Imagine going to see a physician, and rather than talking with you and doing a physical evaluation, he/she immediately starts a diagnostic test. For example, rather than listening to your heart with a stethoscope, the physician immediately completes an EKG.
This is what it would be like for our patients if we skipped a clinical swallowing evaluation and went immediately to an instrumental assessment such as a videofluoroscopic swallowing study or fiberoptic evaluation of swallowing.
Besides giving the patient an opportunity to describe his/her problem (if he/she is aware of it), observing a patient’s response to questions informs us of his/her language and cognitive abilities. This is part of the internal evidence, or key information about the patient that helps shape our diagnostic evaluation and treatment. Along with external evidence – e.g., peer-reviewed research – internal evidence allows us to use the best approach for each client.
We should know if our patient is aware of his/her swallowing problem. Gathering history information from the patient and family can fill in these details. When completing the clinical swallowing evaluation, informally observe language and cognitive functioning. Ask yourself:
- Can the individual follow your directions without repetition or modeling?
- Is the person focused or easily distracted? Do you have to repeat instructions to maintain their concentration?
- Is the individual impulsive during the swallowing portion of the examination? For example, do they attempt to drink large volumes when the neck is hyperextended?
Informal observation of a patient’s cognitive and communication abilities allows the astute clinician to tailor the instrumental evaluation. If warranted, it should influence which compensatory strategies are evaluated as well.
Looking at the Big Picture
Further, this information will impact our treatment recommendations. Individuals with cognitive and comprehension deficits still warrant swallowing rehabilitation, but the delivery of the treatment will require adjustment to meet the language and cognitive needs of the patient. While our focus may be dysphagia, remember, we are still speech-language pathologists.
- Foundas AL, Macauley BL, Raymer AM, Maher LM, Heilman KM, Gonzalez Rothi LJ. Ecological implications of limb apraxia: evidence from mealtime behavior. Journal of the Internation Neuropsychological Society 1995;1:62-66.
- Schroeder MF, Daniels SK, McClain M, Corey DM, Foundas AL. Clinical and cognitive predictors of swallowing recovery in stroke. Journal of Rehabilitation, Research, and Development 2006;43:301-310.