Download Speech and Language Therapy

Speech and
Language Therapy
Rebekah Traynor
Inpatient and Community, Rugby St Cross
Charlotte Courtney and Emily Davies
UHCW Speech and Language Therapy
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
Prevalence of Dysphagia and
Communication difficulties
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Stroke – 30-40% of conscious individuals have
significant dysphagia on day of stroke and 1520% 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)
Definitions – 5 D’s
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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.
Anatomy of the Swallow
Hard palate
Lips
Tongue
Teeth
Epiglottis
Trachea
Oesophagus
Soft palate
Dysphagia
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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
Symptoms of Oropharyngeal
Dysphagia
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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)
Our assessment options
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Videofluroscopy
Fiberoptic Endoscopic evaluation of swallow –
FEEs
EMG traces
Bedside Swallowing Assessment
Fiberoptic Endoscpoic evaluation of
swallowing and Videofluoroscopy
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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.
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
Bedside assessment
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State
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Alert levels
Positioning
Compliance
Interaction
Fatigue
Control of secretions
Oral Intake Malnourishment
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Oro-motor assessment
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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)
Bedside assessment
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Swallowing assessment
 Anticipatory behaviour
 Manipulation of bolus
 Initiation of swallow
 Suspension of breathing
 Cough/throat clearing
 Number of swallows to
 Cervical auscultation
 Vocal changes
 Residue
 Changes
clear
in O2 saturation - >2% below baseline
(Smith 2000)
Aspiration can not be predicted
from any one sign or symptom
from clinical examination
(ECRI 1999)
It’s not just about
coughing/choking
Outcome
Level of risk based on above signs of
penetration/aspiration.
Mild
Moderate
Severe
 Recommendations:
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 Texture
Modification e.g. thickened fluids
 Swallowing Therapy/ Manoeuvres /Postural
changes
 NBM and alternative feeding
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
Diet
Puree diet (Texture C)
 Soft Moist Diet (texture E)
 Normal diet
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Can be with or without bread
Signs of aspiration
Acute – as seen previously
 Chronic
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 Weight
loss
 Refusal of food
 Recurrent chest infections
 Excess oral secretions
 Avoidance of food textures
Complications of dysphagia
Aspiration Pneumonia
 Malnutrition
 Dehydration
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All the above are preventable
Predictors of Aspiration Pneumonia
Currently 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 TTO’s so the patient
can get it on prescription once home
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Communication
The forgotten Role
On discharge from hospital Mr X
can walk to the shop but can’t
ask for the loaf of bread he
wants.
What do you need to
communicate?
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You need to understand what is being said
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You need to have a means of expressing
your thoughts
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Opportunities
Back to Basics...
Non-verbal
communicatio
n
•eye contact
•gesture
•posture
•facial
expression
Speech
• clarity
• rate
Social/Pragmatic
•appropriateness of content
•staying on topic
•taking turns, listening
•inferring intended meaning
Communication
Reading
and
writing
Voice
•volume
•pitch
•intonation
Language
•understanding
•finding words
•ordering the sounds,
and words in a
sentence
Types of communication difficulties
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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
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Dysarthria – muscle weakness causing slurred
speech
Dyspraxia – difficulty programming the sounds in
a word
How do these difficulties affect
communication?
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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
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
If you’ve met one
person with
aphasia……
You have met one person
with Aphasia
Capacity
Dysphasia does not imply mental
incapacity. People with aphasia can
make informed decisions given the
right support to understand and
express their opinions.
Ten top tips
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Use pen and paper
Draw diagrams or pictures
Say one thing at a time
Don’t 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
Don’t pretend to understand
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
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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
Alzheimer’s disease in Alzheimer’s 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