The muscles involved in swallowing may lose mass and strength due to ageing or certain pathological conditions (oesophageal cancer, stroke, Parkinson’s disease). Age-related physiological changes in swallowing (presbyphagia) lead to a reduction in the strength of the swallowing musculature and tongue movement — both recognised as risk factors for dysphagia (1).
Dysphagia is a condition characterised by difficulty swallowing, involving an impaired transit of food or liquids through the tract between the oral cavity and the oesophagus. This may lead to complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, increased hospitalisation, and sarcopenia (2).
Amongst these, conditions, sarcopenia is characterised by the gradual and generalised loss of skeletal muscle mass and strength throughout the body and is, in turn, a risk factor for the onset of dysphagia, as muscle loss directly impacts swallowing capacity (3–5).
Sarcopenic dysphagia: what it is and warning signs
Sarcopenic dysphagia refers to dysphagia that develops as a consequence of sarcopenia — specifically, difficulty swallowing caused by sarcopenia of the skeletal muscles, particularly those involved in the swallowing process (6, 7).
This condition occurs predominantly in adults over the age of 65 who engage in limited physical activity (due to bed rest or partial immobility), have experienced a loss of muscle mass and strength (sarcopenia), or have inadequate nutritional intake (malnutrition). In other words, individuals — particularly older adults with presbyphagia — may develop sarcopenia as a result of illness, inactivity, or malnutrition. As sarcopenia progresses, sarcopenic dysphagia may develop due to reduced function of the tongue, pharynx, and/or the muscles involved in swallowing (8).
The complications of sarcopenic dysphagia are comparable to those of dysphagia described above.
Sarcopenic dysphagia: how to intervene
Physical rehabilitation should include resistance, aerobic, flexibility, and balance exercises, to be performed for at least 20–30 minutes three times a week, in addition to exercises specifically targeting the strengthening of the swallowing muscles (see Box 1). This should be combined with nutritional rehabilitation an increase in aimed at increasing both the caloric (25–35 kcal/kg/day) and protein intake (1–1.5 g/kg/day), as well as supplementation with essential amino acids with a high leucine content.
When necessary, it is important to modify the consistency of ingested liquids or solids, following the guidance of the medical and healthcare team, who must assess the most appropriate method of intake on a case-by-case basis.
For individuals in whom the risk of food aspiration — with consequent development of aspiration pneumonia — is significant, the prevalence of penetration and aspiration generally decreases with increasing viscosity of ingested liquids, thereby improving the safety and efficacy of swallowing. Within the context of aspiration pneumonia prevention, it is also important to maintain adequate oral hygiene to prevent colonisation by pathogenic agents (11–16).
Interventions should include:
- Strengthening of the swallowing muscles (dysphagia rehabilitation)
- Physical therapy (sarcopenia treatment)
- Nutritional support
- Modification of food consistency
- Patient and caregiver education (10)
Physical rehabilitation should include resistance, aerobic, flexibility, and balance exercises, to be performed for at least 20–30 minutes three times a week, in addition to exercises specifically targeting the strengthening of the swallowing muscles (see Box 1). This should be combined with nutritional rehabilitation an increase in aimed at increasing both the caloric (25–35 kcal/kg/day) and protein intake (1–1.5 g/kg/day), as well as supplementation with essential amino acids with a high leucine content.
When necessary, it is important to modify the consistency of ingested liquids or solids, following the guidance of the medical and healthcare team, who must assess the most appropriate method of intake on a case-by-case basis.
For individuals in whom the risk of food aspiration — with consequent development of aspiration pneumonia — is significant, the prevalence of penetration and aspiration generally decreases with increasing viscosity of ingested liquids, thereby improving swallowing safety and efficacy. Maintaining adequate oral hygiene remains essential to prevent colonisation by pathogenic agents (11–16).
Conclusions
Close collaboration between the patient, caregivers, and all medical and healthcare professionals involved is essential to implement targeted interventions aimed at reducing dysphagia and sarcopenia through physical and nutritional rehabilitation.
BOX 1: Physical rehabilitation
Interventions targeting the exercise and strengthening of the entire body’s musculature should be implemented — such as resistance training and compound exercises combining aerobic training, flexibility exercises, and balance training. These are recommended for at least 20–30 minutes three times a week.
Additional physical interventions are useful for the specific strengthening of the swallowing muscles. Examples include:
- Shaker exercise: In a supine position, raise the head and hold the position for 60 seconds. Repeat three times with a 60-second rest interval between each lift. Once completed, perform 30 consecutive head lifts at a constant pace. This exercise is recommended 3 times per day.
- Chin tuck against resistance (CTAR) exercise This is a variant of the Shaker Exercise, performed in a seated position. It involves compressing a rubber ball (or a rolled towel) placed between the chin and the upper chest. The movements and repetitions are the same as the Shaker Exercise, but instead of lifting the head, the chin is pressed towards the chest, working against the resistance provided by the ball.
- Jaw opening exercises: Open the jaw as wide as possible and hold the position for 10 seconds, feeling a stretching sensation. Perform this 5 times with 10-second rest intervals as one set. Two sets per day are recommended.
Note: Exercises should be performed for the first time under the supervision of a physician, physiotherapist, or speech and language therapist, in order to ensure both the safety of execution given the patient’s medical condition, and the correct performance of each exercise.
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- Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019 Jul 1;48(4):601. doi: 10.1093/ageing/afz046. PMID: 31081853; PMCID: PMC6593317.
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- Wakabayashi H. Presbyphagia and Sarcopenic Dysphagia: Association between Aging, Sarcopenia, and Deglutition Disorders. J Frailty Aging. 2014;3(2):97–103. doi: 10.14283/jfa.2014.8. PMID: 27049901.
- Sakai K, Sakuma K. Sarcopenic Dysphagia as a New Concept. In: Dionyssiotis Y. Frailty and Sarcopenia – Onset, Development and Clinical Challenges. IntechOpen. 2017. doi: 10.5772/65153.
- Chen KC, Jeng Y, Wu WT, et al. Sarcopenic Dysphagia: A Narrative Review from Diagnosis to Intervention. Nutrients. 2021 Nov 12;13(11):4043. doi: 10.3390/nu13114043. PMID: 34836299; PMCID: PMC8621579.
- Chen KC, Jeng Y, Wu WT, et al. Sarcopenic Dysphagia: A Narrative Review from Diagnosis to Intervention. Nutrients. 2021 Nov 12;13(11):4043. doi: 10.3390/nu13114043. PMID: 34836299; PMCID: PMC8621579.
- Chen KC, Jeng Y, Wu WT, et al. Sarcopenic Dysphagia: A Narrative Review from Diagnosis to Intervention. Nutrients. 2021 Nov 12;13(11):4043. doi: 10.3390/nu13114043. PMID: 34836299; PMCID: PMC8621579.
- Sakai K, Sakuma K. Sarcopenic Dysphagia as a New Concept. In: Dionyssiotis Y. Frailty and Sarcopenia – Onset, Development and Clinical Challenges. IntechOpen. 2017. doi: 10.5772/65153.
- Morley JE, Argiles JM, Evans WJ, et al. Nutritional recommendations for the management of sarcopenia. J Am Med Dir Assoc. 2010 Jul;11(6):391–6. doi: 10.1016/j.jamda.2010.04.014. PMID: 20627179; PMCID: PMC4623318.
- Yang C, Song Y, Li T, et al. Effects of Beta-Hydroxy-Beta-Methylbutyrate Supplementation on Older Adults with Sarcopenia: A Randomized, Double-Blind, Placebo-Controlled Study. J Nutr Health Aging. 2023;27(5):329–339. doi: 10.1007/s12603-023-1911-1. PMID: 37248756.
- Liu S, Zhang L, Li S. Advances in nutritional supplementation for sarcopenia management. Front Nutr. 2023 Jul 10;10:1189522. doi: 10.3389/fnut.2023.1189522. PMID: 37492597; PMCID: PMC10365293.
- Stout JR, Sue Graves B, Cramer JT, et al. Effects of creatine supplementation on the onset of neuromuscular fatigue threshold and muscle strength in elderly men and women (64–86 years). J Nutr Health Aging. 2007 Nov–Dec;11(6):459–64. PMID: 17985060.
- Chen KC, Jeng Y, Wu WT, et al. Sarcopenic Dysphagia: A Narrative Review from Diagnosis to Intervention. Nutrients. 2021 Nov 12;13(11):4043. doi: 10.3390/nu13114043. PMID: 34836299; PMCID: PMC8621579.
- Liu S, Zhang L, Li S. Advances in nutritional supplementation for sarcopenia management. Front Nutr. 2023 Jul 10;10:1189522. doi: 10.3389/fnut.2023.1189522. PMID: 37492597; PMCID: PMC10365293.
- Morley JE, Argiles JM, Evans WJ, et al. Nutritional recommendations for the management of sarcopenia. J Am Med Dir Assoc. 2010 Jul;11(6):391–6. doi: 10.1016/j.jamda.2010.04.014. PMID: 20627179; PMCID: PMC4623318.
- Sakai K, Sakuma K. Sarcopenic Dysphagia as a New Concept. In: Dionyssiotis Y. Frailty and Sarcopenia – Onset, Development and Clinical Challenges. IntechOpen. 2017. doi: 10.5772/65153.
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- Stout JR, Sue Graves B, Cramer JT, et al. Effects of creatine supplementation on the onset of neuromuscular fatigue threshold and muscle strength in elderly men and women (64–86 years). J Nutr Health Aging. 2007 Nov–Dec;11(6):459–64. PMID: 17985060.
- Yang C, Song Y, Li T, et al. Effects of Beta-Hydroxy-Beta-Methylbutyrate Supplementation on Older Adults with Sarcopenia: A Randomized, Double-Blind, Placebo-Controlled Study. J Nutr Health Aging. 2023;27(5):329–339. doi: 10.1007/s12603-023-1911-1. PMID: 37248756.
