Today is National Swallow Awareness Day, a day to raise awareness of how speech and language therapists (SLT’s) help people living with eating, drinking, and swallowing difficulties. We are also using this day to raise awareness of the interdisciplinary nature of the management of dysphagia and the role that team members play.
Dysphagia is the medical term for eating, drinking and swallowing difficulties. It can affect people of all ages from neonates through to people at the end of their lives. Dysphagia can arise in a broad range of conditions and at STEPS we assess and manage clients with dysphagia secondary to brain injuries, spinal cord injuries, stroke, and progressive neurological conditions. Dysphagia is a complex condition to assess and manage and SLT’s do not manage this in isolation. The journey from being nil by mouth with a percutaneous endoscopic gastrostomy (PEG) to returning to a full oral diet requires dynamic Interdisciplinary team assessment and management, it involves complex decision making, the nuances of which cannot be fully covered within this blog.
For some clients the journey from being nil by mouth to returning to a full oral diet can be steady with varying speed of recovery, for others progress can be affected by varying health needs and their journey may take longer. Unfortunately, not everyone will be able to return to a full oral diet.
Speech and language therapists are core members of the team when it comes to assessing, diagnosing, and managing dysphagia. Diagnosis is made after extensive case history, an oro-motor assessment and bed side swallow assessment. The gold standard assessment for dysphagia is a video-flouroscopy (xray of the swallow) which provides the IDT with in depth information as to the anatomy and physiology of the swallow and the presence of weakness, reduced coordination and importantly whether there is any aspiration and/or penetration present (aspiration is the term used for material that passes below the level of the vocal cords and penetration is the term used where material stays above the level of the vocal cords). Other instrumental assessments available include Functional endoscopic evaluation of the swallow (FEES) which involves passing an endoscope through the nasal passages to directly view the vocal cords from above.
Following the identification of a dysphagia the speech and language therapists identify the consistencies of food and drink which reduce the risk of aspiration/penetration and enhance client comfort. Depending on the severity of the dysphagia some people may need to be nil by mouth (with artificial nutrition and hydration such as a PEG) as all consistencies pose a risk of aspiration. Aspiration can be a contributory factor in the development of aspiration pneumonia which in some cases can be fatal. At STEPS the SLT team work closely with the client, their relatives, dietitians, and the in-house chefs to ensure the client receives food and drink which is nutritional, appealing and in line with the consistencies recommended.
In line with identifying the optimal food and drink consistencies for a person, speech and language therapists will select therapy techniques aimed to improve the nature of the persons dysphagia. The STEPS speech and language therapy team use traditional swallow therapy techniques as well as AMPCare and iQoro. We also use biozoon which is a suitable low risk option within our toolbox and a good starting point for some clients when it comes to returning to oral intake. Ideally therapy will be intensive with input taking place on a daily basis. This will differ from person to person and depend on their overall health, fatigue, and mood as well as the likely prognosis of the swallow.
The SLT team work closely with the physiotherapy team to better understand the client’s postural profile and how best to support this both within therapy tasks and for oral intake. Where possible clients are encouraged to sit out of bed for meals and physiotherapists and occupational therapists will provide guidelines on achieving the best posture for eating and drinking safely. Poor posture impacts on swallow safety. SLT’s work closely with occupational therapy to identify equipment and cognitive strategies to maximise a person's independence with eating and drinking for example weighted cutlery, the use of external prompts to help someone attend to the side of the plate they may be neglecting secondary to having a stroke.
The nursing and rehabilitation assistant team are essential for supporting the implementation of the recommendations and the day to day monitoring of the persons swallow, providing the team with information as to the intake of the client and whether there are any difficulties being observed. This enables timely re-assessment to reduce the risk of developing a chest infection which can negatively impact on a client’s rehabilitation.
The consultant role in the management of dysphagia is to provide the wider team with information pertinent to the prognosis of the client’s overall condition, the impact of their medication on dysphagia and support discussions relating to complex decision making, for example decisions relating to eating and drinking with acknowledged risks.
Where there are concerns in relation to a client’s mental capacity to make an informed decision about eating and drinking the team will come together to assess this (usually lead by SLT) and with the client, family and wider Interdisciplinary team working in the client’s best interests if it is found that they lack capacity to make an informed decision.
The journey from being nil by mouth with a PEG to being able to return to a full oral diet is different for every client, with each requiring a different dose and intensity of therapy depending on their individual circumstances.