Cognition isn’t just about memory or problem-solving—it can directly affect the way we swallow. When cognitive processes break down, patients might not “recognize” food in the mouth or understand what to do with it, putting them at higher risk for aspiration and malnutrition.
A Quick Clinical Example
During my time in acute care, I evaluated a patient in the ICU whose sodium levels were well outside normal limits. The patient:
- Held pieces of solid food on the tongue without attempting to chew or swallow
- Showed marked confusion and agitation
- Could swallow purées and thin liquids safely
Once sodium levels normalized, the patient’s swallowing function returned to baseline—an immediate reminder that medical status and cognition can powerfully shape swallow biomechanics.
Key Cognitive Factors That Affect Swallowing
Leder, Suiter, & Warner (study of n = 4,053 patients with stroke, TBI, various neurodegenerative diseases, dementia, or alcohol/drug-related impairment) examined two simple bedside screens:
- Orientation Questions
- What is your name?
- Where are you right now?
- What year is it?
- Single-Step Verbal Commands
- Open your mouth.
- Stick out your tongue.
- Smile.
Results at a Glance
- Liquid aspiration was 31 % more likely in patients who were not oriented to person, place, and time.
- Liquid aspiration increased by 57 %, purée aspiration by 48 %, and NPO recommendations (“unsafe for any oral intake”) by 69 % in patients unable to follow single-step commands.
A standardized FEES (Flexible Endoscopic Evaluation of Swallowing) protocol confirmed these findings.
“Use of simple orientation questions and single-step verbal command-following to ascertain potential increased odds of both aspiration and safe oral intake prior to dysphagia testing allows for a more precise dysphagia evaluation….” — Leder, Suiter, & Warner
Clinical Takeaways for the Busy SLP
- Always screen orientation and command-following before offering test boluses.
- For patients struggling with either task, start conservatively:
- Begin with smaller volumes or purée consistency.
- Consider thickened liquids or instrumental assessment sooner rather than later.
- Monitor metabolic panels (e.g., sodium) or medications that may alter cognition.
- Collaborate with the medical team—cognitive status and swallow safety often improve together.
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Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation? Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care? You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes. You can get your copy here.
Reference
Leder SB, Suiter DM, & Warner HL. (Year). Impact of cognitive screening on dysphagia assessment outcomes. Journal of Speech, Language, and Hearing Research. (Add volume & page numbers).
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