Dysphagia in Stroke, Neurodegenerative Disease, and Advanced Dementia

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Key points

  • Stroke, neurodegenerative disease, and dementia are disorders that have a high incidence of dysphagia.

  • There are similarities and differences, but common themes associated with an aging population prevail.

  • Aspiration risk varies with the severity of disease and is a challenge to rehabilitate based on presbypharynges, cognitive status, and level of nutrition.

  • It is important to screen for dysphagia in these high-risk groups and to assess aspiration risk early in order to maintain nutrition with

Dysphagia in stroke

Dysphagia is a frequently under-recognized complication of acute stroke, despite its prevalence of up to 78%.1 It adversely affects outcomes as determined by length of hospitalization, and also increases the risk of mortality.2, 3, 4, 5 It is most prevalent in the acute phase, with about half of patients recovering spontaneously (or dying) in the first week.2 The severity of dysphagia relates to the degree of pharyngeal representation in the unaffected cerebral hemisphere, with the most severe

Neurodegenerative disease

Neurodegenerative diseases are among the most important and most common causes of dysphagia in patients seen by neurologists. Muscular dystrophy is a prototypical example of a peripheral degenerative disease affecting muscle that causes dysphagia in the advanced stages of illness. MG is an autoimmune neuromuscular disease, degenerative in the sense that there is increasing damage to the neuromuscular junction over time. Dysphagia may be prominent in some patients with myasthenia, and all

Advanced dementia

In 2001 there were 24.3 million people in the world with dementia, whereas in 2040 the number is estimated to increase to more than 81 million. The prevalence of dementia is estimated to double every 5 years after 65 years of age, and at age 85 years the prevalence is approximately 50%.29 Dementia is a leading cause of death in the United States, with mortality affected by aspiration, hydration, and nutritional status. Data in the year 2000 show approximately 4.5 million people in North America

Sentinel indicators of decline with dysphagia and aspiration risk

Depending on the level of monitoring, advancing disease in combination with the aging process frequently leads to an aspiration event that requires hospitalization, and reassessment of swallowing function at that time shows the aspiration. The treatment team is then faced with the dilemma of supplying the patient’s nutritional needs in the presence of the aspiration risk, and often recommends NPO status, along with placement of a PEG. However, PEG tube placement has not been shown to eliminate

Screening and management protocol for high-risk patients

The development of screening protocols for dysphagia is a key step in early identification of the patient at high risk for aspiration and the consequences of dysphagia, such as malnutrition and dehydration. High-risk patients should be considered following stroke, with neurodegenerative disease, late stages of dementia, advanced age, and certain other medical and surgical conditions.3 Such protocols not only reduce the complication rates of stroke but they are also designed to reduce the

Therapeutic interventions and neuroplasticity

Treatment options for those with neurodegenerative dysphagia include:

  • 1.

    Compensations (diet/liquid consistency alterations, compensatory maneuvers, supplemental/alternative routes for intake)

  • 2.

    Exercises to regain muscle coordination/strength

  • 3.

    Treatments that may more directly stimulate neuroplastic changes in the swallow mechanism

Compensations and exercises are discussed more fully elsewhere in this issue by Murry and colleagues. Although compensatory measures have some efficacy in improving the safe

Treatment options for global laryngeal dysfunction

In patients with acute stroke and those with advanced-stage neurodegenerative disease, the resulting global laryngeal dysfunction can result in major morbidity and mortality. Although a significant proportion of patients who have had strokes recover from their dysphagia within a week, approximately 50% of dysphagic patients are left with swallowing deficits.2

Following early risk stratification, those patients with significant penetration or aspiration should be made NPO and provided with

Summary

Stroke, neurodegenerative disease, and advanced dementia are all characterized by the prominent role of dysphagia. The nature of the baseline diseases both causes the dysphagia and makes the patients more prone to the consequences. Early recognition through a systematic approach helps avoid aspiration, maintains nutrition, and seeks to preserve quality of life.

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