Managing Tactile Defensiveness in Treatment of Dysphagia

Question

Answer

Tactile defensiveness and spitting food out of the mouth are common behaviors in individuals in the middle and severe stages of dementia. Senses are heightened significantly and the individual seeks immediate and sensory gratification with negative reactions to "noxious" stimuli. Noxious stimuli may consist of certain food textures, food dislikes from childhood or other earlier time period, or foods void of taste. Often the individual with dementia can only detect sweet tastes, thus all other food tastes are avoided or "spit out." This is but one example of the moderate to profound sensory deprivation across the sensory categories of temperature, cutaneous pressure and taste sensors over the course of dementia

Specific Considerations for Treatment may include:

Direct Treatment:

1. Light and deep pressure stimulation for restoration of cutaneous pressure sensory function;
   
2. Thermal (warm/cold) applications to the tongue
   
3. Thermal stimulation of the styloglossus and glossopalatine muscles of the tongue, which are responsible for elevating and retracting the posterior 1/3 of the tongue.
   
4. Dietary management with favorite foods and food texture

1. Since individuals detect only sweet tastes, all food items can be sweetened with honey, sugar, or artificial sweetener.

• Dysphagia treatment for lingual sensory integration to facilitate improved oral motor control of the food bolus (earlier stages)
  
• Thermal therapeutic exercises to the styloglossus and glossopalatine muscles to restore posterior lingual elevation function during mastication.
  
• Thermal therapeutic exercises to the posterior 1/3 of the tongue to restore pressure/ thermal/taste sensory receptors to elicit posterior lingual elevation during mastication
  
• Diet management for prescribed diet of _________ (insert recommended diet) with caregiver training, compensatory strategies, and development of a Functional Maintenance Program.

• Monitor food and fluid intake
  
• Increase caloric intake (I.e., double desserts; add butter, gravy, cream; provide fortified high calorie breakfast cereals and bars; add syrup; double breakfast foods
  
• Provide finger foods as they are easier to chew and eat using hands. Examples of finger foods include: Fruit turnover (instead of fruit cobbler); Cheese cubes and fruit wedges (instead of cottage cheese plate); Tarts (instead of pie); Place ground foods onto small sandwiches (ground salami or hot dog and bean into a sandwich instead of hot dog and bean plate); and Ice cream sandwich (instead of ice cream cup)
  
• Provide foods 24/7
  
• Serve meals in the same time and order each day
  
• Serve everyone seated at the table at the same time
  
• Provide one item at a time
  
• Use brightly colored tablecloths/contrasting plates (need to differentiate food from nonfood-figure ground discrimination dysfunction)
  
• Feed the patient in the same place and if possible have the same individual feed the patient each meal
  
• Do not allow interruptions during the meal and eliminate distractions (T.V., radio)
  
• Provide a model of scooping food and placing it in the mouth (can place a spoon in patient's hand)
  
• Pair touch with initiation of feeding
  
• Offer drinks during the meal
  
• Watch for cues from the patient that he/she wants additional food
  
• Need to be aware of patients that swallow without chewing and are at risk for choking on chunkier items