PDF/printer-friendly version: CO-OCCURRING: Dysphagia/Swallowing Problems and Cognitive-Linguistic Involvement

CO-OCCURRING: Dysphagia/Swallowing Problems and Cognitive-Linguistic Involvement

Patients who exhibit more than one speech pathology diagnosis face particular challenges.

Below are the definitions of two such speech pathology disorders, and a listing of the accompanying difficulties and strategies for responding — if they are co-occurring in an individual.

Dysphagia = defined as a disorder of the swallowing process, and may involve weakness or impairment in any of the various phases, or a combination (preparatory (presentation) phase, the oral (mouth) phase, the laryngeal (throat) phase and the esophageal (structure before the stomach) phase. Dysphagia can be identified by difficulties chewing, drooling, choking, coughing, throat clears, breathing changes after swallowing, pain in throat during/after swallows, pain in chest during/after swallows, reflux, etc.). Symptoms can also be silent/unobservable, and can potentially have significant medical consequences.

Cognitive difficulties = defined as an impaired ability to perform short and long-term recall via immediate or delayed capacities, or any difficulties with working memory, procedural memory, sequencing, insight, problem solving, mental flexibility, inferencing, predicting and executive functioning.

When patients exhibit difficulty with both diagnoses, it is recommended to keep these factors in mind:

  • Safety of swallowing involves not only structure/function of the swallowing mechanism itself, but also requires a reduction of behavioral patterns for the risk of swallowing problems to be addressed. Without addressing both behaviors –due to cognitive involvement –and the swallowing itself, the following potential negative medical consequences are at a higher risk for the patient — dehydration, aspiration pneumonia, other upper respiratory infections, urinary tract infections, malnutrition, unintentional weight loss, and potential skin breakdown.
  • Potential behaviors which could impact swallowing involve: impulsivity, refusals, an unsafe fast self-eating rate, uncontrolled vocalizations while eating, refusals to utilize compensatory strategies, taking additional bites without first swallowing the first bite presentation, difficulty recalling strategies cognitively to compensate for physical impairments of swallowing, lack of awareness of unsafe self-feeding behaviors, inattention to food bites in the oral phase, etc.
  • As a result of self-feeding and other behavior patterns that impact swallowing, it is important for caregivers to cue the patient in ways that are effective and successful in achieving the desired outcome.
  • Caregivers should provide short, simple directions — one at a time.
  • Working on recall of strategies outside of a meal in memory tasks aids both the cognitive involvement and supports progress on the swallowing side as well.
  • Be encouraged that it is common for patients to exhibit more than one speech diagnosis. Patients with these two diagnoses are not alone in this phenomenon.
  • Patients with both cognitive and swallowing impairments require more repetition for carryover of skills, and in some cases, cueing for each feeding or drinking task will require 100% cues verbally, visually, or in a tactile fashion (hand-over-hand), and 1 to 1 supervision for all oral intake. Partial supervision may be indicated in some cases as well.
  • Using visual cues/environmental cues to aid the patient to recall strategies tends to be beneficial (writing cues vs. picture symptoms to remind the patient of a strategy).
  • Sometimes, adaptive equipment can be beneficial, such as small-bowled spoons, nosey cups, small forks, etc. Modified foods and liquids are indicated often due to the patient’s difficulty with following directions., as modifying consistencies can aid in compensating for patient’s cognitive and swallowing impairments.
  • It is possible that inattention due to cognitive involvement can negatively impact swallowing performance, due to the attention skills that are required for performing self-feeding tasks. Reducing sights and sounds that can be distracting can assist in managing inattention.
  • Using techniques to compensate for deficits are a benefit to both conditions. The speech pathologist could be asked what individual strategies would benefit both swallowing and cognition, specific to the patient’s presentation of symptoms.
  • Talking about the difficulties in both conditions is helpful. Sharing feelings about the drawbacks and disappointments in what the patient is facing in the swallowing deficits and cognitive difficulties — is beneficial. And sharing about how swallowing impacts the social aspect of speaking and cognitive processes during meals is beneficial, too, as these conditions play off of each other.
  • It is important to for the patient to self-encourage. Gains that are made in either condition should be celebrated intentionally. Little baby steps add up to improved function. Some days gains will not be achieved, so on the days that they occur, it is important to celebrate and document this so when the difficult days come, this can be a reminder to not become discouraged.