This year I approved a request for a mobile FEES (Flexible Endoscopic Evaluation of Swallow) study when I was the interim medical director for PACE (Program for All-Inclusive Care for the Elderly). We had a participant with dementia who had a troublesome persistent congested cough that disturbed his sleep. We considered further modifying the diet to reduce aspiration events as a part of his cough problem, but he was already having trouble maintaining his weight despite optimal family and dietary support. Our speech therapist recommended a mobile FEES study to better assess his swallow function. We had a contract with a company to provide this service at our PACE center. This participant’s swallow was directly observed by our speech therapist by this technology during his lunch at our center. Surprisingly, his swallow was quite safe with minimal risk for aspiration. This allowed us to liberalize his diet, better meet his nutritional needs, and focus on his weak cough and expectoration capacity. This led us to try an Acapella device to create airway vibrations to improve clearance of airway secretions.

In my prior experience as a SNF medical director and provider, the acute hospital and SNF speech therapist relied on Barium cine-esophagram assessments (sometimes called modified barium swallow studies) to decide whether to recommend restricting diet texture and/or liquid thickness. In persons with ADRD (Alzheimer Disease and Related Dementias), these swallow studies often resulted in highly restricted diets (e.g., pureed, nectar thick liquids) with report not available to the provider until days later. These diets are not as palatable as less restrictive diets, and the thickener may have an unpleasant taste, increasing the risk of dehydration. Their value in the acute hospital setting was reported in JAMA IM MAY 6, 2024. In this large study, somewhat counterintuitively, those older than sixty-five with ADRD on a thick liquid vs thin liquid diet had no difference in mortality and were more likely to have respiratory complications like pneumonia.

As a clinician at PACE, I had much more confidence in the ability of a FEES study to identify real-time the areas of swallow dysfunction that might be amenable to a more targeted and palatable approach by our rehab and clinical team then the reports I had previously reviewed after barium cine-esophagography.
FEES has become much more available within facilities for access by our speech therapists and dieticians. At Age Well PACE, we had a contract with a mobile provider who was readily available at the request of our Speech Therapist. On the internet, I found many companies who provide this service in California. These are 3 among others:

• Doorstep Dysphagia Diagnostics: https://www.californiamobilefees.com/
• Mobile FEES Company in Your Area: https://ndoscopy.com/fees-companies-in-your-area-flexible-endoscopic-evaluation-of-swallowing-in-us/
• North Bay Swallow Diagnostics: https://northbaysd.com/services/

In addition, many acute hospital systems now provide this service. I found this review article on FEES from ASHA (American Speech-Language-Hearing Association) to be quite helpful for understanding its potential value and limitations. https://www.asha.org/practice-portal/clinical-topics/pediatric-feeding-and-swallowing/flexible-endoscopic-evaluation-of-swallowing/

Is it time for your facility to “Step into the Water”?