Dementia and Dysphagia with Luis Riquelme

You're listening to a Speech Therapy PD Podcast. Earn 0.1 ASHA CEUs for this episode by completing the accompanying course online at speechtherapypd.com. Hi everyone, it's Renee Garrett, your Speech Therapy PD Podcast host. For Brain Storms, Functional Neurorehab for SLPs. In this week's episode, we're joined by Dr. Louise Requelme, who comes to us with a lot of information and a lot of evidence-based research and was so kind to share his research work with us in the show notes. He's talking to us about dementia care, specifically for patients with dysphagia, but also with consideration to the cognitive decline we often see in our patients with dementia and how we can better access and provide caregiver supports as well. So join us for this episode and as always give us a like and a follow and a positive review on your favorite podcast platform. Hello and welcome everyone. My name is Renee Garrett and I'm your Speech Therapy PD Podcast host for Brain Storms Functional Neurorehab for SLPs. Before we get started, we have a few items to alert you to. Each episode is 60 minutes and will be offered for 0.1 ASHA CEUs. Here are the financial and non-financial disclosures. Dr. Louise Requelme receives a salary from Bereke speech language pathology PC. He also receives an honorarium from speech therapy PD for participating in this podcast. His non-financial disclosure is that he is the co-chair of IDDSI, the International Dysphagia Diet Standardization Initiative. My financial disclosure is that in the owner and founder of BrainBridge Connect and is the host of Brain Storms Functional Neurorehab for SLPs and other webinars on speech therapy PD I receive financial compensation. I'm also an adjunct instructor for both James Madison University and Old Dominion University. My non-financial disclosure is that I'm the secretary for the Communication Disorders Foundation of Virginia. Now without further ado, we welcome our guest Dr. Louise Requelme PhD CCC SLP BCSS fellow ASHA and ASHA honors who is the consulting director of rehabilitation and speech language pathology at my minute my my my night as I butchered that sorry. I'm on an use. I'm on an e-cell. Associate Professor of Promise at Practice at University of Catolica, the Uruguay and adjunct Professor Teachers College Columbia University. His current research focuses on changes in swallow physiology and dementia and pill swallowing. Publications also include relationships between culture and dysphagia. Louise has presented locally and internationally. He serves as co-chair of the IDDSI and a member of ASHA's Healthcare Economics Committee and as I mentioned is the recipient of the ASHA honors and a fellow of ASHA. Louise, Dr. Requelme. Louise works well. Good ass isn't thank you for being with us this evening. So good to see you. Thank you so much for having me. I really I'm excited about being here. This should be a fun hour. Yeah, it's always a fun hour. It's always a fun hour. So let's go ahead and just jump right in. Can you just talk to us about your background and how you got into dysphagia research and that being your primary mode of what you spend your day to day doing? Right, so actually my hard, my passion and where I really have always been is in clinical practice. And then from clinical practice early on, once I received my master's degree and was doing my clinical fellowship at an outpatient rehab facility, then hopped into acute care hospitals and made it to fairly quickly, made it to director. Eventually started my practice and so my practice was the speech pathology team for several hospitals and several nursing homes in Brooklyn and in Queens, New York for many years. Later on, most of the group we were at 1.11 speech pathologists were focused on one major hospital in Brooklyn and most recently, about three years ago, I was recruited to another hospital, my monides health, my monides medical center specifically, but my monides health network. And to run this speech pathology group and their my colleague and friend, Alexandra Soiffer joined me as assistant director. Six months later, they asked me to also run rehab. And so I inherited PTOT and was also having fun with speech pathology. Even with the administrative titles, I still saw patients every day, I had to go in and do a couple of consults, see some patients help out. I would say my monides that wasn't as often as I as I did before. But throughout my career as a clinician, right, as a speech pathologist, my concept always was there's so much I don't know I need to learn more. So I kept reading, I was looking at the research, I'd participating in continuing education. Back then we didn't have zoom in all this, you have to go to conferences and pay for hotels and all that. But luckily, I was in New York City where we had access to a lot of good continuing ed in person. And so that's when initially, interestingly, I don't know if you know this, my my interest area was the bilingual brain bilingualism. And I thought that was fascinating. So I started the doctoral program because I really wanted to explore the bilingual brain a lot, you know, closer. And then for personal reasons, I had to stop the doctorate and for a few years and got involved in politics to the point where nine years later was president of the New York States, speech language hearing association. The 90s was very for for any seasoned clinicians out there that 90s were a very crazy time for those of us in health care. Lots of changes in long term care, especially regulations and requirements and so on. And so many clinicians were suddenly faced with, okay, I'm being asked to work more hours because of the changes in reimbursement, but what do I do? Right? How do I develop a program? How do I get more consults, etc, things like that? And so I had to decide between making sure that we're doing a good job and that we survive and that we don't fall on our face. And I felt that was more important than going back for my doctorate, but eventually I did. And at that point, I was swept into the whole swallowing thing, right? I knew that graduate school. Dispager has always been my passion, not only because I love eating, but I really love the biomechanics and just the pleasure of it all, if you think about it. So now I'm technically semi-retired, but I'm still working part-time for my monities remotely. And I'm running the post-graduate certificate program in dysphagia at Universidad Catolica in Uruguay. And then, you know, the spare to-to-to-co-chairing ITC and things along those lines, volunteering for Asha. It's the stuff we do, the stuff we do. Yeah, I know. Sometimes that hours in the day, I was president of our state association in 2020. It doesn't always say it doesn't get much better than that. It's the thing you want to be president of in the year that we have the first year of the pandemic was really a 10 out of 10 and you're not recommend. Yeah, but you know what? And that's when- but look, look what if you have to find something positive, look what brought it forced us to be skilled at some of this technology, like using Zoom or Microsoft Teams or any of the other platforms and allowing us to obtain CEUs like this, right? Although I always emphasize, especially to the young clinicians, to know you need to go to some in-person activities as well. That networking is invaluable, right? Because you might be sitting next to somebody that's in the same setting as you are, but they do things differently and you might get ideas or you might share with some of what you're doing. And so that's how we continue to grow because that's the idea. Yeah, or like me, I just walk up to people that I've been to their courses for years and say, hey, this is who I am. I'd love to have you on the podcast. Yeah, that sounds familiar. They actually worked out. I'm okay with it. So let's get into aging and this population of dementia. And I kind of- I know we could go all over the place with this, but one of the places I think is a great place to start is talking about Presbyphasia because a lot of people aren't. They've heard the term, but maybe they're not familiar with exactly what it is and how it manifests and what we see in our clinical practice. So that's a great start. You know, my interest has always been in the older adult. And that's the population I've always enjoyed clinically. And so it made sense that research wise, that's also what I was going to focus on in. My dissertation was actually in the area of Parkinson's, but in clinical practice, you know, as I, as, you know, I saw the aging population growing. And then looking at some numbers, I mean, right now 17% of the US population are people over the age of 65. Right? And it's projected that by 2040, that'll go up to almost 22%. Right? So those are high numbers. And if you go onto the World Health Organization website, you'll see that this is impacting all continents. Right? Now, now, Japan has had a population of people over 65. I believe over 30% of their population age 65 and over four about a decade now. And so they've been really doing some research on, you know, cognitive changes and, and, you know, assisted living and doing all that. And, but we're seeing more and more countries, right? You know, some countries in Eastern Europe are going to have those large numbers of, you know, over 30% of the population. World Health Organization used the age of 16, not 65. In South America, there will be some countries, Chile being one of the first ones that will reach those numbers. But Canada will be reaching those numbers before the US. But the US is getting up there based on what I just, what I just shared. And so the big question that I always pose is, so how are we going to handle this in healthcare? Right? I hear G-retritians saying, oh, after 75 or after 80, people respond differently to medications. Right? So they're their cardiac medication or their, their whatever other medication, they don't respond the same way their body is now managing that differently. Then we talk about Presby Fager, right? And in 2019, Dr. Shwini Namasi Bhagya, MacDonald and I published a paper. She's now at McMaster in Toronto, Canada. And where we, we posed that we look at, you know, Presby Fager and this Fager as a continuum. Right? And so, to me, and people have these other, you know, ideas of Presby Fager, some people talk about sarcopenic dysphagia, which I don't necessarily, I'm not a big fan of that terminology, because Presby Fager isn't always because of sarcopenia. And so, so to me, Presby Fager is when you have somebody that's a, this is a weird term, a functional swallower, right? A person that is swallowing well is, is engaging in some compensations, maybe not even volitionally without realizing it, right? And sometimes we see people they modify their textures a little bit or they, they cut their food differently. They're already making some adaptations, but if you ask them if they have a swallowing problem, they say no, right? They just consider that part of it and they compensating well. They might get sick, they might, they might get a UTI, right? A urinary tract infection or they might be weak from some other treatment. And so now they're dehydrated and malnourished. Now they can't compensate as well. And so now along that continuum, they, if we see them, we might say, oh, they do present with a dysphagia with an or a pharyngeal dysphagia that we feel is impacting. And so it requires some some some some treatment, right? Some form of treatment. But it's a continuum. So maybe once they're medically stable or they get better, they make it over this UTI, right? Or whatever is causing this dehydration and malnutrition, they will come back and they'll be at their baseline, right? And it's not only their baseline data, but actually their baseline. Compensations for for swallowing. So that's what I see as as Presby Fage. Why do we need to be smart clinicians and why do we need to be good because we need to not go crazy when we do an instrumental exam, right? And we see something different, right? That different is still allowing for a functional, a safe and efficient swallow, then it's okay, right? That's the way that who are we to say, oh, you have a swallowing problem. We have to intervene immediately, right? The other the other important piece and another concerning part of our clinical practice that's based on some research that's actually quite old is our well, first let me say, we don't all agree on what dysphagia is, right? And so if if you've been watching, we have some of our colleagues, received a grant and that was Dept Souter, Marty Brotke and Giselle Mann, to look at the definition for defining dysphagia. And we there hasn't been a good consensus reached, right? And so when we're reading the literature, we need to find out what that group, what those authors are using to define dysphagia, how they're defining dysphagia. dysphagia isn't just aspiration, right? So we're talking about safety, but we also have to talk about efficiency, right? So is there residue, how's the coordination, et cetera? So we have to be really careful about that. Now in that context, let me say this, that the definition is normal and many times we see clinicians on an instrumental exam see one instance of penetration for a particular texture and immediately switching over to another texture. No, that's incorrect, right? And the same thing with our clinical exam, although voice was a little wet girly and but that was once swallow. NPO for days or weeks before, right? So be careful, but we have data in 1999, Joanne Robinson, her group, published the data, they had three different groups and in the older group, the folks over 65, they found that 17.8% of the swallows they tested thin liquids and semi solids, there was a little penetration in healthy older adults. And then doggate 2006 found that in people under the age of 50, about 7 to 8% of the swallows, there was a limited penetration for thin liquids and semi solids, and they confirmed that 17.8% 17 to 18% in people over 50 years old. So we need to be careful, right? We might follow a protocol during our instrumental that says just, you know, administer three swallows of this thin liquid, but we may need to administer more, we may need to administer six or nine, right to find out what's really happening and tie it in with their respiratory status, their lung status, the whole picture. And we may need to be careful, because we might not be able to communicate on that, that's not what we're focused on, but it's concerning because as we see people age, we're going to see some of those differences. And so we need to think like well educated clinicians and think about about function and about quality of life, right? And that's one of the things I love about it. See, right, the international dysphagia diet standardization initiative, because that allows texture modification with greater importance. And it's not just regular, um, chopped or mechanical soft and puree, and that's it, right? You have no other options. Now you've got minced and moist, you got soft and bite sized, you have many other options. And the other thing is that on one plate, someone can have a variety of different textures, right? Because if on the, on the food pyramid, if they are, um, at a higher number, they are not going to be able to do that. They can have any of the textures that are below that. And then the liquids, they can have any of the ones that are above. So, um, that's wonderful. And that's, that's, that's all about, you know, quality quality of life. Well, and from a cultural perspective too, you'd have to look at what people are eating, what your, like what my plate looked like tonight for dinner and what, you know, I had for lunch. We tend to have, if we call it a regular diet, we tend to have a variety of textures on our plate at anyone given time. So that makes total sense. I should the person with this phagia not be able to enjoy that variety, right? And let's think about the sensory taste, temperature, texture, volume, right? Why should it all be this mush, right? That I think it's called prey. Right. So, um, that's, that's important. But then, then we start seeing, you know, people are now living longer because, you know, we're, you know, they're either, either healthy or, um, the, the healthcare system is allowing them to live, to live longer. And so what happens? That's we know one of the risk factors for cognitive decline, right? So age, as we get older, we're at higher risk for cognitive decline. And then if we go look at that road and get away from dysphagia, what's interesting about cognitive decline is that we don't understand it, right? And so, I mean, there's that whole, some people break it down and too we've got this preclinical part where it's really not detectable. There are changes in the brain, but the person is still functional. It's not even detectable in cognitive tests or things like that. Until then we get to MCI, right? The mild cognitive impairment. And so those are more evidence and those might start, you know, really impacting, but the person's ADLs, right? Their activities of daily living are still okay. So until then they reach the dementia. And globally, I think I mentioned this to you before, in a globally, we're not doing a good job at diagnosing the dementia, right? - Yeah. - I mean, sometimes the dementia's diagnosed by the primary care physician and the patient's placed on a receptor, some other medication without being sent to a neurologist or a psychiatrist which in the US would be best practice to then do their workup to confirm the dementia maybe determine the type of dementia. So when we see this dementia diagnosis in a patient's medical record, we have to ask where did this come from? How true is it? And we very infrequently see the severity. Is it mild? Is it moderate? Is it severe? You know, forget the type. So that makes our treatment our thinking and how we tackle in this case the dysphagia sometimes quite challenging. - Yeah, and you know, when you think about you mentioned mild cognitive impairment and backing up beyond that, we know that for good brain health nutrition and hydration are such big parts of that. And you know, we do that in a continuum for brain health from concussions to TBI to, there's a lot of push for sports related injuries or athletes who have prehab now for cognitive health and brain health. And it's the same way that we're sort of pushing for decreasing the risk that you could develop MCI or you could develop a type of dementia making sure that your nutrition is a big part of that. And so if you combine that with sub-level of dysphagia, then you can see where again, it's like which came first, the chicken or the egg. And then also backing way up to when you were talking about medications, I know one of the things that in acute care we had, we had a whole ortho center and I would often get consults for, you know, AD plusters who fell broke their hip and had to have a hip surgery. And what would happen is they were not able to tolerate the anesthesia like they did when they were 40 or 20 or whatever younger age. And they would not really arouse sufficiently. And you know, you're two hours post-op and they wanna give you a pain pill and the patients and their confidence buttering and you know, not even really awake. And so there's so many pieces of this puzzle, it's not one thing or the other, it's just multifaceted. And I think that's where keeping up with the research and being grateful to people like you who are doing the research so that we can say, okay, this was my thought process and now it's validated by this research. It's there that I can then hand to a physician and say, you know, this is not cut and dry like you think. They don't all have were for individual dysphagia post-op. That's not what happened necessarily. Could it, yeah, of course it could but. And that education piece really is huge in terms of the multidisciplinary care of the patient. But then also being able to understand, you know, when should they call us, right? When should they call us, what can they do? And us being making sure we're available and we understand. We can't expect others to know exactly what the right time or exactly what to do unless we provide some of that education. Because sometimes we don't know it and it might differ from facility to facility, right? Depending on the style of the clinical team or of the whole healthcare team. I wanted to add to this whole puzzle, the impact of frailty. And there's a really nice article. It's, I mean, I guess as time goes by, it's kind of getting old now. It's from 2019, wow, well, I'm being six years ago. By Julie Chikiro in Australia. And it looked at frailty in the context of eating and swallowing, right? And so she talks about, you know, aspiration and choking risk and this whole issue of the modified textures, but also the autonomy of choice. And that's something we can't forget. And when we start looking at ethics, Paula Leslie, Dr. Paula Leslie, who's now in the UK, is also a great, has some really great literature that makes us really think and start looking at that quality of life and the patient's dignity and patient's choice. So with that, I'll say, when I started then looking into this whole aspect of dementia, I was really fortunate to meet and find out that she was just as passionate and interested in this, my colleague and friend, Ashutin and Masiwaya McDonald's, who's that McMaster. And so we started talking and there's an interesting amount of literature looking at the behavioral aspects of not eating or of changes in eating behaviors in people with dementia, right? Some have to do. And so you might read some of the literature on changing the environment, on the color of the table cloths, and the plates and the whole thing, it's all really important. Lighting has been studied in terms of the room where they're eating, where the person is eating, et cetera, et cetera. And I found that interesting, I was okay with that, but I wanted to know what was actually happening in here because my suspicion was it wasn't just the, you're holding the bollus in your oral cavity, right? Why are you holding that bollus there, right? And at this point, the way I think of that bollus hold, right, that people say, "Oh, he forgot to swallow," and I try to educate everybody, you know, people don't forget to swallow, right? But that bollus hold is either, it's either there's really a swallow or praxia or, or I suspect, and there's been a little bit of work done on this, on the attention part of it. What if that bollus was placed in the oral cavity and there's a fly over by the curtain and the person's just focused on what the fly is doing and they totally forget that they have that, that food in there, right? And I learned from a, back then they were called nursing assistants, now there's all these other terms depending on the facility you're in. I learned from a nursing assistant with a lot of experience that sometimes if you place an empty spoon or an empty fork, right, in the oral cavity, you push down on the tongue, suddenly everything starts working again, boom, and they, they propel the bollus posteriorly and swallow. So, all those little things we learned, right, in clinical practice. So, that got me interested into, okay, how we need to start looking at this, right? And, oh, they developed an aspiration pneumonia, but was it because of how they were being fed, were there really problems with, you know, the changes in the physiology, in acute care, people weren't always doing an instrumental exam on them, oh, you know, they're demented, let's just see what they can handle, it was all about texture modification. I said no, and luckily Dr. Namasi Vagyam-Madanald agreed, let's look into this. So, one of our first papers with this population was actually, we looked at quantifying airway invasion and for angel residue and a retrospective sample. And, we looked at 58 patients retrospectively. And, what we found for thin liquids, and this one, this study, yeah, thin liquids and semi solids, what we found was, there was, residue was more common in the molecular, okay? But, the residue that was most unsafe was the residue in the pyroform sinuses, right? And so, the pyro, the residue in the pyroform sinuses was more often unsafe, meaning it would spill over and enter the airway than safe. And so, from our data there, we were, able to analyze and find out that there was a 2.83 times greater relative risk of penetration or aspiration in the presence of thin liquid periform sinus residue. That blew our mind. Because we always thought the semisolids would be the ones that would create more residue. Why are the thin liquids creating more residue? Why in the periform sinuses? Why is that the greater risk for aspiration and not molecular overflow, for example? We don't really have the answer yet, this was back in 2019. I will share that. It made us start thinking about sensory inputs. Again, taste temperature, texture volume. How can we manipulate that to make that different? Right? Then, of course, when there's airway invasion, not everybody coughs. Sometimes there's a silent aspiration and sometimes it's not. That's been really interesting. In that context, as we're thinking about that physiology, I need to talk about Dr. Sonia Malfenter, who's at NYU. She and her lab have been doing some really interesting work in healthy aging. She did a study. She published a study. I believe that she started this train in about 2018 was her first paper, if not before that, where she did MRIs of the pharynx. So looking at healthy older people's pharynx, and one of the things that she found, in addition to other things, of course. But one of the things that she found is that the lumen of the pharynx, in other words, the space inside the pharynx, is larger as we age. And you say, why is that? Because it was Tarkopenia. We've heard about the changes in muscle fibers as we age. And we see it in our legs, we see it in our arms. Those are skeletal muscles. What are these? These are skeletal muscles. So there's Tarkopenia going on. In the 90s, when Joanne Robbins and her group started talking about Tarkopenia, in our field, they were looking at the tongue. And we have tons of information about exercises and changes in the tongue because of Tarkopenia. But nobody has been looking at the pharynx. So Dr. Malfenter actually found, oh, so there's this larger space because of Tarkopenia. So now the healthy older person has to work harder to constrict the pharynx to propel that bolus inferiorly into the esophagus. Again, a compensation, presby phage, maybe, a compensation that we don't think about until, let's say, the patient, again, is sick or weak. And so can't complete that compensation and that full squeeze. And so now she's, she and her team are looking at, in addition to several other things, but what would be some of those exercises that we can recommend to folks that are aging healthily, physical therapists, our colleagues tell people walk around the block, you know, two times or three times. And that's good for your balance and that's good to maintain your tone and blah, blah, blah. Well, what do we have for this, for this area up here, for the oral pharynx? So that's, I think, just an incredible line of research and it's really worth, worth looking at Dr. Sonia Malfenter, M-O-L-F. Okay, so then, then we decided Dr. Namasi, by the way, and I said, okay, so we need to look at just the full package, but before that, we did a couple of other little things. So we looked at, you know, this is argument about acute and un-cute swallows, right? And interestingly, with patients with dementia, we're telling them all the time, "Meet us, swallow," right? "Swallow." "Come on, come on, Joe, swallow." Well, guess what we found. So we, in a cohort of 26 patients, we analyze 105 swallows, acute and un-cute swallows on video foroscopy. And what we found is that there's limited benefit to providing acute swallows to people living with dementia. We found, you know, no major, no significant differences. That's what I was looking for in terms of the response, you know, in terms of bolus location where the swallow was triggered or for angel transit time, etc, with acute or un-cute swallows. But there's still that tendency to go with the, you know, telling Joe to swallow pattern. But so, so we like, so once again, we like, that's very different from the non-dimensional population, right? Where we know there's a difference. We also started looking at epiglotic inversion. And this really was some of the Schweeney students were interested in this. And we said, "Hey, we have the data. Let's look at it." And there we looked at 44 patients where we looked at epiglotic movement. And we know from the literature that epiglotic movement could be, could happen for at least three or four different physiological, physiological reasons. But what we found was that the, first of all, the epiglotic didn't play a major role in airway protection in the population with dementia. And that it was mostly, when it was impaired, it was mostly because of changes in high-oid movement and that connection with the, with the high-oid. So again, another physiological difference that keeps telling us, okay, the person with dementia is swallowing, you know, differently because their, their physiology is changing. So that brought us then, we did this big retrospective study with colleagues at, at New York Methodist Hospital, as it was called back then. And at that point, we looked at 106 patients retrospectively, analyzed 412 thin liquid swallows. And we compared them with existing norms. That's why we did the thin liquids only because we had norms in healthy aging population. And so, you know, what we found was there were really significant differences in several biomechanical parameters, right? In pharyngeal transit time, in swallow response time, in response time to luringo vestibular closure, upper esophageal opening, and the degree of maximum pharyngeal constriction. So all those were different in the person with dementia compared to, to the norms in, in healthy age. And interestingly, though, we didn't have a lot of unsafe swallows. Only about 17% of all the swallows were considered unsafe. So that was another interesting finding. So we're not seeing a lot of these pulmonary sequela, right? In this population, we're seeing a lot of other things like the malnutrition and dehydration and the not eating and so on and so on. And so how much of it is behavioral and how much of it is the changes in the physiology? And so now we've been slowly running a prospective study. And our concern is that we just have to lump everybody in with this diagnosis of dementia. And now what we're doing is we're actually using the mocha as a screener to categorize the person's cognitive status regardless of the type of dementia because we don't know, we're not doing a full dementia workup. We don't have that kind of money. But we are trying to then group our patients into mild, moderate and severely cognitively impaired. And then looking at the swallow on video fluoroscopy and see if we can start seeing a trend or. That's kind of where we are now with that research. I am really happy to say that other colleagues are looking at some other aspects of dementia, which is great because we need the full package, right, to care for this complex population. And so Dr. Samantha Schoen, along with Dr. Namasteva Yama-Donald and Dr. Nicole Robus-Pullian and Wisconsin, they've been looking at caregiver burden, right, and that's something to certainly address. We also need to start thinking about as the population ages, do we always need to go to the tube, right, when that's not quality of life? So we start thinking about the management. But before I, we talk about management. I think you had some other thoughts or things you wanted to say. Yeah, and one of the things that I think always comes up for me is to, you know, thinking about my mother-in-law when she was still living. A lot of the time she would go to her primary care, And it was a new medication or an increase in the dose or an update to something she was taken in addition to something. There was always a new med, there was always a new dose. And we know there's a lot of people who have done great research on that, but having sort of this basic knowledge if you're going to work with this population of patients, whether it's, or even if it's not dementia patients, it's in acute care in general and skilled nursing facilities, long-term care facilities, LTECH, even in inpatient rehab, which is where I started and is still my first love. You need to have this basic understanding of maybe you're not a pharmacist. I mean, I'm not. I don't know about you. You do need to have some baseline knowledge of at least where to go if you're not sure. Talk to your pharmacy team. Take a course on pharmaceuticals and polypharmacy. That's a big impact for the general population. But again, as you mentioned in the aging population, polypharmacy is a concern. And especially in patients with dementia who maybe are not able to communicate and say, you know, I took this new medication and I don't feel right. Something feels different when I swallow or something feels different. Just in general, their general overall well-being changes in response to, I mean, you know, you watch a commercial on TV and it's for a new med. And it's like, why would anybody take that? It's like you have, you may have diarrhea, vomiting, nausea, headache, constipation. And I'm like, well, that sounds really awful. I don't think I want to be part of that. I know, but the commercials look beautiful. At the end, they mess it up for you telling you about all the possible side effect. Yeah. Yeah, all the dancing and the positive music and joyfulness. And then it's like, but you also could have a weird skin infection. It's like, why would you want to take that? But if you can't communicate that, you can't say because you're, you know, you're whatever it is, the attention, the memory, we know those things work together, executive functioning. You know, I teach my students, your brain isn't just isolated to low, look, you know, it's going this way, thought patterns are going this way. They're going up and down. They're, you know, they're all over. Anything's interconnected. And if you can attend to something, you're not going to be able to recall it and vice versa. And then if you have challenges with communication because you do have some sort of dementia, you may not be able to communicate any of that stuff. So that's one thing that I think is a real challenge. Yeah, it definitely is. And that's where we can't stop the speech language in our title, speech language, which is all of this, right? So, so let's not forget that communication piece. And there are things that sometimes through facial expressions, right, that person is telling us. And so sometimes working with the caregivers to pay attention to that or, you know, different reactions and not jump the gun and make assumptions about it, right? I think the other piece, and I didn't mention this before, that, that, you know, little by little, we start learning and there's some, some older data pointing to this. And of course, I question it now because, you know, we don't do a good job at diagnosing the dementia, but, but we have some general thoughts, things like, you know, the frontal lobe dementia, those folks tend to, you know, eat fast and overstuff their mouth. And so, so that's not something that the person is doing volitionally. So making sure the caregiver understands that it's because of their type of dementia, that they're doing that, right? And then figuring out ways to control that pattern or to change that pattern. The other piece that is starting to get more attention, just like I said before, geriatricians are realizing that medications are not absorbed the same way after a particular age. And this is an unhealthy aging. The other reality is absorption changes of nutrition, right? And so, so maybe that really nutritious meal of five years ago is not being absorbed the same way five years later, right? And you're not, and the person is not getting all those benefits. And so they, they still might be deficient in this vitamin or this mineral, et cetera. And so I think that's where, you know, collaborating with our colleagues in nutrition and making sure that they have a chance to meet with the family and and and and train caregivers on how to really pay attention to that. And and also in some dimensions, a taste changes, right? So, so some of the favorite foods are in favorite foods anymore, right? So, so not always making making those of something that impacts again, how we swallow, you know, again, taste, temperature, texture, volume, I mean, the large influence that has on, on how we eat. To me, another, another piece with this population, and we go back to the behavioral pieces, put the food in front of them, right? We eat with our food in front of us. Let them see that food. If they want to hold something, maybe they're there at the point where they can't feed themselves, give them something to hold a crack or a piece of bread, right? So they're active. They're part of this process of eating and smelling and seeing. So that's what I was going to say next is the old factory pieces so often left out. And that's one of the pieces that I learned in my clinical, my, my second off campus clinical was I was in a long term care facility and I had a fantastic clinical instructor. And she would say, this isn't technically evidence space. There's no research to back this up. But if I light an apple cinnamon candle, grandma's going to eat today. And it was so true. Oh my god. But again, I've said that in nursing homes, I've said we need to get a candle factory that makes candles that smell like food. Right. Yeah. Yeah, because there is a sensory piece that people often discount. That's why in some facilities, they do offer finger foods as part of their mainstay diet. Even if they're on something like a mechanical soft or minced in moist, they might say, you know, they can have a sandwich that's cut into quarters because then they can hold it and still have that motor piece engaged with the sensory piece. And when we're looking at even teaching students, that's that that whole motor engagement piece of writing something out helps them retain versus typing. And it's a different, it's a different input. So it might, it might disfage a class which I taught disfage for years. I think, I think this is the first year I'm not teaching a disfage of course. But I always ran, you know, several labs, right? I was on, you know, thickening things and changing textures and then making students actually drink and eat the stuff. So they understood what they were recommending. But the other thing I incorporated because of a personal experience was I have them feed each other, right? Because as adults, we're not used to being fed, right? Unless it's, you know, outlet covered strawberries and champagne, but that's usually in another context. So, so I was in a city years ago, my husband and I liked to entertain, right? We had a big party, blah, blah. And so everybody left. It was time to clean up the kitchen and all that stuff. And that's what I was doing. And here I was washing the stenware, right? So my hands were full of soap and I'm washing the stenware and my husband says, oh, is this your glass of wine that was in the living room? And I said, oh, yeah, bring it over. And it was good wine. We served good wine that night. So, so he's like, oh, here, I'll give you some. And here I am standing in front of the sink, my hands full of soap. I turn my neck. So already I'm in a bad situation right as I turn my neck. And then I see this glass coming towards me, right? And I immediately say, oh, my gosh, wait, there's too much liquid in there. I'm not going to drink all that at once. What am I going to do? What cues will I use? And I realized, oh, pucker your lips, right? So then now the glass landed between my lips and I was able to control how much I took and then with my tongue I pushed it out. And my first reaction was, oh, my gosh, all these adults that when I do my clinical, I'm eating them, right? I'm not giving them the cup. I'm not giving them the spoon or the folks that are being fed in the dining room at the nursing home. And it just changed my whole perspective on that. So now I much more, this was years ago, much more conscious about making sure, you know, if the person can't hold the cup and feed themselves, I at least have them put the hand over my hand so that they can be a part of it. And with the spoon, I make sure that they understand, you know, see what we're doing. Again, they have the food in front of them, not the spoon coming from nowhere and suddenly it lands in for cavity. But those are the little things we don't think about where they might lead us to a misdiagnosis, right? Yeah. Well, think about the impulsivity piece for, you know, some patients with dementia, depending on the type, but also for me, working with a lot of TBI patients across the lot of patients. continue them. There's nothing better if you're looking at impulsivity during the modified barium swallow than the hand in the cup because guess what? At the end of the day when you leave to go home and they get their meal tray and no one's with them, they are chugging a lug in like nobody's business. And so yeah, we want to see, is it, you know, there's a lot of people who go, oh no, no, you don't do that. But you want to see what happens when you're not there too. We can't always control all the variables as much as we'd like to think that we can. And if we can get it on floral or during a phase and see what happens, then we can start to develop our not only our treatment, but do we use compensatory techniques and are the patients going to have the carryover or are they going to have caregivers who are going to have the carryover to help them implement it when you're not there? That's right. We can't forget the the the the real life part of this. Right. We're doing this exam in radiology. It's an esoteric environment. And actually when I was running some videos for my dissertation, I had to really fight to in addition to some of the calibrated SIPs to also use in my study some cup SIPs, right? And I'm happy to see that now more and the literature because that's how a person actually drinks. They don't drink, you know, a 10cc all less from a medicine cup, right? They drink it from from a cup. And so that's been great. And I have to thank Dr. Katrina Steele and her and her lab because they came up in terms of research, how do we how do we know how much the patient took in? And so she came up with a great idea of using a scale. And so we scale in radiology, we weigh the cup when it's empty. We weigh it once we put the barium in there and then we weigh it again after the patient takes the SIP. And so now we know how large that SIP was and that's how we do our stats and we can figure that out. So I will forever be grateful to her and her team for that. So but but that's the reality part of taking then this data and bringing it home. We need to be comfortable if we're working with this population with the literature on the benefits of pegs, which are minimal, right? Because we've had this literature available to us since I want to say the mid 90s, right? pegs don't improve quality of life, pegs don't prolong life and pegs do not improve nutrition. And we have study over study over study over study seeing proving that. And there are still people out there recommending pegs for the 92-year-old with advanced dementia. That's horrible. Okay. Yes. I agree. So get comfortable with that literature and and and really be comfortable in saying that to your to your medical team, right? Clearly we can say to the caregivers, oh no, don't go for the peg, right? They it was offered as an option. Okay. There's the pros and there's the cons and then I have you have to keep it as neutral as you can, right? But but even even if the family chooses the peg, I feel as a clinician and as a fellow human being that specializes in this, I want to figure out what this person can handle safely so that and and ask the caregivers to to provide them that oral stimulation that that that satisfaction of eating something, right? So maybe they're they need the peg for nutrition, but how about their pleasure? How about that? Yoke other love or how about that? You know, that that pudding that's so great or whatever else they might really like because the peg might be in there not because of a of a of a real dysphagia, but more because of a behavioral issue with their eating and etc etc. Right? So we need to think about that. Also, we shouldn't discount the the possibility that someone might benefit from therapy. Okay. And Samantha Schoon and Ashreen and Masuayya Medonald actually published a paper. I think before they got into the caregiver burden or around that that time when they were starting some years back on looking at specifically a tongue strengthening, you know, can people with dementia benefit from something like tongue strengthening? Well, again, people with dementia are one package. There are different types of dementia, different severities. So if they're following some simple commands and they can push against the ball, but they can do this or they could do that. Let's maximize that because that means that they can benefit then from some direct neuro muscular therapy to help increase tone, make it through some of the sarcopenia, etc. So they can continue to eat orally, safely and efficiently. Right? We can't forget that part of this, of our role in maintaining quality of life while maintaining safe and efficient swallowing for folks. So, and I guess with other treatments, there are some, you know, I don't want to say crazy things, but some not proven, not super evidence based things. So sometimes I will suggest that if the patient is willing to do it, right? I mean, patients vary to engage in some singing. Get the caregivers to sing along with with with the with the person with dementia. Why? Why is that important? That's important because think about what you're doing to the respiratory system. Think about what you're doing to the overall skeletal musculature up here in the aura farings, right? And they're moving their tongue and they're coordinating the breathing and you know, how does that, you know, impact swallow apnea eventually have no evidence for this. I have no evidence that says that this helps. But to me, it's something it's one way to get into maintaining that range of motion, maintaining some of that of that function in the context for me in the context of being able to eat by by mouth, right? Well, it also is attention and memory. You have to recall the lyrics or at least some some of them and recall the melody. You know, it's a social thing, much like eating because now you're socially singing that replicates things like church or people who sang together in college or people are car singers. You know, the car singers. Oh my god, I thought you were going to say shower singers, but yeah, I'll go with the car singers. But yeah, yeah, no, that's that's that's totally true. That's totally true. So, so there's a lot that we that we are still able to do. I think as acute care clinicians, sometimes we shortchange ourselves in our role, our role from not only assessment, but also in possible treatment and counseling. We sometimes then say, okay, so the person with dementia came in and but they came in because of a broken hip now they had a hip replacement. So now they're going to rehab. So now the speech pathologist in rehab, are they not going to work with this person or look at the potential they have to do better because it was just going to focus on the physical therapy for them to start, you know, walking and dancing again. So, so are we sure changing what we can really do to improve this populations, this particular patient populations quality of life? I certainly hope if I ever get there that I I'm treated by an outstanding clinician that will let me continue to enjoy my martinis, I will not be thickening my martinis by the way. As time goes on. So, really important stuff. And then I have to slap us in the face with a reality check. When we talk about inequities, right, when we think about just healthcare disparities in general, very often we're thinking about race and ethnicity. And very infrequently, do we start thinking about ageism, about, let's say about this specific population and start watching out for the literature and the work being done in in Wisconsin by Dr. Rayleigh Lloyd. She's doing some some great stuff along with Dr. Nicole Robus Puglia and their team up there. We recently as several, she got several of us together and published a paper on eating and following care disparities in people with dementia. Okay. And she really is working on this conceptual framework that looks at the individual, at the system, and at the community, right? Those different levels as factors that influence person centered eating and swallowing care. Right? There's also another important piece, not only with this population, but in general, is access to food, access to, to texture modification, access to the tools to modify textures. And I think these are conversations we need to have with, with the caregivers, because we can't assume that they have a blender or that they are able to get one of those, you know, quick choppers, right? They might cause we might say, oh, that's only $20 on Amazon, but not everybody has access to Amazon. Not everybody has the $20 to buy that, that chopper on Amazon. Yeah. So those are all factors that are really important for us to, to think about and to now start incorporating our counseling is so different from, I mean, I think about the way I communicate with caregivers now, compared to even five years ago, I'm so much smarter now. And five years ago, I was smarter than five years before that, right? Because we keep learning. And I think, yeah, this is all complicated, but oh, my gosh, what a beautiful challenge. And what a beautiful challenge when we're able to help somebody continue to eat and enjoy, enjoy life through some good food. And I'm going to end with a quick story because I know we're getting close to wrapping up. But so acute care, right? This was years ago back in the early 90s. I'm old, right? So back in the early 90s, we have this actually 92 year old man with advanced dementia at the hospital. And the medical team at the time wanted to place a peg, right? He was not nowhere. She was dehydrated, et cetera. They wanted to place a peg. The daughter was struggling. The daughter was the primary caregiver. And she was struggling because he, because he didn't want this. He had his, his healthcare proxy and all that. He didn't want tubes. He didn't want any of that, right? And he was quite disfagia. He was really having a hard time swallowing. And so she was torn with, okay, so we need to, you know, he needs to go home, but they're telling me he needs a tube or else he's going to die, right? And this and that. So she wanted me to decide for her. I said, no, again, I did my pros and my cons about the peg tube. And so she chose to, and unfortunately, I was almost going to call the ethics committee because I was really mad at this person's medical team. But back, this was back in the early 90s. Bottom line is she decided to take him home without the tube, right? Years later, she walks into my office with a smile. And she says, you don't remember me. Do you? And I said, I totally don't tell me who are you? And she tells me about him. And I totally remembered her. And she was just starting to have some trouble with pills and so on. And so she was so excited when she heard that I was still at the hospital because she always wanted to, to get in touch with me to thank me. Guess what? Her father lived for another six months, advanced dementia and all. Some days he ate, some days he didn't. And she kind of knew from what I had told her that was going to happen. And she says to me, and the day before he died, he had a whole bowl of tapioca, which was his favorite dessert, right? And for the first time in months, he looked up at me and smiled. And the next day he passed away and she was in peace. He died with dignity. He was in control and she was really grateful. So remember that we don't always get to hear stories after their discharge from the hospital. Yeah, no, 100%. We don't. And yeah, I'm with you in that things change in the role of how we counsel our patients and our, how we provide education to the caregivers and support to the caregivers. And I've been really pushing for that because, you know, that that could be a, we could do it on a whole other hour on this whole thing to be honest. But we won't, but we won't right now. Now we'll do that in that. So it'll be fine. I just really thank you for being so willing to come on and share your knowledge and share your research. You've always been such a shining light for me. You want to attend your talks. And so this was kind of you were on my bucket list of folks. So I'm very grateful that you agreed to do this podcast. And I'm looking forward to seeing what you continue to do and being able to meet up soon, hopefully. And thank you so much for having me. I want to thank the audience. Thank people for listening. And I hope this is just the tip of the iceberg. And we all get, you know, to, to read some more, learn some more and start looking at different perspectives so that we can continue to provide the best care and be the best clinicians that we can be. Yeah, I agree. Again, Luis, gracias. And hope to see you soon. And now that we're in and thank you all for being here. Have a great rest of your day or evening. If you're listening to this, you've just wrapped up our wonderful episode with Dr. Luis Rekwame. Hi, it's Renee. And I just wanted to say thank you for listening, but also to kind of provide my key takeaways from this episode. And I think really for me, there's probably just two. One is that we need to always consider the cognitive decline and how that's impactful for dysphagia, patient centered care, shared decision making. And the second thing would be supporting caregivers, you know, I talk about that a lot and a lot of my episodes. But it's really true. We need to be including caregivers as part of our treatment plan and making sure that we give them access to tools and techniques that they can use to promote carryover and best outcomes for our patients. So as always, if you've enjoyed this episode, we'd love to hear from you. If you could leave us a positive review on your favorite podcast platform or just reach out to us directly. We'd appreciate it. Have a great one. Remember to visit speech therapy PD.com to earn 0.1 ashesaeus for this episode and to see our library of over 1400 courses for all things SLP.