Dysphagia, or difficulty swallowing, is a serious medical concern that often emerges as dementia progresses. Dementia involves a decline in cognitive function severe enough to interfere with daily life, affecting memory, reasoning, and communication. Dysphagia involves difficulty moving food or liquid from the mouth to the stomach and is a common complication in advanced stages of cognitive decline. Understanding when this difficulty typically occurs is important for caregivers.
Understanding Dysphagia in Dementia
The specific type of swallowing difficulty relevant to dementia is primarily oropharyngeal dysphagia, involving problems with the mouth and throat phases of the swallow. This includes preparing food in the mouth and the coordinated, automatic reflex that moves material down the pharynx and into the esophagus. Signs of this condition include coughing or choking during meals, a wet or gurgly voice after drinking, or taking a significantly longer time to complete a meal.
When the swallowing mechanism fails, there is a serious risk of aspiration, where food, liquid, or saliva enters the airway and lungs. Aspiration can lead to aspiration pneumonia, a lung infection that is a frequent cause of illness and death in advanced dementia. Dysphagia also significantly impairs the ability to consume adequate nutrition and hydration. This often results in unintended weight loss, malnutrition, and dehydration, which compromise overall health.
The Progression: When Swallowing Difficulties Begin
True physiological dysphagia, characterized by an impaired swallow reflex and muscle function, becomes a characteristic feature of the later stages of dementia. While earlier stages may involve behavioral eating issues, the inability to safely swallow is linked to severe cognitive and functional decline. Difficulty with eating, such as prolonged meal times or needing cues to swallow, can appear in the moderate stages, but the most severe swallowing failure is associated with the end-stage of the disease.
Mapping the progression often uses tools like the Global Deterioration Scale (GDS), where the most severe swallowing problems typically align with Stage 6 or Stage 7. Stage 6, or severe cognitive decline, is when individuals often lose the ability to perform basic daily activities without assistance, including feeding themselves. At this stage, the problem is not just forgetting how to eat, but an actual physical impairment in the complex sequence of the swallow.
By GDS Stage 7, or very severe cognitive decline, swallowing difficulties become profound and often include a loss of basic psychomotor skills. Individuals in this late stage frequently lose the ability to walk, sit up independently, or hold their head up, reflecting the central nervous system’s failure to control swallowing muscles. The prevalence of dysphagia is estimated to be very high (84% to 93%) in moderate to severe dementia patients. Recognizing these physical declines, such as loss of mobility, serves as a benchmark for when severe dysphagia is highly likely.
Underlying Causes of Swallowing Dysfunction
The root cause of swallowing dysfunction is neurological damage and degeneration affecting the brain regions that control the complex swallowing process. Swallowing involves a precise sequence of over 50 muscles and several cranial nerves, coordinated by the brainstem and higher cortical centers. As dementia progresses, the neuropathology disrupts the motor control and coordination necessary for safe swallowing.
One contributing factor is apraxia, where the person loses the ability to perform purposeful, learned movements, such as chewing or initiating the first stage of the swallow. Cognitive decline also leads to reduced sensory awareness of food and liquid in the mouth, which delays the trigger for the automatic swallow reflex. When the reflex is delayed, material can fall into the airway before protective closure mechanisms are activated.
The continuous neurological deterioration weakens the muscles in the mouth and throat, including the pharyngeal muscles, making the physical act of moving the food bolus less effective. This weakness results in a prolonged oral stage where food is held in the mouth and an inefficient pharyngeal stage, often leaving residue that can be aspirated.
Practical Strategies for Safe Eating
Managing dysphagia involves implementing compensatory techniques and environmental modifications to minimize the risk of aspiration and ensure adequate intake. A foundational strategy is maintaining proper posture: the person should sit fully upright with their head slightly tilted forward during meals and for at least 20 minutes afterward. Reducing distractions in the dining area, such as turning off the television or radio, helps the person focus on eating and improves cooperation.
Dietary modifications are frequently recommended to alter the consistency of food and liquids, making them easier and safer to swallow. This may include using commercial thickening agents for liquids to slow their flow, or serving soft, moist, or pureed foods that require less chewing. Pacing the meal is also important, ensuring the person clears their mouth and swallows one bite or sip completely before being offered the next, often with a verbal or physical cue.
A Speech-Language Pathologist (SLP) typically performs a bedside swallow evaluation and recommends specific texture modifications and techniques. They may introduce adaptive utensils or suggest sensory cues, such as using strong flavors or temperature variations, to help stimulate the swallow reflex. In the final stages, when oral intake is no longer safe or sufficient, discussions regarding non-oral feeding methods, such as a feeding tube, are a consideration for advanced care planning.