Does malnutrition cause dysphagia?

To the Editor: The association between protein-energy malnutrition (PEM) and dysphagia is well recognised--dysphagia, if not managed, can lead to PEM. But can PEM cause dysphagia? We had noted occasional patients with severe malnutrition who also had dysphagia, in whom the dysphagia resolved after nutritional repletion. Studies of muscle function in PEM also suggest that PEM could itself lead to dysphagia (1,2). By conducting a retrospective case note review, we sought evidence to support a possible syndrome of dysphagia which is caused by PEM.

We reviewed the Videofluoroscopy Register of the Speech Pathology Department for the period October 1997 to July 2003 when approximately 600 patients were examined. The Videofluoroscopy Service uses state-of-the-art technology, with assessments done in real time and also by analysis of video recordings by skilled speech pathologists. We retrieved the medical records of all patients (n = 34) who had a diagnosis of dysphagia of unknown aetiology following videofluoroscopic examination.

From the videofluoroscopy reports, we confirmed that abnormal swallowing was present among the 34 'cases' and that lack of a clear diagnosis was not due to coding error or technical difficulties. For each case, we sought evidence of a medical condition that could possibly explain the swallowing abnormalities. Cases were excluded if plausible explanations for the swallowing abnormalities were found.

We then reviewed the nutritional status of remaining cases to confirm that PEM was present. Cases were excluded where there was no evidence of PEM on the basis of Body Mass Index <20kg/[m.sup.2] and serum albumin <35g/L (3). Finally, we sought evidence of improved swallowing following nutritional repletion, as added evidence of a causal PEM-dysphagia relationship.

Despite examining case notes of 34 patients we did not find any clinical data to support a causal relationship between PEM and dysphagia (refer Figure 1). This may be because, despite our suspicions, PEM does not in fact cause dysphagia. It could also be that our sample was too small to find the suspected causal relationship between PEM and dysphagia, which may exist, but is extremely rare. Another possibility is that there are frequent coexisting neurological states in older people which influence swallowing and make it difficult to separate PEM as an independent risk factor for the development of dysphagia.

[FIGURE 1 OMITTED]

This research project was funded by a grant from the Lions-John Cockayne Memorial Aged Care Research Fund.

References

1. Vledee MS, Peth LD. Can protein-calorie malnutrition cause dysphagia? Dysphagia 1992;7:86-101.

2. Hudson HM. Daubert CR, RH Mills. The interdependency of protein-energy malnutrition, aging and dysphagia. Dysphagia 2000;15:31-8.

3. Seiler WO. Clinical pictures of malnutrition in ill elderly subjects. Nutrition 2001;17:496-8.

Pauline Cooper

Dietitian-Senior Clinician

Sandra Gates

Manager, Speech Pathology

Kingston Centre

Peteris Darzins

Associate Professor of Geriatric Medicine

Monash Ageing Research Centre

Monash University and Kingston Centre

Melbourne