Dementia and Dysphagia
Caryn S. Easterling, PhD, CCC, BRS-S, and Elizabeth Robbins, MA
In 2004, more than 12% of the population in
the United States was aged 65 years or older.
This percentage is expected to increase to
20% of the population by 2030. The preva-
lence of swallowing disorders, or dysphagia,
in older individuals ranges from 7% to 22%
and dramatically increases to 40% to 50% in
older individuals who reside in long-term
care facilities. For older individuals, those
with neurologic disease, or those with de-
mentia, the consequence of dysphagia may
be dehydration, malnutrition, weight loss,
and aspiration pneumonia. Dysphagia can
be a result of behavioral, sensory, or motor
problems (or a combination of these) and is
common in individuals with neurologic dis-
ease and dementia. Although there are few
studies of the incidence and prevalence of
dysphagia in individuals with dementia, it is
estimated that 45% of institutionalized de-
mentia patients have dysphagia. The high
prevalence of dysphagia in individuals with
dementia likely is the result of age-related
changes in sensory and motor function in
addition to those produced by neuropathol-
ogy. The following article describes evidence
based practices in caring for those individu-
als with dementia and dysphagia with guide-
lines for evaluation and management. (Geri-
atr Nurs 2008;29:275-285)
wallowing is the efficient and safe move-
S ment of a bolus from the mouth to the
stomach without aspiration. Normal swal-
lowing involves the coordinated and synchro-
nized contraction of muscles in the oropharynx,
larynx, and esophagus.1 Four overlapping
phases describe the movement and modifica-
tions of the bolus as it progresses from the
mouth through the esophagus and into the stom-
ach: oral preparatory, oral, pharyngeal, and
esophageal.2 In the oral preparatory and oral
phases, the bolus is mixed with saliva, reshaped,
and chewed when needed to ready it for move-
ment into the pharynx. Food consistency, taste,
and volume dictate the length of the oral prepa-
ratory and oral phase functions.3,4
During the pharyngeal phase, breathing
ceases momentarily as the bolus is moved
Geriatric Nursing, Volume 29, Number 4
through the pharynx. In a sequence of biome-
chanical events, the nasopharynx is sealed by
elevation of the soft palate, the tongue pushes
the bolus toward the pharynx, and the pharyn-
geal constrictors contract. Thus the bolus is
moved through the pharynx via sequential pres-
sure waves. Milliseconds before the onset of
pharyngeal contraction, the hyoid and larynx
move upward to close the laryngeal vestibule
and airway entrance, thereby preventing aspira-
tion. Thereafter, they move forward to provide
the force that opens the upper esophageal
sphincter (UES) to allow the bolus to enter the
esophagus. As the tail of the bolus passes the
UES, the pharyngeal structures return to rest
and breathing begins again.
In the esophageal phase the bolus moves to
the stomach through muscular action called
peristalsis. Peristalsis is the product of the re-
ciprocal relaxation and contraction of the circu-
lar and longitudinal muscles that make up the
esophagus. At rest, the esophagus is a collapsed,
closed tube with a sphincter at each end, the
upper esophageal sphincter at the top and the
lower esophageal sphincter at the bottom. To-
gether, the sphincters function as a protective
mechanism to prevent the esophagus from be-
ing filled with air during speech and nonswallow
activities and from the flow of refluxate into the
body of the esophagus from the stomach.
Swallowing, like many other physiologic func-
tions, depends on a neural network that in-
volves many brain areas. A successful swallow
requires input from the cortex, subcortex, brain-
stem, and cranial nerves. Originally it was
thought that both cerebral hemispheres and the
brain stem had to be damaged for an individual
to have dysphagia.5 However, with the advent of
imaging techniques, it became apparent that
dysphagia can result from a unilateral lesion of
the cerebral cortex.6,7 In a series of studies,
Daniels and colleagues8-10 documented that le-
sions in the premotor, primary motor, primary
somatosensory cortices, insula, and the periven-
tricular white matter can all cause dysphagia.
Both reflexive and voluntary swallowing acti-
vate the precentral gyrus, postcentral gyrus, in-
sula and anterior cingulate gyrus.11-13 Activation
has also been noted in the basal ganglia, al-
275
though the contributions to swallowing are less
remarkable than other previously mentioned ar-
eas of activation.12,14 Also active in swallowing
is the cerebellum, which plays a regulatory role
in volitional swallowing.13,15,16 During voluntary
swallowing, the supplementary motor area be-
comes active bilaterally and is involved in plan-
ning sequential movements of swallowing.17
Dysphagia
Dysphagia is the term used to describe disor-
dered swallowing regardless of etiology. Loge-
mann18 explained dysphagia as difficulty mov-
ing food from the mouth to the stomach and
includes problems with behavioral, sensory,
and preliminary motor acts in preparation for
the swallow, as well as cognitive awareness of
the upcoming eating situation, visual recogni-
tion of food, and all of the physiologic responses
to the smell and presence of food (pg 1). For
example, sensory damage can produce difficulty
with bolus organization, mastication, and pro-
pulsion in the oral preparatory and oral phases;
motor damage can disrupt airway closure and
pharyngeal transport; cognitive damage can pro-
duce confusion and lack of recognition of the
meaning of food.
Prevalence in Individuals with Dementia
Dysphagia is a common sequela of stroke and
the neurologic diseases that produce dementia.
Although there are no studies of the prevalence
of dysphagia in patients with dementia, Horner
et al.19 estimated that 45% of institutionalized
patients with dementia have some type of dys-
phagia.
Is Dysphagia a Consequence of Normal
Aging?
Estimates of the prevalence of swallowing
dysfunction in older (65 years and older) adults
ranges from 7% to 22%. Of those who reside in
long-term care facilities, 40% to 50% have a swal-
lowing disorder.20-28 The incidence of dysphagia
is higher in older than younger adults because of
their increased risk for stroke and other neuro-
logic disorders.29-31 However, the higher inci-
dence of dysphagia in older individuals cannot
be attributed solely to disease and illness. There
are many age-related physiologic changes that
can affect swallowing:
276 Geriatric Nursing, Volume 29, Number 4
Decreased sensitivity of the pharynx and su-
praglottal area28,32-34
Loss of dentition that diminishes the ability
to manipulate the bolus35
Decreased ability to produce saliva36
Decreased tongue pressure during bolus
transit31
Diminished tongue strength37
Slower oral and pharyngeal bolus transit
movement28
Delayed initiation of the pharyngeal reflex28
Reduced anteroposterior UES opening dur-
ing swallowing28
A need for larger pharyngeal volumes to trig-
ger a reflexive pharyngeal swallow38,39
Effect of Increased Bolus Volume
Increased bolus volume produces many ef-
fects on the process of swallowing in older
adults40,41 including the following:
Decreased oropharyngeal transit times
Earlier onset of anterior tongue base move-
ment
Longer duration of palatal elevation
Decreased delay in pharyngeal response
time
Increased duration of hyolaryngeal excur-
sion
Increase in the extent and duration of the
anteroposterior UES opening
Increased deglutitive apnea period, or the
time in which breathing is halted during
swallowing42
Increase in oropharyngeal pressure
Increase in duration of thyroarytenoid
contraction43-46
Effects of Change in Bolus Consistency
As is the case with change in bolus size, al-
terations in bolus consistency specifically in-
creasing bolus viscosity or consistency may
affect swallowing in older adults. Using instru-
mental techniques to verify significant change in
the swallowing physiology, the research dis-
cussed subsequently has illustrated the affect of
increased viscosity on swallow physiology:
An increase in oropharyngeal transit time,
lingual pressure, and the duration of the pha-
ryngeal pressure wave43,44
47
A later onset of swallowing apnea
Change in amplitude and duration of the hy-
popharyngeal pressure39,40
Dysphagia and Dementia
When present, dysphagia predisposes individ-
uals with dementia to dehydration, malnutrition,
weight loss, and aspiration pneumonia.48-50 As-
piration of food and or secretions may predis-
pose individuals to respiratory complications,
aspiration pneumonia, and possibly death.51
With loss of vitality, dementia patients may be-
come more dependent on others for care and
more susceptible to depression. Because de-
pression is frequently associated with loss of
appetite, a vicious cycle may develop that pro-
duces even greater dehydration, malnutrition,
and weight loss.
Individuals with dementia who need to be fed
or cued during a meal are at greater risk of
illness and mortality than those who can feed
themselves.26 Langmore and colleagues51,52
found that a patients degree of functional de-
pendency was an important factor in predicting
occurrence of aspiration pneumonia in institu-
tionalized patients. If proper feeding techniques
are established and maintained, patients with
dementia are able to feed themselves longer and
maintain weight and hydration over an extended
period.53
Dysphagia in Alzheimers Dementia
Patients
An early sign of Alzheimers disease (AD) is
anosmia, or diminished sense of smell. Because
the ability to taste food is related to sense of
smell, many early stage AD patients report that
food does not taste as good. They find highly
seasoned, spicy, and sweet foods more satisfy-
ing, but these changes in food preferences can
negatively affect nutrition.54,55
Memory impairment can contribute to malnu-
trition as well. Morley and Silver56 and Clag-
gett57 reported that the memory impairment of
AD patients may result in their forgetting to eat
a meal or to eat. With progression of AD and the
development of restlessness and increased mo-
tor activity, patients require more calories. How-
ever, their distractibility and agitation can make
sitting for mealtime problematic. As a result,
they often do not fulfill their increased caloric
requirements.
Advanced-stage patients may be unable to
manipulate the bolus or chew food adequately
to meet caloric needs. Changes in the consis-
tency of diet may be needed but not accepted by
Geriatric Nursing, Volume 29, Number 4
the patient. Chouinard58 observed pseudobulbar
dysphagia in many late stage AD patients and its
presence was correlated with the development
of pneumonia, a common cause of morbidity
and death.59 Other risk factors for pneumonia
include eating dependency, poor nutritional in-
take, poor oral hygiene, and decreased physical
activity.60,61
In a prospective study, Horner and col-
leagues19 used videofluroscopy to evaluate
swallow physiology and efficiency in 25 patients
with AD. They found that only 4 of 25 patients
with AD had normal swallow function. The most
prevalent abnormalities were delayed pharyn-
geal response or reflex and prolonged oral
phase. The next most commonly occurring ab-
normality was inefficient pharyngeal clearance.
The severity of the swallow abnormality noted
on the videofluoroscopic swallow evaluation
correlated with the severity of dementia.
Dysphagia in Parkinsons Disease
From 50% to 63% percent of patients with
Parkinsons disease experience oral, pharyn-
geal, and esophageal phase dysphagia.62,63 Com-
mon oral phase abnormalities are lingual tremor
at rest and multiple lingual gestures during oral
bolus manipulation and propulsion. In the later
stages of Parkinsons disease, decreased laryn-
geal elevation, incomplete upper esophageal
sphincter relaxation, pharyngeal residual after
the swallow, and aspiration may be present.64
Dysphagia in Frontotemporal Dementia
Ikeda et al.65 enrolled patients with subtypes
of frontotemporal dementia and AD in an at-
tempt to determine whether these patients
had differentiating characteristic behavioral
changes related to eating. The subtypes of fron-
totemporal dementia were frontal variant fron-
totemporal dementia (fv-FTD; n 23) and
temporal variant frontotemporal (semantic de-
mentia; n 25). Forty-three patients with AD
were enrolled for comparison. They found that
dysphagia developed during late stages of both
variants of frontotemporal dementia, whereas
patients with AD developed dysphagia at an
early stage of the disease. Both fv-FTD and se-
mantic dementia patients experienced an in-
crease in appetite, whereas patients with AD
experienced the opposite. Significant weight
loss occurred in 30% of the patients in the fron-
277
totemporal groups, in contrast to less than 10%
of those in the AD group. Changes in food pref-
erence, that is, craving for sweet foods, was
experienced by 91% of the fv-FTD patients and
80% of the semantic dementia group. In con-
trast, only 21% of the patients with AD experi-
enced food preference changes. Patients with
fv-FTD had abnormal oral behaviors that in-
cluded atypical bite sizes and decreased chew-
ing. Eating nonedible things was a distinguish-
ing characteristic of patients with semantic
dementia only. These types of oral phase dys-
function can result in involuntary bolus move-
ment to the pharynx or into the unclosed airway
before elicitation of a swallow.
Evaluation of Dysphagia
The goal of the evaluation of swallow func-
tion is to determine whether the patient has
dysphagia, what physiologic function is disor-
dered, and whether a change in the manner or
consistency in which nutrition is taken would be
safe and beneficial for the individual.66
Before seeing the patient, review medical
records and note the following:
Diagnosis
Medications with side effects that could con-
tribute to dysphagia
Weight and weight history
Diet consistency history
Whether patient feeds self
Presence of coughing while eating
Presence of throat clearing
History of pneumonia or upper respiratory
infections
Clinical Bedside Screening
Clinical bedside screening (CBS) is a used to
screen for a possible swallowing problem and to
determine the appropriateness of an instrumental
evaluation. The clinician observes how the patient
places a liquid or solid bolus in the mouth, how
efficiently the bolus is contained in the oral phase,
and the amount of time needed to move or chew
the bolus orally and ultimately the amount of time
from oral phase to the performance of a swallow.
CBS protocols are designed to meet the needs of
the patients past nutritional history, medical diag-
nosis, and mental status. CBS protocols have in-
cluded observing the patient swallow a single
3-ounce water swallow to mastication of solid
cookie boluses.67,68 The CBS is an important early
278 Geriatric Nursing, Volume 29, Number 4
screening tool for dysphagia and aspiration risk,
however, because of the varied sensitivity (42%
92%) and specificity (59%91%) of the CBS greater
accuracy in determining the critical elements to be
included in the protocol are warranted.69 CBS is a
compliment to instrumental evaluation and should
not be used in isolation because of the evaluators
inability to determine the physiologic reason for
dysphagia. A CBS does not permit the clinician to
observe the physiologic processes necessary for
safe bolus transport and airway protection. Al-
though the patient may cough or exhibit a change
in vocal quality after trial swallows, bedside
screening will not yield the physiologic reason for
the cough or voice quality change. Aspiration may
be occurring even though the patient does not
cough.70-72 Furthermore the presence of aspira-
tion does not guarantee a cough response. When
aspiration occurs in an awake individual in the
absence of a cough response, it is called silent
aspiration.
Elements of the CBS of a patient with dyspha-
gia include the following66:
Perform an examination of the oral mecha-
nism to clarify cranial nerve function and
assess structural and functional abnormali-
ties
Evaluate the patients ability to comprehend
and use compensatory strategies
Observe the patient during a meal and note
pace of bolus presentation, effect of food
consistency, and behavior during meal
Signs and Symptoms of Dysphagia
Signs and symptoms of dysphagia refer to
complaints or sensations reported by the patient
or caregivers, as well as the observable evi-
dence of dysphagia during the CBS, such as
coughing, throat clearing, and voice quality
changes, to name a few. In a study of dysphagic
stroke patients by Daniels and Foundas,9 only
11% of the patients exhibited aspiration during a
noninstrumental screening, whereas 50% were
found to aspirate when examined fluoroscopi-
cally. Priefer and Robbins73 studied 15 healthy
older control subjects and 10 individuals with
AD and mild dementia as defined by the Clinical
Dementia Rating Scale,74 can have a variety of
swallowing disorders. The patients swallows
were recorded and analyzed using videofluoros-
copy while the patient swallowed varied consis-
tencies and volumes. The patients with Alzhei-
mers dementia had changes in swallowing
ability that included the inability to feed them-
selves, increased oral phase duration, less chew-
ing, delayed pharyngeal response, and inconsis-
tent airway protection compared with healthy
age-matched control subjects.73 In another
study of swallowing ability in patients with de-
mentia, Chouinard, Lavigne, and Villeneuve59 re-
ported coughing with liquids, choking, poor
tongue control while eating, absence of chew-
ing, and holding food in the mouth without swal-
lowing.
The noninstrumental screening can be im-
proved by doing more than watching how the
patient places the bolus in the mouth and the
time needed to swallow. Daniels et al.75 found
that the reliability of the noninstrumental exam-
ination in determining whether the patient was
at risk for aspiration improved when the clini-
cian checked for dysphonia, dysarthria, abnor-
mal volitional cough, abnormal gag reflex,
cough after swallow, and voice change after the
swallow. In stroke patients, the presence of 2 of
these 6 indicators predicted risk of aspiration
and need for a videofluoroscopic swallow eval-
uation to evaluate the physiologic reason for
and timing of the occurrence of aspiration dur-
ing deglutition.68,76 The utility of the CBS can be
called into question; even if aspiration is sus-
pected by the clinician, diet and treatment rec-
ommendations for the swallowing disorder are
not likely to be accurately derived from the
screening because such recommendations are
based on the visualization of the swallow phys-
iology. Visualization of the swallow physiology,
treatment planning, dietary recommendations,
and appropriate follow-up referrals can be ac-
complished through an instrumental evaluation.
Evaluation: Instrumental Assessment
An instrumental evaluation is recommended
when results of the CBS are inconclusive or
suggest that the signs and symptoms of dyspha-
gia are present. The most commonly used in-
struments for evaluation of swallowing by
speech language pathologists (SLPs) are video-
fluoroscopy and videoendoscopy. The instru-
mental evaluation provides important informa-
tion regarding the nature of swallowing
physiology and dysfunction and gives vital infor-
mation regarding treatment approaches and
ways to prevent aspiration.
Geriatric Nursing, Volume 29, Number 4
An instrumental swallow evaluation of the
patient provides information about the follow-
ing66,77,78:
Oral and pharyngeal bolus transit
Airway protection
Bolus clearance of different consistencies
and volumes
Patients pace of eating
Guidelines for Managing Dysphagia in
Patients with Dementia
After the swallowing evaluation, a decision
must be made about the patients potential for
functional improvement of the swallow disorder
and their safety in swallowing liquid and solid
food. The decision is based on the physiologic
nature of the disorder and the ability to alter the
dysfunction through volume or consistency
change, or by using a postural adjustment such
as chin tuck or head turn while swallowing. As
previously mentioned, thickening consistencies
may alter bolus movement through the oral and
pharyngeal portion of the swallow; however,
effects of volume or consistency change or pos-
tural change must be noted during the instru-
mental evaluation. Can the individual benefit
from a change in the manner or consistency in
which nutrition is taken, based on the results of
the instrumental evaluation? Will the patient be
able to safely take nutrition orally if thickened
liquids are given? Will a chin tuck or head turn
be a reliable posture for the patient to alter the
bolus flow? If the patient consumes monitored
small-volume boluses at a slow pace, will nutri-
tional needs be met? The answers to these ques-
tions must be made on the basis of the results of
the instrumental evaluation and the nature of
the physiologic disorder of the swallow as inter-
preted by the SLP. Safe oral intake for the pur-
pose of attaining and maintaining optimal nutri-
tional and caloric needs should be the goal of all
treatment for dysphagia.
Compensatory Therapy Techniques
Compensatory therapies redirect the flow of
the bolus but do not change the physiology of
the swallow. Compensatory techniques include
postural changes, modification of the bolus vol-
ume, consistency, temperature, and the rate of
bolus presentation.
Changes in bolus temperature do not alter the
pharyngeal pressure.39 Temperature has been
279
used to stimulate the afferent receptors of swal-
lowing in dysphagic patients as in the therapeu-
tic application of thermal stimulation.79,80 Ther-
mal stimulation has not been proved to have a
lasting effect on the swallow.80 Presentation of a
sour bolus has been thought to stimulate the
oropharyngeal receptors, leading to greater ac-
tivation of the swallowing centers, that is, the
nucleus of the tractus solitarius and the nucleus
ambiguous. The increased activation produces a
stronger and faster swallow. Clinical research
evidence indicates that a sour bolus improves
timing of the swallow (i.e., shortens swallow
duration), increases strength of muscle contrac-
tion during the swallow, reduces incidence of
penetration and aspiration, and increases the
number of spontaneous swallows following ini-
tial bolus presentation.81-83
The benefit of a compensatory technique is
immediate but does not result in permanent
alteration in the swallow physiology. Individuals
with dementia who are unable to follow the
directions required to perform a compensatory
swallow maneuver or a specific therapeutic re-
habilitative exercise are not good candidates for
an exercise program. However, they may benefit
from a step-by-step program of mealtime cues to
improve swallowing safety. An aide or caregiver
can carry out the cuing protocol designed by the
SLP and the time spent in designing the plan and
caregiver training is reimbursable. SLPs can
also receive reimbursement for providing edu-
cation about communicating with dementia pa-
tients.
Strategies for Supporting Feeding,
Hydrating, and Mealtime Pleasure
Durnbaugh, Haley, and Roberts84 found that
by eliminating distractions during mealtime, in-
dividuals with dementia improved their nutri-
tion and caloric intake. They recommend re-
moving condiments from meal trays and
keeping desserts out of sight until the end of the
meal. Avoid interruptions during mealtimes and
provide encouragement to self-feed.
Burns, Jacoby, and Luthert60 reported that AD
patients in a residential environment required
twice as much time to complete meals as non-
demented patients with physical impairments.
The AD patients in this study experienced 21%
greater weight loss than other nursing home
residents, and laboratory results indicated they
280 Geriatric Nursing, Volume 29, Number 4
had lower intake of iron, protein, and ascorbic
acid.
The following techniques optimize hydration
and nutrition for the patient with dysphagia and
dementia:
good oral hygiene
a consistent environment and seat in the
dining room for mealtime/eating
encouraging 6 small meals and hydration
breaks per day rather than 3 meals per day
including foods that are spicy, sweet, and
sour to maximize sensory input
consulting with a registered dietician about
appropriate high calorie snacks
encouraging self-feeding
not allowing staff to be called away during
meals when they are assisting patients with
meals or snacks
eliminating nonfood items from tables or
trays
making food visually appealing
allowing patients to touch food
providing food choices
not making patients wait when they arrive
for meals
A team approach called Timed Snack Proto-
col was designed by Boczko85 to decrease the
incidence of malnutrition and dehydration in
individuals with dementia residing in skilled
nursing facilities. Residents participating in the
4-week study were weighed weekly, and the
distribution and consumption of snacks were
recorded. Snacks were offered 2 hours after
each meal. Although program enrollment was
small, it was successful in improving hydration
and nutrition, as well as medication compliance.
The snacks distributed in the program included
highly spiced or sweetened finger foods based
on patient preferences.
Feeding Tubes
Delivery of artificial nutrition and hydration via
tube feedings in patients with advanced dementia
is a controversial, as well as an emotional, issue.
Dementia patients at this stage are unable to care
for daily needs and may be bedridden, inconti-
nent, and unable to benefit from the social inter-
action accompanying mealtime, in addition to be-
ing incapable of taking adequate nutrition and
hydration. Percutaneous endoscopic gastrostomy
(PEG) tubes are used most frequently for delivery
of nutrition, and approximately 30% of all PEG
tubes are placed in patients with dementia.86
Chouinard and colleagues59 reported that during
the late stages of AD, some patients enter a cata-
bolic state of negative protein balance secondary
to poor nutritional intake. This state is irrevers-
ible, and therefore the use of enteral feeding is of
questionable benefit to the AD patient. Frequently
family members and caregivers are attracted by
the perceived practical benefits of providing arti-
ficial nutrition and hydration to patients with de-
mentia. Tube feeding has been promoted as a way
to improve and maintain nutrition and maintain
skin integrity by delivering adequate protein; it is
noted to prevent aspiration pneumonia because
nutrition delivery bypasses the upper aerodiges-
tive tract, while potentially improving functional
status and extending life. However, a major con-
cern with use of feeding tubes for nutritional de-
livery in institutionalized patients with dementia is
that it places them at greater risk for aspiration
pneumonia and may in fact contribute to shorter
length of survival.87-89 Research findings indicate
that there is no survival benefit for dementia pa-
tients who receive nutrition via PEG.90 Knebl,
Feinberg, and Tully91 found that nutrition deliv-
ered by tube feeding did not prevent aspiration; in
fact, it may have increased the frequency of aspi-
ration pneumonia. Finucane and colleagues92
found no studies that showed tube feedings im-
proved pressure ulcer healing; on the contrary,
there was an increase in urinary and gastrointes-
tinal output in patients receiving tube feeding re-
sulting in an increase in pressure sores. Addition-
ally, patient discomfort may have been increased
because of the need to use restraints for patients
receiving nutritional tube feeding. These findings
do not indicate that patients with dementia and
dysphagia should be denied the opportunity to
receive artificial nutritional delivery via PEG tube;
however, the decision to do so by the patient or
caregiver should be undertaken with knowledge
and discussion of the risks and benefits.
A preferable alternative to tube feeding is
hand feeding, which allows the maintenance of
patient comfort and intimate patient care.93 Al-
ternative oral nutrition programs have been
tried including caregiver hand feeding of those
patients who are not tube feed and unable to
take adequate nutrition. After 6 months of par-
ticipation in an aggressive nutrition intervention
(which included increased nursing or caregiver
time for feeding and or presentation of finger
foods, as well as oral supplements, environmen-
Geriatric Nursing, Volume 29, Number 4
tal analysis, assisted feeding, and positional al-
terations) improvements were noted in serum
albumin levels, but not in weight and body mass
index, for 50% of the patient participants.94
Mitchell and colleagues95 completed a cost com-
parison of tube-fed versus hand-fed dementia
patients over a 6-month period and found that
the daily nursing care cost was higher for those
who were hand fed. However, billing and reim-
bursement by Medicare in many states is greater
for tube-fed dementia patients compared with
those who are hand fed.
If the patient or caretaker chooses to have a
PEG placed, every effort should be made to
discuss the benefits and risks concerning feed-
ing tube use, establish goals for the use of the
tube, and predetermine how complications from
PEG use will be handled if they arise.
Summary
See Table 1 for a summary of important
points discussed in this article.
Swallowing is the safe and efficient movement
of a bolus from the mouth to the stomach without
aspiration. Like many physiologic functions, swal-
lowing is subserved by a neural network that in-
volved cortex, subcortical areas, brainstem, and
cranial nerves. Age-related changes in sensation,
dentition, and muscle strength make swallowing
less efficient and problematic in many older neu-
rologically adults. Dysphagia is the term used to
refer to difficulty swallowing, whatever the cause,
and it is a common sequela of the neurologic
diseases that are associated with dementia. Man-
aging swallowing disorders in dementia patients is
particularly challenging because they have multi-
ple cognitive deficits that include memory impair-
ment. Clinicians need to evaluate cognitive func-
tion, in particular, memory and language
comprehension, in addition to oral and pharyngeal
bolus transit, airway protection, and bolus clear-
ance for all consistencies and volumes. Although
bedside screening can be helpful in identifying
individuals who need in-depth evaluation of swal-
lowing, clinicians must be cautious about conclud-
ing that aspiration is not occurring in the absence
of cough or voice change after swallowing. Instru-
mental assessment is necessary to be sure that
aspiration is not occurring and to identify the
physiologic basis of dysphagia. Compensatory
techniques to improve swallowing function should
be tested by the clinician for their benefit before
281
 Table 1.
Summary of Important Points
Dysphagia is the term used to describe disordered swallowing regardless of etiology.
It can result from behavioral, sensory, or motor problems (or a combination of these) and is
common in individuals with neurologic disease.
Swallowing depends on a neural network that involves the cortex, subcortex, brainstem, and
cranial nerves.
Although there are few studies of the incidence and prevalence of dysphagia in individuals with
dementia, it is estimated that 45% of institutionalized dementia patients have dysphagia.
The high prevalence of dysphagia in individuals with dementia is likely the result of age-related
changes in sensory and motor function in addition to those produced by neuropathology.
When present, dysphagia predisposes individuals with dementia to dehydration, malnutrition,
weight loss, and aspiration pneumonia. Aspiration of food and or secretions may predispose
individuals to respiratory complications, aspiration pneumonia, and possibly death.
Individuals with Alzheimers disease typically have anosmia, which affects their sense of taste and
may result in less interest in food or a preference for highly seasoned foods.
Some individuals with dementia and episodic memory deficits forget to eat, and their
distractibility and agitation make sitting during a meal problematic.
Late-stage Alzheimers patients may be unable to manipulate the bolus or chew adequately to
meet caloric needs.
Dysphagia is common in persons with Parkinsons disease who have motor deficits; it has been
estimated to be as high as 63% in this population.
The evaluation of dysphagia should include the following: review of medical records, interview
for information about medications and weight history, examination of the oral mechanism, and
an instrumental evaluation when risk of aspiration is a concern.
Clinicians need to answer the question of whether the patient can benefit from a change in the
manner or consistency in which nutrition is taken.
Compensatory techniques may be used to redirect the flow of the bolus and include the
following: postural changes, modification of bolus volume, consistency, temperature, and the rate
of bolus presentation.
Several strategies may be employed to support feeding and hydrating and mealtime pleasure:
eliminating distractions, removal of condiments, keeping desserts out of sight until the end of the
meal, encouraging good oral hygiene, providing a consistent mealtime routine, providing several
small meals during the day, serving finger foods, and focusing staff members attention on
encouraging self-feeding.

recommending their use by caregivers. By ensur-
ing that dementia patients have a consistent meal-
time environment, free of distractions and inter-
ruptions, and receive visually appealing food,
mealtime behavior can be improved and nutrition
and hydration better maintained. Providing nutri-
tious, tasty snacks and beverages between meals
helps to prevent weight loss and dehydration.
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CARYN EASTERLING, PhD, CCC, BRS-S is an assistant
professor with the Department of Communication Sci-
ences and Disorders, University of Wisconsin-Milwaukee,
Milwaukee, WI. ELIZABETH ROBBINS, MA is a research
assistant, Department of Communication Sciences and
Disorders, University of Wisconsin-Milwaukee, Milwau-
kee, WI.
0197-4572/08/$ - see front matter
2008 Mosby, Inc. All rights reserved.
doi:10.1016/j.gerinurse.2007.10.015
285