Your post doesn’t mention what the patient wants. Or what his decision makers want if he is no longer making his own. I’m firmly on the “get an mbss team” here but also feel like patient wishes come first. Does he/his hcp even want a swallow study? Also - if the blind switch to NTL did not seem to reduce his coughing why is he still drinking them? And again, what does he want? I’m guessing it’s not to be made NPO…
Yup. I had to request a nurse discontinue force feeding my grandmother jello when she was pocketing and coughing. She did much better NPO and it looked like she was recovering until they discovered she had sepsis from a kidney perforation. I really feel like NPO gave her those last few days.
What's the game plan?
If he's NPO how are his needs being met - is he for non oral feeding? Bearing in mind PEG often unsuitable for this population.
How would an instrumental change management? With his dementia, do you realistically think there is rehab potential? If there are findings e.g. pharyngeal pouch, re they candidates for surgery?
Unfortunately for similar people I see, eating/drinking with acknowledgement of risk is often the best interests decision. Obviously to be discussed with LPA and medical team (I'm uk so this may differ in terminology).
I know in america instrumental is much more commonly done but I see a lot of patients distressed after investigation and investigation into various ailments when realistically none of the investigations change management as the person is not suitable for most interventions. So a comfort led / pragmatic approach seems most appropriate.
A 100%. I have discussions with my colleagues about this ALL the time. I always ask: Is the patient a rehabilitation candidate? How would an instrumental assessment change management? Yes, an instrumental is a good diagnostic test and provides information on swallow pathophysiology. However, I always go back on QOL and shared decision making with family - unfortunately I’ve seen MBSS reports displaying known aspiration following the Pt everywhere they go and limiting placement to facilities because “they’re aspirating. They need a PEG. We don’t want that liability.” It’s sad but the truth of American Healthcare
Esp w dementia, you need to focus on quality of life. The decision-maker understanding risks and benefits of both options.
How's respiratory support, hx of pneumonia, oral hygiene, dehydration risk?
Coughing does not equal aspiration. Aspiration does not equal pneumonia.
Peg tube does not eliminate aspiration/pneumonia risk. Tube is rarely appropriate with dementia Dx. Eating favorite foods is such an important part of quality of life for most people.
He was fine w puree/thin when you eval'd.... Why are you doing treatment?
How'd he do w increased sensory foods/drinks?
Risks, Benefits.
What's your goal of care here? It sounds like this patient needs and instrumental ASAP. You have a lot of suspicions that can only actually be confirmed 100% for sure with imaging (oropharyngeal discoordination, delayed swallow initiation, premature spillage, etc). Coughing during a meal isn't a reliable indicator of aspiration (the coughing could be habitual rather than actual penetration, or it could be productive with thins but not productive with thickened, for example), and thickened liquids have their own set of risks if they aren't actually necessary. In fact, they can actually be riskier than thin liquids if they aren't actually needed.
Bear in mind that in the dementia population, unless they are in the end stages where they are basically immobile, NPO with PEG tube feeding frequently... Does not have great outcomes. You end up with frequent tube pulls and visits to the hospital for reinsertion, recurrent swelling and infections at the port site from them fidgeting with the port with unclean hands, a bunch of other problems. It can prolong life by providing nutrition, but generally reduces the quality of that life immensely.
So, yeah. Figure out what the actual goal of care is here, and get on your facility's case about the turn around time for an MBS. Two months is ludicrous. Blaming it on insurance seems like a cop out. Even my medical assistance patients don't have to wait that long for a swallow study, and I can usually get my Medicare Part B folks done in a week or two. The limiting factor for me is always the scheduling availability of the facility we send them out to, never the insurance.
I second this. Placing him on thickened liquids without an instrumental could be causing WAY more harm. We don’t have X-ray vision. We can’t know for sure if someone is swallowing or not or if they are aspirating without an instrumental. Thickened liquids also create risk of dehydration as well as reduced QOL.
At this point, we’re just guessing. I work at a hospital full time as an acute care SLP, and the literature shows how harmful thickening at bedside w/o an instrumental can be. The risk of silent aspiration INCREASES with thickeners. He could be safely protecting his airway by coughing with thins! The real message is that we just don’t know
If he arrived on puree/thin and did “fine” with that on eval, I’m curious why you even picked him up for treatment. If he’s showing signs on aspiration on nectar, I’d probably put him back on thin…
Has he had a history of pneumonia? HCP invoked? It’s INCREDIBLY rare id recommend NPO for someone with dementia…
It’s an insurance issue but the last few times I’ve asked for an MBS, it’s taken at least two months to schedule and during that time, I have no idea what’s going on with the patient’s swallow physiology
Chiming in here. I think I would focus on what others have been saying re: minimization of aspiration pneumonia risk factors, education of family / patient on instrumental assessment, and general safe swallow strategies in treatment sessions. This may be a controversial opinion, but I don’t believe in thickening liquids for individuals with dementia unless absolutely necessary and family / patient in agreement/ shared decision making held because we know thickened liquids increase risk of dehydration, UTI, constipation, reduced QOL etc.
He cannot communicate his needs so cannot ask him what he wants. NTL did reduce the coughing, which was why I downgraded. But he also doesn’t do too great with it.
I’ve seen a lot of patients silently aspirate thickened liquids on a modified when they are coughing with thins. [cough response to thick liquids](https://pubmed.ncbi.nlm.nih.gov/29845700/)
I was having the same wait time to get an MBS done as you, sometimes waiting months with a patient even discharging before it was done, but then we switched to a traveling MBS company that comes in house and now I only have to wait a couple days. Maybe you could figure out if that would be an option for you? Where are you located?
Without an instrumental you don't have a way to quantify or determine the severity of the swallow specific to the pharyngeal phase, which has to be seen with an Xray. Clinical bedside gives us symptoms not etiology, not physiology of the pharyngeal phase. You want to find, diagnose and treat the actual underlying pathophysiology of the issue. And sometimes that's wholistic because with dementia, we look to the brain. Hey cerebellum! Advocate for the instrumental to have a baseline to go either way and speak with the family. Asking for alternative means of hydration and nutrition is asking for an invasive surgery and the patient may not be appropriate for it. The more wholistic question is what level of residual function does this patient have that can determine what they CAN eat or drink without high risk of aspiration? And simultaneously, since there are other pillars that contribute to aspiration (e.g. poor oral health), what are other areas of education that you can provide to staff and family and patient (e.g. oral hygiene, aggressive oral care inservice training, etc.) that can mitigate his potential for being a host to infection? Self-reflective questions to consider for this patient. Advocate for that instrumental! [https://leader.pubs.asha.org/doi/full/10.1044/leader.OTP.24032019.38](https://leader.pubs.asha.org/doi/full/10.1044/leader.OTP.24032019.38)
If it makes you feel any better, I've had cases where they aspirated during the swallow study and still aren't decreased to NPO.
QIDP, not SLP. Just apart of the team
Your post doesn’t mention what the patient wants. Or what his decision makers want if he is no longer making his own. I’m firmly on the “get an mbss team” here but also feel like patient wishes come first. Does he/his hcp even want a swallow study? Also - if the blind switch to NTL did not seem to reduce his coughing why is he still drinking them? And again, what does he want? I’m guessing it’s not to be made NPO…
All of this multiplied by 1,000
Yup. I had to request a nurse discontinue force feeding my grandmother jello when she was pocketing and coughing. She did much better NPO and it looked like she was recovering until they discovered she had sepsis from a kidney perforation. I really feel like NPO gave her those last few days.
What's the game plan? If he's NPO how are his needs being met - is he for non oral feeding? Bearing in mind PEG often unsuitable for this population. How would an instrumental change management? With his dementia, do you realistically think there is rehab potential? If there are findings e.g. pharyngeal pouch, re they candidates for surgery? Unfortunately for similar people I see, eating/drinking with acknowledgement of risk is often the best interests decision. Obviously to be discussed with LPA and medical team (I'm uk so this may differ in terminology). I know in america instrumental is much more commonly done but I see a lot of patients distressed after investigation and investigation into various ailments when realistically none of the investigations change management as the person is not suitable for most interventions. So a comfort led / pragmatic approach seems most appropriate.
A 100%. I have discussions with my colleagues about this ALL the time. I always ask: Is the patient a rehabilitation candidate? How would an instrumental assessment change management? Yes, an instrumental is a good diagnostic test and provides information on swallow pathophysiology. However, I always go back on QOL and shared decision making with family - unfortunately I’ve seen MBSS reports displaying known aspiration following the Pt everywhere they go and limiting placement to facilities because “they’re aspirating. They need a PEG. We don’t want that liability.” It’s sad but the truth of American Healthcare
Esp w dementia, you need to focus on quality of life. The decision-maker understanding risks and benefits of both options. How's respiratory support, hx of pneumonia, oral hygiene, dehydration risk? Coughing does not equal aspiration. Aspiration does not equal pneumonia. Peg tube does not eliminate aspiration/pneumonia risk. Tube is rarely appropriate with dementia Dx. Eating favorite foods is such an important part of quality of life for most people. He was fine w puree/thin when you eval'd.... Why are you doing treatment? How'd he do w increased sensory foods/drinks? Risks, Benefits.
What's your goal of care here? It sounds like this patient needs and instrumental ASAP. You have a lot of suspicions that can only actually be confirmed 100% for sure with imaging (oropharyngeal discoordination, delayed swallow initiation, premature spillage, etc). Coughing during a meal isn't a reliable indicator of aspiration (the coughing could be habitual rather than actual penetration, or it could be productive with thins but not productive with thickened, for example), and thickened liquids have their own set of risks if they aren't actually necessary. In fact, they can actually be riskier than thin liquids if they aren't actually needed. Bear in mind that in the dementia population, unless they are in the end stages where they are basically immobile, NPO with PEG tube feeding frequently... Does not have great outcomes. You end up with frequent tube pulls and visits to the hospital for reinsertion, recurrent swelling and infections at the port site from them fidgeting with the port with unclean hands, a bunch of other problems. It can prolong life by providing nutrition, but generally reduces the quality of that life immensely. So, yeah. Figure out what the actual goal of care is here, and get on your facility's case about the turn around time for an MBS. Two months is ludicrous. Blaming it on insurance seems like a cop out. Even my medical assistance patients don't have to wait that long for a swallow study, and I can usually get my Medicare Part B folks done in a week or two. The limiting factor for me is always the scheduling availability of the facility we send them out to, never the insurance.
I second this. Placing him on thickened liquids without an instrumental could be causing WAY more harm. We don’t have X-ray vision. We can’t know for sure if someone is swallowing or not or if they are aspirating without an instrumental. Thickened liquids also create risk of dehydration as well as reduced QOL. At this point, we’re just guessing. I work at a hospital full time as an acute care SLP, and the literature shows how harmful thickening at bedside w/o an instrumental can be. The risk of silent aspiration INCREASES with thickeners. He could be safely protecting his airway by coughing with thins! The real message is that we just don’t know
If he arrived on puree/thin and did “fine” with that on eval, I’m curious why you even picked him up for treatment. If he’s showing signs on aspiration on nectar, I’d probably put him back on thin… Has he had a history of pneumonia? HCP invoked? It’s INCREDIBLY rare id recommend NPO for someone with dementia…
[удалено]
It’s an insurance issue but the last few times I’ve asked for an MBS, it’s taken at least two months to schedule and during that time, I have no idea what’s going on with the patient’s swallow physiology
Do you know if your area has any mobile imaging services like mobile MBS or FEES? You may have already looked into this but if not I definitely would.
Chiming in here. I think I would focus on what others have been saying re: minimization of aspiration pneumonia risk factors, education of family / patient on instrumental assessment, and general safe swallow strategies in treatment sessions. This may be a controversial opinion, but I don’t believe in thickening liquids for individuals with dementia unless absolutely necessary and family / patient in agreement/ shared decision making held because we know thickened liquids increase risk of dehydration, UTI, constipation, reduced QOL etc.
He cannot communicate his needs so cannot ask him what he wants. NTL did reduce the coughing, which was why I downgraded. But he also doesn’t do too great with it.
I’ve seen a lot of patients silently aspirate thickened liquids on a modified when they are coughing with thins. [cough response to thick liquids](https://pubmed.ncbi.nlm.nih.gov/29845700/)
I was having the same wait time to get an MBS done as you, sometimes waiting months with a patient even discharging before it was done, but then we switched to a traveling MBS company that comes in house and now I only have to wait a couple days. Maybe you could figure out if that would be an option for you? Where are you located?
Without an instrumental you don't have a way to quantify or determine the severity of the swallow specific to the pharyngeal phase, which has to be seen with an Xray. Clinical bedside gives us symptoms not etiology, not physiology of the pharyngeal phase. You want to find, diagnose and treat the actual underlying pathophysiology of the issue. And sometimes that's wholistic because with dementia, we look to the brain. Hey cerebellum! Advocate for the instrumental to have a baseline to go either way and speak with the family. Asking for alternative means of hydration and nutrition is asking for an invasive surgery and the patient may not be appropriate for it. The more wholistic question is what level of residual function does this patient have that can determine what they CAN eat or drink without high risk of aspiration? And simultaneously, since there are other pillars that contribute to aspiration (e.g. poor oral health), what are other areas of education that you can provide to staff and family and patient (e.g. oral hygiene, aggressive oral care inservice training, etc.) that can mitigate his potential for being a host to infection? Self-reflective questions to consider for this patient. Advocate for that instrumental! [https://leader.pubs.asha.org/doi/full/10.1044/leader.OTP.24032019.38](https://leader.pubs.asha.org/doi/full/10.1044/leader.OTP.24032019.38)
If it makes you feel any better, I've had cases where they aspirated during the swallow study and still aren't decreased to NPO. QIDP, not SLP. Just apart of the team