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The relationship between dysphagia and clinical and cognitive aspects in elderly patients presented with dementia

ABSTRACT

Objective:

to relate the risk of dysphagia and aspects of eating behavior to the cognitive aspects of elderly people with dementia.

Methods:

35 elderly patients with Alzheimer or vascular dementia were submitted to clinical and cognitive assessments as well as to a questionnaire for assessing appetite/eating disorder and the Dysphagia Risk Evaluation Protocol (DREP). Appropriate statistical tests were applied adopting a significance level lower than 0.05.

Results:

mild dementia occurred in 16 cases, moderate, in 14, and severe, in 5. Complaints of choking/coughing in the medical history, and signs of dysphagia in the DREP, occurred in 9 and 25 elderly patients, respectively, with no differences regarding the type and severity of dementia. Patients presented with dysphagia and alterations in the oral and pharyngeal phases of DREP, were older. Alterations in the pharyngeal phase were associated with poorer performance in the Mini-Mental State Examination (total score, attention/calculation, language). Changes in appetite/weight/eating habits were associated with signs of dysphagia, increasing severity of dementia and functional impairment.

Conclusion:

choking/coughing and signs of dysphagia were high. Changes in appetite/weight/eating habits were related to the severity of dementia and presence of dysphagia, and cognitive disorders and old age were associated with dysphagia.

Keywords:
Dementia; Deglutition Dosorders; Cognition

Introduction

During the aging process, the elderly may undergo functional and/or structural changes in swallowing, which can lead to difficulty in eating and complications such as malnutrition, dehydration and increased risk of aspiration pneumonia and mortality11. Easterling CS, Robbins E. Dementia and dysphagia. Geriatr Nurs. 2008;29(4):275-85.

2. Ney D, Weiss J, Kind A, Robbins J. Senescent swallowing: impact, strategies and interventions. Nutr Clin Pract. 2009;24(3):395-413.
-33. Oliveira BS, Delgado SE, Brescovici SM. Alterações das funções de mastigação e deglutição no processo de alimentação de idosos institucionalizados. Rev Bras Geriatr Gerontol. 2014;17(3):575-87.. Epidemiological studies describe alterations in swallowing in 13 to 40% of the elderly population11. Easterling CS, Robbins E. Dementia and dysphagia. Geriatr Nurs. 2008;29(4):275-85.,44. Chen PH, Golub JS, Hapner EB, Johns MM. Prevalence of perceived dysphagia and quality-of-life impairment in a geriatric population. Dysphagia. 2009;24(1):1-6.,55. Mourão LF, Xavier DAN, Neri AL, Luchesi KF. Association study between natural chronic diseases of aging and swallowing changes referred by community elderly. Audiol Commun Res. 2016;21:e1657 ..

In elderly people with dementia, the presence of dysphagia is frequent, affecting 28 to 45% of the elderly. It occurs due to difficulties in attention, initiative, planning and execution of everyday activities related to the eating process and it is associated with anatomical and functional alterations in the cortical and subcortical regions related to swallowing and eating66. Horner J, Alberts MJ, Dawson DV, Cook GM. Swallowing in Alzheimer's disease. Alzheimer Dis Assoc Disord. 1994;8(3):177-95.,77. Irles Rocamora JA, Sánchez-Duque MJ, de Valle Galindo PB, Bernal Lopez E, Fernández Palacín A, Almeida González C et al. A prevalence study of dysphagia and intervention with dietary counselling in nursing home from Seville. Nutr Hosp. 2009;24(4):498-503..

The clinical evaluation of swallowing allows the identification of possible causes of dysphagia, assessing the swallowing safety, as well as the risk of aspiration, deciding88. Speyer R. Oropharyngeal dysphagia: screening and assessment. Otolaryngol Clin North Am. 2013;46(6):989-1008.,99. Mancopes R, Gonçalves BFT, Costa CC, Favero TC, Drozdz DRC, Bilheri DFD et al. Correlation between the reason for referral, clinical, and objective assessment of the risk for dysphagia. CoDAS. 2014;26(6):471-5..

From the clinical evaluation, which is a subjective assessment, performed by speech therapist, to follow up oropharyngeal dysphagia, the need for objective instrumental assessment, i.e., nasolaringofibroscopy or swallowing videofluoroscopy1010. Nunes MCA, Jurkiewicz AL, Santos RS, Furkim AM, Massi G, Pinto GSA et al. Correlation between brain injury and dysphagia in adult patients with stroke. Int Arch Otorhinolaryngol. 2012;16 (3):313-21..

Despite the relevance of the theme, there are still gaps in knowledge of aspects of swallowing and the relationship between dysphagia and clinical and cognitive aspects in elderly people with dementia. Studies using the Dysphagia Risk Evaluation Protocol (DREP)1111. Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Protocolo fonoaudiológico de avaliação do risco para disfagia (PARD). Rev Soc Bras Fonoaudiol. 2007;12(3):199-205. are scarce.

The hypothesis of this study is that the progression of alterations in swallowing and eating is related to the greater cognitive impairment in cases of dementia.

Thus, the aim of this study was to assess the risk of dysphagia and aspects of swallowing and eating in the elderly with dementia, and relate them to clinical and cognitive aspects.

Methods

The project was approved by the Human Research Ethics Committee of PUC-Campinas, SP, Brazil (Report no. 1584695 - CAAE 5645081690000548). All participants and/or persons responsible for them signed a free and informed consent form.

This is a cross-sectional, descriptive and exploratory study, with quantitative analysis.

Participants

The study consisted of 35 elderly patients, aged 65 years and older, diagnosed with Alzheimer's disease (AD) and vascular dementia (VD), who sought treatment at the Neurology Clinic of the Hospital PUC-Campinas. Diagnosis of dementia was performed by LCF in accordance with the Diagnostic and Statistical Manual of Mental Disorders1212. McKhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CR, Kawas CH et al. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimer's Dement. 2011;7(3):263-9., the recommendations of the European Federation of Neurological Societies1313. Waldemar G, Dubois B, Emre M, Georges J, McKeith G, Rossor M et al. Recommendations for the diagnosis and management of Alzheimer's disease and other disorders associated with dementia: EFNS guideline. Eur J Neurol. 2007;14;14(1):1-26. and the Brazilian Academy of Neurology1414. Nitrini R, Caramelli P, Bottino CMC, Damasceno BP, Brucki SMD, Anghinah R. Critérios diagnósticos e exames complementares. Recomendações do Departamento de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Arq Neuropsiquiatr. 2005;63(3-A):713-9.. Staging of dementia severity was determined using the Clinical Dementia Rating (CDR)1515. Morris JC. The clinical dementia rating (CDR): current version and scoring rules. Neurology. 1993;43(11):2412-4.,1616. Maia ALG, Godinho C, Ferreira ED, Almeida V, Schuh A, Kaye J et al. Application of the Brazilian version of the CDR scale in samples of dementia patients. Arq Neuropsiquiatr. 2006;64(2-B):485-9..

The elderly were recruited during their routine medical consultation at the neurology outpatient clinic and invited to participate in the study. Patients who were unable to take liquids and food by mouth, according to the caregiver or responsible, as well as those who refused to participate, presented with other serious diseases, or were unable to respond to the instruments of cognitive assessment were excluded.

Procedures

For clinical and cognitive assessment:

  • Interview with the patient and caregiver to collect sociodemographic data (age, gender and level of education);

  • Neurological and cognitive assessments: Data from exams were collected from the hospital records and the following cognitive battery tests were applied: Mini-Mental State Examination (MMSE)1717. Folstein MF, Folstein SE, Mchugyh PR. "Mini-Mental State": A pratical method for grading the cognitive state of patients for the clinician. J. Psychiat Res. 1975;31(5):219-24.,1818. Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Suggestions for utilization of the mini-mental state examination in Brazil. Arq Neuropsiquiatr. 2003;61(3-B):777-81. and Category fluency test (animals in one minute) (VF animals)1414. Nitrini R, Caramelli P, Bottino CMC, Damasceno BP, Brucki SMD, Anghinah R. Critérios diagnósticos e exames complementares. Recomendações do Departamento de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia. Arq Neuropsiquiatr. 2005;63(3-A):713-9., CDR1515. Morris JC. The clinical dementia rating (CDR): current version and scoring rules. Neurology. 1993;43(11):2412-4.,1616. Maia ALG, Godinho C, Ferreira ED, Almeida V, Schuh A, Kaye J et al. Application of the Brazilian version of the CDR scale in samples of dementia patients. Arq Neuropsiquiatr. 2006;64(2-B):485-9.;

  • Pfeffer Functional Activities Questionnaire (FAQ)1919. Pfeffer RI, Kurosaki TT, Harrah CH Jr, Chance JM, Filos S. Measurement of functional activities in older adults in the community. J Gerontol. 1982;37(3):323-9.,2020. Sanchez MAS, Correa PCR, Lourenço RA. Cross-cultural Adaptation of the "Functional Activities Questionnaire - FAQ" for use in Brazil. Dement Neuropsychol. 2011;5(4):322-7.: it is a 10-item instrument that assesses the functional autonomy of patients in everyday life activities. The score ranges from 0 (normal) to 30 (dependent); the higher the score, the greater the functional dependence of the patient. The caregiver answered the questionnaire;

  • Neuropsychiatric Inventory-Clinician Rating (NPI-C)2121. de Medeiros K, Robert P, Gauthier S, Stella F, Politis A, Leoutsakos J et al. and the NPI-C Research Group. 2010. The Neuropsychiatric Inventory-Clinician rating scale (NPI-C): reliability and validity of a revised assessment of neuropsychiatric symptoms in dementia. Int Psychogeriatr. 2010;22(6):984-94.,2222. Stella F, Forlenza OV, Laks J, Andrade LP, Avendaño MAL, Se EVG et al. The Brazilian version of the Neuropsychiatric Inventory-Clinician Rating (NPI-C): Reliability and validity in dementia. Int Psychogeriatr. 2013;25(9):1503-11.: Questions soleley regarding appetite and eating disorders over the last four weeks were used. a) Has the patient lost appetite? b) Did the patient present an increase in appetite?; c) Did the patient lose weight? d) Did the patient gain weight?; e) Did the patient present changes in eating behavior, such as quantity per mouthful?; f) Did the patient change preference for types of food, such as wanting to eat too much candy or other specific types of food?; g) Did the patient present changes in eating behavior such as wanting to eat exactly the same foods?; h) The patient eats or drinks inappropriate substances or non-food products; i) Does the patient frequently ask for food and/or beverage even if he or she has just eaten? Data were tabulated with "yes" or "no" answers. The inventory was answered by the caregiver.

For dysphagia assessment:

  • Interview conducted with the patient and the caregiver to collect data on clinical aspects related to the presence of complaints of choking and/or coughing, speech disorders, dyspnea and episodes of recurrent pneumonia;

  • Prior to the application of the protocol, the examiners confirmed if the elderly understood that they should swallow saliva and the presence of cough reflex.

  • Dysphagia Risk Evaluation Protocol (DREP)1111. Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Protocolo fonoaudiológico de avaliação do risco para disfagia (PARD). Rev Soc Bras Fonoaudiol. 2007;12(3):199-205.: One of the objectives of the Dysphagia Risk Evaluation Protocol (DREP) is to identify and characterize clinical signs, as well as the severity of dysphagia1111. Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Protocolo fonoaudiológico de avaliação do risco para disfagia (PARD). Rev Soc Bras Fonoaudiol. 2007;12(3):199-205. . The protocol consists of: a) water swallowing test (11 items); b) swallowing test of pasty food (12 items). In this study, the phases of oral and pharyngeal deglutition were considered. For the oral phase, the following items were considered: anterior oral escape, oral transit time, swallowing quantity and residues in oral cavity. In the pharyngeal phase the following items were considered: laryngeal elevation, nasal reflux, coughing, choking, vocal quality, cervical auscultation, oxygen saturation, and other vital signs (cyanosis and bronchospasm). To ensure patient safety the protocol was initiated by introducing pasty food and then liquid. For the pasty food swallowing test, a 10 milliliter (ml) syringe was used to administer the pasty food in increments of 3 ml, 5 ml and 10 ml. After the fraction of the pasty food, it was placed on a dessert spoon and the patient was instructed to ingest the food from the spoon and swallow. For the water swallowing test, 1 to 5 ml of water was gradually delivered in a syringe and the elderly were instructed to suck water from the syringe while the examiner pushed the plunger gently. The following equipment was used for the protocol: stethoscope, pulse oximeter and vital signs monitoring equipment, 15 ml of water, 54 ml of fine pasty food (thickened with instant food thickener), 5 ml and 10 ml syringes, and a dessert spoon. In this study, the cases were classified as with or without dysphagia.

Statistical Analysis

The occurrence and risk of dysphagia (clinical history and DREP data), aspects of swallowing and diet, were evaluated in elderly with AD and VD. Dysphagia data were related to clinical, functional, cognitive, behavioral aspects, the presence of neuropsychiatric symptoms and the severity of dementia using statistical tests appropriate to each situation.

Quantitative variables were expressed as means and standard deviations (SD) and qualitative variables were expressed as frequency and percentage values (%). Two-tailed Student’s t-test was applied to compare continuous variables, while Fisher’s exact test or Pearson’s chi-squared test were used to compare qualitative data and frequencies of occurrence. The verification of possible associations among the quantitative variables was estimated using the Pearson correlation coefficient.

The data were treated by the software IBM SPSS Statistics, version 22. The significance level was set at p<0.05.

Results

A total of 35 elderly patients were included, of which 24 patients (68.6%) with AD and 11 (31.4%) elderly with VD. The sociodemographic, clinical and cognitive data, the degree of severity of dementia, the total CDR and FAQ scores, and the presence of choking and/or coughing complaints in the medical history, according to the type of dementia, are shown in Table 1.

When the severity of dementia was evaluated, a higher occurrence of mild dementia was observed in the elderly with VD and moderate dementia in the AD group. Age was significantly higher in the AD group when compared with the age of the elderly with VD (Table 1).

Table 1:
Sociodemographic, clinical and cognitive aspects and the occurrence of complaints of coughing or choking, according to the type of dementia

The presence of choking and/or coughing in the medical history occurred in nine (25.7%) cases. There was no significant difference in the occurrence of choking and/or coughing according to the type of dementia, age and performance in the cognitive assessment.

Swallowing: Clinical Data and DREP

The DREP revealed dysphagia in 25 (71.4%) elderly, 21 in the oral phase and 22 in the pharyngeal phase. There was no significant difference in the occurrence of changes in DREP, according to the type of dementia. The elderly with greater severity of dementia in the CDR presented a significantly longer oral transit time with water, higher laryngeal elevation with water and pasty food, changes in cervical auscultation with water and alteration in oxygen saturation with pasty foods (Table 2).

The elderly who had complained of choking and/or coughing in the medical history presented significant changes in the pharyngeal phase - vocal quality (water) (n = 7 vs 2, Fisher's exact test, p = 0.022).

Presence of dysphagia and changes in the oral and pharyngeal phases of DREP was significantly more frequent in older individuals (Table 2).

Table 2:
Changes in the Dysphagia Risk Evaluation Protocol, according to type and severity of dementia

Signs suggestive of dysphagia were significantly associated with changes in the oral and pharyngeal phases in the DREP (Table 3).

DREP data (presence of dysphagia and results of oral and pharyngeal phases) according to cognitive and functional sociodemographic aspects are shown in Table 3.

The elderly with signs of dysphagia and alterations in the oral and pharyngeal phases of DREP were older when compared with those without alterations. There was no significant difference in the occurrence of dysphagia in the DREP, according to gender, disease duration, VF animals scores and FAQ.

Lower cognitive performance in MMSE was significantly more frequent in the elderly with pharyngeal phase change in DREP (Table 3).

Table 3:
Dysphagia Risk Evaluation Protocol results, according to sociodemographic, cognitive and behavioral aspects

The cognitive performance data according to the presence of change in DREP are shown in Table 4.

Table 4:
Cognitive performance, according to the presence of changes in the Dysphagia Risk Evaluation Protocol

The elderly who presented pharyngeal changes in ‘other vital signs’ (cyanosis and bronchospasm) with water and pasty food presented significantly higher scores in the FAQ (presence of functional impairment) (n = 33 x 2, 22.5 (± 6.7) x 29.0 (± 1.4 ), t-test, p = 0.007).

Appetite and Eating Disorders

Table 5 shows the data regarding the occurrence of appetite and eating disorders in the NPI-C, according to the CDR, presence of signs suggestive of dysphagia, presence of alterations in the oral and pharyngeal phases in the DREP and scores in the FAQ.

Table 5:
Questions on appetite and eating disorders of the Neuropsychiatric Inventory-Clinician Rating, according to the Clinical Dementia Rating, signs of dysphagia and oral and pharyngeal phases, in the Dysphagia Risk Evaluation Protocol and Functional Activities Questionnaire

Food/drink requests even after being recently fed was more significant in the elderly with severe dementia when compared with the elderly with mild or moderate dementia in the CDR.

Changes in appetite, weight or eating habits were observed in the elderly with signs of dysphagia in DREP, alteration in the pharyngeal phase of DREP, and in those with greater severity of dementia in the CDR.

Higher scores on the FAQ (presence of functional impairment) were associated with changes in appetite, weight or eating habits, and food/drink requests even after being fed in the NPI-C.

There was no significant difference in the occurrence of appetite disorders and food preference, according to the type of dementia.

Discussion

This study assessed the eating and swallowing aspects in 35 consecutive elderly patients diagnosed with dementia (AD and VD), using the DREP and significant relationships between the impairment of eating and swallowing aspects with clinical and cognitive aspects were observed.

Complaints of choking and/or coughing in the medical history was observed in a quarter of the cases, but there was no relation with age, disease duration, severity and type of dementia. In a study with elderly in the community of the city of Campinas, SP, changes in swallowing were observed in 35.9% of the cases55. Mourão LF, Xavier DAN, Neri AL, Luchesi KF. Association study between natural chronic diseases of aging and swallowing changes referred by community elderly. Audiol Commun Res. 2016;21:e1657 .. The presence of choking and/or coughing with solid and liquid foods and difficulty in swallowing tablets are reported by caregivers of elderly patients with dementia33. Oliveira BS, Delgado SE, Brescovici SM. Alterações das funções de mastigação e deglutição no processo de alimentação de idosos institucionalizados. Rev Bras Geriatr Gerontol. 2014;17(3):575-87.,2222. Stella F, Forlenza OV, Laks J, Andrade LP, Avendaño MAL, Se EVG et al. The Brazilian version of the Neuropsychiatric Inventory-Clinician Rating (NPI-C): Reliability and validity in dementia. Int Psychogeriatr. 2013;25(9):1503-11.,2323. Tavares TE, Carvalho CMRG. Características de mastigação e deglutição na doença de Alzheimer. Rev. CEFAC. 2012;14(1):122-37..

Swallowing: DREP

Signs suggestive of aspiration were elevated in the DREP in our sample. Dysphagia is a common symptom in dementia, ranging in accordance with the type, and it is more frequent in institutionalized elderly individuals11. Easterling CS, Robbins E. Dementia and dysphagia. Geriatr Nurs. 2008;29(4):275-85.,2323. Tavares TE, Carvalho CMRG. Características de mastigação e deglutição na doença de Alzheimer. Rev. CEFAC. 2012;14(1):122-37.,2424. Lima RMF, Amaral AKFJ, Aroucha EBL, Vasconcelos TMJ, Silva HJ, Cunha DA. Adaptações na mastigação, deglutição e fonoarticulação em idosos de instituição de longa permanência. Rev. CEFAC. 2009;11(supl.3):405-22.. Studies have described different values and patterns of disorders in the oral and pharyngeal phases of swallowing, which were probably related to the population studied and the screening methods used55. Mourão LF, Xavier DAN, Neri AL, Luchesi KF. Association study between natural chronic diseases of aging and swallowing changes referred by community elderly. Audiol Commun Res. 2016;21:e1657 .,77. Irles Rocamora JA, Sánchez-Duque MJ, de Valle Galindo PB, Bernal Lopez E, Fernández Palacín A, Almeida González C et al. A prevalence study of dysphagia and intervention with dietary counselling in nursing home from Seville. Nutr Hosp. 2009;24(4):498-503.,2525. Bomfim FMS, Chiari BM, Roque FP. Factors associated to suggestive signs of oropharyngeal dysphagia in institutionalized elderly women. CoDAS. 2013;25(2):154-63.. However, it is known that the clinical evaluation associated with videofluoroscopy presents greater sensitivity in the diagnosis of mild forms of dysphagia, in the assessment of the risk of tracheal aspiration and, thus, defining the prognosis and the therapeutic planning2626. Barbiera F, Condello S, de Palo A, To Daro D, Mandracchia C, de Cicco D. Role of videofluorography swallow study in management of dysphagia in neurologically compromised patients. Radiol Med. 2006;111(6):818-27.,2727. Schelp AO, Cola PC, Gatto AR, Silva RG, Carvalho LR. Incidence of oropharyngeal dysphagia associated with stroke in a regional hospital in São Paulo State - Brazil. Arq Neuropsiquiatr. 2004;62(2B):503-6..

Dysphagia occurred significantly in older patients, suggesting that vulnerability to dysphagia is associated with changes related to age and clinical aspects of dementia11. Easterling CS, Robbins E. Dementia and dysphagia. Geriatr Nurs. 2008;29(4):275-85.,44. Chen PH, Golub JS, Hapner EB, Johns MM. Prevalence of perceived dysphagia and quality-of-life impairment in a geriatric population. Dysphagia. 2009;24(1):1-6.,2323. Tavares TE, Carvalho CMRG. Características de mastigação e deglutição na doença de Alzheimer. Rev. CEFAC. 2012;14(1):122-37.,2525. Bomfim FMS, Chiari BM, Roque FP. Factors associated to suggestive signs of oropharyngeal dysphagia in institutionalized elderly women. CoDAS. 2013;25(2):154-63.,2828. Suh M, Kim H, Na DL. Dysphagia im patients with dementia: Alzheimer versus vascular. Alzheimer Dis Assoc Disord. 2009;23(2):178-84..

Dysphagia was observed in the elderly with mild, moderate or severe dementia, but in our sample it occurred in all cases with severe dementia. Studies have suggested that changes in swallowing in the oral and pharyngeal phases may be present since the onset of the symptomatology of dementia2222. Stella F, Forlenza OV, Laks J, Andrade LP, Avendaño MAL, Se EVG et al. The Brazilian version of the Neuropsychiatric Inventory-Clinician Rating (NPI-C): Reliability and validity in dementia. Int Psychogeriatr. 2013;25(9):1503-11.,2929. Seth R. Weight loss in Alzheimer' disease. In J Geriatr Psychiatry. 1994;9(8):605-20. and the progression of disorders is associated with an aggravation of disease severity and health impairment of the elderly2929. Seth R. Weight loss in Alzheimer' disease. In J Geriatr Psychiatry. 1994;9(8):605-20.,3030. Sato E, Hirano H, Watanabe Y, Edahiro A, Sato K, Yamane G et al. Detecting signs of dysphagia in patients with Alzheimer's disease with oral feeding in daily life. Geriatr Gerontol In. 2014;14(3):549-55..

There was an association between dementia severity and longer oral transit time with water, higher laryngeal elevation with water and pasty foods, changes in cervical auscultation with water and alteration in oxygen saturation with pasty foods. It is well known that individuals are able to compensate for swallowing changes by swallowing slowlier and increase the number of swallowings of pasty food and liquids for complete swallowing33. Oliveira BS, Delgado SE, Brescovici SM. Alterações das funções de mastigação e deglutição no processo de alimentação de idosos institucionalizados. Rev Bras Geriatr Gerontol. 2014;17(3):575-87.,2525. Bomfim FMS, Chiari BM, Roque FP. Factors associated to suggestive signs of oropharyngeal dysphagia in institutionalized elderly women. CoDAS. 2013;25(2):154-63.,2828. Suh M, Kim H, Na DL. Dysphagia im patients with dementia: Alzheimer versus vascular. Alzheimer Dis Assoc Disord. 2009;23(2):178-84..

Similar to the literature, the signs of aspiration were more frequent with water than with pasty food3030. Sato E, Hirano H, Watanabe Y, Edahiro A, Sato K, Yamane G et al. Detecting signs of dysphagia in patients with Alzheimer's disease with oral feeding in daily life. Geriatr Gerontol In. 2014;14(3):549-55.,3131. Rosler A, Pfeil S, Lesssmann H, Hoder J, Befahr A, von Renteln-Kruse W. Dysphagia in dementia: influence of dementia severity and food texture on the prevalence of aspiration and latency to swallow in hospitalized geriatric patients. JMADA. 2015;16(8):697-701..

Greater severity of dementia, presence of signs of dysphagia in DREP, and alteration in the pharyngeal phase of DREP are associated with complaints of changes in appetite, weight or eating habits, suggesting that the worsening of dementia predisposes to eating disorders and swallowing2929. Seth R. Weight loss in Alzheimer' disease. In J Geriatr Psychiatry. 1994;9(8):605-20.

30. Sato E, Hirano H, Watanabe Y, Edahiro A, Sato K, Yamane G et al. Detecting signs of dysphagia in patients with Alzheimer's disease with oral feeding in daily life. Geriatr Gerontol In. 2014;14(3):549-55.
-3131. Rosler A, Pfeil S, Lesssmann H, Hoder J, Befahr A, von Renteln-Kruse W. Dysphagia in dementia: influence of dementia severity and food texture on the prevalence of aspiration and latency to swallow in hospitalized geriatric patients. JMADA. 2015;16(8):697-701..

Swallowing and Cognitive Aspects

The worst cognitive performance in screening tests of memory, language, praxis, orientation, attention, and executive functions was related to several aspects of swallowing, suggesting that there is a complex and reciprocal relationship between impairment of cognitive performance and swallowing disorders in dementia.

Studies have described that the cognitive deficits found in AD may lead to the interruption of the necessary and preparatory actions for swallowing11. Easterling CS, Robbins E. Dementia and dysphagia. Geriatr Nurs. 2008;29(4):275-85.,66. Horner J, Alberts MJ, Dawson DV, Cook GM. Swallowing in Alzheimer's disease. Alzheimer Dis Assoc Disord. 1994;8(3):177-95.. Differently, other authors did not find any association between cognitive alteration and signs suggestive of dysphagia when evaluating institutionalized elderly women using the DREP3232. Guerin O, Andrieu S, Schneider SM, Milano M, Boulahahssass R, Brocher P. Different models of weight loss in Alzheimer disease: a prospective study of 395 patients. Am J Clin Nutr. 2005;82(2):435-41..

Appetite and Eating Aspects

Complaints of changes in appetite, weight or eating habits, and the request for food and/or drink even though having previously been fed have been observed in a great number of cases. It is known that several factors may be involved in the pathophysiology of weight reduction in the elderly with dementia, such as increased energy needs, absorption disorders, nutritional inadequacies, and low food intake2727. Schelp AO, Cola PC, Gatto AR, Silva RG, Carvalho LR. Incidence of oropharyngeal dysphagia associated with stroke in a regional hospital in São Paulo State - Brazil. Arq Neuropsiquiatr. 2004;62(2B):503-6.,3030. Sato E, Hirano H, Watanabe Y, Edahiro A, Sato K, Yamane G et al. Detecting signs of dysphagia in patients with Alzheimer's disease with oral feeding in daily life. Geriatr Gerontol In. 2014;14(3):549-55.. Authors have described a high risk of malnutrition and loss of muscular reserve in anthropometric measurements, progressive impairment of nutritional variables associated with the evolution of the disease, and progressive impairment of cognitive aspects in patients with AD3333. Santos TBN, Tedrus GMAS, Fonseca LC, Bernardi JLD. Alzheimer's disease: nutritional status and cognitive aspects associated with disease severity. Nutr Hosp. 2018;35(6):1298-304..

No differences were observed in the occurrence of eating alterations according to the type of dementia. Differently, other studies have described that changes in appetite are more prevalent in AD when compared with VD2828. Suh M, Kim H, Na DL. Dysphagia im patients with dementia: Alzheimer versus vascular. Alzheimer Dis Assoc Disord. 2009;23(2):178-84..

Eating disorders were associated with greater functional impairment, dementia severity, and occurrence of dysphagia, which may be associated with self-neglect, forgetting to eat, changes in smell and taste, loss of cognitive abilities, or loss of appetite44. Chen PH, Golub JS, Hapner EB, Johns MM. Prevalence of perceived dysphagia and quality-of-life impairment in a geriatric population. Dysphagia. 2009;24(1):1-6.,2828. Suh M, Kim H, Na DL. Dysphagia im patients with dementia: Alzheimer versus vascular. Alzheimer Dis Assoc Disord. 2009;23(2):178-84.,3030. Sato E, Hirano H, Watanabe Y, Edahiro A, Sato K, Yamane G et al. Detecting signs of dysphagia in patients with Alzheimer's disease with oral feeding in daily life. Geriatr Gerontol In. 2014;14(3):549-55.,3232. Guerin O, Andrieu S, Schneider SM, Milano M, Boulahahssass R, Brocher P. Different models of weight loss in Alzheimer disease: a prospective study of 395 patients. Am J Clin Nutr. 2005;82(2):435-41.. However, there is still no consensus on the pathophysiological mechanisms involved in eating disorders and swallowing, which points to the importance of nutritional care in the elderly with dementia.

Study Limitations

This study has some limitations. It is a study performed in a university hospital, but it is not a tertiary public health care center in Brazil. This study is cross-sectional, with a relatively small sample of cases, and the cases were not divided equally between the types of dementias. For dysphagia assessment, the clinical aspects of the complaint and DREP data were used, and objective complementary exams (videofluoroscopy, among others) were not used. However, objective and relevant data were obtained. Studies with larger samples are required to assess the impact of the findings of this study.

Conclusion

Complaints of choking and/or coughing in the medical history and the presence of signs of dysphagia in the DREP were high in our cohort. Changes in appetite/weight/eating habits were associated with dementia severity. Complaints of choking and/or coughing occurred at all ages and correlated with suggestive signs of dysphagia. Cognitive disturbances and old age were associated with the presence of altered swallowing function.

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Publication Dates

  • Publication in this collection
    08 May 2020
  • Date of issue
    2020

History

  • Received
    24 May 2019
  • Accepted
    17 Apr 2020
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