As previously stated, I’ve been doing a LOT of visual swallow studies. Mostly with group home residents who have developmental disabilities.
What am I doing exactly? I don’t have access to FEES or MBS, so I’m basically doing a bedside evaluation. The outcome of which is USUALLY: refer for a FEES or MBS, refer for skilled speech language services to train in safe swallow strategies, diet modification, meal time modification, or no changes!
So here’s how it goes:
1. I generally start with an oral motor examination. This tends to be slightly difficult because this population of older adults (usually 50-60ish) with developmental disabilities didn’t HAVE access to early intervention – and in some cases any intervention at all. So the cognitive skills, the ability to follow simple one step directions with verbal, visual, and tactile cues: not really present. Sometimes they are able to imitate me and in some cases they are able to follow directions (but not always – I don’t count on it.) So at the least I try to get in and check out dentition and structure (size of tongue in relation to oral cavity, lip seal, tone etc.) It’s important to note whether the patient is able to follow directions because this is going to be a major factor in whether I think they’d benefit from skilled speech therapy services focusing on compensatory manuevers.
2. I check out language skills. As with the cognition – a lot of my patients don’t have strong receptive or expressive language. I want to be able to say in my report what their language is like, how do they communicate.
3. I chat with caregivers while the patient is eating. I want to know: Where do they eat their meals? What diet are they on? What kind of supervision do they receive? Have they had previous swallow studies? Previous swallow difficulties? Do they have special tools for eating? (Divided plate, cutlery with handles) Do they avoid giving this person any types of food and why? Is how they’re eating today comparable to their normal habits? What kind of prompts are given to this person and what is their response? Have they seen any signs/symptoms of aspirations/penetration?
Also in the group homes in Delaware the patients are given a “Choking Risk Assessment” – I like to get a copy of that report as well as their most recent nursing assessment. Often times what the nursing assessment says about the person’s diet is different than what the caregivers report and that is important to know.
4. While I’m chatting I’m also checking out the person eating their lunch. I note all foods and drinks trialed and response. Rate, signs/symptoms of asp/penetration, time to initiate swallow, prompts required and response to prompts, peri and inter oral residues, laryngeal excursion. Do they talk while they eat? How is their voice? How is respiration? Rotary chew? Tongue thrust/delayed swallow pattern?
5. Then if I see anything that concerns me, I try out some strategies. If they have the cognition I may try a superglottic swallow, chin tuck, head turn – whatever I think would work best. I might try to encourage small sips, small bites, alternating bites and sips. Here I also check comprehension – do they have a concept of “small” or “slow”? Or are we just saying “Small bites!” over and over to no avail? I’ll try out some different prompting strategies and see how they respond. I may try breaking their meals into smaller portions or bites.
6. I summarize my findings and discuss with caregiver. Generally I provide them with an outline of the National Dysphagia Diet (circling the one I recommend), a list of typical swallow function in older adults, and I may give them something to try out like a visual pacer they could laminate.
7. I write!
Now, I have about an hour for an actual evaluation and it pretty much takes that entire time. Honestly the most common dysphagia I see with this population is RAPID stuffing of food and gulping of liquids. Very impulsive and highly motivated by food. I have never in my life seen this before so the first time it was a REAL SHOCKER. I try to avoid diet modifications because I think diet has a major effect on quality of life, but I will do it for the safety of the person. Usually with the rapid stuffing I recommended 1:1 supervision, with consistent prompts to slow, wait, stop, chew, etc. I also recommend that meals be presented in portions – just a little at a time! Liquids included! They don’t need their entire meal at once. And often cutting food into small bite sized pieces helps slow them down a little.
I’m really enjoying these evaluations so if you have any questions please feel free to ask! Or give me ideas! I love ideas!