cancer; assessment and management of oropharyngeal and esophageal dysphagia in adults; and aspiration due to swallowing dysfunction in children are presented elsewhere.

(See "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)

(See "Aspiration pneumonia in adults".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Apr 13, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Hui D, dos Santos R, Chisholm GB, Bruera E. Symptom Expression in the Last Seven Days of Life Among Cancer Patients Admitted to Acute Palliative Care Units. J Pain Symptom Manage 2015; 50:488.
  2. Prosiegel M, Schelling A, Wagner-Sonntag E. Dysphagia and multiple sclerosis. Int MS J 2004; 11:22.
  3. Logemann JA, Pauloski BR, Rademaker AW, et al. Swallowing disorders in the first year after radiation and chemoradiation. Head Neck 2008; 30:148.
  4. Hutcheson KA, Barringer DA, Rosenthal DI, et al. Swallowing outcomes after radiotherapy for laryngeal carcinoma. Arch Otolaryngol Head Neck Surg 2008; 134:178.
  5. Eisbruch A, Lyden T, Bradford CR, et al. Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys 2002; 53:23.
  6. Eisbruch A, Kim HM, Feng FY, et al. Chemo-IMRT of oropharyngeal cancer aiming to reduce dysphagia: swallowing organs late complication probabilities and dosimetric correlates. Int J Radiat Oncol Biol Phys 2011; 81:e93.
  7. Terré-Boliart R, Orient-López F, Guevara-Espinosa D, et al. [Oropharyngeal dysphagia in patients with multiple sclerosis]. Rev Neurol 2004; 39:707.
  8. Feinberg MJ, Ekberg O, Segall L, Tully J. Deglutition in elderly patients with dementia: findings of videofluorographic evaluation and impact on staging and management. Radiology 1992; 183:811.
  9. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001; 344:665.
  10. Calcagno P, Ruoppolo G, Grasso MG, et al. Dysphagia in multiple sclerosis - prevalence and prognostic factors. Acta Neurol Scand 2002; 105:40.
  11. Davis LA. Quality of life issues related to dysphagia. Top Geriatr Rehabil 2007; 23:352.
  12. Penner JL, McClement S, Lobchuk M, Daeninck P. Family members' experiences caring for patients with advanced head and neck cancer receiving tube feeding: a descriptive phenomenological study. J Pain Symptom Manage 2012; 44:563.
  13. Pollens R. Role of the speech-language pathologist in palliative hospice care. J Palliat Med 2004; 7:694.
  14. Massey BT. Physiology of oral cavity, pharynx and upper esophageal sphincter. Part I ORal Cavity, pharynx and esophagus. GI Motility Online (2006) doi: 10.1038/gimo2. Available online at www.nature.com/gimo/contents/pt1/full/gimo2.html (Accessed on May 29, 2014).
  15. Logemann JA. Evaluation and Treatment of Swallowing Disorders, 2nd ed, Pro-Ed, Austin 1998.
  16. Corbin-Lewis K, Liss JM, Sciortino KL. Clinical Anatomy and Physiology of the Swallow Mechanism, Thomson Delmar Learning, New York 2004.
  17. McConnel FM, Cerenko D, Mendelsohn MS. Manofluorographic analysis of swallowing. Otolaryngol Clin North Am 1988; 21:625.
  18. Martin-Harris B. Integration of breathing and oropharyngeal swallowing: A historical perspective and 13-year research experience. Perspect Swallow Swallow Disord (Dysphagia) 2003; 12:6.
  19. Easterling CS. Getting acquainted with the esophagus. Perspect Swallow Swallow Disord (Dysphagia) 2003; 12:3.
  20. Kendall KA, Leonard RJ, McKenzie SW. Sequence variability during hypopharyngeal bolus transit. Dysphagia 2003; 18:85.
  21. Shaker R, Hogan WJ. Normal physiology of the aerodigestive tract and its effect on the upper gut. Am J Med 2003; 115 Suppl 3A:2S.
  22. Bieger D, Neuhuber W. Neural Circuits and mediators regulating swallowing in the brainstem. GI Motility online (2006) doi: 10.1038/giomo74. Available online at www.nature.com/gimo/contents/pt1/full/gimo74.html (Accessed on May 28, 2014).
  23. Cook IJ, Dodds WJ, Dantas RO, et al. Opening mechanisms of the human upper esophageal sphincter. Am J Physiol 1989; 257:G748.
  24. Mashimo H, Goyal RK. Physiology of esophageal motility. GI Motility Online (2006): doi: 10.1038/GIMO3. Available online at www.nature.com/gimo/contents/pt1/full/gimo3.html (Accessed on May 28, 2014).
  25. Rubenstein JH. Esophageal etiologies of dysphagia: A guide for SLP's. Perspect Swallow Swallow Disord (Dysphagia) 2007; 16:1.
  26. Masey BT. Physiology of oral cavity, pharynx and upper esophageal sphincter. GI Motility online 2006; doi: 10.1038/gimo2. article available online at http://www.nature.com/gimo/contents/pt1/full/gimo2.html (Accessed on July 14, 2014).
  27. Berti-Couto Sde A, Couto-Souza PH, Jacobs R, et al. Clinical diagnosis of hyposalivation in hospitalized patients. J Appl Oral Sci 2012; 20:157.
  28. Goldstein NE, Genden E, Morrison RS. Palliative care for patients with head and neck cancer: "I would like a quick return to a normal lifestyle". JAMA 2008; 299:1818.
  29. Xu B, Boero IJ, Hwang L, et al. Aspiration pneumonia after concurrent chemoradiotherapy for head and neck cancer. Cancer 2015; 121:1303.
  30. Caudell JJ, Schaner PE, Meredith RF, et al. Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys 2009; 73:410.
  31. Hutcheson KA. Late radiation-associated dysphagia (RAD) in head and neck cancer patients. Perspectives on swallowing and swallowing disorders dysphagia) 2013; 22:61.
  32. Hutcheson KA, Lewin JS, Barringer DA, et al. Late dysphagia after radiotherapy-based treatment of head and neck cancer. Cancer 2012; 118:5793.
  33. Pace A, Di Lorenzo C, Guariglia L, et al. End of life issues in brain tumor patients. J Neurooncol 2009; 91:39.
  34. Roe JW, Leslie P, Drinnan MJ. Oropharyngeal dysphagia: the experience of patients with non-head and neck cancers receiving specialist palliative care. Palliat Med 2007; 21:567.
  35. Oberndorfer S, Lindeck-Pozza E, Lahrmann H, et al. The end-of-life hospital setting in patients with glioblastoma. J Palliat Med 2008; 11:26.
  36. Drappatz J, Schiff D, Kesari S, et al. Medical management of brain tumor patients. Neurol Clin 2007; 25:1035.
  37. Hoeben A, Polak J, Van De Voorde L, et al. Cervical esophageal cancer: a gap in cancer knowledge. Ann Oncol 2016; 27:1664.
  38. Gibbs JF, Rajput A, Chadha KS, et al. The changing profile of esophageal cancer presentation and its implication for diagnosis. J Natl Med Assoc 2007; 99:620.
  39. Granda-Cameron C, DeMille D, Lynch MP, et al. An interdisciplinary approach to manage cancer cachexia. Clin J Oncol Nurs 2010; 14:72.
  40. Altman KW, Richards A, Goldberg L, et al. Dysphagia in stroke, neurodegenerative disease, and advanced dementia. Otolaryngol Clin North Am 2013; 46:1137.
  41. Ferguson TA, Elman LB. Clinical presentation and diagnosis of amyotrophic lateral sclerosis. NeuroRehabilitation 2007; 22:409.
  42. Yorkston KM, Miller RM, Strand EA, Britton D. Management of speech and swallowing disorders in degenerative diseases, 3rd ed, ProEx, Austin, TX 2012.
  43. Skelton J. Nursing role in the multidisciplinary management of motor neurone disease. Br J Nurs 2005; 14:20.
  44. Elman LB, Houghton DJ, Wu GF, et al. Palliative care in amyotrophic lateral sclerosis, Parkinson's disease, and multiple sclerosis. J Palliat Med 2007; 10:433.
  45. Mitsumoto H, Davidson M, Moore D, et al. Percutaneous endoscopic gastrostomy (PEG) in patients with ALS and bulbar dysfunction. Amyotroph Lateral Scler Other Motor Neuron Disord 2003; 4:177.
  46. Langmore SE, Kasarskis EJ, Manca ML, Olney RK. Enteral tube feeding for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev 2006; :CD004030.
  47. Spataro R, Ficano L, Piccoli F, La Bella V. Percutaneous endoscopic gastrostomy in amyotrophic lateral sclerosis: effect on survival. J Neurol Sci 2011; 304:44.
  48. Kalf JG, de Swart BJ, Bloem BR, Munneke M. Prevalence of oropharyngeal dysphagia in Parkinson's disease: a meta-analysis. Parkinsonism Relat Disord 2012; 18:311.
  49. Miller N, Noble E, Jones D, Burn D. Hard to swallow: dysphagia in Parkinson's disease. Age Ageing 2006; 35:614.
  50. Hussain J, Adams D, Allgar V, Campbell C. Triggers in advanced neurological conditions: prediction and management of the terminal phase. BMJ Support Palliat Care 2014; 4:30.
  51. Bushmann M, Dobmeyer SM, Leeker L, Perlmutter JS. Swallowing abnormalities and their response to treatment in Parkinson's disease. Neurology 1989; 39:1309.
  52. Noyce AJ, Silveira-Moriyama L, Gilpin P, et al. Severe dysphagia as a presentation of Parkinson's disease. Mov Disord 2012; 27:457.
  53. Thomas M, Haigh RA. Dysphagia, a reversible cause not to be forgotten. Postgrad Med J 1995; 71:94.
  54. Clarke CE, Gullaksen E, Macdonald S, Lowe F. Referral criteria for speech and language therapy assessment of dysphagia caused by idiopathic Parkinson's disease. Acta Neurol Scand 1998; 97:27.
  55. Melo A, Monteiro L. Swallowing improvement after levodopa treatment in idiopathic Parkinson's disease: lack of evidence. Parkinsonism Relat Disord 2013; 19:279.
  56. Menezes C, Melo A. Does levodopa improve swallowing dysfunction in Parkinson's disease patients? J Clin Pharm Ther 2009; 34:673.
  57. Warnecke T, Suttrup I, Schröder JB, et al. Levodopa responsiveness of dysphagia in advanced Parkinson's disease and reliability testing of the FEES-Levodopa-test. Parkinsonism Relat Disord 2016; 28:100.
  58. Hälbig TD, Tse W, Olanow CW. Neuroprotective agents in Parkinson's disease: clinical evidence and caveats. Neurol Clin 2004; 22:S1.
  59. Yamazaki Y, Kobatake K, Hara M, et al. Nutritional support by "conventional" percutaneous endoscopic gastrostomy feeding may not result in weight gain in Parkinson's disease. J Neurol 2011; 258:1561.
  60. Murry T, Carrau RL. Clinical management of swallowing disorders, Plural Publishing, San Diego, CA 2012. Vol 3.
  61. American Geriatrics Society. Feeding tubes in advanced dementia position statement. American Geriatrics Society, New York 2013. http://www.americangeriatrics.org/files/documents/feeding.tubes.advanced.dementia.pdf (Accessed on July 17, 2014).
  62. Martino R, Foley N, Bhogal S, et al. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 2005; 36:2756.
  63. Rüegg S, Lehky Hagen M, Hohl U, et al. Oculopharyngeal muscular dystrophy - an under-diagnosed disorder? Swiss Med Wkly 2005; 135:574.
  64. Hill M, Hughes T, Milford C. Treatment for swallowing difficulties (dysphagia) in chronic muscle disease. Cochrane Database Syst Rev 2004; :CD004303.
  65. Howard RS, Wiles CM, Hirsch NP, Spencer GT. Respiratory involvement in primary muscle disorders: assessment and management. Q J Med 1993; 86:175.
  66. Levinthal DJ, Rahman A, Nusrat S, et al. Adding to the burden: gastrointestinal symptoms and syndromes in multiple sclerosis. Mult Scler Int 2013; 2013:319201.
  67. Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest 2003; 124:328.
  68. Murray J. Frailty, functional reserve, and sarcopenia in the geriatric dysphagic patient. Perspectives on swallowing and swallowing disorders dysphagia) 2008; 17:3.
  69. Altman KW, Yu GP, Schaefer SD. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg 2010; 136:784.
  70. Bortz WM 2nd. A conceptual framework of frailty: a review. J Gerontol A Biol Sci Med Sci 2002; 57:M283.
  71. Cohen HJ. In search of the underlying mechanisms of frailty. J Gerontol A Biol Sci Med Sci 2000; 55:M706.
  72. Carl LC, Johnson PR. Drugs and Dysphagia: How Medications Can Affect Eating and Swallowing, 1, Pro-Ed, Inc., Austin 2006.
  73. Balzer, KM, PharmD, “Drug-Induced Dysphagia”, International Journal of MS Care, page 6, Volume 2 Issue 1, March 2000. Available online at http://ijmsc.org/doi/abs/10.7224/1537-2073-2.1.40 (Accessed on May 30, 2014).
  74. Heckel M, Stiel S, Ostgathe C. Smell and taste in palliative care: a systematic analysis of literature. Eur Arch Otorhinolaryngol 2015; 272:279.
  75. Rudolph JL, Gardner KF, Gramigna GD, McGlinchey RE. Antipsychotics and oropharyngeal dysphagia in hospitalized older patients. J Clin Psychopharmacol 2008; 28:532.