A.  GENERAL CONSIDERATIONS WHEN FEEDING  DIFFICULTIES ARISE:

1. Investigate possible physical causes of feeding problems such as teeth, gums, dentures, digestion, and medication (which can affect appetite or cause dry mouth).
2. During mealtime, noise and distractions should be minimized to help the patient focus on the task of eating.
3. Table settings should be as simple as possible.  Replace forks, plates, and glasses with spoons, bowls, cups with handles, or other adaptive and assistive devices.  The occupational therapist may be consulted for these issues.
4. Serving one food at a time may reduce frustration and confusion experienced by Alzheimer’s patients when they are faced with too many foods served at once.
5. If patients can no longer use utensils, finger foods may be served, or they may have to be fed by a caregiver.

B. SENSORY-MOTOR INTEGRATION PROCEDURES (for patients with apraxia of swallow, tactile agnosia for food, delayed onset of the
oral swallow, and reduced oral sensation):

The following techniques are used to heighten sensory awareness before the swallow attempt.  They are  considered compensatory when used with Alzheimer’s patients, and should be used as part of a maintenance program by the caregiver or the patient.

• present sour bolus. (ex. 50% lemon juice:50% barium)
• present cold bolus or textured bolus.
• Present bolus requiring chewing.
• Present a larger volume bolus (3 mL or more).

• Rubbing faucial arches with a size 00 laryngeal mirror, which has been submerged in crushed ice.
• Presented prior to the patient’s swallow attempt, which will accelerate oral acceptance and initiation of oral stage.
• This technique is considered compensatory in Alzheimer’s patients because it alerts the Central Nervous System, thus lowering the threshold of the swallow center.  Using this technique over an extended period of time will not improve the onset of the oral swallow and the trigger of the pharyngeal swallow.  Rather, the purpose of the stimulation is to heighten the sensitivity for the swallow in the CNS so that when the patient voluntarily attempts to swallow, he/she will trigger a pharyngeal swallow more rapidly.

C. THERAPEUTIC PROCEDURES FOR REDUCED LATERAL TONGUE MOTION (to increase range of motion and improve oral transit time):

1.  Open mouth as wide as possible and elevate front of the tongue, and hold for one second.  Elevate back of tongue, and hold for one second.
2. Stretch tongue to each side of the oral cavity as far as possible, holding for one second on each side.
3. Repeat procedure 5-10 times each day, 4-5 minutes each time.

D. COMPENSATORY AND THERAPEUTIC PROCEDURES FOR PHARYNGEAL SWALLOW DELAY:

1.  Thermal-tactile stimulation and changing bolus characteristics  (therapeutic procedure is mentioned above under section B.)
2.  Postural Techniques (compensatory procedures):

• Limit the amount of each bolus so the bolus can be held in the  pharyngeal recesses and the volume is not so large that it will overflow into the open airway.  Attention must also be paid to the speed at which the patient swallows. Adequate amount of time must be given so that the bolus insured to clear pharynx (don’t want overflow into the airway).
• Head-Tilt Forward- Protects airway more, and in some populations, it widens the vallecular space and increases the chance that the bolus will hesitate in the valleculae during the delay rather than falling into the open airway.
• Chin-Down Posture-  Pushes the anterior pharyngeal wall posteriorly with the chin down.  Tongue base and epiglottis are pushed closer to the pharyngeal wall.  The airway entrance is narrow, and vallecular space is widened.

E. MOTOR ABNORMALITIES IN THE PHARYNX:

1.  Reduced Posterior Movement of the Tongue

• Effortful Swallow:
• Increases posterior motion of the tongue base during pharyngeal swallow, thus improving a bolus clearance from the valleculae
• Clinician instructs the client to squeeze hard with all muscles, which improves pressure exerted by the oral tongue at all points along the palate and at the tongue base, and will increase tongue base movement.

• Therapeutic Procedures:
• No direct therapy technique improves pharyngeal contraction at all levels, however the Masako or Tongue Holding Technique is sometimes used.  This technique may not be appropriate for Alzheimer’s patients, because they typically exhibit a delay in the pharyngeal swallow, and this technique usually introduces a slight increase in pharyngeal delay in normal subjects.
• Compensatory Procedures:
• Alternating liquid and semi-solid or solid swallows so the liquid washes the thicker consistency through the pharynx.
• Limit diet to liquids or a thin paste materials requiring less pressure to clear the pharynx.
• Follow each swallow of food or liquid with several repeat dry swallows.

• Mendelson Maneuver:
• Designed to increase the extent and duration of laryngeal elevation and thereby increase the duration and width of cricopharyngeal opening.
• (This procedure may not be appropriate for Alzheimer’s patients who are notably cognitively impaired, since it requires the ability to follow simple instructions.)
• Clinician instructs patient to swallow saliva several times and pay attention to their neck as they swallow, noting if they can feel something lift or lower.  On the next swallow, the client is directed to hold the elevation for several seconds and then to let it drop.
• Supraglottic Swallow:
• Designed to close the vocal folds before and after the swallow, thus protecting the trachea from aspiration.
• Patients must be able to follow simple directions without becoming upset or confused.
• (Therefore this procedure may not be appropriate for Alzheimer’s patients who are notably cognitively impaired.)
• Laryngeal Elevation Exercise-The Falsetto Exercise:
• Designed to elevate the larynx to the level it would reach during the swallow.
• The patient is asked to slide up the pitch scale as high as possible to a high, squeaky voice.
• When the patient reaches the top of the scale, he/she should hold the high note for several seconds with as much effort as possible.
• The patient may take a hand and gently pull up on the larynx to assist laryngeal elevation during this procedure, but not during swallowing attempts, because the hand may get in the way of the swallow.