Always the same……
So many people assess dysphagia in the same manner, at least from my observations. Sit with them while they eat a meal, feel laryngeal elevation and trial diet modifications. I have rarely watched SLPs complete a thorough dysphagia bedside evaluation.
I have worked to standardize the manner in which I complete my Clinical Swallowing Evaluation. I have started using the SOPE, the MASA, the EAT-10 and the OHAT during every assessment, along with a thorough chart review and assessing dysphagia risk factors.
I can complete a fairly thorough assessment. The SOPE assesses cranial nerves, taste buds and some muscle function. The OHAT assesses oral cleanliness and need for oral care. The MASA has been a fairly accurate indicator of dysphagia and aspiration. The EAT-10 is a self-assessment tool that the patient can complete.
The Yale Swallow Protocol is a screening tool that can be used by nursing staff and the SLP to determine a need for further evaluation. The Yale can be an indicator of aspiration, as it is believed, people that silently aspirate small amounts of liquid will choke with larger volumes. 3 ounces of water is enough to make a person choke, as it is stated per this protocol that silent aspiration is volume dependent.
It is important to assess cranial nerves and to understand the cranial nerves. For instance CN XII, the hypoglossal nerve has no sensory pathways, only motor. This definitely affects the means by which you will treat.
Another point that can drive your treatment protocol is that sensory input drives motor output. If you can increase the sensory input a person receives you can increase the motoric response.
Cranial nerve assessment is vital in understanding dysphagia. Sensory input such as olfactory and optical help to prepare the person for the swallow by increasing saliva and telling the body that it is going to masticate and swallow food/drink. Changing taste, flavor, temperature, texture and size of bolus can influence a swallow.
You can actually tell a lot about a person by their oral hygiene. You can tell who will qualify for a Free Water Protocol. Also, by oral hygiene, you can make an assumption that the person is at higher risk for aspiration pneumonia because of the poor hygiene of the oral cavity. It is important to let nursing and nursing staff know how often to complete oral cavity for patients that are unable to complete this task with independence.
It is necessary to assess motoric function. You treat the motor dysfunction, if present, not the symptoms, i.e. aspiration. If you assess a person and can only tell that they are aspirating, but not WHY they are aspirating, you are no better off than you were before the assessment.
There are many areas of function that are vital to swallowing, labial closure, lingual to palate contact, bolus management and propulsion (lingual strength), velar elevation, tongue base retraction, pharyngeal squeeze, hyolaryngeal excursion (laryngeal elevation, hyoid protraction and hyoid thyroid approximation) and UES opening. All of these are areas assessed through the MBSImP.
Observation of a person eating a meal can also a part of the evaluation. Observation of how a patient swallows pills, how many pills a patient takes, do they self-feed? These can all be indications of aspiration pneumonia. Observation should not compromise every treatment session with the patient.
A Thorough Evaluation
A thorough dysphagia exam is vital and necessary for treatment. A good Clinical Swallowing Examination with instrumental assessment will aid you in accurate assessment for thorough and appropriate treatment for dysphagia.
- Leder, S..B., Suiter, D.M., & Warner, H.L. (2009). Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia, 24(3), 290-295.
- Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298-307.
- 57 Martin-Harris B, Brodsky MB, Michel Y, Castell DO Schleicher D, et al. MBS Measurement Tool for Swallow Impairment—MBSImp: Establishing a Standard. Dysphagia, 2008, Volume 23, Number 4, Pages 392-405.
- Suiter DM, Leder SB. 3 Ounces is All You Need. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2009; 18(4): 111-116.
- Logemann, J.A. (1998). Evaluation and treatment of swallowing disorders (2nd ed). Austin, TX: Pro-Ed.27 Wijting Y., Freed M. (2009). Training Manual for the use of Neuromuscular Electrical Stimulation in the treatment of Dysphagia.
- Hamdy, S. (2006). Role of cerebral cortex in the control of swallowing. GI Motility online.doi:10.1038/gimo8.