Dysfunction in executive control is evident early and is characterized by disorganized thought, behavior, and emotion. Characteristics include a slow, stepwise, and fluctuating progression with memory frequently mildly affected. Vascular dementia may result from multiple cortical or lacunar infarcts, a single strategically placed infarct, or microvascular disease. Neurologic characteristics include fluctuating cognitive ability, visual hallucinations, spontaneous parkinsonism, sleep disturbance, and reduced ability to perform activities of daily living. Many patients with Lewy body dementia have first-degree relatives with Parkinson's disease or dementia. Lewy body dementia, as with AD and FTD, is typically sporadic but may also be familial. Symptoms of FTD include personality changes, mental rigidity, decreased language, stereotyped behavior, hyperorality, and decreased ability to perform activities of daily living. Frontotemporal dementia may co-occur with amyotrophic lateral sclerosis, which is discussed later. As with AD, the occurrence of FTD is primarily sporadic, but familial occurrence due primarily to the tau gene mutation is also evident. ![]() Age is the major risk factor of AD with occurrence increasing exponentially after the age of 65 years however, in the familial variant, onset is earlier.įrontotemporal dementia ( FTD) is associated with severe atrophy of the frontal and temporal lobes with prominent changes in behavior. As the disease progresses, symptoms include inability to complete activities of daily living, agitation, and mutism. Initial symptoms include decreased recent memory and anomia. ![]() Alzheimer's disease is generally sporadic, but a familial autosomal dominant variant has been identified. Neuritic plaques and neurofibrillary tangles are the neuropathologic hallmarks of AD and result in severe brain atrophy with widened sulci and gyri shrinkage. 4Īlzheimer's disease ( AD) is the most common type of dementia. ![]() Deficits in transfer of the bolus in the oral cavity are also prominent. Patients with dementia not only have problems with swallowing but also with feeding in that they may have limb apraxia affecting their ability to use eating utensils and agnosia affecting their ability to recognize and accept food. 4ĭementia is characterized by a decline in one or more major cognitive domains (i.e., language, visuospatial functions) accompanied by impairment in memory. Swallowing abnormalities in stroke are variable and may include oral lateral sulci retention, delayed oral transfer, delayed elicitation of a pharyngeal swallow, decreased hyolaryngeal elevation, and aspiration. With a lateral medullary infarct, neurologic presentation may include ataxia, reduced ipsilesional limb pain and temperature sensation, reduced contralesional pain and sensation of the trunk and limbs, and ipsilesional velar, pharyngeal, and laryngeal paralysis. With a supratentorial infarct, symptoms may include ipsilesional hemiparesis, dysarthria, aphasia, and hemispatial neglect. Neurologic symptoms of stroke vary depending on the specific location of stroke. 3 Eighty percent of strokes are secondary to ischemia, which results from internal carotid artery atherosclerosis or cardiac embolism, whereas hemorrhage accounts for 20%. Stroke affects 2000 people per million worldwide each year 2 and approximately 700,000 individuals in the United States annually. Patients with oropharyngeal dysphagia owing to CNS lesions are best managed by a team approach including a speech pathologist, neurologist, and gastroenterologist.When significant aspiration cannot be prevented, alternatives to oral feeding such as percutaneous endoscopic gastrostomy ( PEG) tube placement should be considered.Videofluoroscopy and videoendoscopy are also valuable in identifying and teaching maneuvers that may facilitate swallowing and prevent aspiration in a patient.Videoendoscopy may also be useful in certain circumstances. Diagnosis of swallowing dysfunction requires careful history and clinical examination, but videofluoroscopy is the gold standard for characterizing the specific abnormality.The swallowing abnormalities in CNS disorders are generally not specific to the type of neurologic disorder.Aspiration is the most clinically significant consequence of dysphagia. Functional swallowing abnormalities include disordered preparatory phase, poor bolus control, difficulty initiating a swallow response, and decreased hyolaryngeal elevation.Degenerative disorders are usually progressive. Stroke is the most common type of nondegenerative disorder.Degenerative disorders are further subclassified based on their main clinical presentation into dementia, movement disorders, and others. For clinical purposes, the disorders can be classified as nondegenerative or degenerative. ![]() Many disorders of the central nervous system ( CNS) can cause oral and pharyngeal dysphagia.
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