Expert: Mary Gordon - 8/7/2011

Question
Hi Mary,
My mom is in the 9th year of AD.  She can no longer walk, hasn't spoken in at least 3 years, has been incontinent for at least 4 years and has been eating pureed foods for over a year.  She lives at home with my dad and wonderful caregivers.  She has been pretty stable;  in this condition for awhile.  I've noticed lately when I visit that she coughs sometimes, a choppy wet cough, probably mucous, especially after she's been fed.  My dad says he's noticed it more also. What does this mean, if anything?  Also, I think she may have developed a bed sore.  Her caregiver said she cleaned what appeared to be an infected pimple on her buttocks.  Could that be a bed sore?

Any advise would be helpful.  Thank you for your kind response.

Answer
Hi Sharon, what you are seeing is caused by dysphagia, which is part of the disease. People in later Alzheimer's develop issues with muscular coordination, as you know - and this includes the muscles involved in chewing and swallowing, and manipulating foods and liquids in their mouths.  

Her wet coughing and gurgling is a good indication she is choking a bit or aspirating, and this is not a positive, as people with this condition are very, very susceptible to aspiration pneumonia and outright choking. A friend's mother actually died when being fed banana pudding - she was chipmunking it rather than swallowing it due to her dysphagia, and the person feeding her didn't realize this was happening (i.e. she kept opening her mouth for more, but was keeping it in her mouth like a chipmunk). She then inhaled all the pudding in her mouth rather than swallow it, and died before an ambulence could arrive.

Although you say she is eating purreed solids, she may also be having trouble with thin liquids. The solution to that is to add a thickening agent like Thick-it (there are many on the market). You can thicken liquids to the consistency of honey or even pudding, and it makes them easier to swallow.

In the US, the experts on assessing dysphagia are speech pathologists. You might want to consult with her doctor about getting an assessment done, to see if they can come up with ideas for dealing with her specific problems. Here is some basic info on what they look at
http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=805977

Hope this helps.

Mary

BBelow are some general tips for feeding a person with dysphagia.

Ensure that foods are neither too hot nor too cold
Feed attractive, tasty, pleasant-smelling foods to enhance appetite
Make sure she is ready to eat i.e. if she still wears dentures, eyeglasses and hearing aids, have them in place.  
Try to make the eating environment quiet and inviting with as few distractions as possible. Try playing some quiet music.
Make sure she is seated correctly i.e. as close to 90 degrees as possible
Try to tuck the chin under so it points to the chest (if necessary have the person in a chair offering head support)
Sit at eye level as you assist the person with eating
Use a teaspoon to avoid putting too much food in the mouth at once
Remind the person to chew each mouthful thoroughly
Touch the person's lower lip to stimulate opening the mouth
Massage the throat to stimulate the swallow reflex
Take as much time as necessary to help the person enjoy the meal
Ensure the person remains sitting in an upright position for at least 30 minutes after each meal
Clean out the mouth after each meal

If the person is not swallowing between spoonfuls, put an empty spoon into the mouth to trigger the swallowing mechanism.
Use wide, shallow glasses instead of tall, narrow ones.
Never feed someone lying down if at all possible and do not tilt the head back. If the person must be fed in bed, prop up with pillows
Watch for foods that have a double consistency i.e. anything with a skin such as peas, grapes, or a solid in a think liquid like a cereal in milk. These may be difficult to manage.
Do not wash food down with a liquid.
Do not use straws for chewing and swallowing problems. Straws increase air swallowing and add to the number of steps required for drinking.