As many as one-third of adults over the age of 65 struggle with difficulty swallowing, or dysphagia. The risk of dysphagia increases with age, and research has well documented that older adults with dysphagia have an increased risk for aspiration, pneumonia and death.
What is less clear is the relationship between dysphagia and psychosocial factors. Health outcomes in older adults are shaped not only by physical diseases but also by mental health and social determinants of health. Social determinants of health are the non-medical factors in a person’s life that influence health outcomes such as race and ethnicity, economic stability, access to transportation and health services, and social support.
Recent studies led by Duke Department of Head and Neck Surgery & Communication Sciences researchers Harrison Jones, PhD, and Seth Cohen, MD, have revealed that dysphagia is associated with negative psychosocial health factors. This research may lead to improvements in the screening, assessment, and treatment of dysphagia in older adults to enhance their overall health.
Anxiety, Food Insecurity, and Being Homebound
Two HNS&CS papers published in 2023 analyzed health data from the National Health & Aging Trends Study in over 4,000 older adults living in the community who received Medicare benefits. In the sample, over 10% of respondents self-reported dysphagia in the prior month.
Relationships between dysphagia and social determinants of health have received very little prior attention, and these papers highlight a need for further research. According to Drs. Jones and Cohen, more participants reported dysphagia than not among people in those who were:
- Hispanic
- Separated, divorced, widowed, or never married
- Had less than a high school education
- Had a total income of less than $27,600
- Medicaid and Tricare recipients
- Rural residents
One paper, published in Journal of General Internal Medicine, showed that dysphagia was associated with significantly increased risk for anxiety and decreased sense of well-being.
Another paper published in Journal of Applied Gerontology showed that dysphagia was associated with significantly increased risk for food insecurity and being homebound.
Both studies controlled for other relevant factors, such as demographics, health characteristics, and risk factors for dysphagia. Their results demonstrate that dysphagia in older Americans is associated with increased risk for anxiety, being homebound and food insecurity. These findings have important implications for the health of older adults living in the community and their health:
- Anxiety may decrease an older adult’s ability to perform daily activities and worsen their physical health.
- Homebound older adults have an increased risk for metabolic, cardiovascular, cerebrovascular and musculoskeletal diseases, as well as psychiatric health problems including cognitive impairment, dementia, and depression. Furthermore, being homebound may interfere with access to healthcare services including those related to dysphagia assessment and treatment.
- Older adults who are food insecure are 65 percent more likely to be diabetic than their food-secure counterparts. They are also more likely to suffer from conditions such as congestive heart failure, high blood pressure, asthma, obesity and gum disease.
Implications and Opportunities
While the associations reported in these papers are concerning, these findings are not bad news. Drs. Jones and Cohen highlight opportunities for new, health-promoting interventions for older adults that can be made at the individual, community and policy levels.
For example, these papers suggest that screening older adults with swallowing difficulty for food insecurity, being homebound, and anxiety may be warranted. These screenings may be a cost-effective way to identify homebound older adults who would benefit from telehealth or home-based treatment services, for example. Identifying food insecurity in older people with dysphagia may prompt meal assistance or other services for nutritional support.
As a result of this ongoing research, Duke Speech Pathology is now screening for financial resource strain, transportation needs, and food insecurity as part of its standard clinical care services for patients with dysphagia.
Seeking Future Findings
“Relationships between dysphagia and psychosocial health have rarely been explored and our findings have important implications for the health of older adults,” Dr. Jones says. “For example, it is already well established that swallowing impairments have negative consequences on health and quality of life. Older adults with dysphagia who also have food insecurity or who are homebound may be at increased risk for negative health outcomes and face additional barriers in seeking out assessment and treatment services.”
Drs. Jones and Cohen caution that more research is needed to understand the causal factors underlying the associations they found. It’s also not yet clear how interventions may or may not affect these associations. The researchers plan to expand and refine their investigations.
As the relationships between dysphagia and social indicators of health are further explored, Drs. Jones and Cohen expect to find ongoing opportunities to develop interventions that improve not only dysphagia symptoms but also the health of older people in all communities and populations.
For more information about their work, please contact Dr. Jones or Dr. Cohen.