SCREEN OF COGNITION AND COMMUNICATION
Information regarding the state of the patient’s voice, speech, language, movement and cognition are all valuable to the SLT, as function or dysfunction in these areas can greatly affect the evaluation and treatment of dysphagia (Daniels and Huckabee, 2008). Disordered speech and voice quality in stroke patients can also be linked to the risk of aspiration, therefore the communication screen may provide the SLT with additional signs that the patient has an abnormal swallow (Daniels and Huckabee, 2008).
A preliminary screen of cognition and communication should be performed prior to the clinical swallowing examination, as any cognitive or receptive deficits will impact on the depth of the ensuing evaluation (Daniels and Huckabee, 2008). For this purpose, informal evaluations can be used to assess cognition and communication.
Cognition

The following areas should be evaluated (adapted from Daniels and Huckabee, 2008, p. 62):

1) Level of Consciousness
2) Attention
  • Focus
  • Neglect
- Sensory neglect
- Motor neglect
- Spatial neglect
- Awareness of deficits
3) Memory

If the patient is unable to maintain consciousness for five minutes without rearousal, the rest of the swallowing evaluation may have to be postponed (Daniels and Huckabee, 2008). Equally, if the patient is uncooperative due to lack of attention or agitation, they should be revisited periodically during the day (Groher and Crary, 2010). An awareness of the patient's medication is also helpful as some medications can either improve or negatively effect a patient's mental status (Groher and Crary, 2010). The patient’s cognition is significant for both further assessment and intervention. The patient needs to be able to follow instructions and recall strategies, such as postural positioning that are suggested by the SLT. Awareness of deficits is integral to rehabilitation. Studies have shown that patients who have poor awareness of their swallowing symptoms do not alter their swallowing behaviours, such as rate and volume of ingestion, in line with their SLT’s recommendations (Daniels and Huckabee, 2008).
Communication

The patient's language should be evaluated for signs of aphasia (Daniels and Huckabee, 2008). Furthermore, the patient's voice and speech should be assessed for signs of dysarthria, apraxia of speech and dysphonia (Daniels and Huckabee, 2008). Details of their overall intelligibility, articulation, pitch, resonance and prosody should also be noted (Daniels and Huckabee, 2008). The patient's vocal quality should also be observed for dysphonia in the form of harshness, breathiness and wetness, as research has demonstrated the importance of these factors as evidence of dysphagia (Groher and Crary, 2010).
If the patient appears to have reduced comprehension, he or she may struggle to understand instructions and fail to perform an act on cue, such as a voluntary cough (Daniels and Huckabee, 2008). Visual cues and modelling may help the client understand and allow the completion of the clinical and instrumental assessments, but intervention may still prove challenging (Daniels and Huckabee, 2008).