Dysphasia
Pragmatic Communication
Cognitive Impairments
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Hospital
Rehab
SNF
Homecare
Outpatient clinic
University
CVA/multi infarct dementia,TBI, alzheimers
dementia
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In rehab settings, therapy needs to be
considered restorative (to return to prior level
of functioning-prior to hospitalization).
The Level of Cognitive functioning is critical
to progress
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What has been described as swallowing dysfunction in young persons may not
be abnormal in very elderly persons. It is difficult to distinguish the effect of
normal aging from the effects of specific diseases or gradual degenerative
changes.
Preliminary observations on the effects of age on oropharyngeal deglutition
Julie F. Tracy, Jeri A. Logemann, Peter J. Kahrilas, Pothen Jacob,
Mindy Kobara and Christine Krugler, Dysphagia, Volume 4, Number 2 / June,
1989
Five measures were significantly changed with increasing age:
— 1. Duration of pharyngeal swallow delay (increased)
— 2. Duration of pharyngeal swallow response (decreased)
— 3. Duration of cricopharyngeal opening (decreased)
— 4. Peristaltic amplitude (decreased)
— 5. Peristaltic velocity (decreased)
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Speech Evaluation: Includes an assessment of
◦ General Neurological functioning
◦ Cognitive Ability*
◦ Feeding and Swallowing Function*
◦ Language Ability , Receptive/Expressive/Pragmatic
*Common sense observations: Handedness,
Hemiplegic, Weakness, Balance, coordination : How
does their skin look? Are they dehydrated?
Formal MEASURES:
 Cognitive Linguistic Quick Test
 Bedside screening (in handout)
 Functional Communication Profile
 Language -Cognitive-Communication Eval
 Aphasia Tests are not normed for Dementia
or TBI, but may provide information on
language abilities.
Aphasia , Apraxia, Cognitive disorders
and Progressive Dementias may co-occur
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ASPECTS OF COGNITIVE PROCESSES
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Constantinidou and Best (2004) Domains of Cognitive Functions
I. Attention- ORIENTING , EXECUTIVE FX AND
ALERTING networks
I.
Distracted periodically throughout the meal
II. Memory
III. Verbal Language
IV Means of learning and organizing new info in the
brain (assigning new info into groups=categorization)
V. Abstract Thought- most difficult
Additionally:
Psycho social- anxiety and depression
Lack of Functional Social-Communication may
negatively effect prognosis.
Restorative –improve skills through repetition
Dynamic aggressive rehab, good potential for
learning.
 Compensatory- developing strategies
:notebook, communication device
 Adaptation-adapting to the environment or
physical condition, caregiver education,
strategies to reduce further dysfunction
 Cognitive prerequisites for effective feeding
rehabilitation are alertness and attention.
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Diagnostic Screening FEES/ Videofluoroscopy
 FEES: Video
 Flexible Endoscopic Evaluation of Swallowing
 Research:.
 Diagnostic measures : Barium Swallow,
Videofluoroscopy, FEES
 Assessing Penetration and Aspiration:
 How Do Videofluoroscopy and Fiberoptic
Endoscopic Evaluation of Swallowing Compare?
Annette M. Kelly, MSc; Michael J. Drinnan, PhD;
Paula Leslie, PhD
The Laryngoscope Lippincott Williams & Wilkins
© 2007 The American Laryngological,
Rhinological and Otological Society, Inc
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RLG
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In skilled nursing-many clients with dementia
will not be considered rehab candidate.
Difficulty following commands and cannot
perform swallowing exercises even with
modeling.
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Oral motor assessment-if diagnosis of
dementia, may have to be informal
(observation) rather than formal.
Speech and Language Assessment- if
diagnosis of dementia, will need to document
items that CNT
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Oral motor assessment-may be informal,
depending on cognitive skills
Food trials
Liquid trials
Often client with dementia will refuse to
eat/drink…need to get family involved. Most
often they will accept food from family
member rather than stranger.
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Rehab- restorative? Many times candidacy for
dysphagia therapy is based on cognitive
abilities-client needs to be able to follow
directions to engage in swallowing exercises
to improve function. If not candidate, may
have to determine appropriate diet
consistency
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Often cannot follow commands, so eval is
more informal..need to observe:
Teeth or edentulous
Rate of intake/impulsivity..if they can self
feed, you might recommend supervision at
meals and small bites at a time or for
liquids,no straw
Pocketing-cheeks?
Lingual residue
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Timely swallow or hold food in mouth-many
clients with dementia require verbal cues to
swallow
Positioning in bed or wheelchair
Can they remove food from utensil
Mastication skills-timely? Many clients with
dementia will masticate food for long periods
of time
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If severe oral stage dysphagia –may
recommend puree. If difficulty masticating
regular solids may recommend mechanical
soft. If facial weakness, may recommend
thickened liquids.
If severe pharyngeal stage dysphagia may
recommend MBS (if suspect pain) or
possibly NPO. Possibly thickened liquids.
Often with severe dementia, client may have
PEG. SLP determines if client remains NPO
or pleasure feeds for quality of life (family
often involved).
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Client coughing on foods/liquids
Poor PO
Weight Loss
New admission or readmission-need to clarify
diet
Constantinidou, F., Thomas, R. D., & Best, P. J. “Principles of
Cognitive Rehabilitation: An Integrative Approach”. Boca Raton,
FL: CRC Press. ©2004.
 Constantinidou, F., Thomas, R. D., Scharp, V. L., Laske, K. M.,
Hammerly, M. D., & Guitonde, S. (2005). “Effects of
Categorization Training in Patients With TBI During Postacute
Rehabilitation: Preliminary Findings” Journal of Head Trauma
Rehabilitation Vol 20(2) Mar-Apr 2005, 143-157.
 Kelly ,Annette M. MSc,. Drinnan, Michael J. PhD., Leslie, Paula,
PhD
“Assessing Penetration and Aspiration: How Do Videofluoroscopy
and Fiberoptic Endoscopic Evaluation of Swallowing Compare?” The
Laryngoscope Lippincott Williams & Wilkins © 2007 The American
Laryngological,
Rhinological and Otological Society, Inc
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