Swallowing and Communication Assessment Instruments

This group covers two related clinical areas that share a caseload. Swallowing instruments include the Eating Assessment Tool for symptom screening, the Mann Assessment of Swallowing Ability for structured clinical assessment, the Penetration-Aspiration Scale for grading airway invasion during instrumental examination, and the MD Anderson Dysphagia Inventory for the effect on quality of life. Voice instruments include the Voice Handicap Index and the Voice-Related Quality of Life measure for patient-reported impact, and the Consensus Auditory-Perceptual Evaluation of Voice for structured clinician rating of voice quality.

Communication instruments such as the Communication Effectiveness Index and the Communicative Participation Item Bank measure whether a person can take part in the conversations their life requires, which is a different question from whether their speech is intelligible.

The important distinction in this group is between what an instrument observes and what the patient experiences, and the two diverge more here than in most areas. The Penetration-Aspiration Scale is scored from a videofluoroscopic or endoscopic examination and describes what happened to the bolus. It says nothing about whether the person finds eating distressing or has stopped going out for meals, which is what the quality of life instruments capture. Both are needed, and one is not evidence for the other.

Screening tools such as the Eating Assessment Tool exist to decide who needs instrumental assessment. Silent aspiration, by definition, produces no cough and can be missed by any symptom-based screen, so a negative screen in a high-risk population is not a clearance.

Check whether the instrument requires an instrumental examination. Scales scored from videofluoroscopy or endoscopy cannot be collected any other way, and a bedside approximation of them is not the same measure.

Check who rates the perceptual voice measures and whether raters have been trained. Auditory-perceptual voice rating has known reliability limits, and multi-rater designs with a consensus procedure are standard for a reason.

Check the population the instrument was developed in. Several measures here were developed in head and neck cancer populations and are used in neurological dysphagia, where the mechanism, the trajectory and the relevant items all differ. Finally, in communication assessment, involve the communication partner. Instruments that ask only the person with aphasia about their communication effectiveness are asking the person whose ability to report is affected by the condition being measured.

What is the difference between a swallowing screen and a swallowing assessment?

A screen identifies people who need further assessment and can be done at the bedside by trained non-specialists. An assessment characterises the swallow in detail, often with an instrumental examination. A negative screen does not rule out silent aspiration.

Can the Penetration-Aspiration Scale be scored at the bedside?

No. It is scored from a videofluoroscopic or endoscopic swallow study. A bedside judgement about aspiration is a different observation and should not be reported as a score on this scale.

Which instrument measures the impact of a voice problem on the person?

The Voice Handicap Index and the Voice-Related Quality of Life measure are both patient-reported and cover impact on daily life. Perceptual ratings such as CAPE-V describe the voice itself and correlate only moderately with how disabling the person finds it.

Should communication partners be involved in the assessment?

Yes where the instrument provides for it. In aphasia in particular, the person's ability to report on their own communication is affected by the condition, and partner-reported measures such as the Communication Effectiveness Index add information that self-report cannot.