Speech and Language Pathology Case Study
Betty* was living independently in her home, until a stroke left her unable to move from the floor for three days before she was found. She was unable to communicate in a functional manner that ensured her safety in her own home, and she moved into a residential aged care facility.
When she was initially assessed for her swallowing, the Speech Pathologist also noticed Betty’s overt communication difficulties and referred her for ongoing services.
Reason for Referral:
Coughing on everything she ate/drank
Placed on thickened fluids and a pureed diet (which she was refusing)
1. Documentation Review
Prior to meeting Betty, the Speech Pathologist’s approach included a detailed assessment of Betty’s medical history including a review of:
MRI-brain and CT-brain scans
Hospital discharge summary
Speech Pathology handover from her hospital admission
Documentation completed by nursing and medical staff
2. Dysphagia (swallowing) assessment.
Cranial Nerve Examination
Upon meeting Betty, the Speech Pathologist noticed that she was having significant difficulties communicating. Despite having clear speech, Betty spoke only one or two words at a time, and often these words did not match the context (e.g. saying cup instead of plate). This indicated that Betty would benefit from another form of assessment.
3. Language Assessment
Expressive (ability to convey language)
Receptive (ability to understand spoken or written language)
Betty’s chest had remained clear since her admission, indicating that no food or fluid had gathered bacteria after accidentally making its way into her lungs (no evidence of aspiration pneumonia). Her brain scans indicated that she had experienced a left-medullary stroke. The location of this stroke was reflected in her cranial nerve examination where Betty demonstrated some right-sided weakness resulting in a facial droop.
She also showed increased coughing during conversation, and a significant amount of saliva in her mouth the more she attempted to speak. As reported by the nursing staff, she coughed inconsistently when provided with both food and fluid, regardless of if the fluid was thickened or the consistency of the food changed (e.g. pureed).
In her language assessment, Betty demonstrated that she was able to understand everything that was said to her, she was just unable to effectively respond verbally. She was able to produce automatic responses (e.g. her name, the days of the week, counting) however was unable to name items, despite identifying that she ‘knew the name’, commonly referred to as the name being ‘on the tip of the tongue’.
A staff member entered the room during the assessment and did not speak to Betty at all as she performed her regular clinical observations (e.g. blood pressure, temperature). Betty grabbed the pen from the Speech Pathologist and wrote ‘no one speaks’ on the assessment booklet.
Betty’s intervention plan included weekly therapy for her communication that consisted of:
Initial introduction of compensatory strategies to allow Betty to get her basic wants and needs met within the context of the facility
Staff training as to Betty’s communication capabilities and the degree of understanding she had
Intervention targeting her word retrieval and her ability to construct sentences (e.g. Betty wore pants vs. pants wore Betty)
Introduction of an augmentative and alternative communication device with software that allowed Betty to press a button represented by a picture and for the device to produce the selected word
Her coughing with meals was assisted by differential diagnosis of the cause of her coughing. Her glossopharyngeal nerve had been damaged by her stroke, resulting in referred damage to Betty’s parotid gland which was producing too much saliva. As her mouth and throat filled with more saliva, Betty coughed to clear it. The Speech Pathologist consulted with her neurologist, and Betty received botox injections to her salivary gland, causing it to function more effectively. This stopped her coughing during meals and in conversation.
After one year of therapy, Betty was using her communication device to augment her own speech. If she was unable to convey what she wanted, she would use the device to do so, allowing her to begin to interact with other residents in the facility.
She developed a strong friendship with a group of four other women within the facility, who played Scrabble at 10am every Tuesday. She was able to regain autonomy with her communication, and care staff were more patient with her, rather than assuming that her difficulty communicating did not mean that she was unable to understand.
Betty continued to receive botox injections every 3-6 months and experienced no further episodes of coughing with meals, and was able to eat and drink as to her preference.
*Some names have been changed to protect the identity of the individuals