“I talk fine. I don’t need a speech-language pathologist.” I occasionally hear something like this when I talk to a new patient. Since I didn’t know that SLPs did anything other than help children who stutter or lisp until I was in my mid-twenties, I don’t even mind. I love telling people how SLPs can help children or adults with swallowing, communication, or cognitive problems.
While I give lots of examples below, the bottom line is that anyone who has a concern about their chewing or swallowing, communication, or cognitive-communication skills should let their doctor know and ask to see a speech-language pathologist.
Free DIRECT download: Reasons to see a speech-language pathologist (patient handout). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- Swallowing.
- Communication.
- Cognition (thinking skills).
- SLPs play a role in helping people live better.
- Related Eat, Speak, & Think posts.
Swallowing
Why assessment is important
Swallowing is a complicated process that involves preparing the food, liquid, or pill to be swallowed and then sending it to the stomach while avoiding the airway.
When something goes wrong, it can lead to choking, dehydration, or malnutrition. It can also lead to something called pulmonary aspiration, which is when food, drink, pills, or stomach contents enter the lungs. This can cause problems, including aspiration pneumonia which can be a very serious illness.
Signs of trouble eating, drinking, or swallowing pills
Trouble with chewing or swallowing is called dysphagia. Here are some common problems that a person with dysphagia may notice.
- Difficulty chewing or swallowing.
- Trouble clearing food out of the mouth.
- Coughing or clearing the throat while eating or drinking, or afterwards.
- Feeling like something’s stuck on the throat.
We’ve all had the experience of “something going down the wrong way”, which likely triggered some enthusiastic coughing. For a healthy adult, this isn’t usually a problem as long as it’s a rare occurrence. But if someone is coughing or clearing their throat every day or with every meal, they should notify their doctor.
Sometimes a person can have dysphagia, but the signs or symptoms can be too subtle to notice. They may have other warning signs:
- Dehydration or malnutrition.
- Unintended weight loss.
- Recent aspiration pneumonia.
Other situations when someone should see an SLP
SLPs can help people avoid or reduce problems by being proactive in situations where there is a high risk of developing a swallowing impairment.
For instance, if someone is in one of the following situations, they may find it beneficial to see an SLP:
- Upcoming or current radiation to the throat area.
- Diagnosis of a neurodegenerative condition like ALS, Parkinson’s disease, or Alzheimer’s dementia.
How SLPs can help
The field of swallowing rehabilitation is constantly advancing. Every year, new research is published that teaches us more about normal and impaired swallowing and how to help.
Swallow assessment
During the clinical assessment, we gather information to help decide if a person has a swallowing problem, whether they should be referred for an instrumental swallow assessment, and what their risk is of developing an aspiration pneumonia.
A clinical assessment includes:
- An interview to find out medical history and the patient’s concerns.
- Examination of the mouth and throat.
- Assessing how the person is eating and drinking.
Based on the clinical assessment, we may recommend an instrumental swallow exam. There are two types, and both are performed by a speech-language pathologist.
One is called a fiberoptic endoscopic evaluation of the swallow (FEES). This involves a tiny camera being passed up through the nose. The camera hangs in the back of the throat, so we can see what is happening as a person eats and drinks normal foods and beverages that have been dyed. It provides a top-down view of the throat.
The other test is called by different names, such as videofluoroscopic swallowing study (VFSS) or the modified barium swallow study (MBSS). It requires an x-ray machine, and barium is added to food and liquid to allow the x-ray machine to detect it. This study can show the passage of food from the lips to the stomach, if the radiologist and SLP choose.
Dysphagia intervention
SLPs educate patients (and families) about the nature of their problem and what the options are for treatment. Patients’ preferences play a large role in determining what the intervention will be. Intervention often combines a number of approaches, including:
- Changing the environment and posture.
- Modifying how a person is chewing or swallowing.
- Altering the food or liquid (ideally a short-term intervention).
- Teaching a swallow exercise program to improve function.
- Educating why oral care is so important for lowering the risk of an aspiration pneumonia.
Sometimes changing the environment or posture are “quick fixes” that can resolve the problem. For instance:
- Turning off the television.
- Sitting upright in a chair.
- Avoiding talking with food in the mouth.
- Slowing down and taking smaller bites and sips.
An SLP may also recommend a change to how a person puts food or liquid in their mouth, and how they chew or swallow it. Altering how a person chews or swallows can compensate for the physical swallowing impairment.
Sometimes, we have to recommend changing the food or beverages themselves. We may recommend softer foods, or thickening the liquids. Ideally, this would be a short-term solution.
In addition, we may recommend a swallow exercise program designed to return the swallowing ability to “normal”, or as close to normal as possible.
Oral care reduces risk of aspiration pneumonia
Finally, we educate people that aspirating food or liquid into the lungs doesn’t cause aspiration pneumonia in and of itself. It’s aspirating harmful bacteria from the mouth and throat into the lungs that can cause aspiration pneumonia. But even so, a person only has a high risk of developing an aspiration pneumonia if they also have a lowered immune system. (The relationship between aspiration and aspiration pneumonia is complicated.)
This is why some people can aspirate every day and not get sick, whereas others can aspirate once or twice and end up in the hospital. We may not be able to control whether we aspirate or have a good immune system, but we should be able to brush our teeth or clean our gums and tongue at least twice a day!
Communication
Why assessment is important
This likely goes without saying, but communication is at the heart of being human. When people lose the ability to communicate, for whatever reason, they lose the ability to perform many typical daily activities. It severely affects social interactions, and it often leads to depression and other health complications.
Communication involves:
- Voice: how the body produces sound.
- Speech: how sound is shaped into words.
- Language: how words are understood or produced to communicate messages.
Language includes listening, speaking, reading, and writing.
Signs of trouble with communication
- Decline in ability to understand or produce speech.
- Trouble reading or writing.
- Word-finding problems.
- Difficulty being understood by others.
- Change in voice quality or loudness of speech.
- Poor stamina for holding a conversation.
Other situations when someone should see an SLP
- Before laryngectomy or radiation treatment to the throat area.
- Diagnosis of neurodenerative conditions that commonly affect speech, such as ALS or Parkinson’s disease.
How SLPs help with communication
There are many things an SLP can do to help people with a communication problem. Depending on the situation, we may:
- Help someone improve or regain communication skills.
- Train the communication partners.
- Alter the environment.
- Teach how to use technology to improve, supplement, or replace verbal communication.
Cognition (thinking skills)
What are cognitive-communication skills?
Cognitive-communication skills include orientation, attention, memory, reasoning and problem-solving, pragmatics, and executive function. Most of these terms are probably self-explanatory. Pragmatics relates to understanding and applying the social rules for communication. Executive function skills are necessary to complete multi-step activities.
Executive function skills include:
- Setting a goal.
- Planning for how to achieve a goal.
- Initiating the plan.
- Staying on task.
- Monitoring and correcting one’s own performance.
- Evaluating outcomes and comparing to the initial goal.
- Changing the plan as necessary to achieve the goal.
Why is assessment important?
If changes to cognitive-communication skills are causing any concern or difficulties with day-to-day life, then we should assess to see if we can help. These cognitive skills are important for staying independent and participating in all life activities (other than sleeping, I guess!).
Signs of trouble with memory or other thinking skills
- Change in memory that is bothersome or concerning.
- Forgetfulness that impacts daily living activities.
- Trouble managing one’s schedule, finances, or medications.
- Difficulty staying on topic.
- Inappropriate social communication.
- Trouble learning new information or procedures.
- Impulsiveness that impairs safety.
How SLPs help
Depending on the situation, SLPs may be able to help a person recover or maintain cognitive-communication skills. Even when a person has a moderate or severe impairment, we may be able to help them learn specific information or procedures through specific teaching methods like spaced retrieval with errorless learning.
While we could all improve our general attention and memory skills, as evidenced by the huge number of games and puzzles available, this isn’t the goal of speech therapy. Our goal is to help people improve or maintain their ability to participate in the activities of their choice. In other words, we want our patients to say “speech therapy helped me do X” by the time we discharge. “X” could be just about anything, as long as it relates to swallowing, communication, or cognitive-communication skills.
For instance, following are some functional goals we can help people with.
Sample functional goal areas
- Remembering names, dates, personal information, and current events.
- Learning strategies for how to remember new information or procedures.
- Initiating and maintaining the topic of conversation.
- Keeping track of important items like keys, wallet, cell phone.
- Using a cell phone, computer, microwave, or TV remote.
- Checking a clock or calendar to keep track of time and appointments.
- Remembering to use a chin tuck or other swallow strategy.
- Following the correct steps to sit, stand, and use a cane or walker.
- Keeping track of own personal schedule.
- Remembering to take medications as prescribed.
- Wayfinding (typically finding one’s way to important places in a facility).
- ADL’s like washing hands or setting the table.
- Prospective memory for intended actions.
- Handling money or the checkbook.
- Reducing troublesome behaviors such as repeatedly asking the same questions.
SLPs don’t take the place of occupational therapists (OT), physical therapists (PT), or nurses, but we do sometimes overlap. I co-treat with other disciplines from time-to-time. For instance, a PT may teach the patient (and me) what the steps are for safely standing up and sitting down, while I teach the patient how to automatically remember and follow those steps.
SLPs play a role in helping people live better
Every discipline plays a unique role in helping people live the kind of life they want. While there are many things that medicine can’t cure, often there are things we can do to help improve independence and safety, while reducing frustration and risk of harm. Our field is constantly evolving as more research is published and technology evolves.
In general, it takes an average of 17 years for research to make its way into clinical practice. So even if a person has seen an SLP in the past, and it didn’t help as much as one would hope, it’s possible that trying again could lead to a different outcome.
Too often, I meet people who have lived with daily annoyances and frustration that could have been resolved months or years earlier, simply because they didn’t know speech therapy could help. If you or someone you know is living with a problem in swallowing, communication, or cognitive-communication, please consider asking your doctor for a referral to an SLP.
Related Eat, Speak, & Think posts
- What is a speech-language pathologist, anyway?
- How to use spaced retrieval with errorless learning to improve memory.
- Collaborative goal-setting to identify meaningful cognitive goals.
- Assess readiness to change for better therapy outcomes.
- SLPs play an important role in home health medication education.
Free DIRECT download: Reasons to see a speech-language pathologist (patient handout). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by Gustavo Fring from Pexels.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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