Dysphagia, cognition and family

Currently i am working with a patient who has profound cognitive impairments, is non-verbal, largely non-responsive and requires hand over hand facilitation and prompting to follow instructuions e.g. to brush her teeth/wash her hands. She has a PEG feed and in the handover was getting trialed on grade 2 thickened fluids.

What i have learnt
The patients family are extreamely stressed about her communication and cognition. I have assessed the patient's swallow using observation and cervical auscultation (as she can't vocalise after swallowing). No abnormalities were noted except for a delayed oral stage and an effortful swallow. The patient was able to eat a yogurt and to drink thin fluids when given hand over hand facilitation. She is dysphraxic so responded best to hand over hand feeding and to thin fluids as this was more natural for her. Her family appreciated being handed over tangible feeding/drinking tasks to do with her.

Psychotherapy joint session

I recently had a joint session with a psychotherapist and a patient with a severe expressive aphasia who is communicating via gesture, speech, writing, drawing and spelling out words on an AAC. The psychotherapist was also trained as a councellor, meaning there was a bit of cross over.

What is psychotherapy? Psychotherapy aims to help clients gain insight into their difficulties or distress, establish a greater understanding of their motivation, and enable them to find more appropriate ways of coping or bring about changes in their thinking and behaviour.
Psychotherapy involves exploring feelings, beliefs, thoughts and relevant events, sometimes from childhood and personal history, in a structured way with someone trained to help you do it safely.

What Happened?
The patient was able to communicate large amounts of complex information when supported by two people. I frequently summarised my understanding of what the patient was communicating in order to give him feedback. I also stated that i didn't think i understood when the patient was unclear. The psychotherapist verbalised and reflected feelings the patient may have been experiencing as he described what happened to him when he had his stroke.

What I learnt

1. Summarising -pt. responded positively to his communication being summarised verbally.
2. Feedback - the patient initiated different strategies when he realised i had not understood.
3. Reflecting - the patient responded well to the psychotherapist verbally empathising with him and discussing feelings.
4. Topic - the patient was motivated to discuss his family and the events surrounding his stroke.

CN exam

Swallowing dysfunction

Signs and symptoms

What can go wrong?

Oral preparatory

• Reduced lip closure: cannot hold food in the mouth
• Reduced tongue shaping : coordination
• Reduced range of tongue movement: cannot form a bolus
• Tongue thrust
• Lip and jaw weakness: material falls in anterior sulcus and lateral sulcus

Oral

• Residue in anterior and lateral sulcus: reduced lip tone
• Residue in the floor of the mouth 
• Reduced tongue elevation: incomplete tongue-hard palate contraction: residue on the hard palate
• Reduced tongue coordination: piecemeal swallow
• Repetitive lingual rocking and rolling: “tongue pumping”(PD)
• Reduced tongue control and tongue-velum seal: uncontrolled bolus-premature loss of liquid or pudding consistency into the pharynx

Triggering Pharyngeal swallow

·       Delayed pharyngeal swallow: when the head of the bolus enters the pharynx and the swallow has not been triggered: liquids may enter the airway first; no CP opening as no swallow has been triggered: Aspiration before the swallow

·       Timing the delay: in sec

Pharyngeal stage

• Nasal penetration during swallow: reduced VP closure.
• Cervical osteophytes
• Residue laterality (for pharyngeal wall weakness)
• Residue in the valleculae after swallow: reduced tongue base posterior movement
• Residue at the pyriform: reduced laryngeal elevation
• Laryngeal penetration: reduced laryngeal elevation
• Aspiration: during the swallow: reduced laryngeal closure

Oesophageal (usually not assessed-for further referrals)

• Oesophageal-to-pharyngeal backflow
• Tracheo-oesophageal fistula
• Reduced motility

MDT management

Laryngeal function examination

An inability to change the pitch may imply reduced sensitivity within and surrounding the larynx.

Pre -Morbid

I've been having difficulties thinking of relevant goals for patients to achieve before discharge. To make realistic goals with complex patients (e.g. co-morbidities/ multiple previous strokes) I have been finding out as much information from previous clinicians, family and patients themselfs, about their previous level of functioning e.g. voice changes, language changes, cognitive changes ..... I have then been combining this with ICF information regarding the patients activities, participation and impairment.

Competency 1: Reading

Logemans chapter 2 and Love and web Chapter 7: The normal swallow and the cranial nerves.

Summary	·         4 stages in the swallow: Oral preparatory, Oral stage, Pharyngeal stage and the Oesophageal stage. ·         Originate from the brainstem and are part of the PNS – provide sensory and motor information to the facial, oral, pharyngeal and laryngeal musculature.
Key information	Oral Preparatory Stage l  Anticipation and Sensory recognition of food. l  Lip seal. l  Nasal breathing l  Mastication (to form a bolus). l  Lip, jaw, tongue & palate sensory & motor function needed [& dentition]. Oral Stage l  CN V (Trigeminal) – responsible for the chewing muscles (Masseter (closes jaw), Temporalis (moves jaw up), Pterygoids (jaw side to side). l  CN VII (Facial) – Lower facial muscles/ lip seal + pressure build up. l  CN XII (Hypoglossal) – tongue l  Tongue moves bolus posteriorly (striping action). l  Open airway l  1-1.5 seconds to complete. l  Nasal breathing l  Need intact labial, tongue, palate and jaw musculature. Pharyngeal stage l  CN XII (Hypoglossal) – tongue/ geniohyoid l  CN V (Trigeminal) – elevates/retracts the hyoid. l  CN VII (Facial) – Stylohyoid elevates the hypoid. l  CN X (Vagus) and Spinal accessory N – innervate the pharyngeal muscles + Cricopharyngeous. Triggered by sensory receptors in the tongue/ oro-pharynx – info to the brainstem/cortex. Elevation of the velum Elevation + anterior hyoid/larynx movement. Closure of the larynx (epiglottis) Opening of the cricopharyngeal sphincter Tongue base retraction to contact the posterior pharyngeal wall. Pharyngeal constriction. Normally the duration of airway closure increases as bolus volume increases. Swallow normally followed by exhalation. Cup Drinking ·         Sequential swallows Older Adults ·         Can still chew with poor dentition. ·         Often have decreased strength of pharyngeal contraction – therefore may have second residue clearing swallows. ·         Increased delayed triggering of the pharyngeal swallow.
Clinical application	l  Oral preparation –        spilling food/drink/saliva from mouth; food pocketing in cheeks; long time chewing, trying to swallow big bits, food/drink goes back too quick/ before the oral/pharyngeal swallow is initiated. l  Oral phase –        holding food in mouth, several attempts to swallow, food left in mouth l  Pharyngeal phase –        food/drink enters airway (penetration / aspiration), coughing / no coughing, food/drink remains in pharynx l  Oesophageal phase –        food/drink remains in pharynx, reflux
What I will do to investigate the articles findings	·         Observe swallowing in 5 patients who do not have dysphagia. Observations: ·         Double swallows ·         Eat and talk ·         Variable hyoid elevation and anterior movement of the larynx.
Literature review	·         Normal swallow is variable i.e. timing, strength…