Reflective log: Cognitive communication impairments and aphasia

1. Think of a recent therapy session or event.

A patient with comprehension impairments and cognitive communication impairments was due to be discharged soon and I needed to review their progress in SLT and consider whether to refer them to further community SLT.

2. Describe the session/experience

I used the cognitive screen of the CAT to assess the patient’s ability to access SLT in the community and completed the comprehension parts of the CAT to look for any improvements in function over their stay. The patient had completed much of the CAT when they had initially come in. The patient was fluent and used complex language but was very distractible and found it difficult to follow/ understand instructions resulting in very low CAT scores. I decided not to refer the patient to community services since they achieved very low scores on the CAT cognitive screen e.g. recognition memory and had not shown any improvements on the CAT despite intensive therapy.

3. What did this session make you feel?

I felt that I needed to have structured some of my initial informal assessments better in order to assess outcomes for a patient with cognitive communication impairments. Some of my SMART goals were hard to outcome e.g. being able to summarise a news article, being able to stay on topic in a one to one conversation about a familiar topic when minimally prompted.  It was difficult to assess for change. I felt it was good that I had done the CAT initially because I could use this to measure change.

4. What would you want to change, and why?

- Consider giving therapists a cognitive communication questionnaire to measure change in ability to access therapy.

 - Consider an MDT baseline e.g. the patient performed similarly in other therapies and was unable to participate fully in therapy sessions/ show any carry over.

5. What has this session has taught you?

- Use more outcome measures/ gain a clearer baseline of functioning.

- consider a patients cognitive ability to engage with therapy and make gains.

- poor performance on the CAT cognitive screen may be a negative prognostic indicator for change.

6. What do you need to learn or find out before the next event?

- Create a questionnaire on access to therapy which can be used as an outcome measure.

- record a conversation with the patient as a baseline to look at how many times they need re-directing as an outcome measure.

- continue to use the CAT cognitive screen to consider whether a patient can access therapy.

Questionnaire

Measure
Able to follow one-stage instructions in context	With modelling, prompting, repetition and tactile prompting	With prompting	With repetition
Able to maintain attention during a 10 minute session	With frequent prompting and re-directing	With occasional prompting and re-directing.	Independently
Able to remember a strategy/ instruction form a previous session	With repetition and prompting.	With prompting	Independently

Mealtime Audit

Here's an audit performa i've prepared for a mealtime audit. I've created it as a checklist to make it quick to use since there are so many patients on the ward. Hopefully this audit will highlight areas which need to be addressed at mealtimes by the MDT.

Mealtime Audit

Measure                              Comments

Correct tray Correct meal Correct drinks  Correct supplements Correct dessert/ soup  Correct bedside guidelines Correct whiteboard guidelines  Correct catering guidelines  Correct supervision/assistance Adequate support to order food/ drinks Appropriate medication preparation Food chart filled out Appropriate feeding/drinking equipment (cup/ cutlery/ straw)

Learning disability and dysphagia

Here is some information i have summarised from the latest RCSLT guidelines on dysphagia in the learning disability population (Wright, D et al 2013).

Learning Disability is defined as a significantly reduced ability to understand new or complex information, to learn new skills and to cope independently.

Discuss eating and drinking with the patients carer and ideally observe them at mealtimes (they may be unable to communicate effectively).

Food Modification

The British Dietetic Association recommends a hierarchy of textures according to need: Fork- mashable diet, pre-mashed diet, thick puree, and thin puree. The type of food texture required is dependent on the oro-motor and swallowing needs of the patient.

Thickeners can be used to reduce the risk of aspiration since they help the patient form a cohesive bolus, thus aiding oropharyngeal control and slowing transit time in the pharynx. However supporting evidence is limited and thickeners affect food palatability, compliance can be an issue, hydration is often negatively affected and there is still a risk of aspiration pneumonia.

Postural techniques to support swallowing

Often need good cognition/ memory e.g. the Mendelsohn manoeuvre, tongue hold technique, and the double swallow.

Swallowing therapy

Independence during mealtimes can enable a person with learning disabilities to control the speed and pace of a meal and therefore to clear the oral cavity before the next mouthful. Hand over hand facilitation can maximise independence.

It is important to involve patients and their carers in care planning and management. Non-compliance by patients/ carers is common. Patients with LD may find it hard to understand the implications of their swallowing difficulties. It is therefore important to communicate to carers the need to follow swallow recommendations in order to reduce the risk of aspiration.

Care Plans

Written care plans are best.They should include eating, drinking and swallowing guidelines and mealtime information forms. Care plans should be individualised, and outline the patients needs, make clear the actions needed to achieve the goals and to evaluate the management process. Care plans should be reviewed regularly.

Monitoring

Patients requiring puree diets/-thickened fluids  are at high risk of developing malnutrition/ dehydration which in turn can negatively affect swallowing. Malnutrition causes fatigue, muscle weakness and impaired coughing, while dehydration reduces the fluid content of saliva.

Carers of patients on puree/ thickened fluids need to encourage their clients to eat/ drink small amounts of food (high energy)/ fluid throughout the day.

Duty of care

We are legally obliged to provide evidence based care and treatment tailored to the individual.

COPD and Dysphagia

COPD and Swallowing

The effects of COPD on swallowing are becoming increasingly well documented and it is thought that between 21-42% of people with COPD will experience symptoms of dysphagia. Conversely only 3-5% of people with COPD and dysphagia are thought to be referred for expert assessment and help.

Effects of COPD on swallowing

1. Faster breathing rate

• People with COPD are likely to need to breath more often in order to get the oxygen that they need.
• This may mean that need for oxygen may overrule the need to protect the airway during the swallow-breath cycle and so disrupt that cycle in order to take a breath.
• Any disruption to the swallow-breath cycle could lead to aspiration e.g. inhaling post swallow instead of exhaling.

2. Reduced lung capacity

• Swallowing is exaccerbated by the reduced lung volume that peole with COPD suffer from.
• Lung volume is thought to be involved in creating pressure in the airway that helps drive the swallow process.
• Reduced lung voulme will reduce the level of this pressure at the time of swallow and this alters the speed at which the swallow occurs.
• Consequently the swallow takes longer and is more likely to leave food and drink behind in the throat.
• Consequently, people with COPD would need to hold the breaths for longer during the swallow BUT they are less able to do so and so are more likely to disrupt the cycle and inhale mid-swallow.

3. Altered swallow-breathing cycle.

• People with COPD also show an altered swallow-breathing cycle to the one shown above.
• They are more likely to swallow during inhalation rather than exhalation.
• They are more likely to need to breath in as soon as the swallow has finished rather than resume exhaltion.
• This means there is a greater risk of inhaling food and drink that could lead to aspiration.

4. Weaker cough

• The body usually resonds to aspiration by coughing.
• People with COPD are more likely to have a weaker cough and so their cough may not be effective to clear food and drink out of the airway.

5. Secretions in throat

• Food and drink can “stick” to any chest secretions in the throat and be left behind after the swallow has finished to be inhaled at a later date 

Interestingly many of these symptoms are more likely to occur on foods that require chewing than semi-solid food or drinks. Presumably this is because chewing requires more effort and may increase shortness of breath. Softer foods therefore often have a reduced risk of aspiration.

Consequences of dysphagia

Increased risk of Aspiration/ aspiration related pneumonia.

A chest infection in a person with COPD may lead to an exacerbation of their COPD symptoms (shortness of breath etc.) which therefore further impacts on their swallowing.

As someone with COPD uses more energy to maintain breathing and oxygen levels during chewing and swallowing, eating and drinking can be tiring. As a result, drinking and eating meals take longer which can lead to eating and drinking less. Eating and drinking less would cause

• a drop in hydration levels which could lead to thicker secretions
• reduced levels of nutrition that could contribute to increased fatigue
• weight loss.

Signs of dysphagia

• Coughing or choking after swallowing food or drinks
• Increased shortness of breath during meals
• Wet or ‘gurgly’ voice after swallowing
• Feeling like food is getting stuck in the throat
• Difficulty chewing foods
• Taking longer to start a swallow
• Food or drink going into your nose

Dysphagia Clinical Notes

Here's are some guidelines that i've used to structure my clinical notes. I've found that putting 'impression' and 'recommendations' as headings has helped other professionals understand my notes.

SLT medical notes structure

Date and Time and Profession (Speech and Language Therapist written out in full)

Subjective (i.e. heard/read)

Reason for referral/review. Pt seen for assessment of swallow, Nursing Staff and medical notes report patient coughing during meals.

If initial assessment; brief summary from medical notes, including any previous SLT input, and current status.

If review: current swallow status. NS report pt managing current recommendations with no concerns.

Consent.

Pt’s response to assessment. Pt asleep, roused easily to voice.

Objective (i.e. seen/done)

Positioning

If initial assessment: Oral assessment: cover; dentition, oral hygiene, oro motor function, i.e. cranial Nerve assessment, CN V, VII, X, XII

Oral trials;

pre-oral stage; comment on feeding

oral stage; comment on lip closure, anterior-posterior transfer, residue, oral hygiene

pharyngeal stage; comment on swallow trigger, hyolaryngeal function, penetration/aspiration

Communication; receptive, expressive, cognition, functional

Discussed with patient/family/therapists/doctor/nurse.

If review: swallow not reviewed because, e.g. discussed with NS, report managing well.

Analysis – impression and recommendations

Impression;

Swallow: diagnosis and severity and characterised by, e.g. mild oral and moderate pharyngeal dysphagia, characterised by weak and slow swallow trigger

indication of risk of aspiration

change from baseline / change from last session

Communication

Recommendations (nb shorter for review or refer to previous ax and full recs)

• Positioning
• Consistencies – food and fluid
• Compensatory techniques – e.g. pace / cutlery / bolus size
• Monitor for signs of aspiration, e.g. coughing
• Symptoms to look out for, e.g. stop if coughing
• Contact SLT and put NBM if signs of aspiration
• Mouth care
• Medications
• Non oral feeding, if appropriate

Sentinal stroke national audit project (SSNAP)

• Aims to improve the quality of stroke care by auditing stroke services against evidence based standards.
• Whole pathway: acute to community based care. 

SSNAP will provide regular, routine, reliable data:

–      to benchmark services national and regionally

–      to monitor progress against a background of change

–      to support clinicians in identifying where improvements are needed, lobbying for change and celebrating success

–      to empower patients to ask searching questions.

SSNAP will be the single source of data for stroke.

–      SSNAP will provide the data for all other statutory data collections including the NICE Quality Standard and Accelerating Stroke Improvement (ASI) metrics.

–      SSNAP will be the chosen method for collection for stroke measures in the NHS Outcomes Framework and the CCG Outcomes Indicator Set (formerly known as the Commissioning Outcomes Framework or COF).

SNAP SLT questions to be filled out for each patient

1.     Was the patient considered to require SLT at this point in their admission?

2.     On how many days did the patient receive SLT.

3.     How many minutes of SLT did the patient receive in total – pulled of EPR.

4.     Date communication first assessed by SLT.

5.     Time communication first assessed by SLT.

6.     If no communication assessment by discharge what was the reason?

7.     Date of formal swallow assessment by SLT or other dysphagia trained professional.

8.     Time of formal swallow assessment by SLT or other dysphagia trained professional.

9.     If no formal swallow assessment by discharge what was the reason?

10.  Date rehab goals agreed.

11.  If no goals, what was the reason (keep reasons for not seeing patients/ completing goals etc.).

Reflection

1. Think of a recent therapy session or event.

I was asked to fill in SNAP data for SLT patients over the last three months (backdated).

2. Describe the session/experience

I leafed through patients’ files and asked SLT’s if they remembered information relating to first contacts etc. In the notes we had not written in which contact was the initial contact so it was difficult to find the initial contact time/ date. I keep weekly timetables of the patients I see/ activities I do but throw these away every week so I had not saved this information and needed to retrieve it from EPR.

3. What did this session make you feel?

I felt stressed and concerned because I needed to provide accurate data for the audit.

5. What has this session has taught you?

•  To write down the date of the initial swallowing/ communication assessment, date of goal setting, reasons for not assessing/ treating a patient, time spent with a client and what time they were seen in a hardback diary which I then keep.
•  To regularly review the goals and outcomes of patients I see.
• To keep a file with summaries of patient goals, outcomes, therapy and assessment so that I can audit my performance in the future.