How to recognize a swallowing problem in someone with dementia

Diane Atwood's mother, has swallowing problemMy mother had a couple of choking episodes recently. I wasn’t alarmed because she’s had swallowing issues in the past. At least twice over the years, she had a procedure that stretched her esophagus because of a stricture or narrowing.

She learned to avoid certain foods or cut them up into small pieces. She would also eat slowly. If food felt stuck in her throat, she knew not to panic. Remaining calm usually relaxed her esophagus and after a minute or so, she’d be fine.

But now she has Alzheimer’s and doesn’t even remember that she had a swallowing problem. On top of that, difficulty swallowing — it’s called dysphagia — is common in people with moderate to severe Alzheimer’s and other dementias. My mother is in the moderate stage. She’s quite aware of what’s going on in the present moment. She may not remember that moment when it’s over, but she can usually tell you if something is wrong.

Signs of a swallowing problem

Many people with dementia can’t communicate well at all. Someone with advanced dementia may end up aspirating food into their lungs without any symptoms of swallowing difficulties. That’s why it’s important to be aware of subtle signs.

  • Coughing during or after eating
  • Constantly clearing the throat
  • Grimace or painful expression when eating
  • Holding food to the side of the mouth
  • Spitting out food
  • Drooling when eating
  • Eating too fast or cramming food into the mouth
  • Unexpected weight loss
  • Change in voice (wet or gurgly, hoarse)
  • Touching the upper chest or throat when eating
  • Taking longer to eat
  • Sorting or playing with food
  • Chewing over and over but not  swallowing
  • Watery eyes
  • Runny nose

Possible causes

There are plenty of things that can make it hard for a person with or without dementia to swallow. Poor-fitting dentures, for instance. When they’re loose, they can rub against your gums or the inside of your mouth and cause an ulcer. Scan this list for other possible causes.

  • Sore mouth or bleeding gums
  • Medications that make the mouth dry
  • Infection of any kind (including a urinary tract infection) that can take away the appetite or add to dementia symptoms
  • Dementia
  • Neurological disorders such as Parkinson’s or a stroke

Phases of swallowing

There are three phases of swallowing.  A breakdown in any one or more of them results in dysphagia.

  1. Oral phase Food is chewed, formed into a ball and moved from the mouth to the back of the throat (pharynx). A person with dementia may have trouble recognizing food in the mouth and may not remember how to swallow. Or he/she may be confused about the order of things. You may notice the person holding food in the mouth without swallowing. It’s called “pocketing.”
  2. Pharyngeal phase Food is moved from the pharynx to the esophagus. The voicebox (larynx) moves up and forward to protect the airway (trachea). A sphincter opens up the esophagus and muscles in the throat tighten to move food down into the esophagus. If the muscles are weak, there’s a risk of food or liquid getting into the airway. When it happens, the person may cough or his/her voice may change in quality.
  3. Esophageal phase Food enters the esophagus, which tightens to “squeeze” the food down toward the stomach. Pressure from the food or liquid causes a sphincter at the bottom of the esophagus to relax and open so food can enter the stomach. Difficulty swallowing happens with the food doesn’t move through the esophagus as it should. The esophagus can tighten up and/or the person may spit up or vomit. A person may complain of something sticking in the chest or throat.

Aspiration and silent aspiration

A person with dysphagia may aspirate — food ends up in the lungs instead of going down the esophagus. Signs of aspiration include:

  • Coughing
  • Sneezing
  • Watery eyes
  • Runny nose
  • Change in voice
  • Change in breathing pattern (shortness of breath)

When food or liquid gets into the lungs and there are no symptoms, it’s called silent aspiration.

Making a diagnosis

Knowing which swallowing phase isn’t working properly is important because it will help determine the course of treatment, says Brianne Metcalf, a speech-language pathologist at Coastal Rehab.

“For example,” says Brianne, “if somebody is experiencing increased difficulty recognizing food and chews over and over taking longer to eat we would treat that very differently than somebody who is aspirating liquids or solids because they have weak throat/pharyngeal muscles.”

Sometimes it’s easy to figure out why someone has difficulty swallowing. Other times, diagnostic tests are necessary. Mostly because of her previous history, my mother’s doctor ordered a barium swallow to make sure her esophagus didn’t have another stricture. She had to drink a white chalky liquid while the radiologist watched on x-ray to see what was going on.

“It assesses the esophageal phase of swallowing and determines the presence of strictures, diverticulum, reflux, dysmotility and Hiatal hernias,” says Brianne.

My mother had no signs of a stricture or a hernia but her esophagus didn’t push the barium through as well as it should.

If someone shows signs of food/liquid going down the wrong way, Brianne says a speech-language pathologist or the patient’s doctor will order a modified barium swallow study.

“This is an objective test that is a moving x-ray of somebody swallowing different food textures,” she explains. “It shows us what is happening in the mouth, throat and the esophagus. For example, it can reveal if somebody is silently aspirating and the reason for silent aspiration (e.g., the larynx may not elevate enough or move forward enough.)”

Normal barium swallow animation
If you’d like to see what the radiologist sees on a barium swallow, I found this example on Wikimedia Commons. I thought it was pretty cool. It’s by Normaler_Schluck-00.jpg (and others): Hellerhoffderivative work: Anka Friedrich [CC BY-SA 3.0], via Wikimedia Commons.

Seeing a speech pathologist

My mother’s doctor referred her to a speech-language pathologist for a swallowing evaluation. Why a speech-language pathologist? “The muscles that are responsible for speech and voice production are also responsible for swallowing,” she says. “We’re highly trained in the area of anatomy and physiology for these muscles.”

Treatments for swallowing problems

Brianne says these are the more common treatments for swallowing difficulties.

  • Modify food textures and liquid consistency to increase airway protection or promote improved intake
  • Train caregivers on ways to modify the environment and presentation of food to promote improved intake/recognition of food/liquid
  • Strengthen muscles (use specific exercises to target the weak muscles)
  • Develop strategy training to compensate for problems (alternate solids and liquids, chin tuck, smaller bites, slower rate)
  • Try Neuromuscular Electrical Stimulation (NMES) to improve muscle strength

Dysphagia is common in people with Alzheimer’s and other dementias. Brianne says about 30 percent of her current patients have dementia and dysphagia. As she works with each one of them, including my mother, she tries to help them improve or maintain their quality of life. 

She’s also trying to reduce their risk of becoming malnourished and/or dehydrated or developing aspiration pneumonia. These are serious complications that can happen because someone can’t swallow properly. That’s why it’s so important to pay attention and to take action. 


Diane Atwood

About Diane Atwood

For more than 20 years, Diane was the health reporter on WCSH 6. Before that, a radiation therapist at Maine Medical Center and after, Manager of Marketing/PR at Mercy Hospital. She now hosts and produces the Catching Health podcast and writes the award-winning blog Catching Health with Diane Atwood.