1. Dysphasia Pragmatic Communication Cognitive Impairments

2.  Hospital  Rehab  SNF  Homecare  Outpatient clinic  University  CVA/multi infarct dementia,TBI, alzheimers dementia

3.  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

4.  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)

5.  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?

6.  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

7.  ASPECTS OF COGNITIVE PROCESSES  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.

8.  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.

9.  Diagnostic Screening FEES/ Videofluoroscopy  FEES: VideoVideo  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

10. RLG

11.  In skilled nursing-many clients with dementia will not be considered rehab candidate. Difficulty following commands and cannot perform swallowing exercises even with modeling.

12.  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

13.  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.

14.  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

15.  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

16.  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

17.  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).

18.  Client coughing on foods/liquids  Poor PO  Weight Loss  New admission or readmission-need to clarify diet

19.  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