Dysphagia Case Scenario

Original Editor - Ansunette Pelser Top Contributors - Jess Bell and Ewa Jaraczewska

Introduction

Speech and language therapists play a crucial role in managing oropharyngeal dysphagia. Their interventions enable patients to eat and drink safely, preventing complications like aspiration pneumonia and improving quality of life.

This fictional case scenario highlights the role of speech and language therapists in assessing and managing oropharyngeal dysphagia.

Client Characteristics

Mr X is 78 years old. He has recently had a stroke and was diagnosed with dementia five years ago.

Current Presentation

Mr X is observed sitting up in bed approximately four hours after breakfast. On speaking, remnants of food are visible in his mouth. He has some drooling, and his speech is slurred.

Chart Review

The nursing notes indicate that Mr X has been losing weight steadily since admission despite receiving nutritional supplements. He is also receiving additional hydration intravenously, as he has been unable to maintain adequate hydration orally. The physiotherapist and nursing staff also note that Mr X is expectorating thick, yellowish-green sputum.

Mr X hasn't yet been referred for speech and language therapy because he does not cough when eating, and his voice sounds clear after eating.

Speech and Language Therapy Assessment

Why would a speech and language therapist see this patient, and what might they find?

There are a number of reasons a speech and language therapist would see Mr X.

Mr X has several risk factors for dysphagia: his age puts him at risk for presbyphagia (swallowing difficulties caused by ageing of the mechanisms involved in swallowing), he has dementia and has had a stroke recently.

The remnants of food in his mouth and his slurred speech suggest difficulty during the oral phase of swallowing. There is also evidence of aspiration: weight loss, dehydration and signs of chest infection (likely aspiration pneumonia). Mr X has no overt signs of aspiration while eating, which raises the suspicion of silent aspiration.

Where possible, the speech and language therapist will first complete an instrumental assessment. If an instrumental evaluation is not possible, the speech and language therapist will use bedside observations to identify which components of swallowing appear to be affected.

Speech and Language Therapy Intervention Plan

The speech and language therapist would likely consult with the medical team regarding the treatment of the suspected aspiration pneumonia. For Mr X, it would be beneficial to place a nasogastric (NG) tube. Placement of the NG tube would allow the speech and language therapist to safely introduce manual swallowing therapy and therapeutic feeding with compensatory strategies.

They would aim toward transitioning Mr X to oral nutrition with appropriate supplementation. They could progressively introduce new, more challenging food consistencies as tolerated. Throughout this process, the speech and language therapist would conduct regular reassessments and modify the plan based on the patient's progress.

The speech and language therapist would also work with Mr X's family, providing education on safe feeding strategies.

Possible Outcomes

Speech and language therapy could help improve Mr X's oral control, enabling him to safely consume puréed foods and nectar-thickened liquids using the compensatory strategies he learned. He would likely start to regain some of his lost weight, and his respiratory status should improve. The NG tube would be removed once appropriate. Mr X's family would ideally learn safe feeding techniques to help prepare for Mr X's discharge home.

Conclusion

This fictional case scenario demonstrates the role of the speech and language therapist in identifying and managing dysphagia and silent aspiration in patients with neurological impairments. It highlights the importance of proactive dysphagia screening and assessment to ensure prompt intervention and improved outcomes.