Clinicians who work with geriatric population often have to identify and educate others about the differences between presbyphagia (age-related changes in swallow function) and dysphagia. I routinely encounter a number of patients with age-related changes in swallow, and healthy adults will often present with subtle and gradual changes in swallow function that are obvious to the patient, family, nursing staff, and the skilled clinician. Patient's often describe requiring extra liquids to take medications or to "wash down" their food, changes in the ability to swallow large pills, increased difficulty with dry, crumbly or stringy foods, and changes in taste and/or texture preferences.
Dysphagia therapy is usually not warranted in cases of presbyphagia if the patient is aware of the swallowing problems and can be supervised by nursing staff, who can also monitor the patient with foods and pills for safety. The speech-language pathologist may be required to provide skilled services if the patient has any deficits in memory or safety awareness, a diagnosis of dementia, or is unable to safely and efficiently consume his or her current diet. In every case, the nursing staff will have documented the interventions and strategies they have tried before referring the patient to the SLP, including crushing medications, giving medications with applesauce, pudding or yogurt, having meats chopped, advising the patient to drink more water with medications and foods, and so on. Nurses will then refer the patient to the SLP if the patient continues to complain of difficulty swallowing or demonstrates swallowing difficulties that might indicate increased risk for aspiration, choking, or malnutrition.
Changes in swallow with aging in people over 60 may include:
● Increased oral residue
● Minimal increase in timing of oral phase of swallow
● Use of "dipper" position, or allowing the bolus to rest on the floor of the oral cavity before using the tongue to pick it up and initiating the swallow.
● Increased residue
● Increased laryngeal penetration (this does not result in increased aspiration)
● Change in timing of initiation of pharyngeal swallow
● Increased esophageal transit time
● Increased residue
Many swallowing difficulties are directly related to age related changes in the structure and function of the swallow mechanism, including changes in muscle mass and strength and changes in the function and bulk of the vocal folds for airway protection. These are exacerbated by other age-related changes in dentition, taste, overall stamina, breath control and support, and so on.
An interdisciplinary approach is vital in treating patients with dysphagia whether they reside in in long-term care (LTC), in an assisted living facility (ALF), or in their own home. There are, however, many challenges to setting up a team or interdisciplinary approach, including time constraints, scheduling, education, and values and motivation of the patient and family. While the majority of therapy time will focus on the individual patient, long-term success will be more likley when a variety of professionals, including family members and even friends, are included. This requires additional planning and education on the part of the SLP, and when developing treatment sessions, it is helpful to include training with others as part of therapy.
Some professionals are more readily for training and education throughout the workday. These team members include:
● Nursing staff
● Physical and Occupational Therapists
● Dietary managers and staff
● Case Manager
Other professionals and team members might have less availability, work in a different setting requiring the patient to travel to them, or rarely come to the LTC facility, including:
● Respiratory Therapists
● Family members who work
Not all staff or family members, or even patients, will buy in to this interdisciplinary approach with the same degree. Some busy professionals see swallowing disorders as something that therapy will deal with, or might be new to a setting where many patients have dysphagia. Some patients and family members do not fully realize the importance of consistent use of swallow strategies or adherence to diet texture recommendations. It may be important at first to be patient and provide information in increments and allow the staff or family members to become comfortable. Allow the patient and the family to feel that they are playing an active role in the decision making process, and help CNAs and nursing staff to become comfortable in implementing your recommendations.
Develop written materials for patient and caregiver information in advance, such as lists of strategies, exercises, diet recommendations, environmental considerations during meals, adaptive equipment, oral care, and so on. Then you can check off what is recommended for that patient. Many books contain such checklists that are reproducible.
In developing a dysphagia treatment plan, include all appropriate caregivers, staff, family members and professionals, as well as the patient, from the beginning. Some may be more or less involved, and you should certainly document the reactions to caregiver training in daily notes. You can also create a short-term goals for family and caregiver demonstration of comprehension of precautions and strategies.
Dysphagia patients in the Skilled Nursing Facility (SNF) or other settings that address primarily geriatric patients requires the clinician is able to understand and interpret normal swallow, aging swallow, and actual swallowing disorders. While swallowing disorders that can be addressed by exercise and compensatory strategies might remain the focus of treatment, the SLP can and should be involved in compensatory strategies, diet texture options, caregiver and family training, and long term planning with geriatric patients and their families.
Nurses often refer patients due to coughing with intake of medicines or foods, decreased appetite, cough with foods/ liquids, or overall decreased PO intake. Often, they might miss pocketing or residue after meals that might later be reported by other rehab staff. It is actually quite easy for staff to miss, or not report, residue, pocketing, etc. in residents that present as alert and verbal. Often these residents are sitting upright and feeding themselves, and "pass" initial screenings.
While typical bedside swallow assessments might focus on oral motor and laryngeal/ pharyngeal function, the clinician in the SNF must recognize and address both the aging swallow and the effects of cognitive deficits on self-feeding, swallow skills, and overall intake of both liquids and swallow.
Speech-language pathologists should be mindful of:
● Decreased intake at meals
● Difficulty swallowing medications
● Cough with intake a certain food texture or liquid consistency
● Unexplained weight loss
● Poor attention to meals or task of eating.
The use of tablet computers and iPads in speech therapy is all the rage recently, and with good reason; however, not all therapy departments or therapists have access to the latest technology or applications ("apps"). In fact, many patients are not comfortable with the flat touchscreens, but will try tasks involving computers with keyboards. I recently identified two patients who were very interested in my use of a computer during therapy. One patient asked if I could show her how to operate a computer so that she could decide if she wanted to buy one for herself at home. The second patient simply reaches for my computer - a lot!- during therapy as I typed my daily notes. So, I decided to bring in my trusty old ThinkPad. It's old, but it's sturdy, and easy to use, and I thought that it might be less intimidating than a touchscreen device.
Patient Number One is a high level patient who is near the end of her course of therapy. Her goals have included memory, sequencing, problem solving, and safety awareness. For this patient, I gave an explanation of the use of the keyboard, mouse, and stylus. With a few demonstrations, she was able to type in information and navigate a simple website. We decided to focus on games, and I instructed her to type in a search for "brain games." One of the results, Sheppard Software, looked promising, and she decided to play the solitaire game. I provided some instruction and cues as she developed her ability to use the computer and stylus, but within a few tries she was playing mostly independently. She was so pleased with her accomplishment that I allowed her to keep playing games after our session ended, instructing her that I would be back in half an hour to retrieve the computer. One of the rehab technicians agreed to assist her if she needed help when I was gone. (Note: this patient was very high level, or I would not have left the equipment with her. Since the computer was my own, should it have gotten lost or damaged, I would have been out of a laptop!).
Patient Number Two was very interested in the way the computer worked, but less able comprehend how to use a search engine or navigate a website. We completed a few Google Image searches for topics he enjoyed (fishing, farming, and hogs), until he lost interest. Then, I let him explore the keyboard on his own. He responded to getting to type his own name with excitement, and enjoyed typing out simple messages and sentences. Next, we tried a matching game, which he completed with a great deal of help from me. When our session was over, he too wanted to keep "playing" with the computer, but this time I explained that I could bring it back tomorrow.
I try to find activities and tools that can be used with as many different patients as possible throughout the day, and using technology in therapy does not mean that you have to to have the very latest in computers or software.
Tangram puzzles are a fun way to address multiple goals, and although we often associate these shape puzzles with children's activities, adults love the puzzles as well. Tangrams can target skills for use of spatial concepts, sorting and organizing skills, attention, problem solving, following directions, describing, and more. Basic tangrams include seven shapes, or tans, although many commercially made sets and games will include more.
You can buy tangrams, or make your own tans. I have used magnetic and cardboard sets that were purchased, and cut out my own. If you do make the tangram pieces, this can be a therapy activity on its own, and a simple web search will give you many options for puzzle designs and solutions.
Just this week I used a tangram set with several different clients. We started out by assessing the patient's ability to recognize and sort the shapes (this set has more that the seven basic shapes), match shapes to words/ categories, and create simple geometric shapes from smaller shapes sever ways. For instance, a large square could be made with two triangles, two rectangles, or four smaller squares. Next, more complicated designs were introduced to patients who caught on to the task.
I worked with a patient and his wife together, explaining to the wife how games could help her husband with attention skills and foster communication. We also worked on cueing skills- using as few verbal cues as possible, allowing him extra time to think through the puzzles and find shapes, and using errorless learning to promote interest and participation in cognitive tasks.
I cannot recall a single patient who did not enjoy the activity in their own way and at their own level. A few patients remained at the sorting and matching level of activities, but may progress on to more difficult activities. Many of the patients asked for my help initially, but then wanted to work the puzzles on their own, demonstrating greater confidence and independence with the puzzles.
When it comes to therapy materials, I rule nothing off-limits, although anything can be overused. Workbooks with reproducible language and cognitive exercises can be a great resource, but they also should be used in a manner that supports skilled services and promotes achievement of goals. There are many great workbooks available, but every patient will not benefit from these tasks.
For an activity to be considered skilled therapy, the speech-language pathologist must be actively involved in the task by matching tasks to goals and skills, assessing performance, providing feedback and training, and adjusting and adapting the task to the individual patient. Placing a worksheet in front of a patient and leaving the patient to work independently can be a great way to assess how a patient approaches problem solving, attention, comprehension of directions, and organization, but if the therapist is not directly interacting with the patient at times throughout the activity and providing feedback, it becomes busy work rather than skilled intervention.
The Pros of Worksheets and Workbooks:
● The same worksheet can be presented more than once to assess progress toward a goal and target ongoing deficits.
● The patient can look for their own errors.
● Worksheets can be saved in order to demonstrate progress to patients and families.
● Workbooks often progress in degree of difficulty.
● Patients might enjoy visual tasks versus verbal tasks.
● Pages can be copied and placed in plastic page protectors. The patient can use a dry erase marker to write the answers on the page protector, reducing the amount of copies needed.
● Worksheets require little set-up or materials.
● Worksheets can address practical skills, such as written communication, attention, problem solving, and comprehension, simultaneously and in activities that approximate real-life tasks, such as balancing checkbooks, creating budgets, planning meals or shopping lists, writing letters.
● Patients who enjoy word and number games and puzzles might find worksheets interesting.
The Cons of Worksheets:
● Some patients might view them as "schoolwork" and might not recognize them as activities for adults targeting specific skills.
● Some patients have poor vision, or cannot read or write, and so cannot complete written tasks.
● Patients might not see worksheets as functional. Many patients no longer are in charge of their own finances or complete their own
Shut the Box is another game I have recently discovered, although it is not a new game at all. My husband and I were introduced to this game by friends, and even though the rules can be fairly simple, it can also be quite addictive! The game involves rolling a pair of dice, and then flipping, or “shutting,” numbered tiles. The article I linked to shows a photo of a game with nine tiles, but there are versions with ten tiles, and the game we play has tiles 1 through 12. To play, you roll the dice, and shut tiles that add up to the amount rolled on the dice. For instance, if you rolled a two and a six, you could flip the eight, a six and a two, a five and a three, or a one and a seven. The purpose is to flip as many tiles as you can, and have the lowest score. Once you cannot flip any more tiles, the tiles that remain upright are added up for your score.
You could easily make a very portable and inexpensive version of this game by writing numbers on index cards and flipping those over instead of buying the game. If you want to use only numbers 1 through nine or one through ten, you could use playing cards and flip those over. You also might want to go here or here for a flash version if you have internet access.
How do I use this game in therapy?
● Recalling written or verbal directions.
● Sequencing tasks.
● Numerical concepts.
● Decision making and reasoning.
● Memory: Print and use the history of the game in recall tasks.
● Memory and expressive language: Discuss other old or traditional games.
● Error awareness: Make intentional errors in math or flip the wrong tiles when it is your turn and see if the patient will catch your mistakes.
There seem to be many alternate rules and variations on the game, so you can try several ways to play. Some patients may need larger dice or even foam dice. Want more games involving numbers and dice? Look over this list of dice games!
And finally, a word of caution: in my area, many people frown upon dice games as “gambling,” so be prepared with an alternative activity.
Lucky me! I found two new games this month that are perfect for language and cognitive therapy. The first is Funglish, a word game that involves categories, descriptive concepts, word retrieval, and question formulation. The game comes with cards printed with six nouns, tiles of descriptive words, a timer, and an easel.
How I used this game:
● Instead of taking the game out of the box and setting it up myself, I had a couple of high level patients assist me during sessions to organize the game correctly and learn the rules. I told these patients that I needed to practice and learn this new game so I could teach it to others.
● The rules call for teams taking turns giving clues, or for one clue-giver and several players. I modify the game so that the patient and I take turns giving each other clues. Alternatively, the game could be played with a family member who is present, or with another therapist and another client.
● I read the rules, and retyped them in a simpler format for some patients. Once the patient had heard or read the rules, I used the directions in recall tasks.
● I enforce the rules differently depending on the patient. Some patients are required to adhere more strictly to the rules; others I give some leeway to in order to encourage development of skills over recalling specific instructions.
● If a patient is unable to grasp the concept of the game, I incorporate Montessori principles of errorless learning, and we explore the game and the words in a way that the patient can understand.
What I like about this game:
● The category tiles are large and made of thick cardboard, making them easier for some patients to see and pick up.
● The category cards are color coded.
● Word cards have a variety of nouns, and there are several words per card, so you can take just a few cards out at a time.
● The game ends after three rounds (if you follow the rules), making it easy to complete a game within a therapy session.
● SLPs will have no problem using the descriptive word tiles and word cards/ lists of nouns in other therapy activities. How about making up a sentence containing at least three of the six words on a card, or finding any words on the same card that could be related in some way?
● You can use the timer, or not.
● The easel that holds the tiles is not especially sturdy, but I also find that it is not necessary to use the easel.
● The print on the cards is rather small. You might need to re-write words on index cards for some patients.
● Some of the fonts on the descriptive word tiles might be difficult to read.
Next week: Another game called "Shut the Box."
I have rediscovered Pinterest for therapy ideas, now that I work in a building with Internet access for therapy purposes. (Note: I understand why some companies deny or limit Internet access to employees, but with the wealth of activities available on the Internet, I suggest that we all advocate for our employees to allow access to at least some internet sites.). Many of our patients are computer literate when they arrive at our facilities, and some are even bringing their our tablets and laptops.
Some patients may already have a Pinterest account, and if not, creating an account can be a terrific language and cognitive exercise. Creating and using an account can involve:
● Memory: creating passwords, remembering how to navigate and log on, recalling email addresses and usernames, etc..
● Categorization: where to place "pins," naming boards,etc..
● Naming: defining searches for items to pin, naming items on a board, naming boards, describing items in a board, etc..
● Thought organization and expressive language: giving opinions about boards and pins, planning new boards, describing boards and pictures pinned to boards, etc..
● Personalized naming tasks: create a board of the patient's family, of frequently used items, clothing, favorite foods, etc.
● Interpreting humor: find cartoons, quotes and mems that involve humor and have the patient discuss what is funny and why.
● Naming around a facility: Take pictures in a empty patient room of the bathroom, call light, furniture, closet , etc.. Then go around the facility and take pictures in the dining room, nurses station, entrances, therapy rooms , etc.. Just be sure not to take pictures of any residents or accidently capture any names on charts, etc.
● Sequencing: navigating websites and search engines, recalling the steps for logging on, booting up computers, etc..
● Accounts can always be deleted when the patient leaves the facility.
While planning therapy sessions, do not forget to search for boards that provide information on speech therapy, dysarthria, aphasia, swallowing, and so on. Therapists around the web are posting ideas and information that can be used with your patients, making planning easier and therapy more fun.
You can find my new board under Jen Kay-Williams. It's quite sparse at the moment, but I am looking forward to developing it. Happy pinning, and please share what you find!
Therapists spend a good portion of their time educating and re-educating patients, families, and caregivers. At times, it feels as if I discuss the same topics over and over, and I'm sure many of you feel the same. One topic I return to often involved patient dignity and the terminology used with adaptive equipment, including adaptive cups.
They are not "sippy cups."Sippy cups are for babies and toddlers. Adults drink from cups.I realize that many nursing professionals and caregivers have never thought about terms such as "sippy cup" in relation to patient dignity, and they mean no harm. I also know that to many people, "sippy cup" is just a descriptive term that identifies that the patient has a special cup to drink from.That's okay; I do not get bent out of shape over it.
As professionals working with adults with swallowing disorders, however, we should never, ever use the term "sippy cup." So why does this term sometimes appear in orders, notes, and communications? I feel that it is sometimes a simple matter of SLPs switching terminology between pediatrics and adult settings, and also a matter of recalling our education and role in adult rehabilitation, as well as being willing to correct others.I always discuss adaptive cups with the dietary department before I write the order to be sure that we are all on the same page concerning what the patient will need. More than once, when I've asked what the dietary department calls a certain cup, I've been told, "Oh, we just say sippy cup."
Here are my concerns:
● The term "sippy cup" is not specific and staff may not know that there are differences between various adaptive cups.
● It is not a professional term.
● It is a matter of patient dignity, even if that patient carries around a stuffed animal or exhibits child-like behaviors. Simply put, do we ask a patient if they want a "blankey" instead of "blanket?" Is a wheelchair a rolly-chair? I think not.
● Writing "sippy cup" in orders or notes does not support the need for skilled intervention and adaptive equipment. A sippy cup can purchased at any dollar store by any person, and it is not meant for adults. Of course, patients have the right to call their own equipment water they choose. A patient can ask for a bib; I bring them a clothing protector. A patient might say "I need my sippy cup." I do not correct that patient, but I do always call it an adaptive cup.
Retail Therapy. We've all heard of it, right? It can be fun to shop, and newspaper advertisements, flyers, and catalogs can make great therapy materials. All you need to do is find a newspaper, advertisement insert, or catalog and read through it. Have the patient:
Search for and write down or name items in a category, like foods, clothing, cleaning products, gifts.
Make a grocery list for a holiday meal and search for coupons.
Find holiday decorations.
Find the best deal on items from a list of wants or needs.
Pick out gifts for a variety of people: family, friends, children, co-workers, etc.
Start with a budget and plan several days of meals, holiday shopping, etc.
Divide items into categories such as wants or needs, healthy and less healthy foods' expensive and inexpensive, holiday and year-round items, etc.
Organize catalog items toys, electronics, music and other items that they are familiar with and those that are new or unfamiliar.
Discuss new or unfamiliar products that the patient may want to try.
Make a holiday gift list and explain why they would purchase items for specific people.
Give opinions about why they would or would not purchase certain items.
Fill out an order form, or role play ordering an item by phone or computer.
Act out customer service scenarios, including complaints, making returns, etc.
Name pictures of items.
Find pictures of items based on descriptions.
Describe items using at least three different adjectives or attributes.
Plan a dinner and find coupons and sale items.
Estimate the cost of specific items and use the advertisements to verify if estimates are high or low.
Make a wish list of items they might want to receive as gifts.
Discuss who advertisements are targeting. Are advertisements effective? How have ads changed over the years?
Discuss how shopping has changed. Are stores too big? Is online shopping easier? How can someone shop if they cannot drive?
I'm sure that you can think of more!
All cognitive-linguistic assessments that I use have questions about orientation, and a quick chart review or screening will usually provide some insight into whether or not a patient is oriented. Often patients have had several changes happen before they are admitted to a nursing facility or before they are referred to therapy for cognitive-linguistic deficits. This might include a fall or illness, followed by a hospitalization, an admission to an acute rehabilitation, followed by a return home or to an assisted living facility with home health care, or possibly placement in long-term care.
Many patients are simply disoriented due to a combination of medical events and diseases, effects of medications or anesthesia, changes in location and routine, and fatigue. Others may have always had deficits in orientation, which can vary throughout the day depending on their particular diagnosis and behaviors such as sundowning. Addressing orientation is important, but identifying patients who will benefit from orientation goals versus those who may not is also important.
Why address orientation?
- To increase safety and independence in the discharge environment.
- To increase the ability to communicate effectively.
- To decrease anxiety, fear, agitation, etc.
- To maximize the patient's feeling of control and belonging.
- To increase the patient's ability to participate in long-term planning.
Who is appropriate for reorientation?
- Patients with acute changes in cognitive skills following surgery, illness, or other medical events.
- Patients with no history of disorientation but who are recently more confused.
- Patients in the early stages of dementia who can use compensatory strategies and understand therapy goals.
- Patients who are aware of deficits in orientation and who voice a desire to improve.
- Patients who can use memory strategies and respond well to memory techniques such as spaced retrieval.
Who may not benefit from reorientation goals?
- Patients in the later stages of dementia.
- Patients who become upset, agitated, angry, sad, or emotionally labile when reoriented to place, time, situation, and family.
- Patients who do not benefit from use of strategies such as spaced retrieval and visual aids for recall of information.
- Patient who have no awareness of their deficits, or deny all deficits.
What if I cannot reorient my patient?
- Try validation techniques to decrease anxiety, anger, sadness, etc.
- If orientation questions result in negative reactions, try to address orientation indirectly by discussing upcoming holidays, reading the paper, discussing current events, looking through mail for current addresses, making a family tree, looking at family photographs, etc.
- Educate staff and family not to confront the patient with orientation tasks or argue if the patient does not reorient.
- Allow for some spontaneous improvement. The patient might feel anxious when directly questioned about orientation, but also may use his own strategies to reorient as he improves in cognitive-linguistic skills
- Reevaluate the patient periodically if appropriate. Some patients will respond better once they become accustomed to new medications or when the effects of anesthesia dissipate.
- Give patients time to grieve or work through emotions when they have experienced a change in living arrangements, physical ability, or communication skills.
Thanksgiving is only a couple of weeks away and I know that many of us try to bring a little holiday cheer into therapy tasks. Thanksgiving is one of the most loved holidays, when family and friends gather together and enjoy food and company. While it can be difficult for patients to miss out on a traditional celebration, many people will enjoy sharing holiday memories and traditions, and taking part in holiday-themed activities.
Here are some Thanksgiving therapy ideas and resources;
● Thanksgiving Trivia for language and memory activities.
● Ask patients to recall favorite foods, recipes and traditions.
● Discuss the pros and cons of commercialization of the holiday season.
● Discuss challenges for people with communication disorders at the holidays. How will the patient cope with large groups of people? What word-finding or speech intelligibility strategies will the patient use?
● Try an online Thanksgiving memory match/ concentration game.
● Name words in given holiday categories: foods, family members, traditions, holidays.
● Write in holiday dates on a blank calendar.
● Ask the patient to sequence steps for completing Thanksgiving preparation tasks, recipes, clean-up, or for how the organize Thanksgiving day from morning to night..
● Practice words, phrases, and sentences that will help a patient communicate on Thanksgiving.
● With the patient's help, write important information that their loved ones will need to know about what helps the patient communicate, swallow, etc. Find one or two family members who can come to a therapy session and learn what strategies can help the patient, and are willing to train other family members. Also teach the caregivers and family what is not helpful to the patient, including speaking for her, or finishing her sentence, or repeating a questions loudly when a patient does not respond.
● Help patients and families plan meals that are easy to chew and swallow for Thanksgiving.
● Prepare patient with dementia, brain injury, etc., for changes in schedules, what the holiday will entail, who will be at the gathering, and so on. If able, talk about stressors that might arise and ways to reduce stress, including sticking to sleep schedules and familiar routines as much as possible.
● Problem solve for holiday mishaps. What should you do if your turkey isn't cooked thoroughly or if you don't have all of the ingredients for a recipe? What if you get lost or have car trouble on the way to your families house? How about if more guests than you expected arrive?
● Practice setting the table for holiday meals. Create a seating arrangement based on who is coming.
As with all holiday-centered activities, be aware that not all patients enjoy or celebrate every holiday. Some patients may have no interest in holiday-themed tasks, so be prepared to move on when necessary.
Many of us are feeling the effects of Daylight Saving Time when we "Fall Back" one hour. As much as we might appreciate the extra hour of sleep, many people notice that it can take days to really adjust, which means waking up and realizing that our alarm won't go off for another hour, not feeling hungry when it's time for a lunchbreak, or not feeling sleepy at bedtime. We all adjust in time, but for seniors a change in schedule can be much more complicated.
In the SNF setting, or even at home when a schedule is followed by caregivers, the geriatric patient might present with a decline in meal consumption, refusal to follow a schedule, restlessness at night, or awakening early. Toileting schedules can be affected, as the patient has physically become used to toileting after so many hours, but caregivers often follow the clock and wait for the "right" time to take a patient to the bathroom.
As we assess new patients using tests such as the Brief Cognitive Rating Scale, Montreal Cognitive Assessment, or Mini-Mental State exam, we should take into consideration that a patient's estimate of time of day might be affected.
How we can help our patients adjust to Daylight Saving Time:
- Remind caregivers and staff that patients might "refuse" toileting, meals, activities, and so on because their internal clock has not adjusted to the new time.
- Advise patients to limit caffeine later in the day. encourage caregivers to help patients relax and prepare for sleep in advance.
- Watch for patients who might attempt to get out of bed at the time their body has become used to.
- Talk to patients about the time change and use reorientation strategies with those who can understand and participate.
- Remember that patients have the right to choose when they go to bed, eat, or get up in the morning, even if the clock says it's time to do something.
- Watch for effects of sleep changes on safety. Disoriented patients are at a greater risk for falls and accidents.
- Do not argue with patients who do not want to eat because they are not hungry at the regular meal time. Offer snacks until the patient adjusts, and encourage the patient to participate in meals in their usual location so that they can become accustomed to eating at the same time.
Speech therapists have conversations about food textures and liquid consistencies on a daily basis with everyone from patients to other therapists to family members and staff. I think that many of us relate to feeling like we are either repeating the same information over and over, and perhaps not really being "heard," or to feeling like everyone wants an easy answer.
Swallowing is quite complicated, right? Just like no two patients always need the exact same medication dosage or type and size of wheelchair, what patients can and should consume for both safety and nutrition/hydration should be more patient-centered, and less of a "one size fits all" approach.
Have you ever worked in a building where anyone with any type of swallowing or feeding difficulty was placed on a pureed diet with thickened liquids for "safety?" Have you worked with staff that believe that any patient who coughs, ever, needs thickened liquids? How about family members who insist that diet textures cannot be upgraded because the patient "failed" a swallow study, or because "this is what the doctor ordered?"
I remember a patient on nectar thick liquids who wanted to use a straw due to positioning and decreased ability to pick up and drink from a cup. He had once had a swallow study in which he aspirated thin liquids via both a cup and a straw, but not nectar thick liquids; however, the SLP conducting the swallow study did not test nectar thick liquids via a straw. Because the nectar thick liquids were not tested with a straw, the family was sure that straws were unsafe with any consistency, and became quite upset that the patient was trying nectar liquids with a straw, and some of staff worried as well. Eventually, the patient gave up on trying straws because it entailed constantly educating staff and family, and was just too much trouble.
We SLPs know that swallow function is a bit different with a straw, and that thin liquids via a straw can move too quickly, causing coughing and increased risk of aspiration, but at some point, it seems to have become commonly accepted that nectar thick liquids cannot be taken via straw, ever. Sometimes they cannot ... but sometimes they can. I have more than one discussion with staff and families about this.
Taking a blanket or cookie-cutter approach to swallowing therapy and diet changes has, in my opinion, led to an epidemic of "one size fits all" treatment and diet modifications. Yes, safety is a big concern, and we so want to avoid aspiration, choking and other risks. Quality of life, food intake, and hydration are also very important, and if a patient can safely drink nectar thick liquids through a straw, why not allow him that? Sometimes, I think we make decisions based on fear of what could happen or of litigation, rather than on what the patient truly wants or on what the patient can do with patient-specific feeding and swallow protocols in place. Patient-centered protocols are definitely extra work and more time-consuming for staff, and might also include adaptive equipment.
We can never remove any risk of choking or aspiration from all patients; young, healthy people have choking incidents as well as do frail people who have dysphagia. Risks are inherent with any intake, and of course we try to reduce those risks through modifications. I would love to hear from other therapists about their decision-making process in diet modifications. Does your facility have a "blanket" policy on diet modifications for aptients with dysphagia? Are staff willing to accept patient specific recommendations? Do you have a Free Water Protocol in place?