Swallowing Difficulties & Dementia

The presence of watering eyes, runny nose and sneezing is frequently discussed when determining predictors of aspiration. Research gathered by Debra Suiter, PhD, CCC-SLP, BCS-S, indicates they are autonomic reflexive responsive to irritants to the eyes or nose and should NOT be considered reliable predictors of aspiration.

Watering eyes and a runny nose occur due to trigeminal field irritation (irritants to the cornea, nasal mucosa, etc.). If nasal regurgitation occurs, that would qualify as an irritant and cause rhinorrhea. Suiter states there is no evidence that these symptoms (or sneezing) are indications of aspiration. Please refer to the following resource for more information: https://www.speechpathology.com/ask-the-experts/predictors-of-aspiration-3399.

The temperature of food/liquid should be carefully assessed on a case-by-case basis and ultimately a person-centered option.

Eating and Swallowing Interventions

Individuals progressing through the stages of dementia may experience increasing difficulties surrounding mealtime, including behavioral challenges (e.g., forgetting to eat, wandering); eating problems (difficulty using utensils or self-feeding); and swallowing disorders (dysphagia; Aselage, 2010; Watson & Green, 2006). For example, individuals with moderately severe cognitive decline may have difficulty manipulating a knife; individuals with severe cognitive decline may have difficulty discriminating between utensils; and individuals with very severe cognitive decline may be easily overwhelmed and require cues to locate food on the plate and to swallow (Voyzey, 2010).

These problems can have an impact on the health of an individual. Decisions regarding treatment should take into consideration the potential health risks associated with eating and swallowing problems, along with the individual’s dignity and quality of life throughout the course of the disease (Hickey, Cleary, Coulter, & Bourgeois, 2018).

Depending on the needs of the individual, goals may focus on one or more of the following:

  • Improving the ability to eat and swallow safely
  • Increasing intake to improve nutrition and hydration
  • Encouraging engagement and participation in the mealtime experience (Hickey, Cleary, Coulter, & Bourgeois, 2018).

Goal selection is person-centered. It considers the wishes of the individual with dementia and their family (e.g., cultural food choices, family rituals at mealtime, and religious beliefs) and involves input from an interdisciplinary team of professionals (e.g., Beckley, 2017). See ASHA’s resources on person- and family-centered care and IPE/IPP. See also ASHA’s Practice Portal page on Adult Dysphagia.

Interventions may include the following:

Thickened Liquids

Research has shown subjects with dementia who were randomized to honey-thick liquids had increased mortality, longer hospitalizations, increased pneumonia, dehydration, and UTIs. Aspiration can NOT be eliminated and when a honey-thick liquid is aspirated, the thick consistently is difficult for the lungs to clear thus at higher risk of the pathogenesis of aspiration pneumonia. Please see the following research articles for further information.

Environmental modifications
  • home-like or naturalistic settings (Aselage & Amella, 2010; Brush, Meehan, & Calkins, 2002; Brush et al., 2011);
  • adaptive seating to improve posture (Liu et al., 2016);
  • verbal prompts and cues to increase food intake (Aselage, Amella, & Watson, 2011; Liu et al., 2016); and
  • increased lighting and decreased visual and auditory distractions (see, e.g., Behrman, Chouliaras, & Ebmeier, 2014; Calkins & Brush, 2003).
Diet modifications
  • Altering the texture, temperature, or taste of foods to facilitate safety and ease of swallowing and to improve intake (see, e.g., Douglas & Lawrence, 2015; Keller, Chambers, Niezgoda, & Duizer, 2012; Yen, 1996) and
  • Including high-energy, nutrition-rich foods to ensure adequate nourishment (see, e.g., Spindler, 2002).
  • Other interventions include strategies to maximize independence and safety (e.g., shopping lists, weekly meal planners, and written cues to sequence mealtime activities or to identify steps for using safe-swallow strategies).
  • For a comprehensive discussion of eating and swallowing interventions for individuals with dementia, see Hickey, Cleary, Coulter, & Bourgeois, 2018.

To help minimize the development of aspiration pneumonia, the following evidence-based management should be implemented:

  • Thorough and daily oral cleaning with a toothbrush/paste
  • Routine dental cleanings
  • Promoting self-feeding

Tube Feeding

Tube feeding for supplemental or alternative intake is sometimes considered for a short or extended period of time for individuals with late-stage dementia. The decision to implement tube feeding is complicated. It should take into account the potential complications of tube feeding and the individual’s quality of life.

Decisions about tube feeding should consider input from the team and should reflect the wishes of the individual and his or her family. Ideally, a discussion about the potential use of tube feeding in later stages of dementia should take place when the individual is cognitively able to communicate his or her wishes about end-of-life options (see, e.g., American Geriatrics Society [AGS], 2014, and Hickey, Cleary, Coulter, & Bourgeois, 2018, for further discussion). 

See below for more information:

A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease.

Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial.

Predictors of Aspiration Pneumonia: How Important Is Dysphgia?

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