Dysphagia 12:212221 (1997)
Springer-Verlag New York Inc. 1997
Eating Changes in Mild-Stage Alzheimers Disease:
A Pilot Study
Beverly Ann Priefer, PhD1,2 and JoAnne Robbins, PhD1,3
1
Geriatric Research, Education, and Clinical Center, Wm. S. Middleton Memorial Veterans Administration Hospital Madison, Wisconsin; 2School
of Nursing, University of Wisconsin, Madison, Wisconsin; and 3Departments of Medicine and Surgery, University of Wisconsin,
Madison, Wisconsin, USA
Abstract. Eating impairment is well documented in the
late stage of Alzheimers disease (AD) but when these
eating changes actually begin in the disease process is
not known. Eating was defined as consisting of two com-
ponents, self-feeding and swallowing. Self-feeding and
swallowing of healthy elderly were compared with a
group of individuals with mild AD. AD subjects received
significantly more partner-initiated cues or direct assis-
tance than controls. In addition, subject-initiated cued
behaviors occurred more frequently in the AD group. AD
subjects demonstrated significantly prolonged swallow
durations for the oral transit duration (cookie), pharyn-
geal response duration (liquid), and total swallow dura-
tion (liquid). This pilot study suggests that self-feeding
and swallowing changes may occur early in the course
of AD.
Key words: Alzheimers disease Eating Swal-
lowing Self-feeding Deglutition Deglutition
disorders.
Cognitive impairment is the defining feature of Alzhei-
mers disease (AD) but it is the concomitant behavioral
and functional impairments that place the individual with
AD at increased risk for institutionalization and death
[1]. The inability to eat is the most life-threatening [26]
of all the functional impairments in AD, with 50% of the
patients losing the ability to feed themselves 8 years after
diagnosis [7]. Altered eating behaviors in AD range from
Correspondence to: Beverly Priefer, Ph. D., Geriatric Research, Edu-
cation, and Clinical Center, Wm. S. Middleton Memorial Veterans
Administration Hospital, 2500 Overlook Terrace, Madison, WI 53705,
USA
walking away from food at the table, to spitting out food,
and choking on liquids and solids [812].
Eating can be defined by two components, self-
feeding and swallowing; therefore, eating dysfunction in
AD may involve impaired ability in transferring food
from the table to the mouth (self-feeding), impaired
transfer of food from the mouth into the stomach (swal-
lowing), or both. When self-feeding becomes impaired,
the individual is at risk for malnutrition and its sequelae;
when self-feeding ceases altogether, the individual be-
comes dependent on the motivation, commitment, and
skill of another person or persons for adequate nutrition
and hydration. Swallowing dysfunction, regardless of
self-feeding status, places the demented individual at risk
for malnutrition, aspiration pneumonia, nonoral feeding,
and death.
What is known about eating impairment in AD is
primarily limited to institutional settings [1117]. As
many as 50% of nursing home residents may require
feeding assistance ranging from organizing and setting
up the meal to total assistance, and 32% of nursing home
residents have been reported to have swallowing prob-
lems [7]. With two exceptions [18,19], most research has
focused on problems associated with institutional care-
givers feeding AD residents. No one to date has system-
atically investigated self-feeding and swallowing in AD
to identify patterns of and relationships between these
two eating components. One reason for this lack of in-
quiry is that eating dysfunction is most manifest in late-
stage dementia when disease severity prohibits many in-
dividuals from reporting symptoms or cooperating with
oropharyngeal examinations [8,11,12].
A major goal in caring for individuals with AD is
to maintain independent ADL function for as long as
possible [20]. Loss of ADL function has important im-
plications for either family or professional caregivers
B.A. Priefer and J. Robbins: Eating in Alzheimers Disease
since decreased function leads to increased dependency
and increased care needs, both of which are emotionally
challenging and time consuming [2125]. Understanding
the nature and course of eating dysfunction in AD using
more physiological measures of dysfunction could po-
tentially result in specific problem-oriented interventions
earlier in the disease process.
We hypothesized that changes in eating behav-
iors begin before that time when eating impairment ren-
ders the individual dependent on others, or a feeding
tube, for nutritional intake. Since early-stage AD holds
the greatest promise for intervention [26], we speculated
that identifying early changes in eating behaviors would
be the first step in understanding the progressive nature
of these changes and essential for designing interven-
tions to maximize eating independence for as long and as
safely as possible. Therefore, a pilot study was under-
taken to design and implement an eating assessment pro-
tocol to determine if differences exist in the eating be-
haviors of individuals with mild AD compared with nor-
mal age-matched controls. Specifically, the questions
asked were (1) Do swallowing durations differ in nor-
mal elderly and individuals with early stage AD? and
(2) Do self-feeding dependency and self-feeding behav-
iors differ in normal elderly and individuals with early
stage AD?
Methods
Subjects
Healthy, older adults and individuals with AD were recruited as paid
subjects. Normal control subjects were recruited from area senior cen-
ters and volunteer organizations. All potential control subjects had to
score 28 or higher on the Mini-Mental State Examination (MMSE) [27]
and did not suffer from any neuromuscular conditions that interfered
with their motor ability to self-feed. AD subjects were recruited from
an area university, the Veterans Administration, community memory
disorders/geriatrics clinics, and the local chapter of the Alzheimers
Association. All AD subjects were initially screened for an established
diagnosis of probable AD according to the NINCDS-ADRDA criteria
[28], scored <5 on the Hachinski Ischemic Scale [29], and met the
criteria for mild dementia as defined by the Clinical Dementia Rating
Scale [30].
All subjects underwent additional screening procedures includ-
ing dental and neurological examinations performed by a university-
affiliated dentist and neurologist. The purpose of the dental examina-
tion was to rule out any oral pathology that might interfere with the
subjects ability to chew and/or manipulate food in the mouth. The
purpose of the neurological exam was to rule out any upper extremity
impairment that might interfere with self-feeding and, in the case of the
AD subjects, to confirm the diagnosis of AD by ruling out any focal
findings suggestive of vascular dementia. All subjects signed consent
forms approved by the university internal review board.
Swallowing Assessment
Subjects were seated in an upright position in the radiology suite for a
videofluoroscopic recording of their swallowing. The fluoroscopy was
213
focused in the lateral view from the lips anteriorly to the pharyngeal
wall posteriorly, and from the nasopharynx superiorly to the cervical
esophagus inferiorly. The swallow study was conducted by a speech
pathologist following a standard protocol [31] using three different
consistencies: a 3-ml liquid; a 3-ml semisolid (pudding mixed with
barium); and a 1.5-cm cookie (coated with EZ-paste). The material
was placed in the subjects mouth, the fluoroscopy was turned on, and
the subject was asked to swallow on command. Subjects performed two
trials of each consistency.
To determine if swallowing differs in AD and elderly control
subjects, durations of five components of a swallow were analyzed
[32]. The definitions of these durations are shown in Table 1. A vid-
eocounter timer imprinted a time code (accurate to 0.02 sec) on each
swallow tape. Frame by frame analysis allowed quantification of the
duration of each of the following 5 swallow durations. The occurrence
of aspiration, defined as the entry of material below the vocal cords,
was also recorded.
A two-sample Wilcoxon test [33] was used to compare control
and AD groups on the swallow duration measures. Since swallowing
durations were hypothesized to be more prolonged in AD subjects, all
comparisons were made using one-tailed tests with a 4 0.05. Data
analyses were performed using the first swallow duration for each
consistency. Averaging the durations of the two swallows per consis-
tency was not done because of technical difficulties in the timing of
fluoroscopy activation for the second swallow in some of the subjects.
Self-feeding Assessment
A standard meal was developed to assess self-feeding behaviors. This
meal was eaten by the subject, the spouse (for controls, spouse or
friend), and one of the authors (BAP). The meal was designed to
represent the everyday challenges people encounter when self-feeding
and was patterned after the type of regular diet served to patients in a
hospital setting. The food and eating challenges were also similar to
those experienced in other common eating situations such as airline
meals or buffet or cafeteria-style meals. Figure 1 is a sketch of a
hospital meal and illustrates several self-feeding tasks that the patient is
required to perform: opening a package that contains silverware and a
folded napkin, opening a carton of milk, opening a salad dressing
packet and pouring the dressing on the salad, opening salt, pepper, and
cream packets, buttering bread, and using a knife and fork to cut meat.
For this study the hospital meal was modified by removing the tray and
serving the food in a more restaurant-like environment with all of the
food served in dishes sitting on a placemat on the table. The test meal
(Fig. 2) consisted of a salad, a choice of salad dressing packets, roast
beef or turkey, gravy in two small souffle cups placed on the plate,
baked or mashed potatoes, peas, roll, Jello, chocolate chip cookies in
plastic wrapping, and coffee, tea, or milk. A bowl on the table con-
tained packets of salt and pepper and small containers of cream.
All participants dined together at a table in a dining room in the
rehabilitation area of a hospital. Two cameras were used: one focused
on the subject and one on the subject and his/her partner.
Videotapes were analyzed on a playback recorder that allowed
frame-by-frame viewing and was equipped with a second by second
video counter. Tapes were initially viewed by BAP to record the se-
quence of events and to refine data collection techniques. Specific
self-feeding tasks associated with each of the food or beverage items
available during the meal were printed on a data collection form (Table
2). BAP and a second rater, a graduate research assistant, recorded the
time the behavior occurred, whether the behavior was cued by the
spouse/friend, whether it seemed appropriate, and any additional com-
ments. For condiment-type foods, such as butter and gravy, notation
was made as to how they were used (i.e., first cup of gravy on meat
214 B.A. Priefer and J. Robbins: Eating in Alzheimers Disease

Table 1. Definitions of swallow durations

Swallow duration Definition

Oral transit duration (OTD) Time from initiation of the posterior bolus movement in the oral cavity to arrival of the bolus at the ramus
of the manidible. Posterior bolus movement is a voluntary action under cortical control.
Stage transition duration (STD) Time from arrival of the bolus at the head of the ramus of the mandible to the beginning of maximum hyoid
bone excursion. Hyoid excursion is thought to contribute to the upward and forward movement of the
larynx which contributes to the closing off of the airway during passage of the bolus through the pharynx.
STD ranges from a negative value, indicating the hyolaryngeal excursion begins before the bolus reaches
the ramus of the mandible, to a positive value indicating initiation of excursion after the bolus has reached
the ramus.
Pharyngeal response duration (PRD) Time from the beginning of maximum hyoid excursion to the hyoid returning to rest. This duration
represents the more automatic pharyngeal phase of swallowing. If the pharnygeal response begins after the
bolus reaches the ramus of the mandible (a positive STD value), the bolus may approach an unprotected
airway (larynx and vocal cords open).
Pharnygeal transit duration (PTD) Time from the arrival of the head of the bolus at the ramus of the mandible to the tail of the bolus through
the upper esophageal sphincter (UES).
Total swallow duration (TSD) Time from the beginning of the posterior movement of the bolus in the oral cavity to the tail of bolus
passing through the UES. Once the bolus is through the UES, the esophageal phase of swallowing begins.

Table 2. Self-feeding tasks associated with meal food and beverages

Napkin Gravy
Unwraps First cup
Initial placement Second cup
Cutlery Disposition of cups
Initial placement of knife, Butter
fork, spoon First pat
Salad Second pat
Opens lid Third pat
Chooses dressing Disposition of wrapper
Pours dressing Beverages
Disposition of used packet Cream in coffee
First bite Sugar in coffee
Fig. 1. Hospital meal illustrating self-feeding tasks: opening a sil- Roll First sip coffee
veware and napkin package, opening a carton of milk, opening a salad Breaks/cuts/opens Opens milk
dressing packet and pouring dressing on the salad, opening salt, pepper, First bite Opens straw
and cream packets, buttering bread, and using a knife and fork. Potato (baked/mashed) First sip milk
Cuts-if applicable Jello
First bite Leaves in place
Meat Moves to other area of table
Cuts First bite
First bite Cookie
Peas Unwraps
First bite First bite
Disposition of wrapper

quency of successful cueing behaviors and/or direct assistance initiated

Fig. 2. The test meal: a salad, a choice of dressing, roast beef or turkey,
gravy in two small cups, potatoes, peas, roll, Jello, cookies in plastic
wrapping, coffee, tea, or milk.
and potatoes). In addition to coding the self-feeding behaviors asso-
ciated with the particular food and beverage items, the tapes were
observed in real time, and when necessary, frame by frame, for cueing
and/or unusual behaviors that occurred throughout the meal.
Self-feeding dependency was assessed by recording the fre-
by the AD spouse, or in the case of control subjects, by the spouse or
friend. Successful cueing and assistance were defined similarly to that
of Gendron and Levesque [20]. A cue was defined as one of the
following:
1. Verbal cueverbally directing or suggesting that the subject per-
form a particular behavior
2. Nonverbal cuegesturing what behavior the subject should perform
3. Physical guidance cuehands-on guidance by another to initiate a
behavior that is then completed by the subject
In addition, for either 1 or 2 to be considered a cue, the subject had to
B.A. Priefer and J. Robbins: Eating in Alzheimers Disease
perform the directed behavior within 15 sec of the cue with no inter-
vening behavior between the administration of the cue and the cued
behavior performed by the subject. For cue [3 to be considered a cue,
the subject had to finish the initiated behavior.
Assistance was coded as either partial or total assistance as
follows: (1) partial assistanceperforming part of a behavior; (2) total
assistanceperforming the entire task for the individual.
The two raters independently viewed the videotapes and iden-
tified episodes of cueing and assisted behaviors. When the two raters
differed in identification of a cue or assistance, a third person viewed
the videotape and rendered a decision. A one-tailed Fisher-Exact test
for proportions was used to test for group differences in frequency of
cueing and/or assisted eating behaviors.
In addition to assessing for subject eating behaviors that were
cued and/or assisted, appropriateness of eating behaviors was also as-
sessed. Defining appropriate/inappropriate and normal/abnormal eating
behaviors is challenging since raters make decisions about the appro-
priateness of eating behaviors based on differing past experiences,
cultural habits, and personal expectations. A methodology is currently
being tested to define normal/abnormal, acceptable/unacceptable eating
behaviors.
Results
Subjects
Fifteen healthy, elderly control and 10 individuals with
mild stage AD participated in the study. The mean age of
the 10 AD subjects was 68 years (SD 4 10) and of the
15 control subjects, 73 years (SD 4 5). All subjects were
ambulatory and lived in the community. AD subjects
lived with a spouse who participated in answering ques-
tionnaires and in eating the videotaped meal. Control
subjects were accompanied by a spouse or friend who
participated in the videotaped meal.
The majority of subjects retained most of their
natural dentition. Control subjects had an average of 27
total teeth with an average of 24 natural teeth; AD sub-
jects had an average of 26 total teeth with an average of
20 natural teeth. No subject wore a complete set of den-
tures. With the exception of one control subject judged to
have slightly diminished saliva, all subjects were judged
by the examining dentist to have normal saliva. One
control subject was found to have a mandibular tori; no
other oral lesions were identified in any of the subjects.
Swallowing
Swallowing data were eliminated for 1 control subject
who was found to have a Zenkers diverticulum on vid-
eofluoroscopy. The duration measures for the cookie
swallow for 1 AD subject and for the semisolid swallow
for 1 control subject are not included in the group analy-
ses since, for both of these subjects, the oral transit du-
ration (OTD) duration was >9 SDs from their respective
group means. Neither of these subjects had extreme du-
rations on any of their other swallows. It is possible that
215
the unfamiliar taste or texture of the substance resulted in
the increased OTD duration.
Table 3 illustrates the means, SDs, and signifi-
cance of control and AD subject swallow durations for
each of the three consistencies. Swallow durations for the
AD subjects were significantly longer than the control
subjects for cookie OTD, liquid pharyngeal response du-
ration (PRD), and liquid stage transition duration (TSD).
No subjects aspirated any materials. Two control sub-
jects and 3 AD subjects demonstrated laryngeal penetra-
tion defined as material in the laryngeal vestibule above
the vocal cords.
A secondary analysis of the subjects >70 years
old was performed since age-related changes in STD,
PTD, and TSD durations have been reported in individu-
als >70 years compared with middle-aged subjects [32].
This analysis included 8 control (mean age 76 4.3
years) and 5 AD subjects (mean age 76 3.7 years).
Table 4 illustrates that for subjects over 70 years, all
solid (cookie) durations except PRD and two liquid du-
rations, OTD and TSD, were significantly more pro-
longed in AD subjects.
Self-feeding
Twenty-four subjects (15 control 9 AD) participated in
the videotaped meal. One AD subject was unable to com-
plete the meal portion of the study. This subject, un-
known to the researchers, developed flu symptoms ear-
lier in the day and, after starting to eat lunch, felt too ill
to continue.
Table 5 illustrates the number and type of cues
initiated by subject partners. One cue was directed at a
single control subject whereas a total of 16 cues were
directed at four different AD subjects with each of these
four AD subjects receiving at least two self-feeding cues
from their spouses. All of the cues, except the control
subjects cue (eat cookies) and two of the AD cues (drink
milk), focused on behaviors involving the manipulation
or use of condiments such as the salad dressing or gravy.
Repeated viewing of the meal videotapes resulted
in identification of several instances where both AD and
control subjects imitated the behavior of either their part-
ner or the principal investigator (BAP). That is, the sub-
jects observed their partner or the principal investigator
(BAP) in a self-feeding action, and imitated this action
within 15 sec of the observation. No intervening action
occurred between the observed action and the imitated
action. Thus, the subject used the action of another per-
son as a cue for his or her own subsequent action. For
example, one woman glanced at her friend who was
opening a packet of salad dressing. The subject, who up
to that point had already eaten some of her meat, pota-
toes, and salad without dressing, reached for the bowl
216 B.A. Priefer and J. Robbins: Eating in Alzheimers Disease

Table 3. Control vs. AD subjects by consistency and swallowing du- who had just finished opening her salad dressing packet,
ration put her hand in a position to pour the dressing when she
stopped, appearing confused as to just where she should
Control AD subjects
Swallow subjects (SD) (SD) pour it. She glanced at her husband who was reaching for
duration Consistency (n 4 14) (n 4 10) Significancea butter to butter his roll. She then looked down at her
plate, touched her roll with her other hand, and moved it
OTD Cookie 0.19 (0.19) 0.41 (0.25) p 0.05
Liquid 0.32 (0.19) 0.37 (0.18) NSb
slightly while still holding the salad packet in a ready-
Semisolid 0.44 (0.41) 0.38 (0.39) NS to-pour position. She glanced back at her husband who
STD Cookie 0.24 (0.48) 0.14 (0.32) NS was still preparing to butter his roll. She again looked
Liquid 0.05 (0.17) 0.18 (0.31) NS down at her plate and was just about to pour the salad
Semisolid 0.33 (0.61) 0.53 (0.80) NS dressing on her meat when her husband looked up, saw
PTD Cookie 0.95 (0.50) 0.77 (0.29) NS
Liquid 0.67 (0.18) 0.80 (0.26) NS
what she was about to do, pointed to her salad, and said,
Semisolid 0.90 (0.56) 1.04 (0.79) NS no, on your salad. She then successfully poured the
PRD Cookie 0.90 (0.20) 1.02 (0.42) NS salad dressing on her salad. This subject appeared to
Liquid 0.93 (0.21) 1.10 (0.19) p 0.05 know that she was unsure of what she should do with the
Semisolid 1.10 (0.27) 1.01 (0.25) NS salad dressing and actively, albeit nonverbally, sought
TSD Cookie 1.33 (0.46) 1.56 (0.62) NS
Liquid 1.30 (0.27) 1.65 (0.50) p 0.05
assistance from her husband by observing his behavior
Semisolid 1.85 (0.87) 1.93 (1.02) NS for an action she could imitate or for a cue from him as
to what to do with the dressing.
a
2-sample Wilcoxon test. We have labeled the behavior of subjects who
b
Not significant.
imitated or who sought to imitate the actions of another
as subject-initiated cued behavior as compared with part-
Table 4. Control vs. AD subjects >70 years by consistency and swal- ner-initiated cued behavior, as previously described.
lowing duration Table 6 illustrates the type and frequency of subject-
initiated cued behavior by both control and AD subjects.
Control AD subjects
There is a significant difference in the number of AD
Swallow subjects (SD) (SD)
duration Consistency (n 4 8) (n 4 5) Significancea subject-initiated cued behaviors (78%) as compared with
control subjects (33%) as measured by the Fisher-Exact
OTD Cookie 0.25 (0.21) 0.51 (0.11) p 0.05 test (p # 0.05).
Liquid 0.29 (0.12) 0.46 (0.16) p 0.05
Semisolid 0.50 (0.46) 0.51 (0.63) NSb
STD Cookie 0.02 (0.34) 0.37 (0.22) p 0.05
Liquid 0.01 (0.13) 0.23 (0.36) NS Discussion
Semisolid 0.30 (0.76) 0.52 (0.68) NS
PTD Cookie 0.66 (0.29) 0.99 (0.23) p 0.05 One objective of this study was to design an eating pro-
Liquid 0.62 (0.21) 0.88 (0.31) NS
Semisolid 0.82 (0.68) 0.97 (0.63) NS
tocol to assess both self-feeding and swallowing ability
PRD Cookie 0.96 (0.18) 0.97 (0.13) NS in individuals with AD. Swallowing ability was quanti-
Liquid 1.00 (0.24) 1.12 (0.23) NS tatively assessed by measuring swallowing durations and
Semisolid 1.09 (0.34) 0.93 (0.22) NS by the presence of aspiration/penetration as recorded on
TSD Cookie 1.23 (0.45) 1.86 (0.34) p 0.05 a videofluoroscopic swallow study. Self-feeding ability
Liquid 1.28 (0.26) 1.81 (0.60) p 0.05
Semisolid 1.89 (0.96) 1.96 (0.93) NS
was assessed by a videotape of the subject self-feeding a
noon meal. Though several earlier studies describe eating
a
2-sample Wilcoxon test. problems in late-stage dementia that are suggestive of
b
Not significant. both self-feeding and swallowing difficulties, this is the
first study to concurrently examine both the self-feeding
containing the dressing packets, chose one, opened it, and swallowing components of the eating process, and to
and poured it on her salad. do so in early-stage AD when subjects were able to co-
In general, these imitated or cued actions ap- operate with the study protocol. Assessing eating ability
peared unplanned; the subjects happened to glance at using this protocol posed little difficulty for the subjects
their meal partner or the principal investigator, noticed and their partners and required about 3 h of time. Further
an action, and then imitated the same action. Neither the study with AD subjects in moderate- and severe-stage
partner or principal investigator appeared to recognize AD are needed to determine the feasibility of the proto-
when the subject was imitating their behavior. One ex- col as the disease progresses.
ception was an AD subject who was clinically the most A second objective of this study was to determine
advanced of the early stage AD subjects. The woman, whether the two components of the eating process, self-
B.A. Priefer and J. Robbins: Eating in Alzheimers Disease 217

Table 5. Partner-initiated cued behaviors and/or assistance

Partners of control subject Partners of AD subject

Type Type
(number of (number of
Subject episodes) Example Subject episodes) Example

7 Verbal (1)
Shall we eat our cookies now?
(subject picks up and unwraps
cookies)
15 Verbal (1) Do you want salad dressing?
Partial assist (1) (Hands subject dressing packet, sub-
ject puts back in dish but chooses
another and goes on to pour
dressing on salad)
20 Verbal (3) Scrape your gravy off your Jello
(subject tries to do so)
Drink your milk (subject drinks
milk)
Do you want Italian or 1000
island? (chooses 1000)
Total assist (3) Removed lid from subjects salad
Poured dressing on subjects salad
Poured gravy on subjects potatoes
22 Verbal (3) Do you want your salad? (sub-
ject opened lid on salad)
Drink your milk (subject drank
milk)
Dont you want your gravy?
(subject eats some gravy)
Nonverbal (2) Points to salad (in conjunction with
verbal cue)
Points to gravy (in conjunction with
verbal cue)
23 Partial assist (1) Wife hands subject dressing packet
(subject proceeds to open)

feeding and swallowing, differ in normal elderly as com-
pared with individuals with early-stage AD.
Swallowing
We hypothesized that swallowing changes begin in the
early stage of AD, and we examined this hypothesis by
measuring five different swallow durations for three con-
sistenciesliquid, semisolid, and solid. We found sig-
nificant group differences in OTD for the solid consis-
tency and in PRD and TSD for the liquid consistency.
OTD reflects posterior bolus movement in the mouth and
is under voluntary control. Prolongation of this duration
may reflect interference with the initial oral preparation
of the bolus and initiation of the swallow.
Abnormal or absent chewing movements [11,34]
and abnormal tongue and jaw movement [35] have been
reported in individuals with dementia. Since the brain-
stem is relatively spared in AD [36,37] an explanation
for oral stage swallowing changes in AD may be found
in the cerebral cortex. The cerebral cortex is hypoth-
esized to play a role in the initiation, modulation, and
integration of swallowing. Animal and human lesion
studies, as well as electrical stimulation studies, suggest
that areas in the cerebral cortex trigger the initiation of
the swallow [38,39]. Martin and Sessle [38], in summa-
rizing numerous animal and human studies, suggest that
the cerebral cortex, in particular the motor and premotor
cortex, may initiate and modulate the motor responses
comprising the swallow. Though positron emmision to-
mography (PET) studies of individuals with mild to se-
vere dementia indicate a relative sparing of the sensori-
motor cortex in AD [26], Haxby et al. [40] have dem-
onstrated hypometabolism in the premotor cortex by
PET scan in individuals with moderate and severe but
not mild AD where mild AD was defined as a MMSE
score of >21. Using these investigators MMSE criteria
for mild AD, our mild AD subjects would fall into the
moderate AD category. Therefore, it is possible that our
AD subjects had some AD involvement of the premotor
area. The premotor cortex, an association area thought to
be important in the planning, organizing, initiating, and
sustaining of motor output [41,42], also has descending
corticospinal and corticobulbar fibers, the latter of which
could carry information to the swallowing center in the
brain stem [41]. Premotor changes due to AD might ini-
218
Table 6. Subject-initiated cued behaviors
Control subjects
Subject Frequency Example
1 1 Removing lid from salad container
3 2 Reaching for Jello
Unwrapping cookie
7 1 Opening salad dressing
17 1 Unwrapping cookie
21 1 Reaching for Jello
tially be manifested as slight prolongation or disorgani-
zation of bolus movement in the mouth resulting in an
increased oral transit duration. This may be more promi-
nent with consistencies that require more oral manipula-
tion such as solids or greater oral control such as liquids.
Several reports exist in the literature of coughing
or choking [11,12,34,35] and delayed swallow [11,34] in
late stage dementia. Prolongation of the PRD in the total
sample for a liquid swallow and in the STD and PTD for
cookie in the >70 group represent pharyngeal delay and
may place an individual at increased risk for aspiration
[43]. Robbins et al. [44] have provided evidence in
stroke patients that cortical input plays a role in initiation
of the pharyngeal swallowing response. Our findings
support the notion that premotor cortex involvement,
secondary to AD, may result in delayed initiation.
The findings in our >70-year-old sample are in-
triguing since, despite small numbers of subjects in each
group, several significant group differences were found
that were not present in the total sample group compari-
sons. This finding may be due to the inclusion of 5 AD
subjects <65 years in the total sample. Gradual changes
in swallow durations with age have been reported to
occur sometime after the age of 45 such that individuals
>70 demonstrate significantly longer swallow durations
than 45-year-olds [32]. It is possible that the younger AD
subjects in our sample did have prolongation of some
swallow durations but that these longer durations were
not apparent when compared with older controls whose
durations were prolonged as a result of age-associated
changes. That is, in our sample, the younger AD subject
swallows may be more similar to the older control group
swallows.
Our swallow findings support the findings of two
other studies of swallowing and AD. Horner et al. [19]
performed videofluoroscopic studies on moderate and
severely demented individuals living in both nursing
homes and the community and Feinberg et al. [18] con-
ducted a retrospective chart review of videofluoroscopies
B.A. Priefer and J. Robbins: Eating in Alzheimers Disease
AD subjects
Subject Frequency Example
15 1 Unwrapping cookie
18 1 Removing lid from salad container
19 1 Unwrapping cookie
20 1 Eating first bite of salad
22 1 Pouring salad dressing
23 2 Reaching for Jello
Unwrapping cookies
24 1 Unwrapping cookies
of demented nursing home residents, including AD resi-
dents. Although swallow durations were not quantita-
tively measured in either of these two studies, they both
suggest that AD subjects do have swallowing impair-
ments, and that the most common appear to occur in the
oral phase, in the transition between the oral phase, and
in the initiation of the patterned pharyngeal response.
Neither of these two studies included a control group, but
our study, demonstrating differences in swallow dura-
tions between control subjects and AD subjects, adds
strength to the existing literature demonstrating swallow-
ing changes in AD prior to late-stage disease.
Self-feeding Dependency
We hypothesized that self-feeding dependency would be
present to a greater degree in mild stage AD compared
with older controls as determined by the number of part-
ner-initiated feeding cues or direct assistance provided
by the partner. We found AD subjects significantly more
likely to receive self-feeding cues or direct assistance
from their eating partner than control subjects. Self-
feeding dependency is well documented in late-stage de-
mentia [12,34,35,45]. Ours is the first study to document
a significant difference in self-feeding dependency in
subjects with mild-stage dementia compared with older
adult controls. The partner-initiated cues or assistance
were directed primarily toward self-feeding tasks related
to food preparation such as pouring dressing on the salad.
Task performance can be conceptualized as being
relatively automatic or relatively effortful depending on
the amount of attentional capacity one must use to per-
form the task [46]. Based on the controlled vs. automatic
processing theory proposed by Schifrin and Schneider
[47], Jorm [46] has suggested that individuals with de-
mentia are likely to retain the ability to perform tasks
requiring little conscious thought (automatic tasks) for
longer periods of time than tasks requiring a great deal of
conscious thought processing (controlled tasks). Using
B.A. Priefer and J. Robbins: Eating in Alzheimers Disease
this automatic vs. controlled framework, Patterson et al.
[48] divided ADL tasks into subtasks based on whether
the subtask performance required automatic or controlled
processing. They report that AD subjects required more
assistance to perform subtasks categorized as controlled
compared with those categorized as automatic ADL sub-
tasks. In the current study, self-feeding tasks directed
toward food preparation (opening a packet of dressing
and pouring it on a salad) require more conscious
thought than the actions of transporting the food into the
mouth from the hand or silverware. The majority of part-
ner-initiated cues/assistance were directed, more con-
trolled processing type of self-feeding tasks.
We can describe the partner-initated cues, but we
cannot attribute motive to these cues. We do not know if
the partner-initiated cues were based on the partners
perception that the subject needed help, a genuine need
for help by the subject, or a long-standing behavioral trait
of the partner to take-over and do for another. All AD changes, both swallowing and self-feeding, begin early
subjects ate with spouse-partners and 6 of the 14 control
subjects ate with spouse-partners (9 controls ate with
friend-partners) but only the spouses of subjects initiated
cues. This leads us to speculate that the cueing initiated
by these spouses was based on their perception of a need
for help regardless of whether the need was genuine.
Our finding of subjects using the actions of others
as a cue to initiate an identical action is an example of
imitation, a common behavior used by most people at
one time or other. Imitation is a type of observational
learning which is used extensively in children but also at
all ages of development [49]. Using the behavior of an-
other as a cue for personal action is a useful learning
modality and is likely to occur in unfamiliar social set-
tings when uncertainty exists as to what to do next. This
is highlighted by the fact that 33% of the control subjects
in our study, eating in an unfamiliar social setting, imi-
tated the self-feeding actions of another person. All but 2
of the AD subjects displayed imitating behaviors. This is
not unexpected since a consequence of AD is increased
uncertainty and confusion in unfamiliar settings [50].
The fact that these AD subjects were able to engage in
imitating behaviors is positive in that the ability to imi-
tate is a necessary cognitive skill for successful partner-
initiated cueing when such cueing is necessary.
Cueing and graduated direct assistance (partial to
total assistance) are interventions frequently recom-
mended to maintain ADL functioning in the AD popu-
lation [20,51,52]. The appropriate use of cues and direct
assistance in AD is a challenging issue since cues or
direct assistance can either compensate for a pure dis-
ability and help to maintain independence or they can
contribute to excess disability by providing assistance
beyond what is needed. Videotaping is a powerful tech-
nique for examining the subtasks comprising a self-fed
219
meal and identifying those tasks that are difficult for AD
individuals to perform. This technique also provides an
opportunity for examining those tasks for which caregiv-
ers either cue or provide direct assistance to their AD
spouse. Little is known about the decision-making pro-
cess a caregiver uses in determining when to intervene or
what type of intervention to use when their AD spouse
exhibits self-feeding difficulty. This study was an initial
attempt to determine whether self-feeding dependency
exists in early AD. A future study with a larger sample,
including both mild and moderate stage AD individuals,
is needed to categorize the types of self-feeding actions
that become increasingly dependent on the assistance of
others as the disease progresses. This information will be
valuable in developing appropriate strategies for caregiv-
ers to use in assisting their AD spouses to maximize
independent function and minimize excess disability.
In summary, this pilot study suggests that eating
in the AD process. The following limitations of this
study must be acknowledged. First, because of strict In-
stitutional Review Board scrutiny of protocols including
AD subjects, we used radiographic exposure time con-
servatively. We elected to limit the bolus size to 3 ml and
to have the subject perform only two swallows of each
consistency [53]. Two swallows per consistency allowed
little margin for error and when technical difficulties
arose during second swallows, data were lost. In future
studies, the swallowing protocol will be modified by de-
creasing the number of consistencies to only liquid and
solid and increasing the number of swallows per consis-
tency. Second, subjects were videotaped eating a noon
meal in a setting different from their eating environment.
Partners may have cued AD subjects more frequently
because they did not want their AD spouse to perform
poorly while being videotaped. Though this is certainly a
possibility, it is also important to examine social or pub-
lic dining behavior, since eating in restaurants or in other
peoples homes is likely to be a part of the couples past
experience, and continuation of this activity may depend
on the eating behaviors of the AD individual and the
cueing practices of the caregiver. And finally, since sub-
jects were videotaped eating only one meal, intrasubject
variability was not assessed. Albeit videotaping allows
behaviors to be accurately captured for analysis, the
analysis of these tapes is time intensive [54]. In our
study, meals (first to last bite) averaged 31 min. Raters
spent 48 h per tape coding behaviors. No studies to
date, employing videotape technology to assess eating
behaviors, have provided intrasubject variability data al-
though such information is needed.
This research was conducted at the Wm. S. Middleton Memorial Vet-
220
erans Administration Hospital and supported by the Alzheimers As-
sociation/George E. Connors Memorial Pilot Research Grant. This is
manuscript publication 97-11 from the Madison VA GRECC.
References
1. Kukull WA, Brenner DE, Spech CE, Nochlin D, Bowen J, Mc-
Cormick W, Teri L, Pfanschmidt ML, Larson EB: Causes of
death associated with Alzheimers Disease: impairment before
death. J Am Geriatr Soc 42:723726, 1994
2. Sitzmann JV, Mueller R: Enteral and parenteral feeding in the
dysphagic patient. Dysphagia 3:3845, 1988
3. Bucht G, Sandman PO: Nutritional aspects of dementia, espe-
cially Alzheimers disease. Age Ageing 19:s32s36, 1990
4. Ciocon JO: Indications for tube feedings in elderly patients.
Dysphagia 5:15, 1990
5. Litchford MD, Wakefield LM: Nutrient intakes and energy ex-
penditures of residents with senile dementia of the Alzheimers
type. J Am Diet Assoc 87(2):211213, 1987
6. Singh S, Mulley GP, Losowsky MS: Why are Alzheimer pa-
tients thin? Age Ageing 17:2128, 1988
7. Volicer L, Seltzer B, Rheaume Y, Fabiszewski K, Herz L, Sha-
piro R, Innis P: Progression of Alzheimer-type dementia in in-
stitutionalized patients: a cross-sectional study. J Appl Gerontol
6:8394, 1987
8. Claggett MS: Nutritional factors relevant to Alzheimers dis-
ease. J Am Diet Assoc 89(3):392396, 1989
9. Fairburn CG, Hope RA: Changes in eating in dementia. Neuro-
biol Aging 9:2829, 1988
10. Morris CH, Hope RA, Fairburn CG: Eating habits in dementia:
a descriptive study. Br J Psychiatry 154:801806, 1989
11. Siebens H, Trupe E, Siebens A, Cook F, Anshen S, Hanauer R,
Oster G: Correlates and consequences of eating dependency in
institutionalized elderly. J Am Geriatr Soc 34:192198, 1986
12. Volicer L, Seltzer B, Rheaume Y, Karner J, Glennon M, Riley
ME, Crino P: Eating difficulties in patients with probable de-
mentia of the Alzheimer type. J Geriatr Psychiatr Neurol 2(4):
188195, 1989
13. Athlin E, Norberg A, Asplund K: Caregivers perceptions and
interpretations of severely demented patients during feeding in a
task assignment system. Scand J Caring Sci 4(4):147155, 1990
14. Athlin E, Norberg A: Interaction between the severely demented
patient and his caregiver during feeding. Scand J Caring Sci
1(34):117123, 1987
15. Davies AM, Snaith PA: Mealtime problems in a continuing-care
hospital for the elderly. Age Ageing 9:10015, 1980
16. Sandman PO, Adolfsson R, Nygren C, Hallmans G, Winblad B:
Nutritional status and dietary intake in institutionalized patients
with Alzheimers disease and multiinfarct dementia. J Am Geri-
atr Soc 35:3138, 1987
17. Kolodny V, Malek A: Improving feeding skills. J Gerontol Nurs
17(6):2024, 1991
18. Feinberg MJ, Ekberg O, Segall L, Tully J: Deglutition in elderly
patients with dementia: findings of videofluorographic evalua-
tion and impact on staging and management. Radiology
183:811814, 1992
19. Horner J, Alberts MJ, Dawson DV, Cook GM: Swallowing in
Alzheimers disease. Alzheimer Dis Assoc Disord 8:177189,
1994
20. Gendron M, Levesque L: Evaluating the functional autonomy of
persons with Alzheimers disease: a tool for observing four ac-
tivities of daily living. Am J Alzheimer Care Rel Dis Res
8:2435, 1994
21. Green CR, Mohs RC, Schmeidler J, Aryna M, Davis KL: Func-
B.A. Priefer and J. Robbins: Eating in Alzheimers Disease
tional decline in Alzheimers Disease: a longitudinal study. J Am
Geriatr Soc 41:654661, 1993
22. Akerlund BM, Norberg A: An ethical analysis of double-bind
conflicts as experienced by care workers feeding severely de-
mented patients. Int J Nurs Stud 22(3):207216, 1985
23. Hu T, Huang L, Cartwright SD: Evaluation of the costs of caring
for the senile demented elderly. Gerontologist 26:158163,
1986
24. Hotaling DL: Adapting the mealtime environment: setting the
stage for eating. Dysphagia 5:7783, 1990
25. Aronson MK, Cox C, Guastadisegni P, Frazier C, Sherlock L,
Grower R, Sternberg B, Breed J, Koren MJ: Dementia in the
nursing home: association with care needs. J Am Geriatr Soc
40:2733, 1992
26. Herholz K: FDG PET and differential diagnosis of dementia.
Alzheimer Dis Assoc Disord 9:616, 1995
27. Folstein M, Folstein SE, McHugh PR: Mini-mental state: a prac-
tical method for grading the cognitive state of patients for the
clinician. J Psychiatr Res 12:189198, 1975
28. McKhann G, Drachman D, Folstein M, Katzman R, Price D,
Stadlan EM: Clinical diagnosis of Alzheimers disease: report of
the NINCDS-ADRDA work group. Neurology 258:34113416,
1983
29. Lanska DJ, Schoenberg BS: The epidemiology of dementia:
methodologic issues and approaches. In: PJ Whitehouse (ed.):
Dementia. Philadelphia: F.A. Davis Co, 1993
30. Hughs CP, Berg L, Danziger WL, Coben LA, Martin RL: A new
clinical scale for the staging of dementia. Br J Psychiatry
140:566572, 1982
31. Logemann JA, Kahrilas PJ: Relearning to swallow after stroke-
application of maneuvers and indirect biofeedback: a case study.
Neurology 40:11361138, 1990
32. Robbins JA, Hamilton JW, Lof GL, Kempster G: Oropharyngeal
swallowing in normal adults of different ages. Gastroenterology
103:823829, 1992
33. Marascuilo LA, Serlin RC: Statistical Methods for the Social
and Behavioral Sciences. New York: WH Freeman & Co, 1988
34. Athlin E, Norberg A, Asplund K, Jansson L: Feeding problems
in severely demented patients seen from task and relationship
aspects. Scand J Caring Sci 3(3):113121, 1989
35. Osborn CL, Marshall MJ: Self-feeding performance in nursing
home residents. J Gerontol Nurs 19(3):714, 1993
36. Blass JP: Pathophysiology of the Alzheimers syndrome. Neu-
rology 43(Suppl 4):S25S38, 1993
37. Henderson VW, Finch CE: The neurobiology of Alzheimers
disease. J Neurosurg 70:335353, 1989
38. Martin RE, Sessle BJ: The role of the cerebral cortex in swal-
lowing. Dysphagia 8:195202, 1993
39. Andre J, Car A: Inputs to the swallowing medullary neurons
from the peripheral afferent fibers and the swallowing cortical
area. Brain Res 178:567572, 1979
40. Haxby JV, Grady CL, Koss E, Horwitz B, Schapiro M, Fried-
land RP, Rapoport SI: Heterogeneous anterior-posterior meta-
bolic patterns in dementia of the Alzheimer type. Neurology
38:18531863, 1988
41. Mesulam MM: Patterns in behavioral neuroanatomy: associa-
tion areas, the limbic system, and hemispheric specialization. In:
MM Mesulam (ed.): Principles of Behavioral Neurology. Phila-
delphia: FA Davis, 1985, pp 170
42. Walsh K: Neuropsychology. A Clinical Approach. Edinburgh:
Churchill Livingtone, 1987
43. Robbins J, Levine RL: Swallowing after unilateral stroke of the
cerebral cortex: preliminary experience. Dysphagia 3:1117,
1988
B.A. Priefer and J. Robbins: Eating in Alzheimers Disease
44. Robbins JA, Levine RL, Maser A, Rosenbek JC: Swallowing 49.
after unilateral cerebral stroke. Arch Phys Med Rehab
74:12951300, 1993 50.
45. Van Ort S, Phillips L: Feeding nursing home residents with
Alzheimers disease. Geriatr Nurs 13(5):249253, 1992 51.
46. Jorm AF: Controlled and automatic information processing in
senile dementia: a review. Psychol Med 16:7788, 1986
47. Shiffrin R, Schneider W: Controlled and automatic human in- 52.
formation processing: II. Perceptual learning, automatic attend-
ing, and a general theory. Psychol Rev 84:127190, 1977
48. Patterson MB, Mack JL, Neundorfer MM, Martin RJ, Smyth 53.
KA, Whitehouse PJ: Assessment of functional ability in Alzhei-
mer disease: a review and a preliminary report on the Cleveland 54.
Scale for Activities of Daily Living. Alzheimer Dis Assoc Disord
6(3):145163, 1992
221
Flavell JH: Cognitive Development. Engelwood Cliffs: Prentice-
Hall, Inc, 1985
Hall GR: Care of the patient with Alzheimers disease living at
home. Nurs Clin North Am 23:3146, 1988
Rogers JC, Snow T: An assessment of the feeding behaviors of
the institutionalized elderly. Am J Occup Ther 36(6):375380,
1982
Thralow JU, Rueter MJS: Activities of daily living and cognitive
levels of function in dementia. Am J Alzheimers Care Rel Dis-
ord 7:1419, 1993
Logemann JA: Treatment for aspiration related to dysphagia: an
overview. Dysphagia 1:3438, 1986
Phillips LR, Van Ort S: Measurement of mealtime interactions
among persons with dementing disorders. J Nurs Meas 1:4155,
1993