Management of Hypersalivation in the Elderly

Initial Evaluation

Distinguish between true hypersalivation (hyperscretion) and pseudo-hypersalivation (swallowing disorder) by looking for signs of dysphagia, such as coughing during swallowing, wet voice after swallowing, and poor secretion management, according to the American Geriatrics Society 1
Refer patients to a speech-language pathologist for instrumental assessment (videofluoroscopy or FEES) to identify specific swallowing disorders that require a different approach, as recommended by the Journal of the American Geriatrics Society 2, 3

Initiate swallowing rehabilitation with progressive lingual strengthening exercises and swallowing maneuvers (forced swallowing, Mendelsohn maneuver), as recommended by the Journal of the American Geriatrics Society 2, 3
Use postural adjustments, such as the chin-tuck position, to open the valleculae and prevent laryngeal penetration, according to the American Geriatrics Society 1
These interventions reduce pulmonary infections and improve swallowing capacity, although the evidence is of low quality, as noted by the Journal of the American Geriatrics Society 3

Scopolamine may be better tolerated than oral anticholinergics in some patients, as suggested by the American College of Chest Physicians 4

Inject incobotulinum toxin A into the parotid and submandibular glands under echoguidance, as recommended by the American College of Chest Physicians 4
This treatment is safe and effective, with prolonged salivary reduction (approximately 4 months), according to the American College of Chest Physicians 4

Reserve radiotherapy for neurodegenerative diseases with invalidating hypersalivation, as recommended by the American College of Chest Physicians 4
Use modern 3D techniques to minimize tissue damage, and be aware of the risk of permanent dry mouth and carcinogenesis, as noted by the American College of Chest Physicians 4

Involve an interprofessional team, including the patient's primary care physician, speech-language pathologist, occupational therapist, dentist, and neurologist, with early involvement of the speech-language pathologist being critical for evaluation and follow-up, particularly in patients with post-stroke or dementia, as recommended by the Journal of the American Geriatrics Society 2, 5

Untreated hypersalivation increases the risk of aspiration, pneumonia, dehydration, and social stigma, as noted by the Journal of the American Geriatrics Society 6
In patients with stroke or dementia, swallowing disorders are strongly associated with reduced survival, according to the Journal of the American Geriatrics Society 6

The American Geriatrics Society recommends against using pharmacological sedation or physical restraints to manage hypersalivation-related behaviors in elderly patients, as this leads to loss of muscle mass, cognitive deterioration, and counteracts treatment benefits 7, 8

The European Society for Swallowing Disorders suggests that untreated hypersalivation increases the risk of aspiration pneumonia, dehydration, social stigmatization, and perioral skin breakdown, highlighting the need for early aggressive management 7, 8

The American Academy of Neurology recommends the use of incobotulinum toxin A injections into the parotid and submandibular glands under ultrasound guidance as a safe and effective treatment for hypersalivation, with prolonged salivary reduction lasting approximately 4 months 7, 8
The American College of Radiology advises that radiotherapy be reserved exclusively for neurodegenerative diseases with invalidating hypersalivation that has failed all other treatments, using modern 3D techniques to minimize tissue damage, while being aware of significant risks such as permanent xerostomia and potential carcinogenesis 7, 8