Case Study: Sans Souci (Dec 2014)

Resident: Fleetwood, Josephine
Community: Sans Souci Rehabilitation and Nursing Center
Concierge: Natalie M-Joseph
Date: January 1, 2015

Speech Language Pathology Dysphagia Case Study

Background and Medical History:
67 year old, African American female, Mrs. Josephine Fleetwood, was admitted to Sans Souci Rehabilitation and Nursing Center on September 10th 2014 secondary to s/p aneurism. Resident was O2 dependent and congested secondary to s/p COPD. She was NPO (nothing by mouth) with full feed via peg tube due to diagnosis of severe oropharyngeal dysphagia.

Speech evaluation was conducted post admission. At the time of the evaluation resident was lethargic, confused and demonstrated cognition deficits and severe disorientation. Speech evaluation revealed mild difficulty with initiating oral intake: opening the mouth and clearing the spoon and sipping from a cup. Severe difficulty in bolus formation: chewing and forming cohesive bolus, severe difficulty transmitting the bolus to the back of the mouth and moderate difficulty in initiating pharyngeal swallow. Resident was edentulous and had severe oral motor weakness at the time. However, due to the fact that her volitional and reflexive swallowing were stimulable, her coughing reflex was present, that oral intake was possible, and that she was eager to eat and drink, Mrs. Fleetwood was enrolled into the speech program.

Overall Goal: To improve oropharyngeal swallow function and to gradually transition the resident from NPO status to safe oral intake for all nutrition and hydration needs.

Interventions:

  • Objective testing (MBS to r/o overt and covert s/s of aspiration)
  • Dysphagia Therapy (oral motor and swallowing exercises, oral feed trials, cognitive-lingual  stimulation)
  • Analysis of diet texture to increase safe oral intake
  • Tailoring compensation strategies and positional techniques to decrease s/s of dysphagia
  • Calorie counts
  • Weight intakes
  • Coordination with MD and Nutritionist (for balancing oral intake with feed tube intake)
  • Coordination with OT for self-feeding via spoon and cup
  • Coordination with kitchen director for tailoring diet
  • Coordination with PT for transfer
  • Coordination with Nursing and CNA staff for monitoring, facilitation and implementation.
  • Training/in-service for caregiving family members and staff: swallowing precautions, implementation of compensatory strategies and positioning techniques, facilitation of self-feeding, diet consistency management and verification, s/s of aspiration.

Treatment and Progress:
Resident was gradually given modified food and liquid consistency along with compensation strategies and positions that were tailored for her safety and oral intake increase. Resident performed swallowing exercises to improve pharyngeal propulsion and laryngeal excursion during swallowing,  practiced dry and multi swallows to improve swallow sequence, used second swallow and liquid wash down to improve oral and pharyngeal clearance. Learned the use of throat clear and volitional cough strategies and chin tuck position in order to protect her air way during swallowing. She performed oral motor exercises in order to improve oral motor function: mastication, bolus formation and managing, bolus transmitting and clearing oral cavity from food residues. Resident was in sitting position during oral intake in the dining room at regular meal hours (lunch and dinner.)

During therapy sessions, Resident became alert and showed strong will and high motivation. She was humorous, quick witted, pleasant and verbally interactive. Although she was a fast learner, at times she exhibited short term memory deficits and occasional confusion and disorientation episodes. Initially resident required maximum modeling, and tactile and verbal cuing in order to perform tasks accurately. However, gradually, the cues reduced. Treatment was provided for two consecutive months.

Training was provided for the resident’s family members. They participated in mixing her thickened liquids, were taught to identify the prescribed food consistency, practiced the cues to facilitate swallowing strategies, and learned about risks of aspiration and chocking and prevention measures.

Results: 
Resident currently is able to sit at the table in the dining room and feed herself 60 to 80 percent of her meal. She eats breakfast, lunch and dinner. Her current diet is restricted to nectar thick liquids, pureed food and a soft sandwiches. She requires initial preparation of her tray, due to her vision impairment and occasional verbal encouragement in order to finish her meal. She may also require occasional help filling her spoon or turning the plate in her direction. Resident independently brings the spoon and cup to her mouth and independently eats her sandwich. “Thank you. I can feed myself.” She requests her coffee and often stops the caregiver from removing the tray if she is still working on her sandwich or coffee “I’m not finished yet.” Resident demonstrated mastering of the swallowing strategies such as clearing her throat and re-swallow, volitional cough, and chin tuck in order to protect her airway.

Feeding via peg was decreased by 500 calories. The nutritionist is currently in the process of managing the balance between oral feed and tube feed with the goal of gradual reduction of tube feed.

Modified Barium Swallow Test (MBS) ruled out signs and symptoms of aspiration with the oral intake of nectar thick liquids and pureed food. Thin liquid trails were tolerated with the use of the chin tuck positioning technique. It was also recommended that all oral feeding trials should be administered while the resident is fully aroused and seated in an upright position.

Worth Noting:
Resident consumed her oral feed trials and meals at the dining room table during regular meal time. The CNA team was working closely with the speech therapist in order to make sure that Mrs. Fleetwood is up and ready for lunch time. Everyone was motivated and excited that Mrs. Fleetwood was eating! The physical therapy team helped us transfer Mrs. Fleetwood to the wheelchair so we could bring her to the dining room.
Oral feeding trials and meals would have not been as effective if they were done in the resident’s bed instead of the dining room. Replicating the natural environment for eating provided sensory and cognitive stimulation: time, place, social environment, smell, sounds, more food and drink choices, and verbal interaction opportunities. In addition, eating in the dining room, stimulated her communication skills and facilitated her arousal and the proper positioning required for safe eating. It also motivated her to participate in her therapy, expedited her healing and made meal time an enjoyable experience.

Speech Language Pathologist
Gaida Hinnawi, MS-CCC-SLP

Director of Concierge Services and Patient Experience
Natalie M-Joseph