Swallowing and Alzheimer's: Disorders and Daily Support

Understanding Normal Swallowing and Its Disorders

Before addressing the specific disorders related to Alzheimer's, it is useful to recall how normal swallowing works. It is a complex mechanism that mobilizes more than 30 muscles and 6 pairs of cranial nerves in less than 2 seconds, in perfect coordination.

The 4 Phases of Swallowing

Swallowing occurs in four successive phases:

• Oral preparatory phase: grasping the food, chewing, forming the food bolus with saliva. Conscious and voluntary phase.
• Oral phase: propulsion of the bolus towards the pharynx by the tongue. Conscious and brief phase (less than 1 second).
• Pharyngeal phase: triggering of the swallowing reflex, closure of the larynx to protect the airways, propulsion towards the esophagus. Automatic and very rapid phase.
• Esophageal phase: transport of the bolus to the stomach by the peristaltic contractions of the esophagus. Automatic phase lasting a few seconds.

Any alteration of one or more of these phases causes dysphagia. Depending on the affected phase, the clinical manifestations differ: difficulty forming the bolus (preparatory phase), oral stagnation (oral phase), aspiration (pharyngeal phase), retrosternal blockage (esophageal phase).

Why Does Alzheimer's Disease Affect Swallowing?

Alzheimer's disease affects swallowing through several intertwined mechanisms:

• Cognitive impairment: the person no longer recognizes food, does not know what to do with it, forgets the steps (chewing, swallowing), may "store" food in the mouth.
• Bucco-facial apraxia: alteration of motor programming, difficulties in initiating or coordinating mouth movements.
• Disinhibition: taking bites that are too large, excessive speed, which overloads the swallowing system.
• Decreased alertness: drowsiness, distractibility during meals, which alters the swallowing-breathing coordination.
• Late motor impairment: at an advanced stage, weakness of the oro-facial muscles, reflex slowing, postural difficulties.
• Medication side effects: sedation, hyposalivation, extrapyramidal disorders related to certain treatments.
• Alteration of taste and smell: very early in the disease, modifies food motivation.

This combination means that dysphagia in Alzheimer's is multifactorial. It cannot be reduced to a single cause and therefore requires a comprehensive assessment and management.

Signs of Swallowing Disorders to Recognize

Early detection of dysphagia signs is essential to avoid complications. Several signs, sometimes subtle, should alert those around and caregivers.

Signs During Meals

• Coughing during or just after ingestion: this is the most indicative sign of aspiration. A cough that occurs with every meal, even if mild, is suspicious.
• "Wet" or altered voice after ingestion: a sign that residues are stagnating in the pharynx.
• Choking with brief respiratory arrest, sometimes with transient purplish coloration.
• Absent or ineffective chewing: the person swallows without chewing, keeps food in a ball in the mouth, or pushes it away with the tongue.
• Silent aspiration: food passes into the airways without triggering a cough. Particularly dangerous as it goes undetected. Suspected by unexplained fevers, recurrent respiratory infections.
• Significant drooling or liquid flowing from the mouth during ingestion.
• Food refusal or turning the head away from certain foods.
• Major slowdown of meals: the meal lasts more than 45 minutes, the person becomes exhausted.
• Multiple swallows needed to swallow a single bite.

Signs Outside of Meals

Several signs outside of meals can also indicate dysphagia:

• Unexplained weight loss: 5% of body weight in a few months is suspicious, 10% is concerning.
• Dehydration: dry skin, dry tongue, concentrated urine.
• Recurrent aspiration pneumonia: lung infections, recurrent fevers, chronic cough.
• Increased fatigue during meals, progressive disinterest in the table.
• Persistent vocal changes: hoarse voice, "gurgling" voice.
• Spontaneous dietary restriction: the person restricts themselves to a few "safe" foods.

Why Are These Signs Often Overlooked?

Several reasons explain why these signs often go unnoticed:

• The person themselves, due to their cognitive disorders, does not complain and does not describe their difficulties.
• Silent aspirations do not provoke coughing, thus no visible alert.
• Family caregivers may trivialize occasional episodes ("they choke occasionally").
• In an institution, staff turnover and time pressure may prevent careful observation of meals.
• Complications (pneumonia, malnutrition) are often attributed to the general progression of the disease rather than a specific swallowing disorder.

Hence the importance, for caregivers and healthcare providers, to systematically observe at least one complete meal per week, in silence, without intervening, to spot subtle signs.

Assessment of Swallowing Disorders

When dysphagia is suspected in a person with Alzheimer's disease, a multidisciplinary assessment is essential. It allows quantifying the disorder, identifying the affected phases, and guiding management.

Speech Therapy Assessment of Swallowing

The speech therapist is the key professional in the assessment. Their evaluation generally lasts 1 hour and includes several steps:

• Complete anamnesis: medical history, evolution of disorders, current eating behavior, ongoing medications, respiratory history (recent pneumonia?), current and previous weight.
• Examination of the oral sphere: dental status, prosthetics, oral hygiene, mobility of lips, tongue, soft palate, jaw.
• Evaluation of bucco-facial praxies: ability to imitate simple movements (lips, tongue, cheeks).
• Evaluation of oral sensitivity: tactile and thermal sensitivity test.
• Cognitive relevance assessment: understanding of instructions, level of alertness, ability to cooperate.
• Swallowing test with different textures: gelled water, yogurt, puree, pieces. Observation of phases, reactions, and any clinical aspirations.
• Daniels water test (Water Swallow Test): ingestion of 90 ml of water in sips, looking for signs of aspiration.

The speech therapist often uses the session tracking sheet to trace the evolution of results over time, which is essential in a condition as progressive as Alzheimer's disease.

Complementary Examinations

Depending on the results of the clinical assessment, several complementary examinations may be indicated:

• Radiokinematics of swallowing (or videofluoroscopy): dynamic radiographic examination with contrast agent, allowing visualization of aspirations and identification of the affected phase. Reference examination but requires patient cooperation, which can be difficult in advanced Alzheimer's.
• Fiberoptic endoscopic evaluation of swallowing (FEES): endoscopic examination allowing visualization of the pharynx during ingestion. Better tolerated than radiokinematics in Alzheimer's patients.
• Dietary assessment: precise analysis of nutritional intake, calculation of BMI, search for deficiencies.
• ENT assessment: search for obstruction, vocal cord impairment, local pathology.
• Dental assessment: dental status, adjustment of prosthetics, which strongly influence chewing.
• Standardized geriatric assessment: MNA (Mini Nutritional Assessment), overall functional evaluation.

Daily Support Strategies

Beyond speech therapy (which has its limits in advanced Alzheimer's disease), it is the adaptation of daily life that makes the greatest difference for the safety and comfort of the person.

Meal Environment

The environment directly influences the quality of swallowing. Here are the key principles:

• Calm and silence: avoid television, radio, multiple conversations. The person with Alzheimer's needs their full attention to eat well.
• Good lighting: so that the food is clearly visible and recognizable.
• Simple presentation: few foods at a time on the plate, visual contrast (colored plate, plain mats), no distracting patterns.
• Adapted dishes: plates with edges (to help fill the spoon), ergonomic cutlery if motor skills are impaired, lightweight and opaque glasses.
• Strict sitting position: trunk upright at 90°, feet on the ground, head slightly bent forward. No meals while lying down.
• Reassuring presence of a caregiver: not to feed systematically, but to observe, encourage, and ensure safety.
• Regular schedule: meals at fixed times to establish a predictable rhythm.
• Oral hygiene: before the meal to stimulate salivation, after the meal to remove food residues (important vectors of respiratory infection in case of aspiration).

Texture Adaptation

Texture adaptation is the most effective intervention in dysphagia related to Alzheimer's. Several levels of adaptation exist:

• Normal texture: no adaptation. To be maintained as much as possible to preserve abilities.
• Chopped texture: foods cut into small pieces, easy to chew.
• Mashed texture: foods passed through a mill, consistency of thick applesauce.
• Smooth pureed texture: foods reduced to a homogeneous puree, without pieces.
• Gel texture: foods solidified in the form of flans or gels, without free liquids.

For liquids, adaptation can range from plain water to thickened liquids at various levels (cream, honey, pudding consistency) using thickening powders sold in pharmacies. Gelled water is another option: water solidified in the form of cubes that are easy to swallow.

The speech therapist recommends the most suitable texture after evaluation. This should be maintained, and any modification must be subject to a new professional opinion.

Swallowing Aids and Techniques

Several techniques can be taught to the person (if capable) or applied by the caregiver:

• Small bites: no more than a teaspoon at a time.
• Conscious chewing: "chew well", "take your time".
• Supraglottic swallowing: inhale → hold air → swallow → voluntary cough → breathe. Strengthens the closure of the larynx.
• Effortful swallowing: "swallow hard, as if you were swallowing a big piece." Increases pharyngeal pressure.
• Postural maneuvers: head bent forward for pharyngeal phase disorders, head turned to the affected side for hemiparesis.
• Repeated swallows: each bite followed by 2-3 dry swallows, to clear the pharynx.
• Drink after each bite: if no aspiration with thickened liquids, to aid propulsion.

These techniques are taught by the speech therapist and should be regularly re-evaluated as the disease progresses and abilities change.

Assistance with Eating

At an advanced stage, the person can no longer feed themselves. Assistance with eating becomes necessary and must follow strict rules:

• Feed while sitting facing the person, at eye level. Not standing, not from above.
• Present each spoonful slowly, wait for the previous one to be fully swallowed before the next.
• Check complete swallowing: has the food been properly swallowed? No visible stagnation in the mouth?
• Announce each food: "here's the puree", "now the meat", so the person can anticipate and prepare.
• Respect the pace: no rushing, no pressure. Better a shorter but safe meal than a full meal at risk.
• Constantly monitor posture: do not let the person tilt, slide, or fall asleep.
• Stop if signs of exhaustion or aspiration appear: it is better to complete with an oral nutritional supplement later than to force it.

The Contribution of Digital Tools for Cognitive Stimulation

While swallowing disorders related to Alzheimer's cannot be treated with digital tools, global cognitive stimulation remains a cornerstone of managing the disease. It has proven effective in slowing cognitive decline and preserving autonomy for as long as possible.

The SCARLETT application from DYNSEO is specifically designed for seniors, including those with mild to moderate cognitive disorders. With an adapted interface, progressive games, and supportive guidance, it offers more than 30 exercises targeting memory, language, attention, calculation, and reasoning.

SCARLETT is used in many nursing homes and at home by family caregivers. It does not replace human support or speech therapy, but it provides a valuable complement: maintaining daily cognitive engagement, preventing apathy that often worsens the condition of Alzheimer's patients, creating moments of shared pleasure with caregivers. Regular cognitive stimulation is now considered an essential component of non-pharmacological management of the disease.

Complications to monitor

Untreated swallowing disorders can lead to several serious complications. Knowing them allows for prevention or early detection.

Inhalation pneumonia

This is the most feared complication. The repeated passage of contaminated food or saliva into the airways causes recurrent lung infections, sometimes severe. More than 50% of deaths in advanced stage Alzheimer's patients are related to inhalation pneumonia.

Signs to watch for: unexplained fever, chronic cough, sputum, shortness of breath, loss of appetite, unusual drowsiness. Any respiratory infection in an Alzheimer's patient should primarily raise suspicion of an inhalation cause, rather than a simple "virus".

Malnutrition

Malnutrition is extremely common in advanced Alzheimer's disease. It worsens all other disorders: cognition, motor skills, immune defenses, healing. Monitoring weight trends is essential.

A loss of more than 5% of body weight in 1 month or 10% in 6 months should raise concern. Several strategies can help prevent or correct malnutrition: enriching meals (fats, protein powder), oral nutritional supplements, meal fragmentation, on-demand feeding.

Dehydration

Dehydration is also very common, sometimes related to thickened liquids that are less pleasant and therefore consumed less. It worsens cognitive disorders (acute confusion), increases the risk of infections and thrombosis.

Be sure to regularly offer drinks in various forms: gelled water, soup, compote, water-rich fruits, ice creams. Distributing throughout the day is more effective than a large glass in the morning and evening.

Social isolation

Swallowing disorders have a significant social impact. The person eats differently from others, slowly, sometimes in another room. This food withdrawal exacerbates isolation and can accelerate overall decline.

As much as possible, maintain shared meals, adapting textures and pace to the individual. Sharing the table remains a pillar of social connection, even when the contents of the plate are highly adapted.

Frequently asked questions

To go further

Swallowing disorders related to Alzheimer's disease require a multidisciplinary and personalized approach. Several resources can assist you:

• Tools for caregivers: our free tools, including the session tracking sheet, are valuable for structuring the monitoring of swallowing over time.
• Cognitive stimulation with SCARLETT: to preserve daily cognitive engagement and prevent apathy, SCARLETT offers games adapted for seniors, including in the early and middle stages of Alzheimer's disease.
• Online memory test: to track overall cognitive evolution, our memory test can be conducted periodically (to be used as a complement, never as a standalone diagnostic tool).
• Catalogue of cognitive tests: our free tests cover several cognitive dimensions useful for evaluating an Alzheimer's patient.
• Professional training: for caregivers, speech therapists, geriatricians, our Qualiopi training addresses neurodegenerative disorders and their daily support.
• Associations: France Alzheimer and related associations offer information, support, and listening places for caregiver families.

Supporting a loved one with Alzheimer's disease and swallowing disorders is a daily challenge that requires patience, expertise, and support. Do not hesitate to seek professionals (speech therapist, geriatrician, coordinating nurse, dietitian) who can assist you and adapt strategies as the disease progresses. Remember: every small adjustment (texture, posture, environment) can prevent major complications and preserve quality of life. And every shared meal, even very adapted, remains a precious moment of connection and humanity.