Modified Mondays: The benefits of Evaluating the Oral Phase (during an instrumental)

Patient Info: 90-year-old edentulous patient referred per family request to advance diet from puree to regular solids. The family was reported to be bringing in other solid foods from home. Nursing had noted choking episodes in the past with solids, so the patient had been on a puree/thin liquid diet. Pertinent medical history included: Chronic Respiratory Failure, h/o Pneumonia (~4 months previously), and Severe Protein Calorie Malnutrition. Although patient appeared to be clinically tolerating current diet and limited trials of soft solids, SLP was hesitant to advance diet given nursing report of “choking episodes”.

Study Results/Recommendations: Minimal to no active mastication attempts. Whole bite-sized cake (mechanical soft) bolus was transferred to pharynx. Fortunately, the patient was subsequently able to clear the solid bolus residue with a cued second swallow followed by a liquid wash. Although no aspiration was demonstrated on the soft solid trial, the patient did appear to be at high risk of choking on solids given absent mastication and because the bolus was initially lodged in the pharynx after the first swallow. This case highlights that even the bedside (clinical) swallow evaluation may not be sufficient alone to evaluate the oral phase. For this patient, an IDDSI diet level of 5 (minced and moist) might have been appropriate however the facility only offered puree or mechanical soft diet levels so it was suggested that the patient remain on a puree (IDDSI 4) with thin liquids (IDDSI 0) and that further education be completed with the family regarding current swallow function, increased risk of choking on solids, and pleasure feed items the family could bring in that would pose less of a choking risk.