In rehab settings, therapy needs to be considered restorative (to return to prior level of functioning-prior to hospitalization). The Level of Cognitive functioning is critical to progress
What has been described as swallowing dysfunction in young persons may not be abnormal in very elderly persons. It is difficult to distinguish the effect of normal aging from the effects of specific diseases or gradual degenerative changes. Preliminary observations on the effects of age on oropharyngeal deglutition Julie F. Tracy, Jeri A. Logemann, Peter J. Kahrilas, Pothen Jacob, Mindy Kobara and Christine Krugler, Dysphagia, Volume 4, Number 2 / June, 1989 Five measures were significantly changed with increasing age: — 1. Duration of pharyngeal swallow delay (increased) — 2. Duration of pharyngeal swallow response (decreased) — 3. Duration of cricopharyngeal opening (decreased) — 4. Peristaltic amplitude (decreased) — 5. Peristaltic velocity (decreased)
Speech Evaluation: Includes an assessment of ◦ General Neurological functioning ◦ Cognitive Ability* ◦ Feeding and Swallowing Function* ◦ Language Ability, Receptive/Expressive/Pragmatic *Common sense observations: Handedness, Hemiplegic, Weakness, Balance, coordination : How does their skin look? Are they dehydrated?
Formal MEASURES: Cognitive Linguistic Quick Test Bedside screening (in handout) Functional Communication Profile Language -Cognitive-Communication Eval Aphasia Tests are not normed for Dementia or TBI, but may provide information on language abilities. Aphasia, Apraxia, Cognitive disorders and Progressive Dementias may co-occur
ASPECTS OF COGNITIVE PROCESSES Constantinidou and Best (2004) Domains of Cognitive Functions I. Attention- ORIENTING, EXECUTIVE FX AND ALERTING networks I. Distracted periodically throughout the meal II. Memory III. Verbal Language IV Means of learning and organizing new info in the brain (assigning new info into groups=categorization) V. Abstract Thought- most difficult Additionally: Psycho social- anxiety and depression Lack of Functional Social-Communication may negatively effect prognosis.
Restorative –improve skills through repetition Dynamic aggressive rehab, good potential for learning. Compensatory- developing strategies :notebook, communication device Adaptation-adapting to the environment or physical condition, caregiver education, strategies to reduce further dysfunction Cognitive prerequisites for effective feeding rehabilitation are alertness and attention.
In skilled nursing-many clients with dementia will not be considered rehab candidate. Difficulty following commands and cannot perform swallowing exercises even with modeling.
Oral motor assessment-if diagnosis of dementia, may have to be informal (observation) rather than formal. Speech and Language Assessment- if diagnosis of dementia, will need to document items that CNT
Oral motor assessment-may be informal, depending on cognitive skills Food trials Liquid trials Often client with dementia will refuse to eat/drink…need to get family involved. Most often they will accept food from family member rather than stranger.
Rehab- restorative? Many times candidacy for dysphagia therapy is based on cognitive abilities-client needs to be able to follow directions to engage in swallowing exercises to improve function. If not candidate, may have to determine appropriate diet consistency
Often cannot follow commands, so eval is more informal..need to observe: Teeth or edentulous Rate of intake/impulsivity..if they can self feed, you might recommend supervision at meals and small bites at a time or for liquids,no straw Pocketing-cheeks? Lingual residue
Timely swallow or hold food in mouth-many clients with dementia require verbal cues to swallow Positioning in bed or wheelchair Can they remove food from utensil Mastication skills-timely? Many clients with dementia will masticate food for long periods of time
If severe oral stage dysphagia –may recommend puree. If difficulty masticating regular solids may recommend mechanical soft. If facial weakness, may recommend thickened liquids. If severe pharyngeal stage dysphagia may recommend MBS (if suspect pain) or possibly NPO. Possibly thickened liquids. Often with severe dementia, client may have PEG. SLP determines if client remains NPO or pleasure feeds for quality of life (family often involved).
Client coughing on foods/liquids Poor PO Weight Loss New admission or readmission-need to clarify diet