What is the next best step in managing a patient with dementia who experienced a choking episode while eating, but has since returned to baseline?

From the Guidelines

The next best step in management and assessment of a patient with dementia who had a choking episode but is now back to baseline is to perform a comprehensive swallowing evaluation, including a bedside swallowing assessment by a speech-language pathologist (SLP) and potentially a modified barium swallow study or fiberoptic endoscopic evaluation of swallowing (FEES), as recommended by recent guidelines 1. While waiting for this formal evaluation, immediate dietary modifications such as serving soft or pureed foods, thickened liquids, and ensuring the patient eats in an upright position with supervision should be implemented. The patient should be monitored closely for signs of aspiration pneumonia (fever, cough, respiratory distress) for the next several days. A medication review is also essential to identify any drugs that might cause sedation, dry mouth, or otherwise impair swallowing function, as suggested by the ESPEN guideline on nutrition and hydration in dementia - update 2024 1. Dementia patients have a progressive decline in their ability to coordinate swallowing, increasing their choking risk over time, and education of caregivers on nutritional problems related to dementia and possible strategies to intervene is crucial, as stated in the ESPEN guidelines on nutrition in dementia 1. Even though the patient has returned to baseline, this choking episode indicates a significant risk for future, potentially fatal events, making proper swallowing assessment and management crucial for preventing recurrence and complications. Texture-modified, fortified foods and drinks should be considered as a compensatory strategy in parallel to treatment of dysphagia and chewing problems to support adequate food and fluid intake, as recommended by the AGA clinical practice guideline on endoscopic eradication therapy of Barrett's esophagus and related neoplasia 1. Regular screening for malnutrition and close monitoring of body weight are also essential in the management of patients with dementia, as emphasized in the ESPEN guidelines on nutrition in dementia 1. In summary, a comprehensive approach to swallowing evaluation, dietary modification, medication review, and caregiver education is necessary to prevent future choking episodes and ensure the best possible outcome for the patient.

From the Research

Assessment and Management of Dementia Patient with Choking Episode

• The patient's choking episode while eating suggests the presence of dysphagia, a common condition in older adults, particularly those with dementia 2.
• A comprehensive assessment of the patient's swallowing function is necessary to determine the cause of the choking episode and to develop an appropriate management plan.
• Instrumental assessments, such as videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES), can provide detailed information about the patient's swallowing physiology and help identify any abnormalities 3, 4.

Diagnostic Evaluation

• The choice of diagnostic evaluation depends on the patient's specific needs and the availability of resources.
• Both VFSS and FEES have been shown to be effective in evaluating oropharyngeal dysphagia, and the choice between the two may depend on the patient's individual circumstances 4.
• Narrow-band imaging in swallowing endoscopy may increase the sensitivity for penetration and aspiration in individual cases 4.

Management Strategies

• The management of dysphagia in patients with dementia requires a multidisciplinary approach, including medical management, nonpharmacologic strategies, and safety interventions 5.
• Dysphagia management strategies may include dietary modifications, home exercises, swallow therapy, surgical intervention, or alternative means of nutrition, such as percutaneous enteral gastrostomy (PEG) tube 6.
• Early dysphagia evaluation and management may be warranted in patients with neurodegenerative diseases, including dementia, to prevent complications and improve outcomes 6.

Next Best Step

• The next best step in the management and assessment of the patient with dementia who had a choking episode while eating would be to conduct a comprehensive swallowing evaluation, including instrumental assessments, to determine the cause of the choking episode and to develop an appropriate management plan 2, 3, 4.
• The patient's care team should work together to develop a personalized management plan that takes into account the patient's individual needs and circumstances, and that includes strategies to prevent future choking episodes and to manage any underlying dysphagia 5, 6.