SLP in acute care

what is communication impairment

an impairment in the ability to receive, send, process, and comprehend concepts or verbal, nonverbal and graphic symbol systems…may be evident in the process of hearing, language, and/or speech

results from damage to parts of brain that contain language

communication impairment is either

developmental or acquired

can pts have more than 1 communication disorders

yes, they can demonstrate one or any combo

what are causes of communication impairments

stroke

tumors

TBI

progressive neurological disease

what is aphasia

type of communication impairment results from damage to parts of the brain that contain language

causes of aphasia

stroke

tumor

TBI

progressive neurological disease

what do symptoms of aphasia depend on

location and extent of damage

how are symptoms of aphasia classified as

fluent and non-fluent behaviors

specific types: Broca’s, Wernicke’s, Global, conduction, anomic, transcortical sensory, transcortical motor

what are characteristics of aphasia

difficulty producing language, difficulty understanding language, difficulty reading/writing

difficulty producing language means

word finding deficits, word substitutions, sound substitutions, neologisms, difficulty sequencing words, adjoining nonsense words

difficulty understanding language means

inability to follow directions/answer yes or no questions

losing meaning with rapid speech or increased utterance length; misinterpreting jokes or taking things too literally

what are considerations for treating aphasia in inpatient setting

can pt tolerate treatment

do these pts have medical and/or cog deficits

is he/she dealing with psych impact of stroke (disbelief, anger, guilt, depression, isolation, panic, and hope)

what is dysarthria

motor speech disorder that results from impaired movement of the muscles used for speech production, including lips, tongue, vocal folds, and/or diaphragm

causes for dysarthria

stroke

TBI

tumors

Parkinson’s

amyotrophic lateral sclerosis (ALS)

Huntington’s disease

Multiple Sclerosis (MS)

dysarthria is categorized by

location of damage and resulting primary deficit

6 types of dysarthria

flaccid

spastic

ataxia

hypokinetic

hyperkinetic

unilateral UMN

mixed

what are characteristics of dysarthria

generally difficult to understand

“slurred”, “choppy”, or “mumbled” speech

slow rate of speech

rapid rate of speech with a “mumbling” quality

limited tongue, lip, and jaw movement

abnormal pitch and rhythm when speaking

changes in vocal quality (ex: hoarse, breathy, hypernasal, hyponasal)

apraxia of speech (AOS)

neurologic speech disorder that reflects impaired capacity to plan or program sensori-motor commands necessary for directing movements that results in phonetically and prosodically normal speech

what are the causes of apraxia

stroke

TBI

tumor

surgical tumor

neurodegenerative diseases

what are salient features of apraxia

reduced overall speech rate

phoneme distortions and substitutions, additions, or complications

syllable segregation with extended intra- and inter- segmental durations

equal stress across adjacent syllables

other characteristics of apraxia

articulation

fluency

rate and prosody

what are characteristics of articulation in apraxia

consonant errors greater than vowel errors

voicing errors

prolonged phonemes

telescoping syllables (dinsar instead of dinosaur)

what is the characteristics rate and prosody

slow

what are the characteristics of fluency

disrupted fluency at attempts at self-concern

silent or audible groping behaviors marked by false starts and restarts

what are strategies to increase communication

establish pt’s attention

slow speech down

minimize/eliminate background noise as able

keep voice at normal level of volume

keep communication simple but adult

use “yes” and “no” questions

break down single step directions & be aware of time it takes to do so

if don’t understand pt, be direct and say so

emphasize key words

‘sign post’: tell topic before you begin ex: we are going to bathroom

what are the factors impacting communication in acute care setting

pt

environment

clinician

what are the patient factors that impact communication in acute care

presence of communication and/or cog impairment

delirium

what are the environmental factors impacting communication in acute care

family presence

physical environment

hospital system

what are the clinician factors impacting communication in acute care

knowledge

communication skills

attitudes/bias

individual characteristics

what is dysphagia

a swallowing disorder. the signs and symptoms may involve mouth, pharynx, larynx, and/or esophagus

what are the terms related to dysphagia

PO

NPO

NG

PEG

what is PO (per os)

indicate oral intake

what is NPO (nil per os)

nothing by mouth

what is NG

nasogastric feeding tube

temporary

what is PEG

Percutaneous endoscopic gastrostomy feeding tube

permanent

what are the 5 categories of the causes of dysphagia

neurogenic

structural

surgical

medical treatments

other

what are the neurogenic causes of dysphagia

stroke

dementia

neurodegenerative diseases

brain tumor

spinal cord injury

TBI

what are the structural causes of dysphagia

head/neck cancer and treatment effects

Zenker’s diverticulum

cervical neck disease

oral/facial or neck trauma

vocal fold paralysis

what are the surgical causes of dysphagia

laryngectomy

glossectomy

esophagectomy

tracheostomy

what are the medical treatments causes of dysphagia

post intubation

radiation

medications

what are the other causes of dysphagia

psychogenic

infections

inflammations

skin, GI, or connective tissue diseases

what are factors affecting swallowing in acute care setting

primary diagnosis

endotracheal intubation

extubation

tracheostomy

tracheostomy with mechanical ventilation

critical illness/injury

deconditioning

what are complications of dysphagia

safety and efficiency of oral intake

nutritional compromise

what are the safety and efficiency of oral intake complications with dysphagia

respiratory problems (aspiration pneumonia) -safety

airway obstruction -efficiency

what are the nutritional compromise complications of dysphagia

malnutrition

dehydration

what are signs of oral dysphagia

drooling

difficulty taking food/liquid from a spoon/straw/cup

food/liquid leaking out of mouth

difficulty moving food around in mouth

difficulty chewing

food/liquid remaining in mouth after swallowing

“pocketing” food in cheeks

food/liquid coming into/out of nose

what are signs of pharyngeal dysphagia

difficulty with initiating swallow

feeling of food/liquid “stuck” in throat

vocal quality changes after eating/drinking

coughing during or after swallowing

throat clearing when eating/drinking

choking/airway obstruction

what are the different ways to evaluate dysphagia

clinical/bedside swallow evaluation

videofluoroscopic swallow study (VFSS/MBS)

fiberoptic endoscopic evaluation of swallow (FEES)

what does the clinical/bedside swallow evaluation entail

includes oral mechanism exam and administration of PO trials

SLP uses clinical judgement to determine most appropriate diet consistency which could be NPO and/or need for use of compensation strategies

what does Videofluoroscopic Swallow Study (VFSS) / Modified Barium Swallow (MBS) entail

objective swallow study completed in radiology in collaboration with radiologist

completed by administering various textures of barium contrast and observing swallow function under fluoroscopy

requires pt to be transported to radiology (must be able to sit upright for at least 20 minutes)

beneficial to rule out silent aspiration

what does Flexible Endoscopic Evaluation of Swallowing (FEES) entail

completed by SLP in pt’s room

flexible endoscope is passed trans nasally without use of anesthetic

positioned to view pharynx, larynx, upper trachea, and upper esophageal sphincter before and after swallow

swallow function is assessed with trails of liquids and foods, often mixed with blue dye

what are management options for dysphagia

basic aspiration precautions

swallowing compensation strategies

diet modifications

dysphagia therapy and exercises

what are basic aspiration precautions for dysphagia

sit upright, small bites/sips, alternate consistencies, eat slowly, wear speaking valve (for tracheostomy)

what are swallowing compensation strategies for dysphagia

chin tuck, turn head to L/R, supraglottic swallow, effortful swallow, multiple swallows, liquids by spoon, no straws

what is an important thing to remember with compensation swallowing strategies and dysphagia

strategy doesn’t work for all pts

same strategy that works for one may not work for another

why are there diet modifications in dysphagia

implemented to increase safety and efficiency of intake

can reduce fatigue which in turn can increase oral intake

can modify liquid, solid, or both as needed based on pt’s individual swallow dysfunction

some pts experience displeasure with modifications which results in reduced oral intake

what is the national dysphagia diet

describes solid and liquid consistencies

not used much anymore

solid and liquid consistencies can occur in multiple combinations based on the evidenced impairment

what are the solid consistencies in the national dysphagia diet

dysphagia diet level 1: pureed textures

dysphagia diet level 2: mechanically altered diet texture

dysphagia diet level 3: advanced textures

regular texture diet

what are the liquid consistencies in national dysphagia diet

pudding thick liquids

honey thick liquids

nectar thick liquids

thin liquids

clear and full liquid diet: imply thin liquids unless otherwise specified

what is the international dysphagia diet standardization project (IDDSI)

a numerical system for foods and drinks consistency

took over national dysphagia diet

food consistency stated first followed by liquid consistency

pt is on a 6-1 diet = soft and bite sized diet and thin liquids

what are the numbers of the IDDSI

7: regular/easy to chew

6: soft and bite-sized

5: minced and moist

4: pureed food/extremely thick liquid

3: liquidized food/moderately thick liquid

2: mildly thick liquid

1: slightly thick liquid

0: thin liquid

what are considerations for IDDSI transition

facility working in may/may not have adopted IDDSI framework

be prepared to hear language indicative of either diet

understand that this is a BIG change for SLPs, RNs, NSTs, and nutrition services

how to thicken liquids

depends on type of thickener

do NOT add ice to thickened liquids

what are dysphagia therapy and exercises

dysphagia therapy is generally a combination of aspiration precautions, compensatory strategies, and/or diet modifications and exercises

diet modifications are usually temporary

many pts spontaneously improve as they recover from their acute illness

oral and pharyngeal strengthening exercises can improve/hasten progress

if pt is known to have risk for silent aspiration, they will require a repeat formal exam (VFSS or FEES) prior to advancing diet

what should the PT know about dysphagia

watch for signs and symptoms of oral/pharyngeal dysphagia in sessions

be aware of pt’s diet level, particularly liquid consistencies (pts will likely ask for water regardless of whether they are able to have or not)

be able to say NO and/or be comfortable letting them know that you are going to check with RN if something seems unclear

be knowledgeable about the complications that arise from aspiration to reinforce education

what are special considerations for dysphagia management

particularly difficult and treatment is physically, mentally, and emotionally demanding

intervention can prompt conversations regarding NG or PEG tube (speech therapists aid MD team in determining most appropriate choice for pt based on extent and severity of deficits)

should a pt require long term diet modifications or NPO recommendation, dysphagia intervention can prompt discussion of _____ ____ ______

goals of care