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Dysphagia > Exam2 > Flashcards

Exam2 Flashcards

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1
Q

What are the risk factors for cancer

A 
Tobacco
Alcohol
HPV in oropharyngeal cancers
Epstein barr in nasopharyngeal cancer
Poor oral hygiene
Vitamin A and B deficiency
GERD in pharyngeal cancers
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2
Q

What causes microorganisms to grow in mouth

A

Lack of saliva

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3
Q

What does TNM stand for in cancer staging

A

Tumor
Nodes
Mestasis

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4
Q

What characterizes T stage 0

A

No evidence of primary tumor

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5
Q

What characterizes T1 stage in cancer

A

Tumor confined to nose or oropharynx

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6
Q

What characterizes T2 stage in cancer

A

Tumor extends into pharynx

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7
Q

What characterizes T3 stage in cancer

A

Tumor involves skull base or paranasal sinuses

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8
Q

What characterizes T4 stage in cancer

A

Intracranial extension, cranial nerves,

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9
Q

What characterizes N0 stage in cancer

A

No regional lymph node involvement

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10
Q

What characterizes N1 stage in cancer

A

Unilateral metastasis in cervical modes less than 6cm

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11
Q

What characterizes N2 stage in cancer

A

Bilateral metastasis less than 6cm

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12
Q

What characterizes N3 stage in cancer

A

Metastasis greater than 6 cm or reach the supraclavicular fossa

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13
Q

What characterizes MX stage in cancer

A

Cannot be assessed

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14
Q

What characterizes M0 stage in cancer

A

No distant metastasis

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15
Q

What characterizes M1 stage in cancer

A

Distant metastasis

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16
Q

In terms of TNM, what is stage 0 in cancer

A

Carcinoma in situ with no node involvement or metastasis

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17
Q

What is stage I cancer in terms of TNM

A

Tumor confined to naso/oropharynx with no nodes or metastasis

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18
Q

What is stage 2 cancer in terms of TNM

A

T1 with unilateral nodes and no metastasis

T2 with no nodes or unilateral nodes

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19
Q

What is stage III cancer in terms of TNM

A

T1 or 2 with bilateral nodes

T3 with no nodes or unilateral

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20
Q

What is stage IV cancer in terms of TNM

A

T 4 with any node involvement and no metastasis

Any T with distant metastasis

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21
Q

What is the current philosophy of cancer treatment

A

Chemotherapy to shrink tumor
Removal
Radiation therapy to get remaining cells

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22
Q

What is the biggest disadvantage of chemoradiation

A

Nausea
Xerostomia (dry mouth)
Fibrosis

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23
Q

What is fibrosis

A

Hardening of tissues

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24
Q

What are the general guidelines for cancer assessment exam

A

Preop conference to discuss outcomes ( 3-4 hours especially if total laryngoscopy)
Counsel about anatomy, show videos
Preop clinical swallowing exam for baseline
Preop fluoroscopy with or without postural or compensatory strategies

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25
What can you expect with surgical removal
``` Removal of structures Decreased movement Scar tissue Wound dihiscene (scarring) Decreased sensation at site Tracheotomy ```
26
What are some common surgeries
``` Primary tumor Mandibulectomy (complete removal) or mandibulotomy ( partial removal) Maxillectomy Laser Laryngectomy Tracheostomy Gastrotomy Neck dissection Reconstruction ```
27
What swallowing problems could occur with a total laryngectomy
Cant neutralize pressure in pharynx No subglottal pressure No hyoid excursion
28
What are the effects of radiation therapy
``` Reduces blood supply to tissues which damages nerve endings Nausea Fibrosis Skin irritation Xerostomia due to damaged salivary glands Peripheral neropathies Tissue necrosis Reduced range of motion Reduced flexibility of pharyngeal/laryngeal structures Reduced speed and movement Reduced sensation of bolus volume Reduced synchrony of movement ```
29
What are the results of chemotherapy
``` Nausea Mucositis Hair loss Xerostomia Infections of oral cavity ```
30
What are the physiologic results of chemoradiation
Reduced strength and coordination of anterior tongue Reduced posterior movement of base of tongue Reduced laryngeal elevation Reduced airway closure
31
What are common cancers
Oral cavity (lips, floor of mouth, tongue, retro-molar trigone) Oropharynx Nasopharynx Laryngopharynx
32
What are characteristics of cancer in lips
``` Mostly 55-65 year old men Alcohol and tobacco risk factors Poor oral hygiene Usually present as non healing ulcers Pain in advanced stages Early lesions may be surgically removed Radiation therapy ```
33
what are the dysphagia symptoms for cancer of the lips
mostly oral stage deficits (labial seal, bolus control and transport) can affect any other structure due to radiation effect
34
what are characteristics of floor of mouth cancer`
found on anterior surface of either side of midline can spread to bone and tongue 30% involve sub-maxillary nodes
35
what are the dysphagia symptoms for cancer of the floor of mouth
mostly oral stage can affect other related physiologic processes radiation can affect other structures
36
Where would you find tongue lesions
anterior 2/3 affect oral cavity posterior 1/3 affect oropharynx lesions at base and poserior 1/3 invade tonsils and are more advanced treatment is radiation or glossectomy
37
what are the results of tongue cancer on swallowing
mostly oral stage partial glossectomy affects bolus prep and hold total glossectomy affects transport removal of base of tongue: pharyngeal stripping and hyoid excursion velopharyngeal port if there is velar resection
38
what is retro-molar trigone
cancer in triangular space behind last molar rare affects tongue, ear canal pain, trismus (jaw spasm) treated with radiation: affects mastication, oral control, transport
39
what structures are involved in cancer of the oropharynx
``` base of tongue tonsils soft palate uvula lateral-posterior pharyngeal walls ```
40
what structures are involved in cancer of the nasopharynx
postero-superior pharyngeal wall lateral pharyngal wall eustachian tube adenoids
41
what structures are involved in cancer of the laryngopharynx
pyriform sinuses posterior cricoid lower posterior pharyngeal walls
42
what are common surgeries for cancer of pharynx
palatal resection pharyngeal resection laryngo-pharyngectomy
43
what are the physiologic results for cancer of pharynx
``` pharyngeal stripping VPC BOT to PPW UES opening hyoid excursion trismus leading to poor mastication ```
44
what is the leading cause of cancer of the larynx
smoking
45
what are the characteristics of larynx cancer
``` supraglottic lesions are usually large usually spreads to epiglottis lymph node involvement in 40-50% not life threatening: removal of larynx subglottic cancers can cause airway obstruction total laryngectomy in most casses ```
46
what are the results of laryngeal cancers
laryngel penetration/aspiration changes due to radiation TEP and tracheostomy influences can influence hyoid excursion and UES opening
47
what are the physiologic results of a hemilaryngectomy
compromised airway protection | unilateral weakness in pharynx
48
what are they physiologic results of a total laryngectomy
airway protection | pressure issues for bolus flow
49
what are two types of artificial airways
endotracheal tube | tracheostomy tube
50
what are complications of a tracheostomy
``` loss of voice psychologic distress speech, language delay loss of smell and taste leading to poor appetite aspiration and impaired swallowing impaired hyoid excursion loss of pressures (subglottal) reduced cough reduced airway sensitivity (dry mouth affets this) difficulties with secretions ```
51
what impact can surgery have on dysphagia
damage to nerve endings (peripheral nerve damage) damage to brainstem during skull based surgeries edema(temporary)
52
what are results of a thyroidectomy
impaired vagus nerve leading to VF paralysis
53
what is a carotid endarterectomy
removal of plaque from arteries can impair vegas nerve for pharyngeal constrictor action, folds impacted
54
what are possible results of cervical spine procedures
impaired CN IX (glossopharyngeal) and X (vagas) could impair brainstem connections to peripheral nerves anterior cervical fusions: decompresses spinal cord nerve roots
55
what are iatrogenic causes of dysphagia
surgery | medications
56
what meds can cause dysphagia
antipsychotics anticonvulsants antipsychotics and antidepressents: tardive dyskinesia and xerostomia respiratory and cardiac meds: LES (lower esophageal sphincter) and GERD cholesterol controllers: generalized myopathies
57
what is COPD and how does it affect swallowing
chronic obstructive pulmonary disease swllowing during inhalation or right after a swallow residue in pharynx could be drawn into airway
58
what are some esophageal disorders
``` achalasia diffuse esophageal spasms nutcracker esophagus strictures shatzki ring GERD LPR esophageal diverticula scleroderma ```
59
what is achalasia
insufficient LES relaxation and loss of peristalsis can be hereditary, degenerative, autoimmune, or from an infection symptoms: dysphagia for solid and liquid, regurgitation and chest pain
60
what is DES
``` diffuse esophageal spasm peristaltic action affected repetitive, high amplitude contractions of smooth muscles of esophagus corkscrew esophagus muscular hypertrophy ```
61
what is nutcracker esophagus
variant of DES | very high amplitude contraction in distal esophagus
62
what are strictures
loss of lumen area (canal opening) normal is 20mm strictures when diameter is less than 15mm symptom: dysphagia when diameter is less that 15mm
63
what are schatzki rings
narrowing in lower esophagus | rings of mucosal/muscular tissue
64
what is GERD
mucosal damage produced by abnormal reflux of gastric contents in the esophagus
65
what are the symptoms of GERD
``` frequent heartburn persistent sore throat hoarseness chronic cough asthma chest pain lump in throat ```
66
what causes GERD
LES impairment relaxation of LES low resting LES pressure increased gastric pressure
67
What is LPR
laryngo-pharyngeal reflux gastric contents reach UES and spill in larynx causes erosion of laryngal mucosa and contact ulcers vocal symptoms and aspiration identified by pH monitoring
68
what is normal pH acidity
below 7 is acidic | 7-14 is alkaline or basic
69
what is esophageal diverticula
sac that protrudes from esophageal wall most common is Zenkers close to UES in area of killian's triangle (between cricopharyngeal sphincter and inferior pharyngeal constrictor muscles) associated with cough, bad breath, regurgitation, repeated pneumonia may see bulge in throat treat with surgery
70
what is scleroderma
connective tissue disorder weakens LES affects smooth muscles in lower 2/3 of esophagus causes hypomotility, heartburn, and dysphagia
71
what is an osteophyte
bone outgrowth that can push against esophagus
72
what is a CP bar
projection at level of C5-C6 causing problems with the UES
73
what are prenatal causes of pediatric dysphagia
maternal diabetes phenylketonuria preeclampsia drug use
74
what are the results of maternal diabetes
disturbances in carbohydrate metabolism (maternal diabetes) causes stillbirths, abnormally large infants, congenital malformations is heart, skeletal and neural tube defects can result in hypoglycemic episodes
75
is is PKU
phenylketonuria is due to the deficiency of the enzyme phenylalanine hydroxylase causes increased phenylalanine concentrations issue with protein metabolism can cause intellectual disability and microcephaly
76
what is preeclampsia
hypertension associated with protein in urine | causes hypotonia and respiratory deficits
77
what are results of maternal drug use
``` reduced and abnormal ear development cleft palate hydrocephaly neural tube deficits heart anomalies ```
78
what are neurologic causes of pediatric dysphagia
``` hydrocephalus micro and macrocephaly intracranial hemorrhage seizure neuropathy, myopathy infections (meningitis, poliomyelities) cerebral palsy ```
79
what are some congenital structural anomalies
cleft lip/palate esophageal atresia/tracheo-esophageal fistula mandibular hypoplasia
80
how does cleft lip affect swallowing
loss of oral pressure nasal regurgitation hypernasality nasal air emission
81
with is esophageal atresia, fistula
hole on wall of esophagus failure of the laryngotracheal tube to separate from esophagus during embryonic development upper two thirds of esophagus ends in closed pouch liquids enter the trachea causing choking, coughing, gag or cyanosis communication between trachea and esophagus
82
how does mandibular hypoplasia affect swallowing
mastication oral pressure oral transport oral pressure can also affect pharyngeal pressure
83
what are pediatric gastro intestinal disorders
necrotizing enterocolitis | GERD
84
What is necrotizing enterocolitis
inflammation and tenderness of intestine ischemia or toxic damage weakens mucosal lining of intestines. bacteria then reacts to breast milk or formula and causes bowel gas that leads to necrosis will have GERD and aversions to food
85
what are problems associated with GERD in infants
abnormal muscle tone exaggerated gag not able to rhythmically move the tone to suckle infantile bite reflexes drooling aspiration poor trunk control behavioral feeding problems (food and texture aversions) preference for thin liquids emesis, reswallowing oral defensiveness/delayed feeding skills
86
what respiratory problems are associated with dysphagia in infants
apnea Infant respiratory distress syndrome transiet tachypenea bronchopulmonary dysplasia
87
what is apnea
cessation of breathing for more than 15 sec caused by CNS problem with no respiratory gas flow and no respiratory effort reduced endurance uncoordinated suck swallow breath/suck number of sucks per swallow increases agitation during feedings
88
what is infant respiratory distress syndrome IRDS
``` alveoli open then collapse and stick after each breath inhibits pulmonary gas exchange increases work load of respiration leads to apnea and hypoxemia surfactant deficiency ```
89
what is transient tachypenea TTN
poor clearance of lung fluid during birth | temporary. no oral feeding during first few days
90
what is bronchopulmonary dysplasia BPD
chronic lung disease CLD of prematurity damage to lung tissue most common cause is mechanical ventilation and oxygen therapy
91
what cardiac disorders are common with dysphagia
congenital heart disease CHD congestive heart failureCHF atrioventricular septal defect AVSD
92
what is congenital heart disease CHD
any malformation of the cardiovascular system in infants
93
what is congestive heart failure
stress to the heart from an overload of fluid and edema
94
what is atrioventricular septal defect AVSD
``` malformation of the heart holes between chambers blood does not flow correctly has lower amount of oxygen characteristic of downs syndrome lungs receive more blood and heart has to work harder ```
95
what genetic syndromes are associated with dysphagia
down syndrome | CHARGE syndrome
96
what characteristics of Downs syndrome is associated with dysphagia
hypotonia leading to poor postural control, neck control, and weak suck GERD is common
97
what is CHARGE syndrome
``` Caloboma (cleft of iris) Heart disease Atresia of the nasal cavity Retardation Genital abnormalities Ear disorders dysphagia related to respiratory problems and heart developmental delays also source of feeding problems ```
98
what is compensation
interventions that do not change the physiology. If the interventions stop, the effect will not remain
99
what is rehabilitation
interventions that change the physiology. If therapy stops the effects will last longer
100
what are the 3 parts of a clinical bedside exam
history/observation cranial nerve/physical exam trial swallows
101
what is the purpose of a clinical swallow exam
to determine candidacy for an objective eval detect possible aspiration to determine which textures are safe to monitor progress of therapy and possibly upgrade recommendations
102
what should you observe prior to CSE
mental status: alertness, initial communication attempts, posture nutritional status: feeding tube. presence of suctioning respiratory status: tracheostomy tube or labored breathing throat clearing: info on residue, sensation, secretions
103
what should you include in the history
specific symptoms of choking: patient complaint weight loss past and current medical history: neurological, ENT, GI, VF paralysis, GERD any previous swallowing assessments cultural considerations
104
How do you test the trigeminal nerve
test facial sensation with cotton wisp, sharp object and check temperature perception corneal reflex looking for asymmetries in blink feel masseteur during jaw clench. test for jaw jerk reflex; observe symmetry of jaw opening
105
how do you test the facial nerve
look for asymmetry of shape, facial expressions, and blinking have patient smile, puff cheeks, clench eyes tight, wrinkle row check tasts with sugar, salt, or lemon juice on lateral sides of tongue
106
what does holding air in cheeks assesses
intraoral pressure
107
how do you test the glossopharyngeal nerve
gag reflex does palate elevate symmetrically when patient says aah check taste in posterior tongue
108
how do you test the vagus nerve
vocal functions: pitch, loudness, quality | ability to cough voluntarily
109
how do you test the hypoglossal nerve
note atrophy or fasciculations stick out tongue to see if it curves to one side or the other push against tongue from side look for errors in articulation
110
what are fasciculations and atrophy signs of
motor neuron lesions
111
unilateral lesions of the motor cortex cause?
contralateral tongue weakness
112
What consistencies should you test during a CSE
thin: 5, 10, 20 mL and continuous puree or pudding: 5mL solid
113
what should you observe during the trial swallow
``` laryngeal palpatation for elevation timing/completeness # of swallows pre-post voice quality coughing/clearing throat oral residue ```
114
What are some standardized CSE tests
Toronto Bedside Swallowing Screening Test: measures voice quality, lingual movement, ability to manage water by teaspoon and cup Mann Assessment of Swallowing Ability Functional Oral Intake Scale
115
what other procedures are used during a CSE
ausculation: stethoscope over airway to listen for aspiration Dye test: presence of aspiration in a trach patient
116
what is ingested during a radiographic assessment
barium sulfate
117
what is the purpose of a VFSS
assess impairments in swallowing physiology | evaluate the efficacy of strategies
118
what is the hierarchy of consistencies during a VFSS
``` thin nectar thick honey thick pudding solids ```
119
what procedures are followed during a VFSS
try all different consistencies and volumes of barium mixture get both a lateral and anterior/posterior view protect against radiation
120
what is the goal of strategies
to keep the diet as least restrictive as possible
121
what postural changes are used to compensate
chin tuck head turn head tilt
122
what does the chin tuck help
delayed swallow initiation impaired base of tongue retraction aspiration especially during swallow
123
what does head rotational help
unilateral laryngeal dysfunction and pyriform residue
124
what does head tilt help
residue in valleculae | pharyngeal weakness
125
which way do you tilt and turn
tilt to strong | turn to weak
126
what strategies are used for residue clearance
liquid wash | repeat swallows
127
what maneuvers aid swallowing
supraglottic swallow effortful swallow masako
128
What does FEES stand for
fiberoptic endoscopic evaluation swallowing
129
what is the advantage of FEES over VFSS
``` visualize secretions directly view surface assess mucosal abnormalities (edema etc) visualize glottic closure clear view of bolus path thru hypopharynx ```
130
what is the advantage of VFSS over FEES
visualize the heighth of swallow see oral and esophageal phases observe completeness of BOT retraction, UES opening and extent of aspiration view submucosal changes such as osteophytes
131
what can only be seen by endoscope
closure of the vocal folds which happens right before hyoid elevation
132
What is cerebral palsy
Motor speec disorder in infants Causes brain structure abnormalities Nonprogressive lesion Causes low muscle tone, spasticity
133
what is the procedure for changing a passe muir valve
``` deflate cuff place valve listen to speech have them cough look for respiratory distress do a clinical swallow exam ```
134
what impact does a tracheostomy have on swallowing
``` increased risk of aspiration due to: poor sub-glottic pressure poor laryngeal elevation reduced upper airway sensitivity because air is not moistened thru nose general muscle weakness (already in ICU) ```
135
what is barrett's esophagus
precancerous changes in the mucosa due to prolonged acid in esophagus
136
what are possible results of a supraglottic laryngectomy
pharyngeal proplusion impaired | airway compromise
137
what are the theories related to cognitive aging
1. general slowing: speed of executive operations decreases 2. inhibition deficit: irrelevant info less suppressed which creates distraction 3. region specific neural aging: 4. transmission deficit: connections between representational units (tip of the tongue phenomenon) 5. working memory reduced 6. resource theory: finite pool of resources shared simultaneously by other cognitive processes 7. frontal lobe aging: loss of activity in frontal regions plays a role in inhibiting irrelevant material
138
what are the 2 subtypes of mild cognitive impairment
1. amnestic: affects memory | 2. nonamnestic: affects thinking skills other than memory
139
what is dementia
1. includes memory deficits and at least one of the following: aphasia, apraxia, agnosia, or disturbance in executive functioning. 2. must be severe enough to impair social and occupational functioning
140
what are standardized screening tools for dementia
1. mini mental status exam ( gold standard) 2. clinical dementia rating scale 3. Blessed dementia scale (family member report) 4. Global Deterioration Scale
141
what are components of comprehensive assessment
1. case history and interview: medical status, education, occupation, socioeconomic, cultural, linguistic background. Auditory, visual, motor, cognitive, and emotional status. Patient/family goals and preferences as well as concerns 2. observation: observe ability to attend, perceive, organize, remember verbal and nonverbal info in ideal conditions in context of various activities 3. informal assessments 4. formal assessments
142
what are informal assessments for dementia
1. oral motor 2. language sample 3. comprehension tasks: follow directions 4. visual comprehension tasks 5. expressive tasks: answering questions, describing 6. reading, and writing tasks 7. cognitive tasks: delay recall, orientation
143
what are formal standardized assessments for dementia
1. Alzheimers Quick Test 2. BDAE 3. Cognitive Linguistic Quick Test 4. Functional Skills Survey 5. NEUROPSI-Attention and memory 6. RAINBO: evaluates communication and swallowing 7. WAB
144
what are symptoms of lewy body dementia
1. symptoms and memory vary significantly from day to day 2. early symptom is difficulty walking, decrease in balance, ability to control physical movements. Frequent falling 3. flat affect 4. visual hallucinations 5. REM sleep disorder. Physically act out the situation in their dreams 6. more men than women
145
what are characteristics of Alzheimers
1. insidious onset 2. progressive course 3. heterogeneous disease
146
what are pathological changes in AD
1. cortex shrinks 2. shrinkage in the hippocampus 3. ventricles grow larger 4. abundance of beta-amyloid plaques and eurofibrillary tangles
147
what are language symptoms in each AD stage
early stage: mild word retrieval, mild decrease in comprehension middle stage: frequent word retrieval deficits, ungrammatical sentences, reduced conversation late stage: nonfunctional reading/writing, limited comprehension, speech limited to single words, bizzare and devoid of meaning
148
what are the 3 common presentations for lewy body dementia
type 1: begins with memory impairment or cognitive disorder over 2 or more distinctive lewy body dementia features type 2: begins with movement disorder that leads to PD then develops symptoms of dementia type 3: begins with neuropsychiatric symptoms
149
what are the core clinical features of lewy body dementia
1. fluctuating cognition 2. neuropsychiatric symptoms 3. motor features of parkinsonism
150
what is the neuropathology of fronto temporal dementia
1. accumulation of abnormal tau protein in cells 2. tau becomes tangles 3. progressive loss of nerve cells in frontal and temporal lobes 4. gliosis: tissue scarring 5. vacuolation: holes form in brain 6. Picks bodies: abnormal cells begin to form
151
what are the characteristics of fronto temporal dementia
1. uninhibited and socially inappropriate behavior 2. loss of awareness of concern about behavior change 3. major increase in appetite 4. loss of speech/language 5. compulsive and repetitive behaviors 6. memory loss
152
what are the subtypes of fronto temporal dementia
1. fronto variant: initial personality change, executive dysfunction, impaired working memory, attention deficits 2. semantic dementia: initial language abnormality, emotional distance, fluent dysphasia, 3. progressive aphasia: like semantic dementia but with non fluent aphasia
153
what are the characteristics of Picks disease
1. personality and behavior change 2. loss of empathy 3. obsessive-compulsive 4. food craving 5. use of wrong words, echoing 6. difficulties in thinking, attention, gradual emotional apathy
154
what are the characteristics of FTDP17
1. behavioral change 2. psychiatric symptoms 3. cognitive decline 4. evntual mutism
155
what are the characteristics of supranuclear Palsy
1. motor difficulties: problems with balance and gait 2. personality/behavioral changes: apathy, irritability, 3. characteristic gaze palsy (vertical eye movement) 4. pseudobulbar palsy (face movement) 5. rigidity of neck and upper trunk 6. poor visual function
156
what are the characteristics of corticobasal degeneration
1. signs of Parkinsonism 2. cognitive and visual-spatial impairment 3. hesitant and halting speech 4. sudden contractions of muscles 5. difficulty swallowing 6. phonologic and spelling impairment 7. visuospatial impairment
157
what is the presentation of vascular dementia
1. comes on suddenly then slow stepwise progresssion from multiple strokes 2. personality and intellect are preserved until late stages
158
what are the characteristics of primary progressive aphasia
1. decline in one or more language functions 2. begins gradually with word finding issues 3. does not affect memory, reasoning and visual perception
159
what are the hallmarks of subcortical dementia
1. bradyphrenia (slow cognition) 2. memory and learning disturbances 3. frontal executive syndromes 4. motor disturbances 5. psychiatric disturbances 6. more rapid progression than primary progressive
160
what are characteristics of pseudodementia
1. rapid onset 2. minimal effort to perform tests 3. cognitive impairment, loss of appetite, difficulty sleeping, social withdrawal
161
what are direct interventions
restorative treatments that aim at improving or restoring impaired function
162
what are types of direct interventions
1. cognitive stimulation therapy: themebased typically in a small group setting, psychosocial and interactive 2. reminiscence therapy: review of life events 3. reality orientation: to reduce confusion and increase awareness. Use visual aids to present info for time, person, and place 4. external memory aids 5. validation therapy: validating values, beliefs and reality of the person to help reduce stress and provide opportunities for them to express feelings 6. simulated presence therapy: playing audio recordings of close relatives
163
what are indirect interventions
1. communication skill training: training caregivers to assume some responsibility in communication 2. environmental modifications

Dysphagia (3 decks)

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