To refer or not to refer

That is the question

I've seen a number of different lists of criteria for dysphagia referrals over the years.

And this is mine.

Indicators for dysphagia (swallow disorder) referral to a speech and language therapist (adult patients); one or more may apply:

Choking episode requiring first aid
Prolonged, persistent or distressing bouts of coughing during or after swallowing
Chest infection/s or (aspiration) pneumonia – may be recurrent
Regurgitation or vomiting
(Suspected) reflux/GORD
Food or drink comes out of the nose (nasal regurgitation)
Pain or discomfort on swallowing
Dry mouth (xerostomia)
Excess saliva (sialorrhea)
Reports sticking sensation in throat or oesophagus after swallowing or persistently at rest
Impulsivity/cramming/over-filling the mouth
Unable to hold food or drink or tablets in the mouth (falls out of mouth)
Unable to clear food or drink or tablets from the mouth (residue in mouth/pocketing/pouching)
Struggling to initiate swallow / reflex not kicking in or is significantly delayed
Change in dentition or oral health
Frequent throat-clearing
(Increased) wet/gurgly voice that is not readily cleared
Increased time to eat or drink
Unexplained weight loss
Unexplained decreased engagement in eating and drinking or taking tablets
Dehydration
Malnutrition
Medication or other treatment has changed swallow function (iatrogenic cause)
Difficulty co-ordinating breathing with swallowing/holding breath to swallow
Fatigued from effort of eating or drinking
Increased confusion or change in cognitive or psychological state / distractibility
Progression of disease (including reduced independence eating and drinking)
Query if (new) equipment would aid safer/more effective/comfortable eating and drinking or when lost or broken equipment cannot be (quickly) replaced
Tracheostomy +/- ventilator +/- weaning or recent decannulation
End of Life
Clinical information required to aid any of the following:

o carrying out a Mental Capacity Assessment regarding Eating, Drinking and Swallowing

o Eating and Drinking with Acknowledged Risk (previously ‘Feed at Risk’) including whether JJ vs Spectrum case is relevant

o PEG insertion, removal or change of feed as a result of swallowing issues or improvement

Thickener prescription issues
To clarify issues/problems/confusion regarding Eating, Drinking and Swallowing Plan/communication-breakdown between healthcare professionals/services
Any perceived improvements in condition and/or symptoms that merit an upgrade/improvement in food or drink textures
Service-user or their family/significant other/s requested review – state rationale
Other healthcare professional has requested SLT referral – state who plus rationale if not ticked above
Something else – state issue/concern/wish

It's a comprehensive list but note the caveat on coughing. It must be either prolonged, persistent or distressing. The 'odd cough' isn't sufficient to cause concern, in fact, I'd argue it's a good sign. Coughing is a safety reflex that clears the airway of the hazard[i]. It shows that the person has sensation. Lacking sensation can result in choking and is highly correlated with aspiration pneumonia[ii].

It's also worth remembering that people can aspirate and nothing bad happens. Others will aspirate a small amount once and get a severe pneumonia. The extent to which someone is at risk of harm from aspiration must be determined by the speech and language therapist along with the multi-disciplinary team, and input from significant others and of course, the person him/herself if able. So, aspiration alone might not be an issue; the extent of someone's vulnerability to choking and respiratory diseases is the issue[iii].

Also, it's worth referring people when they have shown signs of improvement. Let's not overly restrict people on IDDSI Level 2 mildly thick fluids and IDDSI Level 4 purée diet, when they've fully recovered from a stroke, for example. I've seen people recover to the point of normal diet and fluids and enteral feeding is stopped. Every speech therapist, who has worked with adults with dysphagia will be able to recount tales of recovery, some of which are astonishing.

I hope you’ve found this helpful and that it aids decision-making around making referrals to speech and language therapists for adults with dysphagia.

[i] Imoto, Yoshimasa, Akihiro Kojima, Youko Osawa, Hiroshi Sunaga, and Shigeharu Fujieda. “Cough Reflex Induced by Capsaicin Inhalation in Patients with Dysphagia.” Acta Oto-Laryngologica 131, no. 1 (January 1, 2011): 96–100. https://doi.org/10.3109/00016489.2010.516013.

[ii] Ball, Laura, Lotte Meteyard, and Roy J. Powell. “Predictors of Aspiration Pneumonia: Developing a New Matrix for Speech and Language Therapists.” European Archives of Oto-Rhino-Laryngology, August 6, 2023. https://doi.org/10.1007/s00405-023-08153-z.

[iii] Palmer, P.M. and Padilla, A.H., 2022. Risk of an adverse event in individuals who aspirate: A review of current literature on host defenses and individual differences. American Journal of Speech-Language Pathology, 31(1), pp.148–162. Available at: https://doi.org/10.1044/2021_AJSLP-20-00375