Treating Dysphagia: The Role of Speech Language Pathology

[Ashley Agan MD]
So in your evaluation, I guess we'll just kind of take it from the top, as a patient comes to see you or you're going to see them, if it's mobile, what's the history taking look like? What's important? What are important things to be asking? And I guess, another thing from our side of it, what important things that we need to be asking to, before we're sending patients your way?

[Theresa Richard SLP]
Yeah, yeah. It's sort of all the above, just a normal case history, what surgical interventions have they had? What does their medical history look like? Medications is a huge thing too, as I'm sure you guys know, medications can impact the swallow greatly. So sometimes it's just nothing that we can do therapeutically as much as just recommending, sending them back to the physician, getting a change in their medications.

[Ashley Agan MD]
Are there particular medications that are common ones that stand out that affect the swallow?

[Theresa Richard SLP]
There are, especially a lot of muscle relaxers. If you think of the swallow, it's about 40 different muscles that make the swallow happen. So sometimes if you have patients on Ativan or something like that, or another form of muscle relaxant, and they complain that they can't swallow, that's something to consider. So that's sort of when we work closely with the psychologists and the facility too, to see what can we do to sort of relax this patient or ease the behaviors that they're having, but also still allow them to be able to eat by mouth because it can be very dangerous. There's many cases of patients aspirating or choking while on a muscle relaxant.

The other thing is the Parkinson's medication. So Levodopa. The timing of those, we've seen, it's night and day. If you see a Parkinson's patient before or after they've had their medication, it can be just the most uncoordinated swallow ever, but you give them the medication and it's all of the sudden beautiful. So that's one thing as soon as you see a patient with Parkinson's and if you know that they're on Levodopa regimen, make sure that they're eating about a half an hour after they've been given that medication. So that's something that's very common in that to be an easy solution in nursing homes.

[Gopi Shah MD]
When you do your evaluation, do you have them time the medication so that you get the best possible test?

[Theresa Richard SLP]
Ideally. Yep. Yep. Cause sometimes you just can't get anything. And also just educate them too and just say, Hey, without this medication, you're going to be calling me in again, because it's going to be really ugly. The patient's going to be struggling. So do you want to do it before the medication or after? There's obviously pros and cons to both sides, but you want obviously the patient to be eating and swallowing as effectively and safely as possible.

[Ashley Agan MD]
Do you find that medications that have dry mouth as a side effect of those? Because I tend to blame that a lot because I'm like, well, you just don't have enough saliva. And your mouth is too dry. Do you see that?

[Theresa Richard SLP]
Absolutely. Yeah, Yeah, absolutely. And I think, one thing too, is those lemon swabs. A lot of people tend to in the nursing homes or in the hospitals tend to tell people to use those, to sort of do oral care, which no, we should just be using a toothbrush and toothpaste for oral care, but the lemon swabs too dry out the mucosa immensely. So then people don't have enough saliva to be able to produce a swallow. So usually I just tell everyone, please throw out all the lemon glycerin swabs. And yeah. So if you're a producer of those, please don't come after me, but figure out a way to keep the mouths wetter.

[Gopi Shah MD]
Yeah, that's a good question, Ash. And when I think about it in the peds world, Theresa, do you ever see, in terms of secretion right? Secretion management is a big thing. And every once in a while a patient might be on something like glycopyrrolate or a scopolamine patch to help dry it up a bit. Do you ever find that that can be that dysphasia or something can be a side effect from that medication as well?

[Theresa Richard SLP]
Absolutely. I know the scopolamine patches are such a necessary evil sometimes. I know we see patients, almost for lack of a better term, drowning in their own secretion. So they'll be recommended one of those patches, but then on the flip side, it dries them out so much that they can barely swallow. So that's something that I think is so important for the speech pathologist and the doctors to work so closely together to weigh the pros and cons of that. Because I've seen the scopolamine patches help tremendously, but then I've also seen them tip back the other way and cause all these unwanted side effects. So when I do see that patch, I usually will bring it up and just probe a little bit more. Why did you start using this patch? Have you noticed anything different since? And sometimes patients are like, it's been a lifesaver and other times they’re like I'm so dry. So that's when we'll go back to the doctor and just try to brainstorm it. Is there something else we can do?

[Gopi Shah MD]
It's such a hard balance. Because of secretion management, aspiration, are they eating and drinking that little bit, how much benefit? It's such a tough balance with so many different factors.

[Theresa Richard SLP]
Right, right. Because obviously we don't want them aspirating all their own secretions too. So if it's helping in that aspect, then that’s wonderful.

[Gopi Shah MD]
Yeah, but like, if there's amazing pleasure and that 15 CCS of whatever, four times a day, like that's a little bit of joy that I can bring my kid or my relative. That's still huge too.

[Ashley Agan MD]
Moving on kind of through your visit and you've asked your questions and kind of gathered your history. What's next, I guess, it might depend on where you are, right? If you're at bedside or from your office.

[Theresa Richard SLP]
Yeah. If the patient obviously can communicate, and if they can tell you, or if you have access to a family member too, I like to sort of hear what does a normal meal look like? What foods do they typically like to eat? What are some cultural considerations to think of too? Because sometimes we'll make recommendations to slow a patient down or things like that, but it's the way they've been eating for a million years. And a lot of patients with developmental disabilities, especially kids with down syndrome, they eat in a very, for lack of a better term, it looks ugly under a swallow study. You would just say, this is a mess, but for them it's completely functional. And they may have never had an aspiration event. They may have never had a pneumonia. So it's really important to collect that data ahead of time, because what we've seen in our field is sort of just being too conservative by saying, oh my goodness, this is not functional. We need to alter the diet or we need to thicken the liquids. And then you can send the patient to all these behaviors because you've just modified things that they don't understand, or for what reason and decrease the quality of life. I like to take a lot of steps back and just see what is normal, what is considered functional for them? Because we're just learning now that the range of normal is much, much, much bigger than we once thought. So if we can get that information from the patient or a family member, that's something that's really so crucial because we don't want to be thickening a patient’s liquids without knowing for sure that that's absolutely what they need to be on.

[Ashley Agan MD]
I'm glad you brought up pneumonia. Because I think, when I was a junior resident, I kind of thought if a patient coughs, when they eat, then they should be NPO. Like aspiration equals don't eat. Right. But, now it's like, well, if you're not getting pneumonia, then maybe you have a strong cough and if you aspirate a little bit, you can get it out and we don't have to just keep you from eating. Right. Which is probably the worst thing you can do for a patient that's maybe having some issues. Because maybe, I don't know, you don't use it, you lose it and maybe things get worse. I don't know.

[Gopi Shah MD]
I was going to say those little minor modifications might be 20,000 steps back. I feel like, tell us about your experience.

[Theresa Richard SLP]
Yeah. So we know a lot more about sort of the pillars of pneumonia at this point. Now we know that you have to have a lesser functioning immune system. So if you have a well-functioning immune system, your chances of getting pneumonia are a lot less. Another thing to consider is the oral microbiome. What does that look like? If you have healthy oral care, you're brushing your teeth, toothpaste, mouthwash, you're killing all that oral bacteria. So the chances of it, even if it does go into the lungs and you aspirate, the chances of it turning into pneumonia are really slim. And part of the healthy immune system, we say, are they a walkie-talkie? Are they walking and talking? Because if they're up and functional and moving, then obviously they're going to have a stronger immune system. So those are things to consider too, before we even look at, okay, so is this patient aspirating? Okay. Yes they are. But how was their immune system? How is their oral care? These are the things to consider. If those things are poor, then we know that they're at a much higher chance of aspirating.

My son for one, is what we call a functional aspirator. So he does aspirate. We've seen it on a swallow study. He's never had pneumonia. Obviously, he's got severe special needs. So we are religious about brushing his teeth constantly. He doesn't walk on his own. He uses a gait trainer, but we make sure to get him up in it a few times a day, things like that to keep walking, keep his immune system functioning. So there's a lot to consider with that. And then on the flip side, if we do see that patients have recurrent pneumonia or they are in for aspiration pneumonia, what causes it? So then we try to go backwards and figure out that puzzle piece, is it because of a poor immune system or do they have a true dysphasia? That they are aspirating all the time. So we've talked about, this is just a really complex mechanism.

But, Dr. Susan Langmore, who's one of the researchers that created the FEES procedure that I do, actually wrote a seminal paper. I think she wrote two iterations of it, 1998 and 2002, on the predictors of aspiration pneumonia and dysphagia actually was number seven. So, things like dependent for oral care, dependent for feeding, the number of medications, smoking, multiple medical diagnoses, number of decayed teeth and suctioning are all before dysphasia. So these things are all really important to consider as well. And like I said, we for just lack of knowing better, just assume when you aspirate it turns into pneumonia. Right. But there's so many other factors that we have to consider before we just say, oh, you're going to get pneumonia if you aspirate, here's some thickened liquids, good luck.