Traditionally, interventions for dysphagia in older patients are compensatory in nature and are directed at modifying bolus flow by targeting neuromuscularly induced pathobiomechanics or by adapting the environment.

The growing interest in underlying mechanisms of strength-training exercises for dysphagia is particularly applicable to older people because of documented sarcopenia in this population. Exercise can be of benefit by means of muscle strengthening leading to an enhanced swallowing function. It can be of benefit in persons who remain in the preclinical stage of presbyglutition by helping to reestablish reserve. Individuals can participate in therapy to strengthen pharyngeal and oral musculature to reduce the adverse effects of muscular and sensory impairment. Depending on the area(s) of weakness, oral and pharyngeal muscle-strengthening exercises will be performed.

A compendium of studies has demonstrated that exercise regimens can promote change in swallowing in robust older adults. Lingual-resistant exercise promoted increased isometric and swallowing pressure in a group of healthy older adults. A subgroup in this study also underwent pre- and postexercise magnetic resonance imaging, and an increase in lingual volume was noted in each participant. In a study of the effects of the Shaker exercise, about half of the older people demonstrated an increase in anterior and superior movement of the hyoid bone between the mandible and the larynx, facilitating laryngeal elevation and upper esophageal sphincter opening. It can be difficult to know when an individual might benefit from swallowing diagnostic techniques or intervention strategies. Although speech therapists typically rely on patients, the community-dwelling older people may be overlooked [23].

For older people, treatment may include a variety of compensatory and rehabilitative techniques. Positioning the patient can compensate for weak structures and increase airway protection.

Swallowing therapists believe compensatory strategies are less demanding on the patient in terms of effort. These strategies include postural adjustment, slowing the rate of eating, limiting bolus size, adaptive equipment, and the most commonly used environment adaptation, diet modification. Postural adjustments are relatively simple to teach to a patient, require little effort to employ, and can eliminate misdirection of bolus flow through biomechanical adjustment. A general postural rule for facilitating safe swallowing is to eat in an upright posture (90° seated) so that the vertical phases (pharyngeal) of the oropharyngeal swallow as well as esophageal motility capitalize on gravitational forces. Upright posture also can assist in precluding early spillage of food or liquid from the horizontal oral phase into the pharynx and a potentially open airway as well as diminishing the probability of nasal regurgitation. A less obvious postural adjustment is useful for patients with hemiparesis. For this group of patients, a common strategy is a head turn toward the hemiparetic side, effectively closing that side off to bolus entry and facilitating bolus transit through the non-paretic pharyngeal channel. If the pathophysiologic condition is the uncoupling of the oral from the pharyngeal phase of the swallow (indicated by a delay in onset of airway protection), a simple chin tuck reduces the speed of bolus passage, thereby giving the neural system the time it needs to initiate the pharyngeal and airway protection events prior to bolus entry.

Older individuals and especially those with dysphagia take longer to eat. Eating an adequate amount of food becomes a challenge not only because of the increased time required to do so but also because fatigue frequently becomes an issue. To promote a safe, efficient swallow in most individuals with swallowing and chewing difficulties, the following recommendations are useful:

Eating and drinking aids can assist in placing, directing, and controlling the bolus of food or liquid and in maintaining proper head posture while eating. For example, modified cups with cutout rims (placed over the bridge of the nose) or the use of straws prevent a backward head tilt when drinking to the bottom of a cup. A backward head tilt, which results in neck extension, should be avoided in most cases because food and liquid are more likely to be misdirected into the airway. Spoons with narrow, shallow bowls or glossectomy feeding spoons (spoons developed for moving food to the back of the tongue) are useful for individuals who require assistance in placing food in certain locations in the mouth. More importantly, these utensils and devices promote independence in eating and drinking. A speech pathologist can make suggestions about appropriate aids for optimizing swallowing safety and satisfaction. Occupational therapists are experts in the area of adaptive equipment and can help obtain products that are often available commercially. Diet modification is the most common compensatory intervention and is a totally passive environmental adaptation. Withholding thin liquids such as water, tea, or coffee, which are very easily aspirated by older adults, and restricting liquid intake to thickened liquids are almost routine in nursing homes in an attempt to minimize or eliminate thin liquid aspiration, presumably the precedent to the long-term-related outcome, i.e., pneumonia. Increasing the viscosity of liquids using thickener additives decreases the rate of flow and allows patients more time to initiate airway protection and prevents or decreases aspiration. Rehabilitative exercises are more active and rigorous than alternative interventions for dysphagia. Traditionally, a rehabilitative approach to dysphagia intervention has been withheld from older patients because such a demanding activity has been assumed to deplete any limited remaining swallowing reserve, thus potentially exacerbating dysphagia symptoms. The super-supraglottic swallow, effortful swallow, Mendelsohn maneuver, and the tongue-hold or Masako maneuver, as well as the Shaker exercise are examples of exercises requiring direct patient participation. Use of the supraglottic swallow increases airway protection as does a chin tuck position. Adaptive equipment (small-bowled spoon, shortened straw, cups with extended lip, and so forth) is used to control bolus size and allow midline introduction of bolus decreasing labial leakage. Modification of food consistencies and viscosity of liquids may also be recommended (e.g., puree, soft mechanical, thickened liquids). If it is determined that a patient is not a candidate for oral feeding, alternative means of nutritional support must be considered (nasogastric tube, percutaneous).