The Clinical Swallow Evaluation: More than Applesauce and Graham Crackers

Several years ago, I had an experience that substantially shaped my view of the clinical swallow evaluation. I’d been called to complete a swallow evaluation for a woman before her discharge that day. Her physician wanted her swallow function reviewed, and she and her son were waiting on my arrival to begin the discharge process.

Evaluating Swallow Function

I arrived to find a pleasant elderly woman, who had been admitted several days earlier with renal failure and respiratory difficulties, and her (perhaps understandably) irritated son.

Her evaluation went as follows:

• She reported no difficulty swallowing and denied cough, vocal changes, or any other potential signs of dysphagia.
• Her oral mechanism examination was unremarkable, so I quickly progressed to swallow trials.
• She ate the applesauce and the crackers I provided and washed it all down with serial water swallows – all while talking about her day!

Patient and Family Member Perceptions of Swallow Evaluations

It was clear that her swallow function was normal. She was eager to tell me about her granddaughter’s high school graduation that day and their plans for her party later that afternoon. I explained that I would be happy to let her doctor know the results and get her discharge paperwork completed quickly to send her on her way. As I left the room, her son turned to me and said, “Are you kidding me? We’ve been waiting almost an hour for applesauce and graham crackers? I could have given her applesauce and graham crackers!”

My first reaction was to defend my practice. Suddenly, I was able to see the evaluation through his eyes—a therapist came into his mother’s room, chatted with her about her granddaughter, and gave her a snack.

Why Patients Don’t Always See the Value of Clinical Swallow Evaluations

This experience illustrates both the challenge and strength of the clinical exam. As we try to simulate functional and “real-life” eating, the “evaluation” becomes less visible to family members, staff, and even the patient. Swallowing is variable and at times idiosyncratic. The parameters of the swallow response — tongue propulsion, tongue base retraction, pharyngeal stripping, hyolaryngeal excursion, upper esophageal sphincter opening, etc. — vary with the utensil used, bolus size and viscosity, and any number of patient-specific characteristics.

Staying Focused on Your Responsibilities

Our task is to accurately interpret our observations, identify aspiration risk factors, and evaluate them in the context of the patient’s medical history and current medical status. Aspiration clearly is a cause for concern, but we can only truly evaluate it in the context of:

• The patient’s immune system function
• Nutritional status
• Overall degree of disability
• Respiratory function

It doesn’t take special equipment or technology, but it does require training and expertise. Applesauce and graham crackers indeed!