Speech and Language Therapy

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Speech and Language Therapy

• Rebekah Traynor
• Inpatient and Community, Rugby St Cross

Charlotte Courtney and Emily Davies UHCW Speech
and Language Therapy
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A few facts about a normal swallow

• swallowing is a sequence not a reflex
• you swallow your saliva 1000 times a day
• a gag reflex is not an indicator of dysphagia
• pooling can be normal
• up to 2 swallows to clear is normal
• variable no. of chews depending on consistency

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Prevalence of Dysphagia and Communication
difficulties

• Stroke 30-40 of conscious individuals have
  significant dysphagia on day of stroke and 15-20
  one week post (RCSLT 2005)
• 20-30 of stroke survivors experience Aphasia.
• Dementia bronchophneumonia was leading cause of
  death in Alzheimer's disease 28.6 in this study
  were found to be aspirating (Horner et al. 1994)

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Definitions 5 Ds

• Dysphagia - Difficulty transporting
  food/liquid/saliva from mouth to stomach.
• Dysphonia alteration in voice due to abnormal
  pitch, loudness and/or quality resulting from
  disordered laryngeal, respiratory or vocal tract
  functioning.
• Dysarthria neuromuscular speech disorder which
  result from paralysis, weakness or
  inco-ordination of speech muscles.
• Dyspraxia impaired ability to carry out
  volitional movements disorder of motor
  programming.
• Dysphasia Disorder of language processing can
  affect speech, comprehension of speech, reading
  and writing.

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Anatomy of the Swallow
Soft palate
Hard palate
Lips
Tongue
Teeth
Epiglottis
Trachea
Oesophagus
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Dysphagia

• Difficulty transporting food/liquid/saliva
• from mouth to stomach.
• Oral preparatory stage recognition, lip seal,
  chewing, taste.
• Oral stage initiated when tongue manipulates
  bolus. Bolus propelled to pharynx (1-11/2 sec)
• Pharyngeal soft palate elevates, tongue base
  retracts and pharynx wall constricts, Larynx
  prepares for closure, cricopharyngeal sphincter
  relaxes. (1 sec)
• Oesophageal food passes into oesophagus and
  carried by peristalsis into the stomach

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Symptoms of Oropharyngeal Dysphagia

• Aspiration Entry of material into the airway,
  below the true vocal folds
• Penetration entry of material into the larynx at
  some level down to but not below the vocal folds
• Residue material left behind in the mouth or
  pharynx after the swallow
• Reflux (backflow) material from the oesophagus
  into the pharynx or nasal cavity.
• Silent aspiration 40 of patients, who
  consistently aspirate on Videofluroscopy, show no
  signs of doing so at bedside examination
  (Splaingard 1988)

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Our assessment options

• Videofluroscopy
• Fiberoptic Endoscopic evaluation of swallow
  FEEs
• EMG traces
• Bedside Swallowing Assessment

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Fiberoptic Endoscpoic evaluation of
swallowing and Videofluoroscopy

• Gives a moving X-Ray image of the swallow
• Anatomical structures and their movement during
  the swallow can be seen
• Able to view of all stages of swallow Allows for
  differentiation of
• penetration and aspiration of bolus.
• Only able to see a limited number of swallows due
  to radiation exposure times

• Allows a view of the structures and tissues in
  the pharynx/ larynx and a moving image of the
  swallow
• Can be carried out at the bedside
• Can be used for multiple trials of food and
  drink, even a whole meal.

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Bedside assessment

• State
• Alert levels
• Positioning
• Compliance
• Interaction
• Fatigue
• Control of secretions
• Oral Intake - Malnourishment

• Oro-motor assessment
• Oral dyspraxia
• Dysarthria highest predictor of oral stage
  dysphagia compared to facial weakness or reduced
  oral sensation (Logemann 1999)
• Facial weakness
• Dysphonia absence of voice can indicate
  inability to adduct vocal folds, needed for cough
  reflex, therefore reducing airway protection
  (Atkinson McHanwell 2002)

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Bedside assessment

• Swallowing assessment
• Anticipatory behaviour
• Manipulation of bolus
• Initiation of swallow
• Suspension of breathing
• Cough/throat clearing
• Number of swallows to clear
• Cervical auscultation
• Vocal changes
• Residue
• Changes in O2 saturation - gt2 below baseline
  (Smith 2000)

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• Aspiration can not be predicted from any one sign
  or symptom from clinical examination (ECRI 1999)

Its not just about coughing/choking
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Outcome

• Level of risk based on above signs of
  penetration/aspiration.
• Mild Moderate Severe
• Recommendations
• Texture Modification e.g. thickened fluids
• Swallowing Therapy/ Manoeuvres /Postural changes
• NBM and alternative feeding

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Thickened Fluids
Stage I Description Forms a thin coat on the
back of a spoon Can be drunk from a cup Can be
drunk through a straw
Stage II Description Forms a thick coat on the
back of a spoon Can be drunk from a cup Can not
be drunk through a straw
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Diet

• Puree diet (Texture C)
• Soft Moist Diet (texture E)
• Normal diet
• Can be with or without bread

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Signs of aspiration

• Acute as seen previously
• Chronic
• Weight loss
• Refusal of food
• Recurrent chest infections
• Excess oral secretions
• Avoidance of food textures

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Complications of dysphagia

• Aspiration Pneumonia
• Malnutrition
• Dehydration

All the above are preventable
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Predictors of Aspiration PneumoniaCurrently
completing research at UHCW

• Dependence of feeding best single predictor of
  pneumonia
• Dependence of oral care
• Number of decayed teeth
• Tube feeding
• More than one medical diagnosis
• Number of medications
• Smoking
• Langmore 1998

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Please remember

• Include the patients recommendations on the
  discharge letter stage of fluid and type of
  diet, there is no such thing as stage 2 diet!!
• Put thickener on the TTOs so the patient can get
  it on prescription once home

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Communication
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The forgotten Role

• On discharge from hospital Mr X can walk to the
  shop but cant ask for the loaf of bread he wants.

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What do you need to communicate?

• You need to understand what is being said
• You need to have a means of expressing your
  thoughts
• Opportunities

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Back to Basics...
Communication
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Types of communication difficulties

• Aphasia (dysphasia) - breakdown of the language
  centres in the brain and can cause difficulty
  speaking, writing, reading and using numbers.
• Expressive aphasia
• Receptive aphasia
• Global aphasia
• Dysarthria muscle weakness causing slurred
  speech
• Dyspraxia difficulty programming the sounds in
  a word

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How do these difficulties affect communication?

• No speech
• Reduced understanding of language
• Producing the wrong word
• Difficulty finding the word
• Incorrectly saying sounds in words
• Jumbled speech
• Reduced awareness of speech
• Reduced clarity

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What does this mean for the individual?

• Social isolation
• Reduced confidence
• Limited opportunities to talk to people
• Depression
• Strong emotional reactions anger
• Increased dependency

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What you can do
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If youve met one person with aphasia

• You have met one person with Aphasia

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Capacity

• Dysphasia does not imply mental incapacity.
  People with aphasia can make informed decisions
  given the right support to understand and express
  their opinions.

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Ten top tips

• Use pen and paper
• Draw diagrams or pictures
• Say one thing at a time
• Dont rush slow down and be patient
• Write key words
• Always recap to check you both have understood
• Relax be natural
• Ask what helps
• Reduce background noise
• Dont pretend to understand

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Your team at UHCW

• There are 3.4 wte neuro based speech therapists
  to cover the whole hospital
• There is 1.6 wte head and neck SLTs that cover
  ward 32 and head and neck out patients
• We work from 8am - 4pm
• Our guidelines state
• We see stroke patients in 24 hours of referral
• We see all other Dysphaiga in 48 hours of
  referral
• We see communication patients in 5 working days

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References

• ECRI Report (1999) Diagnosis and Treatment of
  Swallowing Disorders (Dysphagia) in Acute-Care
  Stroke Patients. Evidence Report/Technology
  Assessment No. 8. (Prepared by ECRI
  Evidence-based Practice Center under Contract No.
  290-97-0020.) AHCPR Publication No. 99-E024.
  Rockville, MD Agency for Health Care Policy and
  Research.
• Horner , J., Alberts, MJ, Davison, D., cook, GM.
  Swallowing in Alzheimers disease in Alzheimers
  Disease and associated disorders, 1994.
• Langmore, S., Terpenning, M., Schork, A., Chen,
  Y., Murray, J., Lopatin, D., Loesche, W. (1998)
  Predictors of aspiration pneumonia How important
  is Dysphagia? Dysphagia, 13, 69-81
• RCSLT (2005). Clinical Guidelines. Bichester.
  Speechmark