Today we have Thankful Theodore as our Modified Monday patient. Why is he thankful? Because Theodore was put on thin liquids after a year of being on nectar thick. Did he need thickened liquids for that long? Or did he need thickened liquids at all? It’s doubtful. There was never an instrumental assessment that determined his swallow function. It was assumed that because he had a voice change and coughed occasionally when drinking that he needed his liquids thickened, even though Theodore had never had any respiratory problems and his lungs were clear. Theodore was the quiet type and didn’t complain much about being on thickened liquids, but after a year had gone by, it was nursing staff who wondered why the patient was on thickened liquids and requested a re-assessment.
In this video, the clips progress from tsp sips to independent cup drinks of thin. Nectar and puree are included in these clips as well. At times there is oral residue present which spills into the pharynx after the swallow, but the patient independently swallows again to clear this. This is not the entire MBSS that was completed, but it gives you some snapshots of a functional swallow, especially with thin liquids which were never penetrated or aspirated.
As long as these incidents keep happening these stories will be told and re-told. How do we prevent these things from happening though? For one, a good routine screen program is recommended to identify those who have improved over time. Someone might have an acute illness and be changed to an altered diet/liquids, insurance cuts them before they are back to 100%, and they stay on that diet forever, even though they might have had further gradual improvement over the next few weeks or months. Or perhaps, they were taken off a medication that caused dysphagia and their swallowing improved afterwards (psych meds are a big offender), but it went unnoticed because the patient was thought to have chronic dysphagia. A routine (monthly or quarterly) swallow screen program would increase the likelihood of capturing these improvements. Another way to prevent this from happening is (drum roll please and insert dramatic effect) PERFORMING INSTRUMENTAL SWALLOW ASSESSMENTS to see how a patient is swallowing to begin with. Signs and symptoms of aspiration do NOT mean that a patient is definitely aspirating.
Thankful Theodore is now on thin liquids and while he didn’t speak up about not liking the thickened liquids, his smile said it all when he was changed to thin. Let’s not make it so the squeaky wheel always gets the grease. Watch out for the quiet ones as well.
Disclosure: This patient’s name is not Theodore, but the name goes quite well with “thankful”.
Assessment Across the Life Span: The Clinical Swallow Evaluation | American Journal of Speech-Language Pathology (asha.org) (reviews limitations of CSE)
