Compensatory versus Rehabilitative Dysphagia Management Approaches are More Frequently Recommended in Hospitalized Persons with Alzheimer’s Disease and Related Dementias

Abstract

AbstractBackgroundPersons with Alzheimer’s disease and Related Dementias (AD/ADRD) frequently develop difficulty swallowing (dysphagia). Two general categories of dysphagia management approaches are initiated by Speech‐Language Pathologists (SLP): compensatory (e.g., modifying fluid/food characteristics) and rehabilitative (exercise‐based). While compensations may improve swallowing safety (no airway invasion) and efficiency (no residue) in the short term, they do not actively target swallowing muscles (e.g. rehabilitative approaches) to induce lasting change in physiology. Additionally, compensatory recommendations are often based on clinical examinations (Desai, 2020) that do not permit visualization of swallowing possible with instrumental assessment (e.g. videofluoroscopic swallow study, ‘VFS’) which may lead to recommendations that are misaligned with swallowing physiology. This study aimed to elucidate whether the frequency of compensatory versus rehabilitative recommendations differs based on VFS findings. Specifically, we sought to characterize: 1) dysphagia management recommendations and 2) VFS findings contributing to these recommendations in a cohort of hospitalized patients with AD/ADRD.MethodThe retrospective sample included all inpatients (n = 122) with AD/ADRD (≥50 years) referred for a VFS at an academic hospital in 2014. AD/ADRD was determined by a diagnosis in the EHR and/or if the patient was taking medication(s) prescribed for AD/ADRD. Dysphagia management recommendations and VFS outcomes including swallowing safety (Penetration‐Aspiration Scale (Rosenbek, 1995) ‘PAS’ scores), efficiency (oropharyngeal residue), and biomechanical impairments (as identified by the SLP) were abstracted from the EHR. The absence (PAS scores 1,2, or 4) or presence (PAS scores 3,5,6, 7, or 8) of airway invasion was further classified (Steele, 2017). Descriptive statistics were calculated to analyze the data.ResultAll recommendations were compensatory with no rehabilitative treatments offered (Table 1). Across recommendations, pharyngeal phase impairments (e.g., pharyngeal delay) and inefficiency (e.g., vallecular residue) on VFS were more common than oral phase impairments/inefficiency. While relatively infrequent, airway invasion was most observed in the pill, solid, and liquid modification groups (Table 2).ConclusionIn this cohort, all dysphagia treatment recommendations were compensatory approaches focused on optimizing swallowing safety and efficiency. While these recommendations were aligned with VFS findings reflecting pharyngeal phase impairments/inefficiency, they highlight a missed opportunity to address swallowing impairments by directly targeting underlying physiology with a rehabilitative approach.