[Dysphagia] Logemann results

[eripley at yahoo.com (Irene Campbell-Taylor)]

Patient #2: Saw on 6/14, a 94 year old female originally diagnosed with pneumonia, and a history of atrial fibrillation, fecal impaction, hypertension.
  *** Clearly dehydrated and what medications was she taking?
   
   Initial visit revealed patient with head-forward posture (probable osteoarthritis)
  *** More likely osteoporosis
   
  Patient's dentition in very bad shape; perhaps a half dozen in mouth are broken and blackened. 
  *** Highly probable source of pneumonia.
  At first session also patient's voice barely above a whisper; 
  *** Why? Respiratory difficulty? Weakness? Dysarthria?
  RN on case concerned about keeping pt. hydrated.
  *** Good call!
  2nd session canceled when pt. went into hospital for urosepsis (enterococcus) and aphasia.
  *** Hospitalized for aphasia?  Is this a typo? And the UTI yet another sign of dehydration.
  2nd session took place 7/2. Patient displayed no voice whatsoever, mouthed 2-3 word responses, judged to comprehend light conversation and light humor. Appeared to be dozing much of the time, same posture, weakly and barely lifted head.
  *** Cause?
   RN concerned whether peg tube needed, and/or hospice to be considered.
  *** PEG definitely not indicated in a patient like this.
  Spoke with doctor and explained all, and agreed with his statement that "she's on her way out." 
*** In a different setting, this is the type of patient we would use ?clysis on and watch for potentially dramatic change in a day or two. Why assume that this lady who is weak, dehydrated and probably malnourished cannot be improved? Certainly not without trying. There isn?t enough information given to make that kind of decision. What is her complete history? Has she had a stroke or other neurological event? If she is taking digoxin for the atrial fib.could she be digoxin toxic ? very common in older persons with this particular medication. Are her meds at the right dosage ot too high ? again all too common in the elderly. Is she taking any neuroleptic or other psychotropic medications that could be affecting her and might be d/c?d or changed?  There are multiple variables to be considered ? one of the things that makes geriatric medicine so challenging.

Vera Karger <vkargerslp at mac.com> wrote:  Patient #2: Saw on 6/14, a 94 year old female originally diagnosed with pneumonia, and a history of atrial fibrillation, fecal impaction, hypertension. Initial visit revealed patient with head-forward posture (probable osteoarthritis) in wheelchair, fed pureed food and nectar thickened liquids. However, this texture modification was initiated about 3 years prior not by medical order, but by husband's decision, based on fact that a dev. delayed grown son was on that diet, and wife has almost no dentition, so he made that decision. (Still, the intake stated diet to be regular soft.)  

  Patient's dentition in very bad shape; perhaps a half dozen in mouth are broken and blackened. This is a middle class family that could afford dental work, but the patient has refused for many years.
  

  At first session also patient's voice barely above a whisper; feeds self pureed food slowly; gets thickened liquids by sips, straw or spoon, but thickening of liquids is inconsistent. (Very commonly found.) All caregivers were instructed and educated re thickening of liquids in a consistent manner, also reviewed possibility of water protocol, and clarified food textures, using NDD as guideline. RN on case concerned about keeping pt. hydrated.
  

  2nd session canceled when pt. went into hospital for urosepsis (enterococcus) and aphasia.
  

  2nd session took place 7/2. Patient displayed no voice whatsoever, mouthed 2-3 word responses, judged to comprehend light conversation and light humor. Appeared to be dozing much of the time, same posture, weakly and barely lifted head. RN concerned whether peg tube needed, and/or hospice to be considered.
  

  At this 2nd session introduced water protocol as a strict structure for this patient. Spoke with doctor and explained all, and agreed with his statement that "she's on her way out." At 3rd session two days later, reviewed and reinforced protocol. Spouse reported patient coughing less, but at this stage I'm not viewing that as a sign  either positive or negative.
  

  Any comments appreciated.
  

        Vera  Karger, M.S., CCCS
  Monroe, CT
  vkargerslp at mac.com
  









Dr I Campbell-Taylor
Clinical Neuroscientist
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