Dysphagia and Patients with Alzheimer's

Of course, I wish I knew lots more about the swallowing exam in the patient in question, as well as how far the dementia-related cognitive decline has progressed. Because there is a hyperactive gag, there is a strong hint that the areas of primary cerebral involvement have moved past the parietal-temporal-limbic pattern often seen first in dementia of the Alzheimer's type, and past the frontotemporal involvement often seen in that cluster of dementias (the gag implies upper motor neuron system damage). Also, when motor control issues come into play in a patient who originally presents with dementia, the patient is often near the endstage of his or her CNS decline, and cognitive impairment is quite severe. I'll also assume that we don't have to deal with the occurrence of abnormal oral reflexes such as the tonic bite.

Working from those assumptions, it is likely that the person with dementia is being fed by caregivers, and not independently at all. Any compensations that are necessary, from diet modification to postural changes, are only those that can be implemented by a caregiver. It is also likely that textures requiring mastication have already been eliminated from the diet, for both cognitive and motor reasons. With the gag being hyperactive, it is probably best that the textures that are safe for the patient to swallow are particularly smooth, to reduce the chance that gagging will occur due to small lumps in a bolus.

Keeping the spoon anterior in the oral cavity will obviously reduce the likelihood that even a smooth bolus will trigger the hypersensitive gag. Of course, whether or not the patient has adequate oral transit will be a factor here...if the bolus is held anteriorly then you're dead in the water.

Borrowing a page from those who specialize in orally defensive children (which is not my expertise...I paraphrase Joan Arvedson here) , slight downward pressure on the lip (and anterior tongue) when inserting the spoon into the mouth may encourage lip closure around the spoon, and the food should then be at midtongue. There the food is at a location that encourages bolus formation and a relatively automatic initiation of the pharyngeal swallow.

If the gag is so hyperactive that it is consistently triggered by the placement of the hoped-for bolus at midtongue, then oral intake of food may be unlikely, and the safest liquids are what can be given most consistently (with that safety ideally having been determined by instrumental evaluation).

Dr. Stein's professional interests include acquired communication and swallowing disorders of neurogenic and structural origin, including aphasia, motor speech disorders, and head and neck surgery. He has presented and published on the topics of outcome and treatment efficacy in these patient populations, as well as the management of programs for delivering services to patients in the healthcare environment. He holds the Certificate of Clinical Competence in Speech-Language Pathology from the American Speech-Language-Hearing Association, and is a member of the Neurophysiology and Neurogenic Speech and Language Disorders Special Interest Division. As the Assistant Chair of IUP's Department of Special Education and Clinical Services, he serves as the Speech-Language Pathology Program Director.