How do I write a home‑health speech‑language pathology referral for a 78‑year‑old male with a recent left middle cerebral artery ischemic stroke, mild Alzheimer disease, witnessed coughing during meals, recent aspiration pneumonia, current thin liquids and pureed diet, 4 kg weight loss, taking oxycodone (generic) and donepezil (generic), and requiring caregiver assistance?

Writing a Home Health Speech-Language Pathology Referral for Swallow Concerns

Your referral should state: "Home health speech-language pathology evaluation for oropharyngeal dysphagia including clinical swallow assessment and instrumental testing recommendation (videofluoroscopic swallow evaluation or fiberoptic endoscopic evaluation of swallowing) to determine aspiration risk and guide treatment recommendations." 1

Essential Components to Include in Your Referral

Patient Demographics and Primary Diagnosis

• Age: 78 years old 2
• Primary diagnosis: Left middle cerebral artery ischemic stroke 2, 1
• Comorbidities: Mild Alzheimer disease 2

High-Risk Clinical Indicators (Critical to Document)

Aspiration Risk Factors:

• Recent aspiration pneumonia (this alone mandates SLP referral per ACCP guidelines) 2, 1
• Witnessed coughing during meals (74% sensitivity and 74% specificity for aspiration) 2
• Unintentional weight loss of 4 kg (indicates malnutrition and possible aspiration) 2, 1

Current Swallowing Status:

• Currently on thin liquids and pureed diet 2
• Requires caregiver assistance with feeding 1, 3

Medications That Increase Aspiration Risk

• Oxycodone (sedative medication increases aspiration pneumonia risk 8.3-fold) 4
• Donepezil 4

Functional Status

• Requires caregiver assistance for meals 1, 3
• Patient is alert and able to participate in assessment (critical contraindication screening) 2, 3

Why This Patient Requires Urgent SLP Evaluation

The combination of stroke, witnessed coughing during meals, recent aspiration pneumonia, and weight loss gives this patient a 91% sensitivity for oropharyngeal dysphagia and aspiration. 2 The ACCP guidelines provide a Grade B recommendation (substantial benefit) that patients with these high-risk conditions must be referred for oral-pharyngeal swallowing evaluation. 2

Silent Aspiration Concern

• Older adults have higher rates of silent aspiration (55% of aspirating patients show no cough reflex), making bedside nursing assessment alone insufficient 1, 3
• This patient's age (78) and neurological condition (stroke plus dementia) place him at extremely high risk for silent aspiration 1, 3

What the SLP Will Provide

Clinical Bedside Assessment

• Cranial nerve examination 1
• Assessment of lip closure and saliva pooling 1
• Observation of swallowing with various consistencies 1
• Evaluation of voluntary cough strength 2

Instrumental Testing Recommendation

The SLP will determine if videofluoroscopic swallow evaluation (VSE) or fiberoptic endoscopic evaluation of swallowing (FEES) is needed because bedside evaluation alone cannot detect silent aspiration or determine which therapeutic interventions will prevent aspiration. 1, 3 Instrumental assessment is not just diagnostic but therapeutic—it identifies which specific compensatory strategies (chin tuck, liquid thickness modifications, multiple swallows per bolus) eliminate aspiration during oral feeding. 1, 4

Treatment Plan Development

• Specific diet texture and liquid consistency recommendations 1, 4
• Compensatory swallowing strategies 4
• Caregiver education on safe feeding techniques 3, 5

Common Pitfalls to Avoid

Do not delay referral waiting for "stability" unless the patient is lethargic, has absent swallow response on command, respiratory rate >35 breaths/minute, or is delirious. 3 This patient with recent stroke and aspiration pneumonia needs immediate evaluation to prevent recurrent pneumonia and further weight loss. 2, 1

Do not assume current diet modifications are adequate without instrumental assessment, as 55% of aspirating patients have silent aspiration that cannot be detected clinically. 1, 3

Document the opioid use prominently as sedating medications dramatically increase aspiration risk and may need adjustment by the prescribing physician. 4

Expected Outcomes with SLP Intervention

Implementation of SLP screening and evaluation programs has resulted in dramatic reductions in aspiration pneumonia rates. 1 Early SLP intervention improves time to initiate oral intake, time to reach full oral intake, and reduces hospitalization rates. 3