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AbstractAspiration and pneumonia are common in people with eating, drinking and swallowing difficulties. Thickened liquids are often used as a first-line measure by speech-language pathologists and other health and social care professionals to reduce aspiration and pneumonia in people with eating, drinking and swallowing difficulties. This approach, and the relative lack of evidence of benefit, has come under increased criticism in recent years. This aim of this review is to examine alternatives—or complementary approaches—that might be considered by SLPs and other professionals treating people with eating, drinking and swallowing difficulties. We examined the current research evidence and will discuss medical factors, bolus modification approaches, rehabilitation approaches, hygiene and residue reduction interventions, physical and postural interventions, common sense strategies, and other issues to consider when using thickened liquids. We conclude that there are many options available to health and social care professionals who are supporting people with eating, drinking and swallowing difficulties, some of which have a less, equal or more supportive evidence base than thickened liquids. A broad multidisciplinary and multifactorial approach is beneficial, and more acceptable to, people with eating, drinking and swallowing difficulties.

ABSTRACTObjectiveCommunication is fundamental to mental health services for every patient, caregiver and clinician interaction. Without adequate communication skills, the aspiration to inclusion, engagement and recovery is likely to fail. Speech and language therapists provide specialist knowledge directly with patients, and indirectly via clinicians and caregivers. The objective of this study was to explore current UK provision and practice of speech and language therapists supporting working age adults with mental health conditions.MethodA ten question online survey was shared on social media and sent to a network of speech and language therapists interested in mental health services in September 2019. Responses were analysed using descriptive statistics supported by free text survey responses.ResultsFrom survey closing in March 2020, 96 responses were received from across the four UK nations describing widely varying services. Respondents reported concerning gaps in SLT provision, other professions not understanding the SLT role, but over 75% of respondents reported multidisciplinary ways of working.DiscussionRisks associated with communication impairment are often overlooked. The understanding of mental health professionals about the role of speech and language therapists is patchy. Highlighting awareness amongst the mental health workforce about communication impairment will improve access to treatment and care for all patients.

Purpose:Medications can produce side effects that negatively impact swallowing and cognition. Speech-language pathologists (SLPs) who know which medications their patients are taking are able to consider the potential impact of medication side effects on their patient's swallow function and progress in therapy. The goal of this investigation was to gain preliminary information on how often SLPs report that they review a patient's medications as part of their standard practice, as well as the most common reasons for not reviewing patient medications.Method:A 10-item online questionnaire was distributed to practicing SLPs to collect information regarding their clinical experience, patient caseload, and whether they routinely review patient medications. Logistic regression analysis was used to determine which variables were associated with medication review.Results:Responses were received from 205 SLPs. Approximately half reported “always” reviewing patient medications (n= 116). The most frequent reason given for not reviewing medications was lack of pharmacology training. The results indicated that SLPs with 15 years or more of experience were nearly 3 times more likely to review medications than SLPs with less experience. Not all Special Interest Groups participated in the distribution of the survey.Conclusions:Many SLPs reported that they did not consistently check patient medications as part of a patient evaluation. Of concern is the possibility that SLPs do not realize the importance of medication knowledge. Clinicians may gain familiarity with the medications and understanding of the impact that medications have on their patients as they accrue clinical experience. Future research should investigate the best ways to promote knowledge of this topic in new clinicians.

The Royal College of Physicians has recently published guidance on supporting people with eating and drinking difficulties. Although much of the advice in the guidance is sensible and helpful, in this paper we argue that the recommendations regarding ‘risk feeding’ decisions are flawed. In particular, there is a failure to clearly identify the nature, frequency and severity of different risks. There is an undue emphasis on aspiration as a risk and as a potential cause of pneumonia, and the limited evidence base for many interventions to manage risk is not adequately acknowledged. There is an emphasis on multidisciplinary team decision making at the expense of individual professional responsibility. We conclude that this guidance regarding risk feeding supports an unduly defensive approach to oral intake and should not be adopted as a standard of medical practice.

PurposeThis article discusses the complexities of caring for individuals with dementia with an interdisciplinary team approach. The overlap and potential conflict between speech-language pathologists (SLPs) and occupational therapists (OTs) are addressed. SLPs and OTs have potentially similar roles when caring for people with dementia, so it can be difficult to decipher whose job it is to implement similar therapy techniques. However, there are ways health care professionals can prepare themselves to work collaboratively and potentially avoid conflict among team members, such as overstepping their professional boundaries and scopes of practice. This article discusses three beneficial techniques for interprofessional collaboration: acquiring sufficient knowledge about the scopes of practice of both SLPs and OTs, developing effective communication skills, and identifying the intentions of each therapeutic technique.ConclusionsThere is no straightforward or universal answer to the question “Whose job is it?” when considering SLPs and OTs in caring for people with dementia. Deciding whether an SLP or an OT should implement certain aspects of therapy depends on the roles of each professional and how they can benefit the patient. Interdisciplinary team members must work together to identify how their roles interact and overlap. SLPs and OTs must have a solid knowledge base about each other's scopes of practice, develop effective communication skills, and be able to identify the intentions of their therapy. Developing these skills allows SLPs and OTs to work harmoniously in interprofessional teams.

PurposeWorking with patients and families with different cultural backgrounds is now commonplace in all areas of speech-language pathology. This includes supporting those with eating, drinking, and swallowing problems. Becoming more culturally sensitive as clinicians requires us to think less of them versus us,and instead what matters to them,and how best for us to provideexpert care.Our starting point for this important topic is not how we tweak our clinical recommendations to fit someone's “culture.” Rather, let us examine what is culture and how should it factor into our professional work? We need to understand how our patients and families view health and well-being, or lack thereof, in general. This will enable us to frame our support and offer optimal care to all stakeholders. This leads naturally to a consideration of the concepts of autonomy, informed consent, and how these factor into person-centered care, and shared decision making.ConclusionsAs well as gaining an understanding of the frameworks of health and illness, we consider how food and drink are much more than mere nutrition and hydration. Foods signal our individual and collective identities. Thus, to be a respectful and professional clinician, we need to appreciate our role as a cultural guest with all whom we serve. We propose that there is no such thing as being “culturally competent.” Expert clinicians possess a respect for the patient and their expertise-by-experienceof health and illness. Such respect is founded in the position of cultural humility, to be a guest of someone's world view, in the same way that we respect being a guest in a patient's physical home.

Background:Liquid nutrition delivered through a tube is often used amid difficulty swallowing. Tube feeding has been shown to have a relationship to pneumonia and mortality. Aim:Researchers investigated the relationship of feeding route (oral or tube) to patient outcomes. Design:Data were collected on outcomes (pneumonia, depression, mortality), feeding route, presence/absence of dysphagia, and covariates (chronic obstructive pulmonary disease [COPD], stroke, mortality risk, illness severity, sex, age). Researchers collected data over a 45-month period to ensure an adequate sample size for matching. The method of sampling was retrospective, archival data analysis. Propensity score analysis resulted in 94 matched, balanced pairs. Covariates were isolated from the treatment effect. Participants:The records of 2,180 inpatients treated by Palliative Medicine were considered, and 292 met the inclusion criteria. Results:Results revealed 10.14 times greater odds of pneumonia (OR = 10.14; p< .001) with tube feeding compared to oral feeding in patients with dysphagia and end-stage COPD or end-stage stroke. Results also revealed increased odds of depression (OR = 2.79; p= .01) and mortality (OR = 3.02; p< .01) with tube feeding compared to oral feeding. Conclusion:Study findings should encourage consideration of oral nutrition at the end of life.

Billions of health care dollars go towards caring for older adults. Medicare per-person spending rises steadily with age and doubles between ages 70 and 95 (Neuman, Cubanski, Huang, & Damico, 2015). The baby boomers, born between 1946 and 1965, represent a large wave of older patients entering the United States health care system today. The boomer demographic is significant for its size and longevity, thereby adding pressure to an already strained health care system.Of critical importance to the boomers is where they expect to live until they die and how they expect to be cared for. Aging in placehas become a common phrase and signals the boomers' overwhelming desire to remain at home until the end (Lai, 2008). According to the United Nations, by 2025 Japan will be the country with the highest proportion of individuals aged 75 or over, followed by Sweden and then Italy (Ogawa & Matsukura, 2007). What can we learn from Japan about graceful aging? This article discusses multiple factors responsible for longevity in Japan, ranging from perceptions of aging to government policy.

The replacement of fluids (usually water), may be undertaken in one of three ways: orally: People may drink it or it may be administered via an enteral tube;intravenously where fluid is provided via a cannula into a vein; orsubcutaneously, where fluids are administered between the subcutaneous layer of the skin and fat. This is called hypodermoclysis.As speech-language pathologists (SLPs) monitor the ability to swallow, they are in an ideal position, particularly in community settings, to identify problems with hydration. People with dysphagia may require a modification to their diet. Fluids are frequently thickened, which then results in reduction of fluid (water) intake. When the amount of water drunk is exceeded by the amount of water lost (e.g., urine, feces, sweat, and breath) dehydration may result. Clinically, dehydration may present as agitation, dry skin and tongue (mouth), and reduced skin elasticity.Hypodermoclysis is a simple technique that can be used in the community with minimal training and can be used to supplement oral intake. The SLP is ideally placed to suggest this to the physician caring for the patient.

“My patient refuses thickened liquids, should I discharge them from my caseload?” A version of this question appears at least weekly on the American Speech-Language-Hearing Association's Community pages. People talk of respecting the patient's right to be non-compliant with speech-language pathology recommendations. We challenge use of the word “respect” and calling a patient “non-compliant” in the same sentence: does use of the latter term preclude the former? In this article we will share our reflections on why we are interested in these so called “ethical challenges” from a personal case level to what our professional duty requires of us. Our proposal is that the problems that we encounter are less to do with ethical or moral puzzles and usually due to inadequate communication. We will outline resources that clinicians may use to support their work from what seems to be a straightforward case to those that are mired in complexity. And we will tackle fears and facts regarding litigation and the law.

Historically speech-language pathologists (SLPs) were a “fix-it”-focused rehabilitation profession. In recent years we have been drawn into decisions that are more challenging. Our profession has an increasing awareness of the complexity and subtleness required in decision making. How do other professions grapple with this complexity and in particular the concept of the “futility” of medical intervention? Perhaps the two of the most closely allied disciplines in this area are bioethics and medicine and I invited two colleagues to consider this topic with me. Dr. Nancy Rourke is a bioethicist with experience in Catholic and philosophical ethics, long-term care and end-of-life health care ethics. Dr. Tamara Sacks is a physician with experience in internal medicine, palliative care and hospice. We encourage the reader to step beyond the confines of the historically rehabilitation focused profession in order to gain understanding that will benefit our patients and families.

Speech-language pathologists (SLPs) are increasingly challenged by the medical complexities our patients present and gripped by the fear of litigation, if patients decline physically under our care. One response to these pressures may be to practice defensive medical speech-language pathology. We propose that best practice is ethically achieved by deliberately using specific external and internal resources to practice undefensively. We suggest how consideration of these materials and processes will help SLPs ensure evaluation and clinical decision-making processes are as effective, evidence-based, and transparent to patients, caregivers, administrators, and payers as possible.

Clinical decision-making in most cases of dysphagia is neither black nor white. Risk factors predisposing a person to pneumonia, malnutrition, or dehydration can never be reduced to zero chance. Clinicians often believe that patients they consider as “unsafe for oral intake” will somehow have the best outcome if they eliminate aspiration while swallowing by using a feeding tube. In many cases, there is no evidence or reasonable expectation that a feeding tube will maintain or improve the patient's quality of life, health, or life expectancy. Feeding tubes can increase discomfort, worsen outcomes, or result in earlier mortality. Clinical decisions must integrate best clinical judgment, patient values and expectations, and best external evidence of a patient's whole health status not just dysphagia. We must carefully consider ethical imperatives governing health care practice, especially when a feeding tube is a possible intervention choice.

ABSTRACT: Dysphagia is a distressing problem in amyotrophic lateral sclerosis. Patients and caregivers must decide whether to use supplementary non-oral feeding. The deliberations and timing of this decision may be haphazard. The optimum time for this choice, in terms of residual (quality) life expectancy and decision competency, is unknown. Health-care workers may fear that even the offer of enteral feeding might be construed as an unwelcome landmark on the disease deterioration. This paper provides a qualitative report on the subjective experiences of 2 patients deciding whether to have a PEG or not. Semi-structured interviews were conducted with each patient and transcripts are provided for the reader to review.

Objectives/Hypothesis:We aimed to investigate whether the type of dysphagia examination (fiberoptic endoscopic evaluation of swallowing [FEES] or videofluoroscopy) influences the scoring of penetration and aspiration.

The aim of this study was to examine swallow respiratory characteristics using a notebook computer system. A relatively simple system assessing easily identifiable features is more likely to be incorporated into everyday clinical practice. Eighteen patients (age range = 51–82 years) with dysphagia poststroke and 50 healthy volunteers (age range = 20–78 years) were recruited. The patient group was less likely to always breathe out postswallow on water (9/15 cf 46/49), and some did not breathe out immediately postswallow at all (3/15 cf 0/49, p < 0.01). The pattern was similar with yogurt. Multiple swallowing was identified in the patient group and surprisingly with a large number of the volunteers for all bolus types but was more common in the patient group (p < 0.01). This trait is usually attributed to impaired swallows; that it is prevalent in the normal population has implications for using it as a dysphagia marker in clinical assessments. Yogurt has intrinsic features that increase multiple swallowing and caution should be used when identifying an impairment based on multiple swallowing with such a test substance. In the control group there was a high correlation of swallow apnea on 5 mL of water compared with 20 mL of water (r = 0.759, p < 0.01) and 5 mL of yogurt (r = 0.871, p < 0.01), indicating a possible individual swallow respiration pattern. This was also evident in the patient group. No significant difference in length of swallow apnea was found between the two groups. No evidence was found to link swallow respiration characteristics with aspiration as identified on simultaneous videofluoroscopy. The patient group had a wide range of impairments which suggests that stroke severity is not the sole determinant of swallow respiratory changes.

The aim of this study was to examine respiration characteristics at rest in healthy volunteers and patients with poststroke dysphagia, using a simple notebook computer-based system. Eighteen patients (age range=51–82 years) with dysphagia poststroke and 50 healthy volunteers (age range=20–78 years) were recruited. The patient group had a wide range of stroke severity as assessed using the Scandinavian Stroke Score (SSS 6–51) and Barthel Index (BI 2–20). Length of breathing cycle, rate, and a measure of the variability of the cycle length were examined. The patient group had a shorter mean cycle length (2.93 s compared with 3.91 s, p < 0.01) and hence faster respiration rate (0.35 Hz compared with 0.26 Hz, p < 0.01). The control group showed greater variability in the cycle length (10.78% compared with 6.56%, p = 0.01). There was no correlation between the SSS and BI and resting respiration variables. This suggests that it is not stroke severity alone that affects breathing. The differences observed in resting respiratory rate suggest that respiratory monitoring as a useful adjunct to the clinical bedside assessment warrants further investigation.

The article presents an analysis on the efficiency of transcutaneous neuromuscular electrical stimulation (NMES) as a therapy for patients with dysphagia in Great Britain. The electric current released by NMES can activate the swallowing muscles which can lead to strengthening of muscles. Moreover, the use of NMES can enhance the efficiency of thermal-tactile stimulation in treating post stroke patients.

The article presents a study on the lack of a reliable rating scale which is essential to determine the clinical efficiency of endoscopy for speech and language therapists in Great Britain. The study intends to determine the importance of conducting an endoscopic rating scale because this is vital to identify the needs of patients with dysphagia. It presents a rating form developed for endoscopic swallow studies which will benefit speech and language therapists.