Alzheimer Disease Comorbidities: Dysphagia

Key Takeaways:

• Dysphagia is a serious complication of advancing Alzheimer disease that can be the cause of life-threatening pneumonia due to aspiration as well as other complications, including malnutrition and dehydration.

• Despite these risks and the frequency with which dysphagia occurs, impairments in swallowing are not necessarily recognized by patients or their caregivers, meaning that healthcare providers should screen routinely for dysphagia in Alzheimer patients.

• The 3-ounce water test is a simple screening tool, but referral to speech-language pathologists or others skilled in the diagnosis and treatment of swallowing disorders should be considered for the assessment of severity and treatment.

• Due to the fact that some, but not all, patients respond to dietary changes or changes in neck position to address the symptoms of dysphagia, treatments are often patient-specific.

• Oral care, such as regular teeth brushing to reduce the presence of microorganisms should be part of a strategy to reduce the risk of complications, such as pneumonia, associated with persistent dysphagia.

This transcript has been edited for clarity.

Cough and swallowing are airway-protective behaviors that, when impaired, significantly increase the risk of developing serious medical morbidities, including dehydration, malnutrition, airway obstruction, and pneumonia. And these medical complications are highly prevalent in people with Alzheimer's disease with pneumonia, often cited as one of, if not the leading cause of death in this patient population. 

Currently, most research suggests that somewhere between 75% to 87% of people with Alzheimer's disease develop impairments in cough and/or swallowing at some point during the disease process.^[1] And what's striking is that impairments in cough and swallowing are rarely perceived by patients and caregivers, meaning that if you the provider asks the patient how they feel their swallowing is, they're likely to say that they feel like their swallow is normal, or if they do feel like there's changes to their swallowing, they tend to underperceive the severity of these changes. 

And so, because of this, it's critical to routinely screen for cough and swallowing impairments in all people with Alzheimer's disease. So, some risk factors and red flags that you, the provider, can look out for as relates to dysphagia is thinking about the number of medications that a patient is taking. So, we know that the more medications that a patient's taking the more likely they are to have dysphagia, especially if we're at five or more medications. 

People who are also at risk of dysphagia are people who have a sarcopenia, lower body mass index and/or various degrees of malnutrition, and also older age.^[2] People with advanced Alzheimer's disease are approximately 37 times more likely to have dysphagia than someone with more of the early to mid-stage Alzheimer's. However, management tends to be much more successful for cough and swallowing impairments when they start their management earlier on in the disease process. And so, providers should really recommend swallowing evaluation by a speech-language pathologist earlier on rather than waiting until there's profound changes to swallowing or more advanced Alzheimer's disease. 

All of these risk factors are great when evaluating someone with Alzheimer's disease and trying to identify dysphagia. There’s some simple screeners that can also be done by either provider or nurses, for example. One very popular screen is the 3-ounce water swallow test.^[3] 

And so, this just involves giving a patient 3 ounces of water and asking them to drink that water slow and steady but without stopping. And it's considered a fail for the screen if they are not able to drink the whole thing or if drinking the water is interrupted. So, they stop and start, stop and start, or if they cough or throat clear immediately or up to 1 minute afterwards. 

So, identifying risk factors or red flags or giving someone the symptom screen would be a great way to identify someone who’s at risk of dysphagia. And when you identify those risks, the next appropriate move would be to refer those patients to a speech-language pathologist who has specialized training in dysphagia. 

One easy way to identify a speech pathologist who has specialized training in evaluating and treating dysphagia and especially in people with Alzheimer’s disease is to go to www.swallowingdisorders.org [American Board of Swallowing and Swallowing Disorders], and there’s a way to find a specialist there. So that website has a registered list of board certified specialists in swallowing and swallowing disorders, although it’s important to recognize that there are many other very well-qualified speech pathologists who aren’t necessarily board certified. 

Management of cough and swallowing problems in this patient population is very complex—thinking about the types of exercises, the type of strategies, [and] dietary recommendations [or] whether or not a feeding tube should be recommended.^[2] There’s no quick fix that works for everybody. So, things that we think about oftentimes are asking a patient to tuck their chin when they swallow or to thicken their liquids. 

And the reality is that that helps for some people, but it actually makes other people worse. They’re more likely to aspirate. And the only way to know is to have an instrumental assessment of swallowing, so either an endoscopic assessment or a fluoroscopy assessment. And these, again, should be done by a well-trained speech-language pathologist. 

So, to conclude, I think one recommendation that you can give to all of your patients with Alzheimer’s disease to lower the risk of any dysphagia-related medical morbidity is to really encourage high oral care. So, we know that one of the biggest risk predictors of developing something like pneumonia is reduced oral care. So, encouraging your patients to have frequent oral care, specifically brushing their teeth and gums, not just mouthwash, is one way to really reduce that risk.