Explanation
In this module on feeding assistance for persons with dementia (cognitive impairment), we cover first the definitions of each type of dementia and then the characteristics of dysphagia for each type of dementia. We end by looking at the assistive methods for particular symptoms of dysphagia in persons with dementia.
In this module, learners will study
1)To understand the characteristics of dysphagia and the types of dementia (cognitive impairment).
2)To understand methods of feeding assistance for persons with dementia (cognitive impairment).
Explanation
With the exception of dementia with impaired consciousness, dementia is one of the syndromes where, as a brain disorder, cognition is impaired in a complex manner with consciousness unaffected. It is normally chronic or progressive, and peripheral symptoms include psychiatric symptoms and behavior disorder. Cognitive impairment is the impairment of speech, behavior, cognition, memory, attention, and executive function that cannot be explained by paralysis or by sensory or perceptual dysfunction caused mainly by brain damage. Especially in the acute phase of dementia, when impaired consciousness can often develop, we first need to determine if the need for feeding assistance is because of impaired consciousness or because of dysphagia, which can also develop with dementia (cognitive impairment) with consciousness unaffected.
Key points:
•Understand the definition of dementia
•Understand the definition of cognitive impairment
Explanation
We talk about eating and swallowing by referring to the anticipatory, preparatory, oral, pharyngeal and esophageal stages. In the presence of dementia, 3 of these stages tend to be readily influenced: the anticipatory stage, where patients recognize (perceive) the food and carry it to their mouth using chopsticks or cutlery; the preparatory stage, where food is moved in the mouth and shaped into a bolus by chewing; and the oral stage, where the bolus is transported to the pharynx.
Key point
•Understand the phases of swallowing that are easily influenced by dementia (cognitive impairment)
Explanation
The cognitive impairments that greatly influence dysphagia are as follows: memory disorder, agnosia, visuospatial disorder (hemispatial neglect), motor impairment such as in chewing or moving the food in the oral cavity (apraxia), language impairment (aphasia), and executive function impairment (including impaired attention). In addition to these, in dementia, peripheral symptoms like psychiatric symptoms and swallowing problems caused by behavioral disturbances (eg, abnormal eating behavior) can also develop alongside the main symptoms of cognitive impairment.
First, memory impairment may involve forgetting when the last meal was eaten because of episodic memory impairment, not knowing how to eat and/or the steps in eating because of procedural memory dysfunction, not being able to recognize food and utensils due to visual and tactile agnosia, not knowing the position of food or utensils (knife, fork, chopsticks, dishes) or where to place them because of visuospatial impairment such as hemispatial neglect, not knowing how to use tools and utensils due to ideational or ideomotor apraxia, and not being able to perform voluntary action well such as putting food in the mouth, masticating, and moving the bolus toward the pharynx because of buccofacial apraxia (including swallowing apraxia).
Explanation
The characteristics of language impairment (aphasia) include not being able to clearly express food preferences or ask for food because of motor aphasia, and not being able to comprehend the language and vocabulary used about feeding or instructions about important points during meals because of sensory aphasia. Executive function impairment may manifest as developing socially unacceptable eating behaviors such as stopping eating because of attention disorder, getting up and leaving during meals, allotriophagy (eating objects that are not food), excessively fast eating because of inhibition impairment, holding food in the mouth without swallowing, difficulty initiating the movements to transport food to the pharynx, experiencing changes in the flavor of food, and stereotypic eating behavior such as making the same meal or eating the same food.
Key point
•Understand what kind of dysphagia can be seen in cognitive impairment
Explanation
Let's look now at the characteristics of dysphagia in the main types of dementia.
Alzheimer's dementia is a disease centering on the temporal lobe including the hippocampus, and in the early stage we may see problems in meal preparation because of executive function disorder and with forgetting the previous meal because of memory disorder. In the middle stage, we may see agnosia, visuospatial disorder, impairment in feeding because of apraxia, or interrupted eating because of attention disorder. In the late stages, we may start to see the difficulty of opening mouth from orofacial apraxia and impaired transport of food from the oral cavity to the pharynx.
Lewy body dementia is a disease centering mainly on the occipital lobe, and we may see changes in cognitive function and attention disorder, difficulty understanding the positional relationship between food and utensils because of spatial neglect, and problems with eating, spillage, and interruptions in eating because of visual hallucinations. This is often accompanied by parkinsonism, and similar impairments may be seen in the case where dementia develops during the course of Parkinson's disease.
Explanation
Frontotemporal dementia is a disease centering on the frontal and temporal lobes, and we may see changes in eating habits such as ritualistic eating behavior or changes in preference to sweet foods, heightened appetite or overeating, allotriophagy, overfilling the mouth because of inhibition disorder or eating too quickly, holding food in the mouth because of executive function disorder or interruptions in mastication, difficulty initiating movements to transport food into the pharynx, interruptions in eating movements and leaving the table before finishing eating because of attention impairment.
In vascular dementia, the symptoms that develop vary depending on the damaged region in the brain, and the characteristics also vary. Visuospatial impairment and agnosia as sequela of stroke may develop. These are the symptoms of dysphasia that develop in the anticipatory phase. Also, in combination with these symptoms, aphasia, apraxia, and motor impairment and trismus due to damage to the pyramidal tact and extra-pyramidal tract can often develop. These are the symptoms of dysphagia that develop in and after the preparatory phase.
Key point
• Recognize the characteristics of dysphagia for each type of dementia.
Explanation
The characteristics of abnormal feeding behavior arising from peripheral symptoms of dementia are excitability, lack of calm, not being able to sit still during meals because of hyperkinesias, not being able to focus on meals because of becoming distracted, and increased energy nutrition requirement
For those with aggression, we may see patients refuse food or decline feeding assistance from others, refuse to sit at mealtimes and eat by themselves, and throw things at or hit out at the person helping with feeding. We may also see anorexia or apastia (refusing food) with associated weight loss, and slow eating and longer eating times because of depression. Because of delusions, patients may think their food is poisoned or they may refuse food thinking that the person preparing or bringing the food has poisoned it. Patients may also have visual hallucinations, such as flies present over the table, or they might not be able to concentrate on eating due to visual and auditory hallucinations3.
Key point
• Understand what feeding behavior can be seen with peripheral symptoms of dementia
Explanation
To feed dementia patients with dysphagia, we need to evaluate their dementia (type, main symptoms, peripheral symptoms) and cognitive impairment (memory, cognition, behavior, language, attention, executive function impairment) and to understand each aspect of their impairments, limitations on activities, and restrictions on participation. ]
Then, based on these presenting impairments, limitations on activities, and restrictions on participation, we need to provide training from physiotherapists, occupational therapists, and speech therapists that includes compensatory methods as well as provide feeding assistance at actual mealtimes.
Key point
•Understand the flow to performing eating assistance for dementia (cognitive impairment)
Explanation
1) Managing agnosia and visuospatial impairment (Figure 1)
To manage agnosia and visuospatial impairment, we help patients who have trouble seeing the food by adjusting their posture and placing food where they can see it. Also, by being creative with the placement, color, size, and shapes of eating utensils used, we can make the differences in food more recognizable. By putting a landmark on places and objects that patients find difficult to see as well as guiding them with verbal instructions and hands, we can prompt them to continue eating. For the neglected side, we can provide patients with feedback by using a large mirror or we can use a table that can be switched around. During mealtimes, we can provide not only visual stimuli, but also tactile stimuli as well as change flavor, consistency, and temperature.
Explanation
2) Managing ideomotor apraxia and ideational apraxia (Figure 2)
In addition to patients with ideomotor or ideational apraxia receiving therapy from occupational therapists, we can do the following during actual mealtimes: simplify the procedure for eating the meal by preparing eating utensils in the order the patients will use them such as one spoon and fork, and repeatedly practicing this. We can guide patients by lining up the utensils in the order they are used. Oral eating is prompted by using self-help devices such as spoons that are easy to grip or dishes that are easy to scoop food from.
Explanation
3) Managing buccofacial apraxia (including swallowing apraxia) (Figure 3)
Buccofacial apraxia (including swallowing apraxia) may co-occur with motor aphasia. In such cases, we can provide help with the aphasia and voluntary movement of the buccofacial region. In addition to patients receiving therapy from speech therapists, we can do the following during mealtimes: by utilizing preserved pharyngeal stage function, directly move small portions of food to the back of the tongue using a syringe or bottle with a nozzle. For difficulty of opening the mouth, it is prompted by combined use of K-point stimulation. The sucking reflex is used to help close the mouth.
For tongue motor disorders, we can stimulate the tongue with a small spoon holding a bolus, enhance voluntary movements, tip out the contents of the spoon on the back of the tongue, and transport the bolus towards the pharyngeal region. In this case, we can better stimulate the swallowing reflex by initially adding thermal-tactile stimulation. This can be done by touching the anterior palatine arch or the soft palate with a chilled spoon or ice stick, the.
Explanation
4) Managing executive function disorder (Figure 4)
For patients who overfill their mouth with food because of inhibition disorder or eating too quickly, and for patients who start eating more quickly, we can adjust the mouthful size by using a smaller spoon, adjust their portions with smaller dishware, give verbal cues and have a helper actually guiding their hand to adjust the pace of eating. For symptoms of sterotypic eating behavior where patients continue to eat the same food, we can serve each food on a separate plate, for example. For attention impairment, we can avoid suddenly talking during meals and minimize environmental noise such as from the television and nearby conversations. To enable patients to focus on eating, we can set up an environment with little stimuli by blocking their line of sight with curtains and stopping unnecessary visual stimuli. If a meal is interrupted by patients become distracted or losing attention, we can prompt them to continue eating with verbal cues and guidance. For patients who overfill their mouth and have difficulty initiating swallowing, we can stimulate the swallowing reflex with the methods we discussed for buccofacial apraxia using ice massage (in slide 12)
Key point
• For each type of cognitive impairment, understand what kinds of mealtime assistance may be needed
Explanation
1) Alzheimer's dementia
In Alzheimer's dementia, because severe dysphagia doesn't develop until the late stages, adjusting the environment in the anticipatory and preparatory phases plays a key role. Most effective assistance that helps memory and executive function mainly during the preparation of meals (eg, writing notes about cooking instructions, using cooking appliances equipped with automatic fire extinguishers, or having someone help). Depending on the situation, because patients can generally eat by themselves, it's important to provide meals they are used to and maintain an environment suitable for attention disorder.
2) Lewy body dementia
For Lewy body dementia (including Parkinson's disease accompanied by dementia), because this is accompanied by fluctuations in cognitive function, we should look for changes in symptoms with administration of medication and set up a daily routine around this for mealtimes. Also, because posture deteriorates during meals due to Parkinsonism, we need to pay attention to adjusting their posture while eating. We should also be mindful of the placement of utensils and food because many patients have impaired visual perception.
Explanation
3) Frontotemporal dementia
For frontotemporal dementia, in addition to providing the assistance for executive function disorder mentioned in slide 13, we need to prevent the risk of choking from eating too quickly because of inhibition impairment. We can reduce the mouthful size by using small spoons or separating foods into different dishes. We should also consider providing blended food, avoiding solids that can lead to choke.
4) Vascular dementia
For vascular dementia, various cognitive impairments can develop depending on the region of damage. These symptoms are further complicated by dysphagia, which by itself (ie, without accompanying dementia) is a common sequela of vascular disorder. So, we then need to combine methods of feeding assistance for the different cognitive impairment that develop.
Key point
• For each type of dementia, understand what kind of feeding assistance may be needed
References
- Higashiyama M: Indirect training methods; clinical impairment in dysphagia in the anticipatory, preparatory, and oral phases, 2nd edition, The Society of Japanese Clinical Dysphagia Research edition, Ishiyaku Publishers, Tokyo, pp220-224, 2008.
- Ikeda, M: Eating behaviors in patients with dementia in their daily life. Japanese journal of neuropsychology, 21 (2): 98-109, 2005.
- Kindell, J (author), Kaneko Y(translator): Feeding and swallowing disorders in dementia, Ishiyaku Publishers, Tokyo, pp1-3, 2005.
- Priefer BA, Robbins J: Eating changes in mild-stage Alzheimer's disease: a pilot study, Dysphagia, 12(4): 212-221, 1997.
- Shinagawa S: Eating in dementia. Japanese journal of geriatric psychiatry, 20(7):744-749, 2009.
- Sudo N, Toba K: Nutrition management for each disease, state of care 3) Dementia. Geriatric Medicine, 45(3): 251-258, 2007.
- Matsui T, Ogawa R, Kunishige T, Mori S, Matsushita Y, Yokoyama A, Arai H, Higuchi S, Maruyama K: Eating and dysphagia in dementia, Geriat. Med 45(10): 1277-1282, 2007
- Yamada R: Characteristics eating and dysphagia and care seen in persons with dementia; based on disease specific traits of dementia, Case Journal of Dementia Care, 1(4): 428-436, 2009.
