Difficulty swallowing, also known as dysphagia, can occur at any stage of dementia. However, it becomes more common in the later stages as the disease progresses. Dysphagia is a symptom that requires proper management to avoid complications like aspiration pneumonia and malnutrition.
Overview of Dementia Stages
To understand when swallowing difficulties may arise, it helps to review the typical stages of dementia:
- Early Stage – Mild cognitive decline such as memory loss, but still able to function independently.
- Middle Stage – More pronounced symptoms like confusion, wandering, and personality changes. Requires more assistance with daily activities.
- Late Stage – Severe loss of cognitive function and physical abilities. Completely dependent on others for care.
The rate of progression through the stages varies significantly from one person to the next. On average, early stage lasts 2-4 years, middle stage 5-8 years, and late stage 1-3 years. But some people decline much faster while others remain in an early stage for a decade or more.
When Swallowing Problems Start
Mild swallowing problems can begin in the early and middle stages of dementia. The person may eat more slowly, cough or choke occasionally, or have difficulty managing some food textures. However, overt swallowing disorders usually emerge in the later moderate to severe stages.
In the late stage of dementia:
- 85% of people develop significant dysphagia
- Swallowing problems are a leading reason for appetite and weight loss
Severe dysphagia requires modifying food consistency and texture, along with assistance during meals. Tube feeding may be necessary if eating by mouth becomes unsafe or inadequate for sustaining nutrition and hydration.
Why Swallowing Declines
There are several reasons why dementia progresses to impact swallowing function:
- Cognitive impairment – Forgetting to swallow, lacking attention to eat slowly and carefully
- Muscle weakness – Throat muscles weaken, affecting the ability to safely move food to the stomach
- Loss of coordination – Less control over the synchronized swallowing process
- Oral hygiene – Poor dental health exacerbates chewing and swallowing issues
- Medications – Side effects like dry mouth or drowsiness may interfere with eating
All the neurodegeneration that takes place with dementia eventually affects the complex brain signaling required for normal swallowing. Recognizing and managing dysphagia is imperative for people in the later moderate to severe stages.
Signs of Swallowing Problems
How can you identify possible swallowing difficulties in someone with dementia? Be on the alert for any of these common signs:
- Coughing or choking during meals
- Wet/gurgly voice quality after eating/drinking
- Holding food in mouth without swallowing
- Difficulty chewing or managing mixed textures
- Loss of liquid/food from mouth when eating
- Poor lip closure and tongue control
- Frequent throat clearing during/after meals
- Recurrent lung infections like pneumonia
- Unexplained weight loss or dehydration
Any signs of aspiration like coughing, change in voice, or sudden shortness of breath require immediate medical attention. Also monitor for subtle cues like spilling from the mouth or hesitation when swallowing certain foods.
Screening Tests for Dysphagia
To evaluate swallowing ability, doctors may perform screening tests like:
- Water swallow test – Assessing ability to drink water without difficulty
- 3-ounce water swallow test – Drinking 3 ounces of water without stopping
- Pulse oximetry – Monitoring oxygen saturation levels before and after swallowing
- Cervical auscultation – Listening over the neck with a stethoscope during swallowing
If screening indicates dysphagia, a videofluoroscopic swallow study or fiberoptic endoscopy may be warranted to fully examine the nature and severity of the problem.
Risks of Dysphagia
Swallowing disorders lead to two major complications if not managed properly:
Aspiration Pneumonia
Aspiration means food or liquid entering the airway instead of the esophagus. This can occur silently with no outward signs of coughing or choking. When foreign material gets into the lungs repeatedly, it leads to aspiration pneumonia – one of the most common infections in people with dementia.
Pneumonia causes fever, labored breathing, chest pain, and confusion. It is the leading cause of death among dementia patients. Proper feeding techniques and food textures can help prevent aspiration and pneumonia in dysphagia.
Malnutrition & Dehydration
Difficulty swallowing makes it harder to maintain proper nutrition and hydration, resulting in:
- Unintended weight loss
- Loss of muscle mass
- Fatigue and weakness
- Impaired wound healing
- Greater risk of infections
People with dementia often need higher caloric intake due to increased metabolism. Working closely with a speech therapist and dietitian is vital for optimizing safe swallowing and adequate intake for people with dysphagia.
Managing Dysphagia in Dementia
Addressing swallowing issues requires a comprehensive approach including:
- Eating techniques – Proper posture, pacing, cues
- Food/liquid modifications – Adjusting textures and thicknesses
- Oral care – Ensuring good dental and oral health
- Assistive devices – Using cups or utensils adapted for dysphagia
- Swallowing exercises – Targeted tongue and throat muscle strengthening
A speech therapist conducts swallow evaluations to determine safe food consistencies and designing an intervention plan. The goals are to promote safe, efficient swallowing while providing adequate nutrition.
Adapted Food Textures
Food can be altered to make it easier to chew and swallow. Common modifications include:
- Pureed – Smooth, pudding-like consistency
- Ground – Coarse pureed texture
- Minced – Small, bite-size pieces
- Soft solids – Moist,semi-soft foods
Liquids may be thickened to different nectar or honey viscosities. Using thicker liquids can improve control when drinking. A speech therapist will advise on safe textures for each individual.
Mealtime Assistance
People with moderate-severe dementia often need supervision and assistance during meals. This can involve:
- Verbal prompting to swallow
- Pacing the meal and providing cues
- Ensuring proper positioning
- Placing food boluses in the mouth
- Alternating liquids and solids
Caregivers need training on how to watch for signs of aspiration and properly assist with eating and drinking. This helps ensure meals are a safe, calm, and dignified experience.
When to Consider Tube Feeding
If dysphagia becomes severe and threatens nutrition, hydration, and respiratory health, tube feeding may become necessary. Tubes for artificial nutrition include:
- Nasogastric tube – Inserted through the nose down to the stomach
- Gastrostomy tube – Surgically placed into the stomach through the abdomen
- Jejunostomy tube – Placed into the small intestine
Tube feeding formulas provide liquid nutrition and medications. Careful hand feeding is still important for pleasure and stimulation. Tubes should be viewed as supplemental rather than a total replacement for eating by mouth.
Considering Goals of Care
The risks and benefits of artificial nutrition require careful consideration of the person’s prognosis, overall health, and goals of care. Tube feeding does not prevent aspiration since oral secretions are still present. It also increases risk of diarrhea, intestinal damage, and agitation.
In advanced dementia, studies show tube feeding may not extend life or improve comfort. Alternatives like manually assisted oral feeding or thickened liquids may be preferable. Discussions with health providers, family, and caregivers ensure decisions align with the patient’s wishes and best interest.
Preventing Aspiration Pneumonia
People with dysphagia require diligent care and monitoring to avoid pneumonia. Prevention strategies include:
- Oral care after every meal and at bedtime
- Keep head elevated 30-45 degrees while eating
- Follow instructions from speech therapist
- Promptly treat any respiratory infections
- Provide adequate hydration
- Humidify air if needed
Modify diet and liquid textures according to what is safest for swallowing. Recognize signs of possible aspiration like coughing during meals. Have suction available and respond appropriately if food or liquid does enter the airway.
Improving Quality of Life
Even with dysphagia, focusing on comfort and quality of life is essential. Ways to make mealtimes more enjoyable include:
- Favorite foods adapted for safe swallowing
- Calm, unhurried meals in a soothing environment
- Culturally appropriate foods
- Engaging multiple senses – aromas, textures, tastes
- Social interaction during meals
Ongoing oral care and moisturizing the mouth and lips also provides comfort. With patience and proper support, eating can still be a source of dignity and shared time for people with dementia and dysphagia.
Conclusion
Swallowing difficulties predominantly emerge in the later moderate-severe stages of dementia. Proper management is crucial for preventing aspiration pneumonia and malnutrition. While dysphagia poses risks, following individualized plans for adapted foods, mealtime assistance, oral care, and other therapies can optimize safe swallowing and nutritional intake. Careful discussion around artificial feeding is important. Even with the challenges of dysphagia, focusing on quality of life and creating meaningful mealtime experiences remains a key goal.