Dementia and Dysphagia

What does a dysphagia therapist need to know when treating patients with dementia?

In this article, you’ll find dysphagia treatment tips that are specific to dementia.

Please note that this article is intended for speech-language pathology professionals qualified to assess and treat dysphagia in adult patients.

For premade Dysphagia handouts and treatment guides, check out our shop!

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Dementia and Dysphagia

Individuals with dementia may develop dysphagia, especially as their disease progresses.

While the signs of dysphagia depend on the cause and severity of each person’s dementia, here are some common signs:

• Coughing and choking
• Longer oral/pharyngeal duration
• Reduced hyolaryngeal movement
• Prolonged swallow apnea
• Reduced airway protection
• Impaired chewing
• Reduced bolus management
• Pocketing food, overstuffing mouth
• Reduced sensation

Factors that impact dysphagia in patients with dementia:

• Reduced appetite
• Reduced level of consciousness
• Cognitive deficits (memory issues, impulsivity, unable to follow strategies, etc.)
• Sensory deficits (diminished sense of taste, visual-perceptual changes, impaired hearing)
• Poor oral health
• Complications of Parkinson’s disease

Dementia and Dysphagia Treatments

When treating dysphagia in patients with dementia, remember to zoom out. Dementia is progressive, and there’s only so much you can do within your scope of practice.

Problem-solve with colleagues. Collaborate with dieticians about supplementary nutrition and with the other care team members to support your care plan. Remember that you can’t make a reluctant patient care about (or even remember!) your recommendations.

Do your best to keep patients safe, support their quality of life—and enjoy the human being in front of you!

Below are evidence-based interventions to consider when treating dysphagia in patients with dementia.

1. Spaced Retrieval

Spaced retrieval is an effective strategy for patients with mild to severe dementia.

It’s been shown to help with self-feeding and remembering compensatory swallowing strategies in patients with dementia in long-term care (Husak, R. S., et al. 2017).

To test if your patient is a good candidate for this strategy, do a mini spaced retrieval session.

Spaced Retrieval Step-by-Step

1. Ask the question
   • Ask your patient a specific, open-ended target question
   • “What should you do after taking a bite of food?”
     
2. Give the correct response
   • “Take a drink”
     
3. Ask the question again
   • Ask the exact same target question again and wait for an immediate response. The answer should exactly mimic your correct response
   • “Take a drink”
     
4. If correct, move on to step 5. If incorrect, go back to step 1
   
5. Wait for 15 seconds, then ask the exact same question again
   • Continue to increase the time between asking the question again
   • Start with 15 seconds, then increase to 30 seconds, 1 minute, 2 minutes, 4 minutes, 8 minutes, etc. You may go up to a half-hour or beyond.
   • Remember, the response must be correct to increase the time interval.
   • If incorrect, go back one time interval (or until they’re successful)

An effective spaced retrieval question and target response are:

1. Short and to the point
2. Leads to recall
   • What should you do after taking a bite of food? “Take a drink”
3. Uses their own words
   • Point to the call light, memory book, dining room, etc., and ask, “What would you call this?” to hear what they call it in their own words.

Read Spaced Retrieval for Adult Speech Therapy.

2. Dementia Swallowing & Compensatory Strategies

Choose strategies based on what’s best for each individual patient. Use spaced retrieval to help patients remember their swallowing strategy. Below are some examples.

Dementia swallowing and compensatory strategies:

• Slow down
• Alternate bites and sips
• Small bites and sips
• Make sure all food and drink are swallowed before the next bite/sip
• Check mouth for unswallowed food
• Chin tuck
• Use adaptive equipment (smaller utensils for patients who take big bites, straws, etc.)

3. Dementia and Sensory Processing

Patients with dementia often have impaired sensory processing. This can present as a diminished sense of taste, temperature, vision, hearing, and/or visual-perceptual impairments.

All of these sensations are important to successful feeding.

During your dysphagia treatments, consider safely increasing the intensity of the target sensation while decreasing distracting sensations.

Ways to support sensory processing:

• Add intense flavors (add honey, add salt, alternate sweet and salty while adhering to any dietary restrictions)
• Add intense temperatures (colder liquids, chilled pudding, alternate hot and cold)
• Add carbonation
• Add appropriate smells (bread machine)
• Add the right lighting (sit near a light, turn on lights, natural light)
• Add self-feeding or hand-over-hand to increase proprioceptive and tactile input
• Add visual contrast (colored utensils and plate against a white background, or add a placemat in a contrasting color)
• Decrease noise (turn off the TV, move to a quieter space, add white noise)
• Decrease visual clutter and glare
• Add comfort. Choose a comfy seat that supports good posture. And choose a time when the patient is not fatigued.

Read Environmental Modifications for Dementia Treatment.

Diet Modifications and Sensory Processing

Consider sensory processing when modifying the diets of your patients with dementia. If you downgrade a food or liquid texture, it can impact the sensory experience of eating and you may need to up the intensity of the sensory input.

Also consider the impacts of muted flavors and unappetizing thickeners on your patient’s dysphagia goals.

For more on modified diets, read How to Advance Diets.

4. Dementia and Oral Hygiene

Encourage good oral hygiene to decrease the risk of aspiration pneumonia.

For patients with dementia, use spaced retrieval and adaptations (built-up handle, small brush head, heavy toothbrush, angled brush) as appropriate to support good oral hygiene.

Oral Care for Dysphagia:

• Use a clean toothbrush with soft bristles and toothpaste
  
• Brush your teeth and tongue once in the morning and once in the evening (some patients may need to brush more often)
  
• Perform oral care before eating or drinking to avoid bacteria entering the airway.
  
• Remove dentures to properly clean gums and palate. Properly clean dentures.
  
• Floss before you go to bed
  
• Use alcohol-free and sugar-free mouthwash, if you choose to use mouthwash
  
• Visit the dentist for a cleaning & check-up every 6 months
  
• Treat xerostomia (dry mouth) by sipping water throughout the day. Consider a mouthwash to reduce bacteria.
  
• For patients who are NPO, lean forward over the sink/basin to catch oral secretions.
  
• Avoid alcohol, caffeine, and sugary drinks

5. Advanced Dementia and Tube Feeding

A systematic review for the World Health Organization’s Package of Intervention for Rehabilitation recommends:

• Avoiding artificial feeding in people with severe dementia
• Considering nutritional support (i.e. artificial/tube feeding) for transient dysphagia only
• Considering ethical and legal principles about introducing or withdrawing artificial nutritional support (Jeon, Y., et al. 2022)

The American Geriatrics Society also does not recommend feeding tubes for older adults with advanced dementia.

They elaborate that careful hand feeding has been shown to be as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status, and comfort. Tube feeding is also associated with unwanted outcomes (American Geriatrics Society, 2014).

More Resources

References

• _{American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. (2014, August). American Geriatrics Society Feeding Tubes in Advanced Dementia Position Statement. Journal of the American Geriatrics Society, 62(8), 1590-1593. https://doi.org/10.1111/jgs.12924}
• _{American Speech-Language-Hearing Association (n.d.). Dementia (Practice Portal). Retrieved August 17, 2023, from www.asha.org/Practice-Portal/Clinical-Topics/Dementia/}
• _{Butler, E. (2022). When Dementia and Dysphagia Co-Occur: The Role of the SLP. Dysphagia Cafe. Retrieved August 17, 2023, from https://dysphagiacafe.com/2022/06/16/when-dementia-and-dysphagia-co-occur-the-role-of-the-slp/}
• _{Husak, R. S., & Page, C. G. (2017). The effectiveness of spaced retrieval on improving self-feeding and use of compensatory swallowing strategies in individuals with dementia residing in a long-term care facility. EBP Briefs, 12(2), 1–9. Bloomington, MN: NCS Pearson, Inc.}
• _{Jeon, Y. et al. (2022). A Systematic Review of Quality Dementia Clinical Guidelines for the Development of WHO’s Package of Interventions for Rehabilitation. The Gerontologist. gnac105, https://doi.org/10.1093/geront/gnac105}
• _{Mansolillo, A. (n.d.) The Essentials: Dysphagia and Dementia. Medbridge. https://www.medbridge.com/courses/details/essentials-dysphagia-dementia}