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GOALS/DOCUMENTATION
COMPONENTS OF GOAL (MAY WANT TO
INCLUDE)
Complexity
Abstract
ADL
Basic
Basic social
Complex
Personal
Simple
Cue types
No cues
Written cues
Tactile cues
Gestural cues
Verbal cues
Modeling cues
Visual cues
Dysphasia techniques
90-90-90 degree positioning
Adaptive feeding equipment
Altered bolus placement
Altered rate
Alternating solids and liquids
Chin tuck
Double swallow
Effortful swallow
Tilt head
Head turn
Mendelssohn maneuver
Oral search for residuals
Super-supraglottic swallow
Supraglottic swallow
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Therapist action verbs (to be used with) ST components
Therapist action verbs
Components
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Instructed
Introduced
Facilitated
Emphasized
Presented with
Modified
Upgraded
Revised
Downgraded
Adjusted
Initiated
Progressed to
Educated on
Transitioned to
Altered
Enhanced
Coordination
Demonstrated
Addressed
Stimulated
Use of
Categorization
Inferencing
Segmented
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Bolus control
Lip seal
A/P transit time
Laryngeal elevation
Swallow initiation
Pharyngeal excursion
Oral sensation
Lingual /labial symmetry
Lingual/labial strength
Lingual/labial coordination
Airway closure
Base of tongue retraction
y/n accuracy
Following commands
Obj ID
Word retreival
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Volume
Attention
Problem solving
Memory
Tactile manipulation
Cause/effect relationship
4
DYSPHAGIA
Stages of the swallow:
1. Oral phase
 Voluntary stage
 Masticate bolus prevents leaking of food
 Buccal muscles are tense to prevent pocketing
 Bolus in front of mouth
 Labial seal
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Oral transport substage
Voluntary
Jaw and lips closed
Food moved to back of mouth by tongue
Lasts 1 sec
2. Pharyngeal stage- starts when bolus hit faucial arches
Involuntary
Sensory info from receptors in back of mouth and in pharynx goes to swallowing center in medulla.
Palatopharyngeal folds pull together medially to form a slit in upper pharynx which bolus passes
through
 Velum is raised preventing entry of food into the nasopharynx
 Tongue is retracted preventing food from re-entering mouth
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Laryngeal substage--airway protection
 Larynx and hyoid bone pulled upward and forward, enlarging the pharynx and creating a vacuum in
hypo pharynx which pulls the bolus downward.
 True and false vocal folds adduct (closure begins at level of true VF and progresses to false VF and
then to ari-epiglottis folds.
 Epiglottis drops over top of larynx protecting airway and diverting bolus to pyriform sinuses. The
bolus passes down on both sides of epiglottis. If liquid bolus, epiglottis acts as ledge to slow
movement thru pharynx giving the VF time to adduct and larynx time to elevate.
3. Esophageal stage
 Involuntary
 Bolus moved down esophagus via peristalsis and gravity
 Larynx lowers to normal position
 Cricopharyngeus muscle contracts to prevent reflux
 Lasts 8-20s (in elderly peristalsis is slower)
(Logemann, 1983, 1989,1997; Cherney, 1994)
SWALLOW CHANGES IN HEALTHY AGING ADULTS
A. Primary Effects of Normal Aging - Effects of Age Alone in HEALTHY Elderly
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1. The 60 – 80-year-old
a. Timing of the Swallow
1) Oral transit times slightly but significantly longer in older adults (.5-.6
sec). Tipper (tongue tip against alveolar ridge at initiation of swallow) vs.
dipper (tongue tip behind lower teeth at initiation of swallow) swallow
types - Elderly more often dippers
2) Pharyngeal delay times slightly but significantly longer in older adults
(.5-.6 sec)
3) Pharyngeal wall contraction inconsistently found to be slower
4) Reduced tongue pressure
b. Safety and Efficiency of the Swallow
1) Penetration occurs more frequently
2) Aspiration occurs no more frequently in the elderly
3) Residue is generally only slightly greater (2-3%) in the elderly than in
younger adults
2. 80+ year-olds - Range and pattern of pharyngeal movements during the swallow in
80-year-olds are different from younger adults which increase the older adult's risk of
dysphagia as the result of illness and subsequent general weakness.
a. Reduced reserve - especially in men
1) Hyoid & laryngeal maximum vertical movement significantly reduced in
the elderly
2) Hyoid and laryngeal movements up to the time of cricopharyngeal
opening virtually identical in young adults and elderly patients
b. Reduced flexibility
1) Cricopharyngeal opening durations across volumes reduced in the
elderly
2) Cricopharyngeal opening diameter across volumes reduced in the elderly
a) Timing similar to 60-80-year-olds
b) Safety and efficiency of swallow unchanged
c. Range of motion exercises may improve reserve and flexibility in otherwise
normal,
healthy elderly.
3. Conclusions
a. Healthy older adults exhibit highly safe and efficient swallow
b Illness causing extreme weakness may cause dysphagia in otherwise normal over
80-year-olds
© 2008 Jeri A. Logemann, Ph.D
http://americandysphagianetwork.org/Changes_in_Normal_Swallow_with_Age.pdf
The components of normal s wallowing process.
A problem with swallowing can be caused by a defect in any of them.
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Signs and Symptoms:
Oro-pharyngeal dysphagia include the following:
 Difficulty trying to swallow
 Choking or breathing saliva into your lungs while swallowing
 Coughing while swallowing
 Regurgitating liquid through your nose
 Breathing in food while swallowing
 Weak voice
 Weight loss
Esophageal dysphagia include the following:
 Pressure sensation in your mid-chest area
 Sensation of food stuck in your throat or chest
 Chest pain
 Pain with swallowing
 Chronic heartburn
 Belching
 Sore throat
2011 University of Maryland Medical Center
Signs and symptoms of aspiration
 Eyes watering
 Reddening of face
 Change in rate of respiration
 Difficulty/inability to breathe
 Change in lung sounds
 Audible breathing
 Facial grimacing
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Coughing
Gagging
Attempts to clear throat
Wet vocal quality
Chest pain
High/low back pain
Cannot produce voice, or can only talk in whisper
States that something is stick in throat
Feeling of fullness in throat
Dysphagia Assessment and Screening --Long Term Care
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Screening
 Clinical sensory motor examination
 Chart and medication review
 Meal time and feeding observation
 Risk for aspiration
 Oral hygiene
Assessment
 Voice quality
 Medication review
 Cognitive screening
 Swallowing questionnaire
 Caregiver interview
 Assess feeding environment
 Weight and health status
 Dietary consult and modifications
 Evaluate need for instrumental assessment
(The Swallowing Manual: Rubin, Broniatowsky, Kelly; 2000)
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DYSPHAGIA ASSESSMENT QUESTIONNAIRE
Do you have difficulty swallowing?
Do you have pain when you swallow?
Do you have difficulty chewing hard foods?
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 Do you have a dry mouth?
 Do you have excess saliva or drooling?
 Do you cough or choke before, during, or after swallowing?
 Does your voice become hoarse after swallowing?
 Do you notice food coming up into your nose?
 Do you have heartburn or indigestion?
 Do you have difficulty swallowing liquids/solids/pills?
 Do you react to spicy foods?
 Has your reaction to hot or cold food changed?
 Have you had episodes of airway obstruction?
Have you had pneumonia or aspiration pneumonia?
(The Swallowing Manual: Rubin, Broniatowsky, Kelly; 2000)
When a diet may need modified:
If there is a(n):
Oral dysfunction--thin liquids
Delayed swallow--thicker liquids
Reduced laryngeal closure--purees and thickened liquids
(Hegde, Davis 2010)
SWALLOWING GOALS
Short Term
GOAL Pt will….
Consume (diet level)
without any difficulty--
TARGET
HOW TO
masticating
Diet downgrade
Dentures in?
Moisten food
Forming or
manipulating
bolus
Diet downgrade
Alternating solids and liquids
Liquid wash
Increase labial
coordination for
mastication and swallow
from (%) to (%).
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Increase safe swallow by
improving swallow
initiation reflex from
(seconds) to (seconds)
Initiating
swallow
Thicker bolus
Improve oral and
pharyngeal control of bolus
to increase PO intake.
Oral/pharyngeal
control
Posterior tongue presentation of bolus
Apply pressure on tongue with spoon
Straw for liquids
Utilize compensatory
strategy of
alternating
solids and
liquids to assist
in bolus
manipulation
and oral
clearance with
min/mod/max
verbal cues.
liquid wash to
assist in bolus
manipulation
and oral
clearance
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Postures that
promote safer
swallowing
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Increased
sensory
awareness
(target is to
apply sensory
stimulus prior
to swallow)
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Modification of
volume in food
presentation
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Chin down--widens valleculae
Chin up- helps drain food to back
of mouth
Head rotation toward weaker
side-helps direct food to more
efficient side of pharynx
Chin down and head rotation--may
promote better laryngeal closure
during swallow
Head tilt to stronger side--directs
food to that side (Hegde, Davis
2010)
Application of downward pressure
on tongue with a spoon
Sour bolus before presenting
normal bolus
Cold bolus
Bolus that needs to be chewed
Large volume bolus (Hegde, Davis
2010)
Larger/smaller bolus
Slower rate of smaller bolus
(Hegde, Davis 2010)
Pt will use <dysphasia
techniques with <0-100% >
accuracy during for
<meals/feeds> using
<diet/liquid> for
<0-100%> intake without
observable signs of
aspiration.
Long Term:
Pt will:
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safely and adequately nourish and hydrate self on diet level/LRD with no s/s of
aspiration.
safely tolerate PO intake/diet level as primary source of nutritional needs
improve safe and effective swallowing skills with least restrictive diet
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Improve and maintain safe and effective swallow function
have safe and efficient swallow of regular consistency diet and thin liquids.
COGNITION
Cognitive-linguistic Therapy
 Orientation, memory groups
 Current events (newspaper/daily events & discussion)
 Problem-solving
 Safety
 decision-making
 Reasoning
 Sequencing
 Verbal expression
 Sentence completion
 Music therapy
 Open-and closed-ended questions
 Naming, categorization
 Voice, fluency, articulation, etc.
 Communication aides/boards
 Compensatory training
 Auditory comprehension/receptive language
 Following directives/commands
 “wh” questions
 organizing/processing information with use of maps, puzzles, games, etc.
 Categories
 yes/no questions
 abstract thinking
 visual/logical solutions/scanning
 Numbers
 written communication
 compensatory training
Tara Reed Courville, MCD, CCC-SLP & Lisa Young Milliken, MA, CCC-SLP
The Alzheimer’s Association has developed the following “Ten Warning Signs”:
1. Memory changes that disrupt daily life.
One of the most common signs of Alzheimer’s, especially in the early stages, is
forgetting recently learned information. Others include forgetting important dates or
events; asking for the same information over and over; relying on memory aids (e.g.
reminder notes or electronic devices) or family members for things they used to handle
on their own.
What are typical age-related changes? Sometimes forgetting names or
appointments, but remembering them later.
2. Challenges in planning or solving problems.
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Some people may experience changes in their ability to develop and follow a plan or
work with numbers. They may have trouble following a familiar recipe or keeping track
of monthly bills. They may have difficulty concentrating and take much longer to do
things than they did before.
What are typical age-related changes? Making occasional errors when balancing a
checkbook.
3. Difficulty completing familiar tasks at home, at work or at leisure.
People with Alzheimer’s disease often find it hard to complete daily tasks. Sometimes,
people may have trouble driving to a familiar location, managing a budget at work or
remembering the rules of a favorite game.
What are typical age-related changes? Occasionally needing help to use the
settings on a microwave or record a television show.
4. Confusion with time and place.
People with Alzheimer’s can lose track of dates, seasons and the passage of time. They
may have trouble understanding something if it is not happening immediately.
Sometimes they may forget where they are or how they got there.
What are typical age-related changes? Getting confused about the day of the week
but figuring it out later.
5. Trouble understanding visual images and spatial relationships.
For some people, having vision problems is a sign of Alzheimer’s. They may have
difficulty reading, judging distance, and determining color or contrast. In terms of
perception, they may pass a mirror and think someone else is in the room. They may not
realize they are the person in the mirror.
What are typical age-related changes? Vision changes related to cataracts.
6. New problems with words in speaking or writing.
People with Alzheimer’s may have trouble following or joining a conversation. They
may stop in the middle of a conversation and have no idea how to continue or they may
repeat themselves. They may struggle with vocabulary, have problems finding the right
word or call things by the wrong name (e.g. calling a watch a “handclock”).
What are typical age-related changes? Sometimes having trouble finding the right
word.
7. Misplacing things and losing the ability to retrace steps.
A person with Alzheimer’s disease may put things in unusual places. They may lose
things and be unable to go back over their steps to find them again. Sometimes, they may
accuse others of stealing. This may occur more frequently over time.
What are typical age-related changes? Misplacing things from time to time, such
as a pair of glasses or the remote control.
8. Decreased or poor judgment.
People with Alzheimer’s may experience changes in judgment or decision-making. For
example, they may use poor judgment when dealing with money, giving large amounts to
telemarketers. they may pay less attention to grooming or keeping themselves clean.
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What are typical age-related changes? Making a bad decision once in a while.
9. Withdrawal from work or social activities.
A person with Alzheimer’s may start to remove themselves from hobbies, social
activities,
work projects or sports. They may have trouble keeping up with a favorite sports team or
remembering how to complete a favorite hobby. They may also avoid being social
because of the changes they have experienced.
What are typical age-related changes? Sometimes feeling weary of work, family
and social obligations.
10. Changes in mood and personality.
The mood and personalities of people with Alzheimer’s can change. They can become
confused, suspicious, depressed, fearful, or anxious. They may be easily upset at home, at
work, with friends or in places where they are out of their comfort zone.
What are typical age-related changes? Developing very specific ways of doing
things and becoming irritable when a routine is disrupted.
Overcoming Challenges
Language, hearing or vision problems as well as low levels of health literacy may present
obstacles to effective communication. Providers should take the following issues into
account for both individuals and family.
• A person with dementia may sometimes require more time to process information and
may take longer to respond to a question.
• Short sentences, visual cues or pictures may help the person with dementia understand
what he or she is hearing. Hearing loss is very common in older adults and is often
undiagnosed.
• Determine if the person with dementia or the family caregiver has difficulty hearing or
seeing. Do they require a hearing aid or eyeglasses? Are those items being used and are
they effective?
• Some people may not be “health literate.” They may need help to understand some
health concepts, terminology, or the implications of treatment options. When health
literacy is low, simple verbal explanations may be more effective than written
information.
The Language of Behavior
All behaviors, including reactions to daily care, are a form of communication. The direct
care provider is responsible for interpreting and responding to behaviors. For example:
• A person repeatedly refusing a certain food or beverage may mean he or she does not
like it. Simply changing the item may eliminate this behavior. If it persists, it is possible
that the person has trouble swallowing. This may require a feeding swallowing
evaluation.
• A person who resists getting dressed may be in pain due to arthritis. Controlling for pain
and/or minimizing physical movements that cause pain can address this behavior.
• A person who seems to misunderstand a lot or does not respond when spoken to may
have hearing loss. Proper care and use of hearing aids or other recommended assistive
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listening technology is important.
• A person who resists a bath may feel under attack when someone tries to help take off
clothes.
(Alzheimer’s Association)
Resident characteristics contributing to food and fluid intake include
 cognitive status (Young, Binns & Greenwood, 2001),
 ability to eat independently (Kayser-Jones & Schell, 1997)
 physical limitations,

difficulty swallowing (dysphagia; Steele, Greenwood, Ens, Robertson, & Seidman-Carlson, 1997)

care provision with up to half of residents requiring assistance (Priefer
& Robbins, 1997), including monitoring, verbal encouragement, and physical assistance (Van Ort
& Phillips, 1995; Kayser-Jones & Schell).
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Environmental characteristics contributing to adequate intake include food quality,
absence of environmental distractions (e.g., noise), and noninstitutional features (e.g.,
tablecloths)
*** Residents monitored by staff during mealtimes are significantly less likely to have
low food and fluid intake. Similarly, even after adjustment, residents having their meals
in public dining areas are much less likely to have low intake relative to those in their
bedrooms.
Attention
Strategies to help attention
 Self awareness. Learning to be aware of your current level of attention,
concentration, and fatigue can help you know when to attempt tasks and when
to take a break. One way to do this is to create a scale from 1 - 10, with 1
representing total relaxation, and 10 representing total stress and exhaustion.
When you are about to attempt a task, look at your scale, if you score yourself
between 1 and 3, you are probably ready to achieve things. If you score
between 4 and 6, you can probably manage completing a short and easy task.
If your score is higher, it is probably appropriate to take a break and attempt
any tasks later.
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“Internal distractions” can also have an affect on attention. These are feelings
such as stress or depression which will occupy your mind and distract you from a task. It is
important not to attempt tasks that require a lot of concentration when you have internal
distractions. Some people tell themselves that they will allow time later to think about
things that are bothering them so that they can focus on the task at hand. If you feel anxious
about completing a task, write down what worries you, and you will often find
that your fears are unfounded. Write down rational responses to irrational
fears.
 Build your confidence. Aim for progress rather than perfection when
attempting a task. If the task seems too big, make a plan that is specific and break it into
small steps, giving yourself a break after each step. If things go wrong try not to criticize
yourself, just take a break and then attempt the task again, one step at a time. Congratulate
yourself when you have completed a task.
 Planning. Planning and writing down a task can make it seem a little easier.
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Write down the steps, include your brain breaks and your reward at the end. If
things do not go to plan, know that you can stop and re-attempt the task
tomorrow. If there are lots of jobs to do, prioritize and don’t overload yourself.
Agree to complete 2 or 3 small tasks each day.
 Be Flexible. Remember, be flexible, if things are not going as planned, stop and
re-plan, or just have a break and do something else.
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Stay on track. It can be easy to become distracted especially if the task is mundane.
Staying on track with mundane tasks is difficult for everyone. There are a number of
things you can do to help you complete the task. Divide up a mundane task and do a
bit every day. Give yourself a list of affirmations such as “I can do this”, “keep
going”, “let’s get this done”, to motivate yourself. Promise yourself a reward when
you complete the task.
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Monitoring your fatigue. This is probably one of the most important strategies we
can use. Many people with brain injury suffer higher levels of fatigue than normal
and must be aware that fatigue will have a major impact on attention capabilities.
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Consider your environment. When you are trying to attend effectively in an
environment that contains many distractions it is unlikely that you will be effective.
Reduce noisy distractions such as TV, radio or other people talking. If your environment is
cluttered and messy, try and tidy things up a little. Working in a clutter free environment is
easier than working in a messy one.
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Allow plenty of time to complete tasks.
 Eliminate distractions. When there are distractions, try and decide how best to
manage them. Decide what the distractions are and how you can change them e.g. if you
want to talk and it is too noisy in a certain room because of the TV, you can either turn off
the TV or go to another room to talk. If you cannot change the environment then try and
move to a new environment. If you are unable to complete a task because of distractions,
write it down your task and attempt it again later.
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Develop Systems. As with other cognitive difficulties caused by brain injury it
is advantageous to develop systems such as checklists and reminders which take the load
from your attention skills
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Brain Breaks. Set time periods for tasks and then have a “brain break” before
continuing. You can use alarms to prompt you. Some people use alarms on
their mobile phones.
 Health. Looking after all aspects of your general health will help you perform
better on a daily basis. The 4 main areas to be aware off are Nutrition, Sleep,
Exercise and Relaxation. Make sure you have a well balanced and healthy diet and stay
well hydrated. Make sure you have a regular and sufficient night time sleep, as well as
sleep breaks in the day if needed. Try and do some exercise every day to stay reasonably
fit. Relaxation is sometimes overlooked, but contributes to a positive and healthy lifestyle.
Everyone relaxes in different ways, but it is important to find some time everyday to get
away from your stress and worries. Going for a walk, meditating and yoga are all good
ways to relax.
 Reading is often difficult following a brain injury. Try to read when you feel at
your most attentive.
 Try not to Multi-task. Focus on one task at a time. Trying to multi-task may mean that
you achieve nothing or make a poor attempt at everything.
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If you have to divide your time between 2 tasks try and do one task that relies on
mental concentration and one task that is physical e.g. listening to the radio while
cleaning the sink.
 If you are switching between tasks, try and take a small break between switching to
give your brain time to adjust. Some people find it helpful to say aloud what they are
doing when they change tasks to help them stay on track.

Listening to, and following conversations sometimes requires lots of mental
energy. Try to self monitor so that you are aware when your attention is beginning to falter.
Try and repeat important points in your head. Pick out the key pieces of information and
disregard the non-important stuff. Develop active listening skills to manage conversations:
- Clarification - requesting extra information or repetition
- Probing questions - ask questions to gain further information
- Paraphrasing - this allows the listener to make sure you understood
- Summarizing - pulls together key points and concludes the topic
Quick Checklist for Attention Skills following Brain Injury
 Learn to be self aware and monitor your level of attention
 Monitor your fatigue and schedule in breaks
 Allow plenty of time to achieve tasks
 Make a plan and break your task into small steps
 Adapt your environment to eliminate distractions
 ·Evaluate and monitor distraction before starting a task

Be flexible - stop, re-plan, or reschedule if you need to
 Develop systems of alarms and reminders to keep focused
 Manage internal distractions

If you are anxious, write down your fears
 Try and attempt one task at a time
 Allow yourself “brain breaks” between tasks
 Congratulate and reward yourself when you have completed a task

Health - nutrition, sleep, exercise and relaxation
 Self monitor during conversations
 Try and use active listening skills during conversations
 Make other people aware of your difficulties
Icommunicatetherapy.com
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Executive Functioning (initiating, carrying out, and completing tasks effectively
and successfully)
There are a number of processes to completing a task successfully. Firstly we will
discuss the steps to completing a task and then we will focus on strategies to facilitate
this process:
 Have an awareness that a task requires initiation. If you do not have an awareness that
you are running out of food, you will not initiate a trip to the supermarket.
 Plan the task. Break the task down into steps, make a list.
 Initiate the task. Start the task and follow it through.
 Manage any unplanned difficulties that occur.
 Complete the task.
 Review how the task went and think about any changes you need to make, so that the
task is easier next time.
Icommunicatetherapy.com
GOAL Pt will….
TARGET
HOW TO
Increase thought
organization to 80%
proficiency.
Increase sequencing for 3
step tasks/3 items to 80%
proficiency.
Increase attention to task to
(minute range) for 3
consecutive sessions.
Attention
Increase auditory
comprehension of spoken
langue to 80% proficiency.
Auditory comprehension
Impaired
attention--reinforce
client for paying
attention (Hegde,
Davis 2010)
Auditory comp of
spoken language-- first
ask clients to point to
named pics/obj/body
parts. Ask y/n
questions. Then, ask
for correct responses to
phrases and sentences.
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Ask to follow
instructions. (Hegde,
Davis 2010)
Fxl reading comprehension
target basic skills for
every day functioning
(reading a newspaper)
(Hegde, Davis 2010)
Increase memory for daily
routines utilizing external
cues with 100%
proficiency.
Memory for daily routines
prepare lists of daily
routines and written
signs and instructions
(Hegde, Davis 2010)
Increase orientation to
time, place, and person to
100% across 3 consecutive
sessions.
Orientation
Increase verbal expression
to 7/10
words/names/actions for
ADLs to promote
independence
Verbal expression
Design questions
testing orientation
(where are you now?
What time is it?)
(Hegde, Davis 2010)
select names of
objs/persons/actions
that are immediate use
to client. Synonyms,
antonyms, rhyming,
spelling, completing
sentences.
Increase fxl reading
comprehension to 80%
accuracy
Increase verbal expression
to phrases and sentences in
7/10 responses.
requests, commands,
demands, wh
questions, y/n
questions. (Hegde,
Davis 2010)
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Answer y/n questions
related to <complexity>
information with
<0-100%> accuracy with
<cue type> to understand
caregiver requests.
y/n questions
Verbally demonstrate
comprehension of object
function with <0-100%>
accuracy with <cue type>.
Word finding/obj ID
Increase fxl abstract
reasoning abilities for
ADLs to 80% proficiency
Abstract reasoning
Follow <1-3> step
commands with <0-100%>
accuracy with <cue type>
to understand <purpose>
Following directions
<explain, follow> safety
strategies for ADLs with
<0-100%> accuracy with
<cues>.
safety
Abstract reasoning-teach correct
inferences draw from
read or narrated stories.
Includes absurdities,
proverbs/metaphors.
(Hedge, Davis 2010).