May 05, 2015, By: Colleen Braun-Janzen, MA
Q: I’m delivering care to residents in a long-term care facility. What potential problems in the areas of speech and swallowing do I need to be aware of?
A: Speech and swallowing require the coordination of breathing patterns, vocal cord function, movement of the articulators and esophageal function. Age-related changes may impact the structure and physiology of these processes and contribute to subtle changes in speech and swallowing. When combined with comorbidities such as stroke or respiratory conditions, these changes may be more serious. I fanned out your question to some of my speech-language pathology colleagues, whose impassioned responses highlighted dealing with comprehension deficits, using thickened liquids and promoting oral health.
We can’t assume that residents understand us. If in doubt, ask some yes/no questions to which you know the answers, to determine if individuals comprehend basic information. When we ask if residents are having pain or whether they need anything (questions to which we don’t know the answers), we can’t be confident that they hear what we hear! For persons with comprehension impairments, it is important to communicate clearly and simply. Make eye contact when speaking, ask one question at a time, and avoid medical jargon and asking questions in the negative. For example, a yes response to “You don’t want your lunch?” might mean “Yes, I do want my lunch” or “Yes, I don’t want my lunch.” As well, allow extra time for the person to respond to a question.
Thickened liquids are often prescribed for persons at risk of aspiration. Although this may be an appropriate solution for some, thickened liquids shouldn’t be used as a default. In certain situations, they may worsen swallowing problems. If thickened liquids are prescribed, follow the instructions. I have witnessed the results of “eyeballing” the measurements, with residents left with a gelatinous glob. Furthermore, it is important to make recommendations in the context of residents’ goals of care and preferences. Many residents will not accept thickened fluids; in fact, they hate them! This may lead to their avoiding liquids altogether, which in turn reduces fluid intake and puts them at increased risk of dehydration or a UTI. A comprehensive swallowing assessment is critical in determining what textures and strategies are appropriate for each individual. Alternative safe swallowing strategies include upright positioning, compensatory postures such as a chin tuck, swallowing exercises, and a free water protocol (i.e., someone on thickened liquids is permitted to have regular water between meals).
A number of studies demonstrate an association between routine oral hygiene and lower incidences of aspiration pneumonia for residents of nursing homes. At Deer Lodge Centre, nurses complete oral assessments for all residents, including those who are edentulous or who have feeding tubes. Their care plans must include a minimum of twice-daily oral hygiene. Oral hygiene includes care of teeth, dentures, soft tissue surrounding the teeth, roof of the mouth, floor of the mouth, lips, cheeks and tongue. The University of Manitoba’s Centre for Community Oral Health website has useful fact sheets and videos on this topic.
Colleen Braun-Janzen, MA, a registered speech-language pathologist, is the clinical service leader for speech-language pathology for Deer Lodge Centre, a long-term care and rehabilitation facility in Winnipeg.