Dysphagia Presentation (to volunteers)

Audience

Hospital volunteers who sometimes support patients at mealtimes.

Content
Lecture

•  Inroduced SLT, my role, where I work and what volunteers might be expected to do.
• What is dysphagia + risks + signs of
• Safe feeding strategies
•  SLT recommendations – showed example bedside signs e.g. nil by mouth. Fluids (thickened/ normal), Diet (normal, soft, soft-mash, puree, tasters
• Malnutrition and dysphagia
• Volunteer responsibilities when working with dysphagic patients e.g. asking nurses for info.
• Top ten tips for feeding.

Activities

• Thickening drinks
• Feeding each other, one person pretending to have hemiplegia/ sensory deficit e.g. hemiplegia/ closing their eyes (eater) and one person practiced feeding in a attentive/ neglectful way e.g. not talking through what they were doing.
• Reflecting on the activities. How did it feel to be the eater/ feeder?

How did it go?

•  Activities and props e.g. bedside SLT dysphagia recommendation sign and a menu from the ward – worked well to break up the presentation and engage the volunteers.
•  Examples/ client case studies interested the volunteers.
•  Reading out text was not so engaging for the volunteers.

Improvements for next time

•   Images on a powerpoint e.g. feeding tubes, drowsy looking patient, supplements, chest for aspiration pneumonia….
•  Case studies to work through – split the large group up into four – what would you do if 1 – Patient struggling with meal, 2 Patient has requested normal fluids repeatedly 3. Aggressive patient 4. Patient keeps falling asleep.
•  Ask more about experiences – eating/ drinking diff. / choking … and then relate these to the training. E.g. imagine if you had a coughing fit everytime you drank.

Clinical audit training

Here's some of my summaries and notes from a clinical audit training session:

Clinical Audit

What is an audit ?

 ‘The systematic and critical analysis of the quality of the clinical care’

 Aims ‘to evaluate how local practice resembles best practice.’

Audit cycle

-  Determine standard to be audited

-  Collect data

-  ? meeting standard

- If not, decide on a strategy for change  and put in place.

-  Monitor effective change.

  Start with a Standard or a guideline.

  Discuss your project with your supervisor and Clinical Audit and Effectiveness Lead.

  Identify Clinical Lead to lead the project.

  Write up and present findings at the end of the cycle.

Process Audit – e.g. questionnaire to patients e.g. where you given instruction in how to …. Where you given advice about…..

Outcome audit – records/computer records audit – e.g. how many patients developed aspiration pneumonia, questionnaire to patients – e.g. extent of understanding regarding ….

How to choose an audit

-          Frequency – repetition can lead to skills slipping

-          Level of risk

-          History – past problems etc./ complaints

What makes a good audit?

-          Patient centred, possible to measure, frequently occurring problem, good team invovlvement.

Criterion – an element of care/ activity that can be measured.

Standard – describes the level of care to be achieved for any particular criterion (have a minimum, ideal and optimum).

Collecting data

-          Plan and involve all staff.

-          Consider if you need to look at all occurences or a sample.

-          Sampling technique

-          Use data collection forms/ questionnaires

Videofluoroscopy - Observation

Observations

• Lead therapist - directed, decided on consistencies/ repetitions.
• Treating therapist - fed the patient, made up the barium coated food, stated when ready to start recording, advised on strategies to use/ what the client is like at baseline.
• Explanations - Process was explained clearly for the patient + what they needed to do (sit in position + eat/ drink normally when asked to). Given rationale, talked through anatomy, offer given to go through the video afterwards.

Notes

1. Swallow attempt, consistency and amount.
2. Symptoms observed e.g. overspill, delay, residue - where/when/how much.
3. Disorder e.g. reduced BOT - PPW approximation.
4. Aspiration/ penetration scale.
5. No. of swallows to clear.

Watching the video

• It was useful talking through my thinking with the lead therapist.
• The focus was on aspiration/penetration and then worked backwards from there to consider the reason for aspiration.
• The video's are normally replayed repeatedly on a separate occasion when writing the report.

Mini - report

Client 

• Right subdural haematoma, recent hospital acquired chest infection ?silent aspiration.
• Currently eating a soft diet and drinking thin fluids.

Oral stage

• Slow prolonged oral stage when eating soft foods requiring chewing.
• Effortful chewing and bolus transfer.
• Difficulties initiating a swallow when swallowing teaspoons of water. Delayed swallow trigger with overspill into the valleculae. Able to trigger a swallow quicker when cup drinking.

Pharyngeal Stage

• Delayed pharyngeal swallow trigger.
• Overspill of bolus' into the valleculae on both soft food and liquids. Penetration observed at the level of the valleculae.
• No cough reflex triggered in response to residue.
• Clearing swallow cleared all of the residue.

Strategies

• Clearing swallow was successful.

Conclusion

• Mild oro-pharyngeal dysphagia characterised by reduced oropharyngeal sensation leading to a bolus overspill and a delayed swallow trigger. Risk of silent aspiration. No aspiration when the patient ate/drank slowly and used clearing swallows.

Recommendations:

- Soft diet, Normal fluids (clearing swallows, slow drinking, monitor chest status).

Interpretations

What Happened?

I had a joint session with a Somali interpreter and a patient who had aphasia. I wanted to see if the patient could participate in a discussion around their discharge destination/ care needs. The patient had severe aphasia in both languages. I asked the interpreter questions I had prepared beforehand and asked her to interpret the patients responses. The patient stated 'home' when asked about discharge destination showing some comprehension by also asking 'when'. I rephrased questions for the interpreter and the patient did not appear to understand any more complex decisions/ concepts e.g. care needs. The interpreter had told me that she thought the patient understood the questions.

How did it make you feel?

• I felt that i could have prepared some picture resources to use alongside the interpreter.
• I felt that it was helpful to have pre-prepared questions to ask.
• I felt that i should not have asked the interpreter if she felt the patient understood the questions and should be clearer about asking the interpreter to translate everything word for word.

What will you do next time?

• Prepare written information to support the interpreter and prepare picture resources.
• Re-phrase questions/ information to really check the patients comprehension.
• Ask the interpreter to interpret word for word.

Nectar

Leder et al (2012)

• Looked at patients who aspirated on water but could manage a puree diet.
• Compared nectar and honey consistencies.
• Aspiration is often due to age related loss of muscle bulk/ strength, reduced functional reserve, generalised weakness, deconditioning, or reduced cognitive functioning.
• Thickened fluids slow down bolus flow.

Method

• 84 patients referred to SLT with dysphagia, who managed a puree diet but aspirated on water on the 3 ounce water test were chosen.
• FEES was used to ascertain if they aspirated on honey/ nectar thick fluids

Results

• 100% of patients did not show signs of aspiration on either honey or nectar thick fluids.
• Patients reported that they preferred the thinner consistency.

How this affects my practice

• I will consider recommending nectar thick consistencies/ assessing swallowing on nectar if patients are having compliance issues with syrup thick fluids.
• Nectar as a step down from syrup during dysphagia therapy.

Cognitive Communication Impairments - case2

Brief History

• 88 year old client with a large deep L-MCA with a haemorrhagic transformation.
• Severe cognitive impairments - response initiation, memory, attention, executive functions.

Speech and language

• Very quiet voice - ? self monitoring.
• Language - understanding occasional keywords and understanding parts of conversations in context (attention was a limiting factor). Tangential speech unable to remain on topic, much of the clients speech didn't make sense. Complex sentences/ phrases and words appeared easier for the client to retrieve than simple word/ phrases e.g. man riding bike was - person is accessing the motion cylinders for propulsion. Semantic deficits on the CAT. Severe difficulties following simple instructions in therapy sessions e.g. lift arm.
• Insight - client was aware that they had had a stroke and that they were finding it difficult to participate in therapy.

Therapy session

• Guided conversation on therapy and how therapists could help the client to help themselves.

Guidelines developed with the client (written in their own words and laminated so that they could be referred to in therapy sessions).

1. 'i want you to show me how i can help myself'.
2. 'show me what you need me to do'
3. 'tell me why i need to concentrate on something'
4. 'tell me how long i need to do something for'

Recommendations/ strategies that worked

• Ticking off completed activities.
• Keeping a written list of activities to be done in a session (clients reading was very good).
• Explaining the goals of each activity.
• Writing down key points the client made so that you can refer back to them to keep the client on topic using their own words.
• Reducing distractions.

Apraxia of speech - research and idea's

I've recently had a few patient's with AOS, so decided to update my knowledge using Duffy's text and lay down some ideas based on my observations.

Emotions can help
I have a patient with severe AOS who is better able to communicate when the subject is emotive and they are able to be relaxed. One of my idea's is to chose emotive words/ topics to work on in therapy which are also more meaningful for the client e.g. Home/ discharge, Stroke/ recovery, Family....

The theory: - The Motor speech Programmer's (MSP) left hemisphere functions are strongly linked to the linguistic attributes of speech (phonologic, semantic, syntactic...) and the right hemisphere's MSP functions are more strongly linked to speeches emotional/ affective attributes. Therefore you can get some information from tone of voice etc. and maybe you could use emotional/ affective prompts to support the MSP.

Singing can help
- Clients may be able to sing, count or swear.

I have used singing to allow clients to be stimulable for a sound and then worked on integrating that sound into a word.

Duffy update
Severe Apraxia of speech

• Disturbed planning/ programming of movements for speech (MSP)
• Can occur without impairments on non speech tasks/ without verbal/ reading comprehension impairments (e.g. non-verbal oro motor exam may be normal).
• Often coexists with aphasia and dysarthria.
• Predominantly due to left cerebral hemisphere pathology (especially parietal/ frontal).

Positive indicators for AOS

• Narrative/ conversational speech = most difficult (varying patterns of stress and syllables).
• Difficulties on repetition tasks (challenge speech planning/ programming not word retrieval).
• Sequential Motion Rates (very sensitive to AOS - are the ability to move from one articulatory position to another) e.g. repeat 'catastrophe' 'pataka'

Assessment
Articulation

• Imprecise, distorted substitutions, distorted perseverative substitutions (nanana for banana), distorted anticipatory substitutions e.g. popado for potato, distorted additions.

Rate + prosody 

• SLow rate, variable vowel duration, stress errors on words/ syllables, decreased phonemic accuracy with increased rates.

Fluency

• False starts/ re-starts, effortful groping, sound + syllable repetitions

MSP

• Establishes the plans/ programs for the cognitive (e.g. affect...)/ linguistic (e.g. words) goals of speech.
• Organises motor commands to produce syllables, words and phrases at particular rates/ patterns of stress/ rhythm.
• Linguistic input to the MSP = from the Left Hemisphere's perisylvian area (temporoparietal cortex, post. frontal lobe, insula, basal ganglia and thalamus)
• Selects, sequences, activates and controls pre-programmed movement sequences.

AOS and other apraxia's

• AOS can co-occur with limb apraxia (deficits with purposeful limb movements).
• This can impact on communicative gesture use/ AAC accessibility.

Cognitive Communication Impairment - case study

Client

• L-MCA stroke, left handed, no aphasia/ dysarthria, very mild cognitive impairments on the MOCA assessment.

Assessment

• Informal language screen - no impairments.
• Informal language assessment - conversation on employment and medical history, observation during a Physiotherapy and OT session.
• Findings - client had difficulties with topic shifting, turn taking, reduced awareness of his impairments, and verbose tangential responses during conversations. These difficulties lead to him having difficulties participating in therapy (PT, OT, SLT) since he was unable to perform tasks well when speaking and was unable to monitor his output.

Intervention

•  LA - Trobe questionnaire was completed with the client and with his partner in order to look at their views on his communication and ho it had changed. Results - the clients premorbid communication style had been exacerbated by his stroke.
• SLT went through the LA - Trobe with the patient, his partner and therapists, providing clear examples of his communication behaviours. The client highlighted behaviours to work on.
• Group - the client attended communication groups/ breakfast group/ stroke education group and received peer feedback.

Outcomes

• Client was able to participate more in therapies (report form therapists).
• Client self - monitored more becoming less verbose in group conversations.

Mos Def - NG feed

NG - feeding and not in a good way

http://www.youtube.com/watch?v=z6ACE-BBPRs

Ramadhan

This year, the fasting month of Ramadhan is from

*9^th July 2010 – 7^th August 2013

*(Subject to sighting of the new moon)

 Background

Ramadhan is the month of fasting when the Quran (Muslim Holy Book) was revealed to the prophet Muhammad. For Muslims it is a special month of spiritual reflection and revitalisation, when they try to spend as much time as possible in prayer and other ritualistic exercises.

Fasting

·      During Ramadhan fasting is compulsory for all adult Muslims and they must refrain from drinking and eating during daylight hours.

·      Fasting lasts from dawn to sunset. This may have implications for patients. 

·      Those fasting need a meal before the break of dawn and another after sunset. 

Exempt from Fasting

·      All those who are ill (Physical or mental illness) or frail.

·      Very elderly or mothers, who are breast-feeding.

·      Lactating women who have concern about their own, or their child’s health.

·       Are exempt from the obligation, some may nevertheless insist on fasting.

·      As a result, the nursing and medical staff may have to discuss the administration of medicines.

Prayers

·      Alongside the customary and obligatory prayers, which are said five times a day, there are additional prayers and other spiritual exercises, which are mostly carried out at night. In addition, during the last ten days of the fast there are further prayers and spiritual exercises to be held.

·      For the purpose of prayer, water for ritual ablution may be required.

·      Some patients may ask for a prayer mat, a copy of the Quran or a Ramadhan prayer-timetable. 

Eid-ul-Fitr

The end of the month is marked by the celebration of Eid-ul-Fitr. This is one of the most important festivals in the religious calendar. It is also a great social and family occasion that begins with a compulsory congregational prayer in a mosque or any other suitable place.

Conversational partner training

Key Points:

• Reveal competence/ find  examples of positive conversational behaviours. 
• Access peer support - have another SLT view the video, they can be more detached and/or do a CPT group so that other family members can offer each other support.
• Try using a scale to identify positive/ negative behaviours.

Advice

• Run conversational partner group sessions. These are separate from individual therapy sessions and may reduce the pressure family's may put on you to do impairment based therapy.
• Set small functional goals e.g. to use photos as conversational starters.
• CPT group - discuss clips and then have separate individual sessions before coming back together and discussing learning outcomes.
• CPT often requires a lot of time e.g. staying late to ensure a family member can attend/ reviewing clips.
• Use scales to help identify negative behaviours e.g. behaviours 12345 - how often did you see these? - the client could rate 2 positive behaviours and one negative behaviour.
• Use an issue e.g. supporting a patient to make a decision about their care/ discharge as an example for CPT e.g. when we ........ to help .... make a decision we used .......

Convincing clients to try CPT

• Show examples of clips e.g. from SPARK DVD's to the patient/ client before beginning CPT in order to demonstrate what it is about.
• Explain that CPT is proven to get people to use certain skills/ behaviours in functional situations.
• Remove the video aspect.
• A family may be too much in crisis to engage with CPT or need more insight.

Method

• Get your perception and their perception of conversations informally and then more formally e.g. with sections from SPARK/ CAPPA/ LA - TROBE.
• Preview video's of the patient + friend/family member having a conversation before the joint session.
• Show clips of the video and highlight what went well, discussing the specific behaviours. You can use checklist sheets to help clients identify behaviours (SPARK is usefull for this + has checklists - but with formal language).

Further research

• Clinicians at UCL are creating online resources for CPT

Detective board

Watching the wire gave me an idea, a detective board/ visual way of looking at a patients case to get an overview (goals, interests, diagnoses....).