Through technological advancements and increased research into normal and abnormal swallowing, speech-language pathologists (SLPs) and other rehabilitation professionals have been able to extend their roles in dysphagia assessment and treatment with older adults. This expanding scope of practice creates unique challenges as well as benefits for all rehabilitation professionals. Professionals must stretch their boundaries and sometimes their comfort zone and develop their knowledge to provide the best intervention for individuals with dysphagia. This has been particularly the case for SLPs in medical settings since at least half of their caseloads are now composed of individuals with dysphagia. Before the 1980s, individuals with swallowing disorders were relegated to living with the problem or to receiving alternative nutrition. Research and clinical innovations have allowed us to assess and treat these individuals and offer true potential for return to typical or at least functional eating.
Currently, SLPs perform clinical evaluations and instrumental assessments of swallowing, using both videofluoroscopy and fiberoptic endoscopy. The use of neuromuscular electrical stimulation, which physical and occupational therapists have used for years, is being explored for the treatment of swallowing disorders. Modified foods and liquids are more readily commercially available with enhanced quality and with efforts toward standardization for patients who require diet alterations. Teamwork between the American Dietetic Association and the American Speech-Language-Hearing Association (ASHA) to develop a standardized dysphagia diet system has occurred. An intense focus on evidence-based practice in dysphagia has been initiated by ASHA. Multicultural initiatives to improve interaction and service delivery between SLPs and patients of diverse backgrounds have been in place for several years.
Adequate nutrition and hydration are critical for recovery and for participation in rehabilitation programs, but individuals must have a safe method of nutritional intake as determined by the dysphagia team. Nutritional dilemmas are not always simple, and often a decision must be made about the use of alternative nutritional means versus oral feeding. These decisions become more complicated when individuals do not have an advanced directive and cannot state their wishes. The benefits of alternative nutrition versus oral feeding are not always clear, which makes decision making more difficult. Individuals with dysphagia are entitled to an informed decision about the means of nutrition that they receive even when this choice is seen as risky by rehabilitation professionals. Rehabilitation professionals must balance patient choices with professional integrity and professional liability. The ability to eat as normally as possible plays a major role in quality of life and is important to all individuals.
The field of dysphagia presents opportunities for SLPs to serve as multidisciplinary team leaders and ensure that individuals receive the most comprehensive care possible. Physical and occupational therapists are important team members to address positioning, strength, feeding skills, and adaptive equipment needs. Nursing staff often are the first to identify potential swallowing problems and are critical for follow-through with the daily treatment plan devised by the team so that the patient may eat safely. Registered dieticians determine the caloric and metabolic needs of the individual and design a diet that fits those needed criteria as well as any modifications recommended in texture and consistency by the SLP. The physician must recognize the need for dysphagia intervention and authorize all treatments. Specialists such as gastroenterologists and pulmonologists may be needed to address respiratory or gastrointestinal problems related to eating and swallowing. Social workers are critical to help identify and assist with psychosocial and financial issues related to eating and obtaining food as well as advanced directives and end-of-life issues. All team members must be alert for the signs and symptoms of dysphagia so that they can initiate the appropriate referral to the SLP.
This issue of Topics in Geriatric Rehabilitation presents an opportunity to discuss current issues in dysphagia practice as well as exciting advances in research. A multidisciplinary focus with clinical tips applicable to all rehabilitation providers has been utilized in this issue. Nancy Swigert, CCC-SLP, discusses dysphagia assessment from screening to instrumental assessment and the limitation and advantages of various methods. Debra Suiter, CCC-SLP, and Caryn Easterling, CCC-SLP, follow that article with a piece on current treatment and practice patterns and evidence-based practice in dysphagia intervention. Maria Spicer, RD, and I discuss nutritional issues with individuals with dysphagia. Faerella Boczko, CCC-SLP, and Katherine Feightner, OTR, discuss the teaming of occupational therapists and SLPs working with patients with dysphagia. Luis Riquelme, CCC-SLP, presents cultural considerations for all rehabilitation professionals when working with individuals from diverse backgrounds. Helen Sharp, CCC-SLP, and Lynn Brady-Wagner, CCC-SLP, address advance directives and ethical issues that may arise with swallowing and nutritional problems in older adults especially related to end of life. Pelletier provides an extremely comprehensive review of the mechanism of taste and how taste and taste changes affect eating and swallowing. This is an area of research and a body of literature that may be new to rehabilitation professionals but one that has critical ramifications for eating, appetite, and swallowing. Lastly, Minn Yoon and Catriona Steele, CCC-SLP, explain the impact of oral care on the health of older adults and the relationships between oral health, dysphagia, and aspiration pneumonia.
In summary, this issue of Topics in Geriatric Rehabilitation contains a unique set of clinical and research articles authored by some of the strongest and most-active researchers and clinicians in the field of speech-language pathology and rehabilitation. Each article stands alone and also correlates well with its companion articles to present a comprehensive picture of the state of dysphagia management with an emphasis on the roles of the entire rehabilitation team. This information should be applicable to a wide variety of professionals in varied medical settings and assist with daily clinical care.
Lori A. Davis, EdD, CCC-SLP