I recently put a call out on twitter asking the speech and language therapy community what they have been doing clinically to deliver services or support people with dementia.The response was so lovely, so many people are doing so many things. We are hoping to collate the information we have gathered so far for a report. However in order to do this we need links to articles, blogs, reports or policies. Many of those who came forward did not unfortunately, have any references. So we decided that this blog might be a great place to share these fantastic practice examples for the wider speech and language community. If you would like to share any of your initiatives please do get in touch.
The first blog on sharing practice for people with dementia during COVID-19 is from speech and language therapist, Janice Ko, who has written the following fascinating description of how she has adapted her practice:
Just before the government announced the recent lockdown, the nursing homes I support as a speech and language therapist decided to stop having visitors. This included community healthcare professionals. We negotiated with the nursing home managers to continue delivering services via telehealth, specifically to manage swallowing difficulties, thus teleswallowing. The majority of residents with dysphagia also have dementia. Nursing and care staff at the homes receive regular training on how to support communication and safe eating and drinking for people with dementia. However, because everything happened so quickly, I had not had time to establish any formal training specific to teleswallowing.
At the beginning of the pandemic the NHS recommended prioritising assessments and interventions for people with a high risk of aspiration pneumonia including those with progressive conditions (NHS England and NHS Improvement, 2020). Thus we quickly read and made sense of the available evidence and guidance, and put together a local policy on teleswallowing. The research indicated that the impact of teleswallowing had been positive within the UK and overseas.One example of this was work done at Blackpool Teaching Hospitals NHS Foundation Trust (2014) where they found that when comparing recommendations made during face-to-face versus remote swallow assessment there was 100% agreement on modified diet recommendations and only minimal difference (0.5 scoop of thickener) on fluid recommendations. The samples in this project included people with dementia who were described as having relatively ‘poor’ cognition.
The RCSLT Telehealth guidance (2020) suggested consideration of a number of risks when carrying out telehealth, such as issues related to technology and the communication barriers caused by remote sessions. Additionally, some other risks and considerations for people with dementia must be considered when assessing their ability to participate in teleswallowing including:
- Is it be ethical to carry out a session when the resident does not understand the risks specific to teleswallowing?
- Will it cause unnecessary distress if I, as a therapist, am present on a screen during the resident’s mealtimes?
- Will it be too distracting if the device is placed in front of the residents and verbal instructions are given to staff surrounding the resident during the session?
We concluded that the risks of not receiving speech and language therapy input for dysphagia, such as malnutrition, aspiration pneumonia, and death (RCSLT, 2005), outweigh the risks of establishing a teleswallow service. To account for the possible risks, pre-session briefing phone calls are provided to staff at the care homes, and real time training is delivered concurrently during the session for nursing and care staff. We have continued to adopt a flexible approach with teleswallowing. For example, as when planning a face-to-face session, should a resident not be suitable for assessment or the session cause the resident distress, the session is terminated. This approach has been possible thank to staff’s support.
During the remote sessions, I have realised the value of working closely with the multidisciplinary team in order to optimize the environmental factors during mealtimes. The early days of setting up teleswallowing were challenging for both myself and the nursing home staff. It took us some time to adapt and solve issues that had never been highlighted before teleswallowing. As the service became established sessions have been running smoothly and importantly, outcomes of the sessions have been positive so far given none of the residents have developed any chest infections.
The biggest benefit of having the option to continue dysphagia management remotely is minimising the spread of Covid-19 during these unprecedented times. Thankfully the confirmed cases at the nursing homes we support have been low. Additionally, teleswallowing has allowed us to respond quicker to referrals, upskill staff and cascade benefits to other residents in the nursing home. As an SLT team we have also developed our own skills. And most importantly, we have reduced the risks of chest infections and other dysphagia related issues that can lead to hospital admission. These benefits are reflected in the summary presentation on teleswallowing (University of Cumbria, 2015)
Now that the pandemic situation has evolved and things are a little calmer, I feel it is time for me to reflect on what the ‘new normal’ will be for our service when supporting people with dementia in care homes. It also seems a good time to develop training materials for teleswallowing so care home staff can be more well-equipped and more confident. More personally, the opportunity to set up and carry out teleswallowing has challenged me to explore the possibilities of how technology can support more efficient and flexible ways of working and to adapt my clinical skills to better support my clients.
Blackpool Teaching Hospitals NHS Foundation Trust (2014) Teleswallowing Service Evaluation Report. https://teleswallowing.com/wp-content/uploads/2014/12/Teleswallowing_service_evaluation.pdf Accessed on 19/06/2020
NHS England and NHS Improvement (2020) COVID-19 Prioritisation within Community Health Services. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0145-COVID-19-prioritisation-within-community-health-services-1-April-2020.pdf 19/06/2020
RCSLT (2020) Telehealth guidance. https://www.rcslt.org/members/delivering-quality-services/telehealth/telehealth-guidance Accessed on 19/06/2020
RCSLT (2005) Speech and language therapy provision for people with dementia-Position Paper. https://www.rcslt.org/-/media/Project/RCSLT/dementia-paper.pdf Accessed on 19/06/2020
University of Cumbria (2015) Teleswallowing – from Pilot to Service Transformation: barriers to the adoption of successful telehealth solutions. https://www.kingsfund.org.uk/sites/default/files/media/EBidmead%20Teleswallowing-Presentation%2017062015.pdf Accessed on 19/06/2020