Possible Interventions for Moderate Dysphagia in Clients with Dementia

Interventions used for dysphagia are often broadly separated into two categories – rehabilitation and compensation (Groher and Crary, 2010, Huckabee and Pelletier, 1999). Groher and Crary describe rehabilitation as intervention affecting lasting improvement on the swallowing mechanism, by addressing the specific impairment (p.276). Compensation on the other hand is considered by Groher and Crary (p.276) to be short term interventions that do not cause change to the physiology, but assist improved swallowing. This is how the interventions for clients with dementia will be discussed.

Rehabilitation
There are several rehabilitation strategies that are used to address dysphagia. Some examples are oromotor exercises and effortful swallow techniques. These are used to strengthen the muscles and structures involved in swallowing and in turn strengthen the overall swallow (Groher and Crary, 2010). The client group are those who have moderate to severe dementia and would therefore experience a significant degree of cognitive impairment. Therefore rehabilitation strategies would be inappropriate for this group. Huckabee and Pelletier (1999) point out that many of the rehabilitation strategies,such as those involving exercises, require the clients to follow complex instructions. They are not interventions that another person can assist them with. They also involve a number of movements that must be sequenced in a specific order. The cognitive impairment suffered by those with dementia would make it difficult for rehabilitative interventions to be carried out.

Compensation
Compensation strategies are commonly used in the treatment of dysphagia in dementia. Some compensatory techniques can be carried out with minimal adjustments by the client. Other strategies are more complex and therefore are more difficult for the client with dementia, due to the reduced cognitive ability. Some of the compensatory strategies can be supported by a caregiver and therefore could be employed with clients who have dementia.
The compensatory strategies dicussed are:
- Dietary modifications - discussed on the next page- Other bolus control strategies
- Postural changes
Postural Changes
Several types of postural adjustments are used to compensate for swallowing problems. Two that are commonly used are described below. It is important to consider that postural changes may not be appropriate for clients with dementia for the same reasons that rehabilitation strategies are not appropriate (Groher and Crary, 2003). However most of the instructions that a client is given for this task are simple. It is unlikely that clients with dementia will achieve postural changes on their own. They may be able to do this with support from nursing staff. Huckabee and Pelletier (1999) point out that before postural modifications can be made a client must first be in the normal body and head position for eating. To achieve this position the individual needs to be sitting upright with the head straight. If this is not possible for the client to achieve wither this would need to worked on first or postural changes would not be used.
Raising the Chin This movement widens the oropharynx. It takes advantage of gravity to push the bolus towards the pharynx (Groher and Crary,2010).
Chin- tuck movement This movement helps to protect the airway. It narrows the oropharynx and helps to facilitate laryngeal vestibule closure (Groher and Crary,2010). It can also help to decrease premature spillage as it stops gravity from prematurely pulling bolus into the pharynx (Huckabee and Pelletier 1999)



Other Strategies for controlling the bolus
The benefit of these strategies for clients with dementia is that they are easy to carry out and can be done by the caregiver and with their support.
Lingual or Finger Sweep A client can be cued to clear use their tongue to clear the food from their oral cavity. If the client finds this too difficult, they can use their finger or a caregiver can use a finger to clear the oral cavity (Huckabee and Pelletier 1999). Caregivers need to wear gloves when doing this. Prior to clearing the oral cavity with their finger, the caregiver needs to ensure the client is aware of what they are going to do as they may bite their finger. Unfortunately due to reduced cognition, this may happen despite the explanation.

Careful Placement of Bolus Clients with dementia often experience poor sensation and weak lingual movements (Crary and Groher, 2003). Oral stage dysphagia is common (Groher and Crary, 2010). One of the strategies that can help to compensate is thinking about careful bolus placement in the mouth during feeding. Huckabee and Pelletier (1999) discuss this, saying that the bolus should be placed in the part of the mouth with the strongest movement. They caution however, that this technique should not be used to force-feed noncompliant client as this is not ethical practice. The client could be shown how to do this themselves if able, alternatively a caregiver could be trained to do this for them.