magistrsko delo
Alja Lia Gržinič (Author), Irena Hočevar-Boltežar (Mentor), Zvezdan Pirtošek (Co-mentor)

Abstract

Demenca je izjemno heterogena motnja z vrsto različnih simptomov. Med te sodijo tudi motnje požiranja, ki se pogosto pojavljajo pri osebah z demenco različnih oblik. Težave, vezane na požiranje, se razlikujejo glede na obliko demence, hkrati pa tudi glede na napredovalost demence, pri čemer so ponavadi izrazitejše v kasnejših oziroma bolj napredovalih fazah bolezni. V prvem delu teoretičnih izhodišč, ki se je osredotočal na požiranje, smo najprej opisali proces požiranja, in sicer anatomijo ter faze normalnega požiranja. Nadaljevali smo z motnjami požiranja, v sklopu katerih smo predstavili epidemiologijo in etiologijo težav, nevrogene motnje požiranja, klinične simptome, ki nakazujejo na moteno požiranje ter diagnostiko slednjega. V drugem delu teoretičnih izhodišč smo se posvetili demenci in njenim najpogostejšim oblikam. V začetku smo opisali klinično prezentacijo demence in razlike med slednjo ter blago kognitivno motnjo, nato pa smo podrobneje predstavili štiri izmed najpogostejših oblik demence: Alzheimerjevo bolezen, demenco z Lewyjevimi telesci, vaskularno demenco in frontotemporalno demenco. V tretjem delu teoretičnih izhodišč smo združili spoznanja iz prvega in drugega poglavja ter pri vsaki izmed opisanih oblik demence navedli motnje požiranja, ki so zanjo najbolj značilne. V sklopu empiričnega dela naloge smo želeli ugotoviti, katere težave s požiranjem so značilne za vsako izmed najpogostejših oblik demence, ali je izrazitost težav s požiranjem povezava z napredovanjem demence ter ali se dojemanje težav s požiranjem med bolniki in svojci razlikuje. Naš vzorec je sestavljalo 61 bolnikov z demenco in njihovih svojcev, ki so v času našega raziskovanja obiskali Ambulanto centra za kognitivne motnje na Nevrološki kliniki UKC Ljubljana. Sodelovanja niso bili zmožni 4 bolniki, zato smo v teh primerih pridobili samo oceno svojcev. Težave s požiranjem smo merili z lestvico FOIS in vprašalnikom EAT-10+, ki smo ga oblikovali na podlagi že obstoječega vprašalnika EAT-10. Slednjemu smo dodali 3 vprašanja in 10 postavk, ustvarjenih na podlagi značilnosti težav s požiranjem pri demenci, opisanih v literaturi. Vprašalnik EAT-10+ in lestvico FOIS so bolniki izpolnili sami zase, svojci pa so se pri ocenjevanju težav nanašali na to, kar opažajo pri svojem bližnjem z demenco. Preostali podatki, ki so nas za namene raziskave zanimali, so bili rezultat na testu kognicije – kratkem preizkusu spoznavnih sposobnosti (KPSS), rezultat na montrealski lestvici spoznavnih sposobnosti (MoCA), indeks medialne temporalne atrofije (MTA), rezultat lumbalne punkcije, motnja govora in oblika demence. Slednje smo pridobili s pomočjo pregleda medicinske dokumentacije. V našem vzorcu so se težave s požiranjem pojavljale pri 29,5% bolnikov. Izsledki raziskave so pokazali, da so se pri osebah s patologijo Alzheimerjeve bolezni najpogosteje pojavljale težave, kot so kašljanje pri ali po požiranju, zmanjšana želja po hrani, napor ob požiranju tablet, podaljšano trajanje postopka žvečenja in oblikovanja grižljaja, napor ob požiranju čvrste hrane, potreba po večkratnem požiranju oziroma zalivanju hrane z vodo, da gre v celoti naprej po žrelu, težave z žvečenjem in napor ob požiranju tekočin. Pri osebah z ostalimi oblikami demence (vaskularna in mešana demenca) so prevladovale težave s požiranjem čvrste hrane, pojavljale pa so se tudi težave s kašljanjem pri ali po požiranju in podaljšanim trajanjem postopka žvečenja ter oblikovanja grižljaja. Ugotovljeno se sklada s tem, kar je o motnjah požiranja pri Alzheimerjevi bolezni in vaskularni ter mešani demenci napisano v literaturi. Pri analizi povezanosti med izrazitostjo težav s požiranjem in napredovanjem demence smo dobili mešane rezultate. Povezanost med samooceno požiranja bolnikov in rezultatom na testu KPSS je bila pozitivna, torej v nasprotju s pričakovanim in literaturo. Nasprotno pa je bila povezanost med oceno požiranja, ki so jo podali svojci in rezultatom na testu KPSS negativna oziroma obratno sorazmerna, kar se sklada s pričakovanim in literaturo. Pozitivno povezanost smo odkrili tudi med oceno bolnikov in oceno svojcev ter rezultatom na testu MoCA, kar je bilo ponovno v nasprotju s pričakovanim in literaturo. Potrebno pa je poudariti, da so bile vse povezave šibke (med 0,1 in 0,3) in statistično nepomembne. Glede na to, da nižji rezultat na testih KPSS in MoCA pomeni večje napredovanje demence, višji rezultat na EAT-10+ pa izrazitejše težave s požiranjem, smo pričakovali, da bo povezava med obema testoma in postavkami vprašalnika negativna oziroma obratno sorazmerna. Rezultate, ki niso v skladu s teorijo, si razlagamo z lastnostmi našega vzorca, in sicer s stopnjo napredovanja demence pri bolnikih, ki so ga sestavljali. Velik delež je namreč še na stopnji blagih kognitivnih deficitov, kjer težave s požiranjem še niso tako očitne oziroma izrazite. Smo pa rezultate, ki so skladni s pričakovanim in teorijo, odkrili pri povezavi med indeksom MTA in izrazitostjo težav s požiranjem. Med njima je bila pozitivna povezava, kar pomeni, da večja atrofija hipokampusa oziroma bolj napredovala demenca pomeni večje težave s požiranjem. Nazadnje so nas zanimale še razlike v dojemanju težav s požiranjem med bolniki in njihovimi svojci, kjer smo ugotovili, da so pri vsaki izmed postavk EAT-10+, razen pri eni postavki, svojci v povprečju podajali višje ocene kot bolniki, kar pomeni, da svojci bolnikove težave s požiranjem dojemajo kot bolj izrazite v primerjavi z bolniki samimi. Naša raziskava predstavlja prvi korak k sistematičnemu razumevanju motenj požiranja pri osebah z demenco v slovenskem prostoru. Dobljeni izsledki osvetljujejo razsežnost in kompleksnost te pogosto spregledane težave, hkrati pa postavljajo temelj za prihodnje raziskovalno in klinično delo. Nadgradnja tovrstnih spoznanj bo v prihodnje ključna, tako za poglabljanje strokovnega znanja, kot tudi za zagotavljanje multidisciplinarne obravnave, katere nepogrešljiv član je tudi logoped, saj je taka obravnava za zdravje in boljšo kvaliteto življenja bolnikov nujno potrebna.

Keywords

požiranje;disfagija;demenca;Alzheimerjeva bolezen;EAT-10;

Data

Language: Slovenian
Year of publishing:
Typology: 2.09 - Master's Thesis
Organization: UL PEF - Faculty of Education
Publisher: [A. L. Gržinič]
UDC: 61(043.2)
COBISS: 248157443 Link will open in a new window
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Downloads: 31
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Other data

Secondary language: English
Secondary title: Swallowing disorders in people with dementia
Secondary abstract: Dementia is an extremely heterogeneous disorder with a wide range of symptoms. Among these are swallowing disorders, which often occur in individuals with various forms of dementia. Swallowing related difficulties vary depending on the type of dementia, as well as on the stage of the disease, typically more pronounced in the later or more advanced stages. In the first part of the theoretical framework, which focused on swallowing, we began by descibing the process of swallowing – specifically, the anatomy and the phases of normal swallowing. We then continued with swallowing disorders, covering the epidemiology and etiology of these issues, neurogenic swallowing disorders, clinical symptoms indicating impaired swallowing, and diagnostic methods. In the second part of the theoretical framework, we focused on dementia and its most common forms. We started by describing the clinical presentation of dementia and the differences between dementia and mild cognitive impairment, then provided a more detailed presentation of four of the most common forms of dementia: Alzheimer's disease, dementia with Lewy bodies, vascular dementia, and frontotemporal dementia. In the third part of the theoretical framework, we brought together the insights from the first and second chapters and, for each of the described types of dementia, outlined the swallowing disorders most characteristic of that specific form. As part of the empirical section of the thesis, we aimed to determine which swallowing problems are characteristic of each of the most common forms of dementia, whether the severity of swallowing problems is related to the advancement of dementia, and whether patients and their relatives perceive these difficulties differently. Our sample consisted of 61 patients with dementia and their relatives, who visited the Outpatient Department of the Center for Cognitive Disorders at the Neurology Clinic of the University Medical Center Ljubljana during the time of our research. Four patients were unable to participate, so in those cases only the relatives' assessments were obtained. Swallowing difficulties were measured using the FOIS scale and the EAT-10+ questionnaire, which we developed based on the existing EAT-10 questionnaire. To the latter we added 3 questions and 10 items, which were created based on the characteristics of swallowing difficulties in dementia as described in the literature. The patients completed the EAT-10+ questionnaire and the FOIS scale for self-assessment, while the relatives based their evaluations on their observations of the swallowing difficulties present in their relative with dementia. Other data of interest for our research included the results of the KPSS cognitive test, the MoCA cognitive test, the MTA index, lumbar puncture results, type of speech disorder and the type of dementia. This information was obtained by reviewing medical records. In our sample, swallowing difficulties were present in 29.5% of patients. The findings of the study showed that individuals with Alzheimer’s disease pathology most frequently experienced symptoms such as coughing during or after swallowing, reduced appetite, difficulty swallowing pills, prolonged chewing and bolus formation, effortful swallowing of solid foods, the need for multiple swallows or washing food down with water to help it pass through the throat, problems with chewing, and effortful swallowing of liquids. Among individuals with other types of dementia (vascular and mixed dementia), the most common issues were related to swallowing solid foods, along with coughing during or after swallowing and prolonged chewing and bolus formation. These findings are consistent with the existing literature on swallowing disorders in Alzheimer’s disease and vascular/mixed dementia. In the analysis of the relationship between the severity of swallowing difficulties and the advancement of dementia, we obtained mixed results. The correlation between patients’ self-assessment of swallowing and their score on the KPSS test was positive, which is contrary to expectations and existing literature. On the other hand, the correlation between caregivers’ assessment of swallowing and the KPSS test score was negative, or inversely proportional, which is in line with expectations and literature. A positive correlation was also found between the patients’ and caregivers’ assessments and the MoCA test score, which again contradicted expectations and previous research. However, it is important to emphasize that all correlations were weak (between 0.1 and 0.3) and statistically insignificant. Given that a lower score on the KPSS and MoCA tests indicates more advanced dementia, and a higher score on the EAT-10+ indicates more severe swallowing difficulties, we expected a negative or inverse correlation between the two tests and the questionnaire items. We interpret the results that do not align with theoretical expectations as being influenced by the characteristics of our sample; specifically, the stage of dementia of the patients included. A large proportion of them are still at the stage of mild dementia, where swallowing difficulties are not yet as apparent or pronounced. On the other hand, we found results that are consistent with expectations and theory in the correlation between the MTA index and the severity of swallowing difficulties. There was a positive correlation between the two, meaning that greater hippocampal atrophy and thus more advanced dementia is associated with more severe swallowing difficulties. Finally, we also examined differences in the perception of swallowing difficulties between patients and their caregivers. We found that for each item on the EAT-10+, except one, caregivers on average gave higher ratings than patients. This suggests that caregivers perceive patients’ swallowing difficulties as more severe than the patients perceive them themselves. Our research represents the first step toward a systematic understanding of swallowing disorders in individuals with dementia within the Slovenian context. The findings shed light on the scope and complexity of this often overlooked issue, while also laying the groundwork for future research and clinical work. Building upon this knowledge will be essential in the future, not only for deepening professional expertise, but also for ensuring multidisciplinary care, in which the speech and language therapist plays an indispensable role, as such care is crucial for the health and improved quality of life of patients.
Secondary keywords: swallowing;dysphagia;dementia;Alzheimer’s disease;EAT-10;Demenca;Univerzitetna in visokošolska dela;
Type (COBISS): Master's thesis/paper
Study programme: 0
Thesis comment: Univ. v Ljubljani, Pedagoška fak., Logopedija in surdopedagogika
Pages: 1 spletni vir (1 datoteka PDF (125 str.))
ID: 27387681