What is the management approach for a patient with dementia presenting with a sensation of a globe?

Management of Globus Sensation in Patients with Dementia

The management of globus sensation in patients with dementia should focus on identifying the functional nature of the symptom, ruling out organic causes, and implementing non-pharmacological interventions before considering medication. 1

Understanding Globus Sensation in the Context of Dementia

Globus pharyngeus is a functional disorder characterized by:

• A recurrent, non-painful but uncomfortable sensation of a lump in the throat
• Absence of dysphagia, odynophagia, or gastro-esophageal reflux disease
• Symptoms that are more obvious between meals and improve with eating
• Often associated with throat clearing, sensation of mucus buildup, repeated swallowing, and pharyngolaryngeal tension 1

In patients with dementia, these sensations may be particularly distressing as cognitive impairment can limit their ability to understand and cope with the symptoms.

Diagnostic Approach

Initial Assessment

1. Differentiate globus from dysphagia:

   • Globus is a sensation of a lump without actual swallowing difficulty
   • Determine if food and liquid pass normally (globus) or with difficulty (dysphagia) 1

2. Rule out organic causes:

   • Perform a thorough neurological examination to identify any focal abnormalities that might suggest stroke or other neurological conditions 1
   • Consider anatomical neuroimaging (MRI preferred over CT) to exclude structural lesions 1
   • Evaluate for signs of gastro-esophageal reflux disease

3. Assess for psychological factors:

   • Evaluate for psychological stress, which can exacerbate globus symptoms 1
   • Screen for anxiety and depression using validated tools like the Geriatric Depression Scale 1

Management Strategy

Non-pharmacological Interventions (First-line)

1. Patient and Caregiver Education:

   • Explain the benign nature of globus sensation
   • Reassure that the sensation, while uncomfortable, is not dangerous
   • Provide clear explanation that this is a functional disorder, not a sign of disease progression 1

2. Behavioral Techniques:

   • Teach relaxation exercises focusing on the throat and neck muscles
   • Implement swallowing exercises to reduce throat tension
   • Encourage adequate hydration 1

3. Environmental Modifications:

   • Ensure calm mealtimes with minimal distractions
   • Position the patient upright during and after meals
   • Avoid foods that might exacerbate the sensation (very dry foods, spicy foods)

4. Cognitive Approaches (if cognitive status allows):

   • Distraction techniques when the sensation occurs
   • Simple cognitive behavioral therapy approaches adapted for cognitive impairment
   • Mindfulness techniques focused on acceptance of the sensation 1

Pharmacological Interventions (Second-line)

If non-pharmacological approaches are insufficient:

1. Consider antidepressants:

   • Low-dose antidepressants may be beneficial based on evidence from overlapping disorders causing oesophageal discomfort 1
   • Start with low doses and monitor closely for side effects, especially in elderly patients with dementia

2. Avoid unnecessary medications:

   • Limit use of medications that might worsen cognitive function
   • Be cautious with antipsychotics due to black box warnings in dementia patients 2

Special Considerations in Dementia

1. Communication Adaptations:

   • Use simple, clear language when explaining the condition
   • Provide written information for caregivers
   • Repeat information as needed due to memory impairment 1

2. Caregiver Support:

   • Educate caregivers about the nature of globus sensation
   • Teach caregivers how to respond when the patient complains of the sensation
   • Assess caregiver burden regularly, as this is a major determinant of hospitalization and nursing home placement 1

3. Monitoring:

   • Schedule regular follow-ups to assess symptom progression
   • Watch for development of actual swallowing difficulties (dysphagia), which would require different management
   • Monitor for weight loss or decreased oral intake 1

When to Refer to Specialists

Consider referral to specialists when:

• Symptoms persist despite initial management
• There is uncertainty about the diagnosis
• Symptoms progress or change in character
• There is development of actual swallowing difficulties
• Neuropsychiatric symptoms become prominent 1

The management of globus sensation in dementia requires a careful balance between addressing the uncomfortable symptoms while avoiding unnecessary interventions that might increase confusion or side effects. By focusing on non-pharmacological approaches first and involving caregivers in the management plan, most patients can achieve significant symptom relief.