Modified Mondays: Normalizing the Swallow - Normal isn’t Perfect

This video is a bit long, but it’s worth the extra time to think about what this patient’s swallow really is. As you are watching, it can be easy to jump right to what is “not right” about the swallow. It’s kinda slow, sometimes a little messy and disorganized, and there’s penetration, but if you know the whole picture of the patient, you can start to recognize that maybe it’s not all that disordered.

This is a patient with moderate dementia, he has been on softer solids (IDDSI 6) with thin (IDDSI 0) since admission to long term care quite some time ago. The facility SLP had been asked to see the patient due to some coughing and “also it always takes him forever to eat”. When looking at the history, the patient had been eating most of his meals, weight was stable, lungs clear, normal activity. He enjoyed puzzles, old movie trivia, and he was pretty social (which turned out to be another reason his meals took a while-he likes to talk.) The point is… this swallow is pretty normal for HIM. It could be a quick reaction to change him to puree, based on how long he takes with the cookie-but the big picture is that he LIKES what he eats, his weight is stable, and even though he’s a little slow, so are lots of people when they eat (Case in point: my super chatty 16 year old son… it has always taken him FOREVER to eat a meal). It could also be easy to change him to nectar, given the consistent penetration with thin-but lungs are clear and we know that penetration can be normal for many people.

Each instrumental assessment takes skill to not only gather information on the patient’s physiology, but also to combine that information with what we know clinically about the patient and then decide if that patient shows impairment…. or might just have a normal (not perfect) swallow.