As we age, swallowing foods and liquids can become harder to do. When someone has trouble swallowing, it is defined as dysphagia. Dr. Nicole Pulia discusses dysphagia and its signs, effects, treatments, and relation to Alzheimer’s disease. Guest: Nicole Pulia, PhD, CCC-SLP, Assistant Professor of Geriatrics, University of Wisconsin School of Medicine and Public Health
Intro: Welcome to Dementia Matters, a podcast created by the Wisconsin Alzheimer's Disease Research Center. It's our goal to humanize Alzheimer's research so that our community, our patients, our participants, and anyone else interested can get a better understanding of the work that's happening to fight back against this disease. My name is Nathaniel Chin, and I'm a geriatric and memory clinic physician at the University of Wisconsin. I'm also the family member of someone living with dementia. I'll be serving as your host for this podcast and asking the questions I believe are on the minds of many in our community. Thanks for joining us.
Dr. Nathaniel Chin: Welcome to Dementia Matters. Our guest today is Dr. Nicole Pulia, an assistant professor of geriatrics at the University of Wisconsin. Dr. Pulia studies swallowing issues in the elderly population and works to find treatments for improved swallowing. You'll hear her talk a lot about the condition dysphagia and that is in simple terms when someone is having trouble swallowing. Dr. Pulia, thank you for joining us today.
Dr. Nicole Pulia: Thank you so much for having me.
Chin: Most people under the age of 65 never experience trouble swallowing. Food, pills, coffee, water, they all go down smoothly. Can you briefly explain what happens to the mouth and the throat during a normal swallow?
Pulia: It's actually really interesting when you think about what it takes to make a swallow happen. It's really complicated. You have to have a lot of coordination of various muscles in the mouth and throat, nerves, as well as the brain controlling what's actually happening. The first thing to think about when we start to eat something is if it's something that you have to chew, first you have to chew it up and prepare it to be swallowed. A really important part of that is saliva. If someone doesn't have enough saliva, experiencing a dry mouth, that can make it difficult to chew things up. Also having adequate teeth or well-fitting dentures is another piece too, but a big component of a successful swallow is the tongue. The tongue plays a huge role in swallowing. Once the liquid or the food is put in the mouth, the tongue has to pull it together into a cohesive ball that sits on top of the tongue and then the tip of the tongue comes up to the roof of the mouth and kind of anchors against the roof of the mouth and then gives a good push on whatever it is that you're swallowing to move it back. The tongue will sequentially contact the roof of the mouth to push the food or liquid into the throat. Then once the food and liquid comes into the back of the throat, there are sensory information or signals that go up to our brain, to our brain stem in particular, that then say, ‘Oh, I think there's something here to swallow. We probably should do something about this’. Once that information is triggered, then it initiates what we call a motor response in the throat. So in your throat you have two tubes. You have one tube that goes to your lungs, so probably most people are familiar with a windpipe, but there's a structure that sits on top of the windpipe called your voice box or your larynx that has your vocal folds. When you talk you take a breath in and then you let the air to vibrate your vocal folds. Just behind that tube is your esophagus, and that's the tube that brings the food all the way through into the stomach. When we're just sitting here breathing, we're just letting air come in and out of our voice box and into our windpipe, into our lungs. When you swallow though, you have to close off your voice box and your windpipe essentially and open your esophagus to let the food and liquid into your esophagus. If anything goes wrong in that coordination, it can be a problem. Then there are also parts of the tongue that are in the throat that are really important for pushing the food and liquid through the throat, giving it a nice big push from behind, and also muscles in the throat itself that squeeze the food through. So that's kind of an overview. And then once the food and liquid enters the esophagus, then there's a wave of muscle contraction that moves the food and liquid into the stomach.
Chin: I think that's the third time I've had you explain that to me, and each time you do it I feel like I’ve learned something new, which tells me how complicated this process is.
Pulia: Yes absolutely, and we know that we swallow 600 to 1,000 times a day without even thinking about it. It can be really devastating for someone when swallowing goes awry because of how much that impacts our daily life.
Chin: And it's such a complicated process that unfortunately it isn't hard to believe that when a person has a brain issue that their swallow could become affected.
Pulia: Absolutely. You know, there are so many different conditions that can result in dysphagia or swallowing dysfunction because it is so complicated. There are so many ways that it can be affected.
Chin: Why don't you tell us what happens to the swallow mechanism just as a person ages normally?
Pulia: Yeah, so we do know that there are age effects on swallowing. There are a couple different ways that that happens. One is in the transit of the food and liquid through the mouth and the throat. We know that generally that gets slower as we age, so the tongue moves a little bit slower, the closure of the airway happens a little bit slower. We also know that the ability to sense things in the mouth and throat decreases as we age. Sometimes taste sensation can be affected. Then as a result, we need that sensory information to know what to do with the food and liquid and to have an effective swallow. Also the strength of muscles you know as you age decreases. Also just the overall mass of muscles declines with advancing age. We've now in more recent years started to understand that the head and neck muscles are involved in that as well, so the tongue itself actually experiences some of that decline in strength and mass with advancing age. There are also strength changes in the ability to really give a good push to the food or liquid through the mouth and throat.
Chin: This is regular swallowing. Is that something that is permanent or can it be treated and hopefully improved?
Pulia: Yeah. In most cases, dysphagia can be effectively treated. It does depend on what the underlying condition is but we have a lot of things that we can do to effectively treat dysphagia. It can be that what we use from a rehabilitative standpoint can resolve the issues as well, so it just kind of depends on the underlying cause for dysphagia.
Chin: So four dimensions, I know this is a hard thing to answer since there's many different causes of dementia and everyone's course of dementia is different, but how does the aging swallow change for people who do have dementia?
Pulia: Yeah. We have some really nice studies that have compared swallowing biomechanics or the function of the swallow in individuals with dementia as compared to healthy older adults and we do know that there are more changes that happen in the swallow in patients with dementia as compared to just sort of the normal aging process. We know, again, that the swallow is a little bit slower. There's also what we call a pharyngeal delay or a slow start to the swallow, so this is where the material can come out of the mouth and into the throat before the airway closes and that happens more frequently in people with dementia.
Chin: Now when should people with any form of cognitive impairment be evaluated for a swallowing problem?
Pulia: We know that these changes actually happen in the mild phases, in the beginning of the progression. In those early phases, we often don't see some of the negative consequences that come from dysphagia such as material going into the lungs. It may just be more subtle changes in the timing of the swallow, whether or not there's any material left over in the mouth and throat after the swallow, so more subtle things that are happening early and then worsen with disease progression. So, you know, I think seeing your geriatrician on a regular basis. It's something that you can start to bring up really early just to have that evaluation and see kind of where things are at.
Chin: What's the big deal or the clinical relevance, I guess, with problems swallowing?
Pulia: There are a variety of negative health outcomes that can happen from dysphagia. The most serious, I think, we would say would be the development of pneumonia. When material goes into the lungs rather than into the esophagus and the stomach, that material has bacteria in it and can also cause damage to the lungs itself but the bacterial component is what leads to the development of pneumonia. We know that pneumonia is one of the most common causes for mortality in patients with dementia specifically, so how much of pneumonia development is related to dysphagia that's something that we need to understand more. Probably a lot of those cases do have some underlying component of swallowing issues. The other things to think about would be dehydration. If someone's having difficulty swallowing liquids, they usually will sort of self-regulate. They know it's very uncomfortable to aspirate. It definitely can be, you know, a problem that people want to avoid and so they will decrease the amount of liquid intake that they have. Then accordingly it can also lead to malnutrition because people don't want to eat as much.
Chin: We talked about symptoms and the importance of knowing when you might be aspirating. What complaints do people usually have when they are in fact aspirating?
Pulia: I think the most common symptom that we hear is that people report coughing during meals. It can be difficult if someone has sort of just a cough all the time due to other medical conditions, but an increase in coughing frequency when drinking and eating can be definitely a clear sign. Unfortunately, a lot of our older adults and patients with dementia do not actually cough in response to things getting into the lungs. We call that silent aspiration, and again that's related to those changes in sensation that happen with advancing age so it's not always the case that they'll be coughing when someone gets something down the wrong way. Some other things to look for would be a throat clear like a subtle throat clear. Even that sounds like (clears throat), that can definitely be a sign that there's a little bit of sensation but not enough to trigger a cough. Some other things would be changes in the voice quality. There's a very distinct, wet, gurgly voice quality that happens when people get something down the wrong way because, as we talked about, the voice box sits on top of the windpipe and the vocal folds are there so if material comes into the voice box and is sitting on the vocal folds when that person goes to talk, you actually hear the material like moving around in their throat, so listening carefully to see if there are changes in the way the person's voice sounds when they're eating and drinking. People also tend to limit oral intake, limit what they're eating in amounts and also have some aversion to eating and drinking.
Chin: Now if you have dementia and you develop dysphagia, can you ever return to eating regular food? I ask this because a lot of my patients are on modified diets. Some of them don't mind it and others wish that they could go back.
Pulia: Once you do have a diagnosis of dysphagia and you're on a modified diet, it may be that you need to stay on that diet for a prolonged period but it really is so critical to have conversations with the team, with the speech language pathologist about what the goals are. You know, our job is to identify swallowing dysfunction, identify occurrences of aspiration or material getting into the lungs, educate you about that, talk to you about what's happening, but then ultimately it's really the patient and the family's decision about how they kind of want to proceed knowing that there are risks that include pneumonia, malnutrition, and dehydration. You can make a decision to go ahead and choose to drink regular liquids knowing that there is that risk, but that doesn't mean then that the speech language pathologist doesn't have anything to offer. We have a lot we can talk about in terms of how do we optimize the safety of the swallow. There's a lot actually that goes into safe swallowing. We can make recommendations about, you know, the pace of eating, alternating liquids and solids, taking single small volume sips of liquid rather than drinking consecutively all in a row. There are ways that we can modify the way that you swallow your pills. There are a lot of things that we can do to make the swallowing process safer, even with an acknowledgement that with those strategies there may still be some problem that happens without modifying the diets, but there are things that we can do to make it safer even within that.
Chin: In addition to being an astute clinician and speech therapist who sees people and treats people on a fairly regular basis, you're also a researcher.
Chin: And a prominent one at that. I know you wouldn't say that, but I can tell you the ADRC is very excited about your research.
Pulia: Oh thank you.
Chin: If you could share with our listeners what you're working on, I think they would really like to know.
Pulia: Sure, absolutely. Well, some of my work early in my career looked at a specific approach to treatment for swallowing where we can systematically strengthen the tongue. We have a device that we use. It's a pressure bulb that goes on the top of the tongue. You take your tongue and you push it up against the roof of your mouth. It's almost like it's the same thing as if you were lifting barbells at the gym; you're essentially lifting barbells for your tongue. We're hoping to receive some funding to examine the efficacy of some of these strengthening approaches in early stage dementia.
Chin: I can imagine there's going to be a lot of buzz now in the community now that you've mentioned this potential study, and so who are you looking to recruit?
Pulia: So we would be looking for individuals with a diagnosis of dementia, does not have to be specifically Alzheimer's disease, and some complaints of swallowing difficulty. If there are complaints or concerns from the caregiver then, as part of the study, we can actually set up that swallow study in the beginning so that we can define what's happening with the swallow. We need people to be living at home and to have an actively involved caregiver.
Chin: So you don't have to be enrolled at the ADRC already. You would accept people in the general community?
Pulia: Yes, absolutely.
Chin: Well I think that's really exciting and I'm hopeful that this study gets underway.
Pulia: Thank you.
Chin: So really, I just want to thank you again for coming on and I do hope in the future we can have you come back.
Pulia: Absolutely, I would love to.
Outro: Dementia Matters is brought to you by the Wisconsin Alzheimer's Disease Research Center. The Wisconsin Alzheimer's Disease Research Center combines academic, clinical, and research expertise from the University of Wisconsin School of Medicine and Public Health, and the Geriatric Research, Education and Clinical Center of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. It receives funding from private, university, state, and national sources, including a grant from the National Institutes of Health for Alzheimer's Disease Centers. This episode was produced by Rebecca Wasieleski and recorded and edited by Alex Wehrli. Our musical jingle is "Cases to Rest" by Blue Dot Sessions. Check out our website at adrc.wisc.edu. You can also follow us on Twitter and Facebook. If you have any questions or comments, email us at firstname.lastname@example.org. Thanks for listening.