care strategies for dysphagia

Each individual’s medical situation is unique. For those patients who were not NBM, the overall level of compliance with all speech and language therapy advice in the first audit was 52%, which is comparable to the results of a similar study where 46% of patients were compliant [20]. Pick and choose for your patients based on the signs and symptoms they present. There is a need to develop alternative dysphagia management strategies such as social and hand feeding techniques with a focus on comfort rather than risk, and outcomes pertaining to quality of life. In 100% of these (n = 16) no aspiration occurred when a chin tuck strategy was recommended at onset of WSS. Results 42 patients underwent THO. Email: Search for other works by this author on: © The Author 2005. Epub 2019 Jun 3. You can practice swallowing exercises while holding your breath in order to strengthen your throat and sphincter muscles and help prevent choking while drinking and eating 1. Odderson IR, Keaton JC, McKenna BS. Additionally, the magnitude of problems An appropriately trained dysphagia practitioner will assess and advise patients on: • Changing the consistency of fluids to make swallowing safer e.g. Non-compliance with recommendations is associated with adverse outcomes, high mortality rates and aspiration pneumonia as a cause of death [19]. Methods: This website and all its content is for informational purposes only and should not be used as a substitute for consultation with an appropriate health care professional (e.g., a Speech-Language Pathologist who specializes in Swallowing and Swallowing Disorders). Treatment reduced the degree of oral dysfunction, (dissociation) and pharyngeal dysfunction (penetration and constrictor paresis). 2019 Jun;40(3):227-242. doi: 10.1055/s-0039-1688837. Though 68% exhibited signs of dysphagia, 46% had poor oral There were 114 consecutive patients who met the following criteria: (1) stroke as defined by clinical history and neurological examination with compatible computed tomographic or magnetic resonance imaging scan; (2) age 20 to 90 years, inclusive; (3) no known history of significant oropharyngeal anomaly; and (4) videofluoroscopic evidence of dysphagia. X-rays were repeated at two four-month intervals following initiation of treatment procedures. Thank you for submitting a comment on this article. Speech-language pathologists play a central role in the management of patients with dysphagia. Managing patients with dysphagia Management strategies for dysphagia may involve food and/or fluid modification, swallow rehabilitation and compensation strategies. However, without adequate training in this specialist area, it is unlikely that these factors alone would have been sufficient to produce the level of improvement demonstrated. Within 2 months of the completion of audit 1, the following changes in practice had been instigated: A ‘Dysphagia Compliance Group’ was formed. We therefore decided to investigate the level of compliance with our recommendations throughout the hospital and to identify, where possible, the reasons for non-compliance. Methods: Items were generated based on the International Classification of Functioning framework. Smithard DG, O’Neill PA, England RE et al. Parker C, Power M, Hamdy S, Bowen A, Tyrrell P, Thompson DG. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. The work was done at University Hospital LewishamLewisham High StreetLondon SE13 6LHUK. This study has confirmed that swallowing problems following acute stroke are common, and it has been documented that the dysphagia may persist, recur in some patients, or develop in others later in the history of their stroke. Direct strategy usually refers to treatment that involves food, whereas indirect strategy refers to an exercise regimen performed without a food bolus. The nurse or doctor may ask a speech pathologist for advice about your needs. National Dysphagia Diets and International Dysphagia Diet Standardization Initiative This chapter identifies the National Dysphagia Diets and the International Diets. The reasons for non-compliance with each recommendation in audit 1 are summarised in Table 4. Intervention study to reduce complications of dysphagia in patients with acute stroke. 2020 Jun 9;1-9. doi: 10.1007/s00455-020-10144-9. • Ensure that effective mouth care is given to people with difficulty in swallowing after a stroke, in order to decrease the risk of aspiration pneumonia. To establish the prevalence of dysphagia in a population of children with CP, and to determine if any factors are related to dysphagia, we studied 56 CP patients, 5 … To assess the effects of swallowing management in patients with acute nonhemorrhagic stroke placed on a clinical pathway, and to evaluate whether swallow function on admission can be used as a predictor of length of stay (LOS) and outcome disposition. Despite significant limitations in clinical service provision during the pandemic of COVID‐19, a safe and reasonable dysphagia care pathway can still be implemented with modifications of setup and application of newer technologies. The swallowing mechanism was felt to operate more quickly, more efficiently, and with fewer swallows at the end of the 18-month study. In order to reduce the risk of aspiration and choking, managing dysphagia may involve changing the textures of food and drinks. Results: These results from mice provide novel insight into specific VFSS metrics that may be used to characterize dysphagia in humans following facial nerve injury. Smithard DG. Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are present as well. identified has implications for both resource and staff-training requirements in long-term care facilities. Oral care should be performed at least twice a day morning and night, but people with dysphagia may need extra oral care before and after meals. Observations were made at all mealtimes and of drinks throughout the day. Drinks and other liquids may need to be thickened so they are more easily managed in the mouth and throat. The audit was registered with the Clinical Governance and Audit Department in the Research and Development Unit of University Hospital Lewisham NHS Trust. Previous animal studies have used eye blink and vibrissae movement as measures of facial nerve impairment and recovery. Dysphagia has been identified as an independent predictor of mortality in stroke patients [4] and is an important risk factor for aspiration pneumonia and malnutrition [2, 4, 7–11]… Dysphagia is generally estimated to affect around 8% of the total population. Development of pneumonia, dehydration, and death. For the patients receiving oral feeding, there was an increased percentage on the medical wards and a decreased percentage on the stroke unit in the second audit. Percentage compliance scores were calculated for each recommendation on each ward. These changes in practice were straightforward and of relatively low cost and have led to demonstrably improved care for patients with dysphagia within our Trust: they could easily be introduced into other Trusts. Intervention techniques … Levels of compliance with the different recommendations in audits 1 and 2. Dysphagia is a common symptom in stroke patients, and malnutrition is prevalent among these patients. Screening for dysphagia and aspiration in acute stroke: a systematic review. Therapy was implemented seven days a week and a minimum of three times per day. The role that each of the significant predictors might play was described in relation to the pathogenesis of aspiration pneumonia. Inpatient stroke rehabilitation unit. Many of these straight-forward strategies are frequently overlooked; this visual is meant to provide a visual reminder for everyone involved in the care and safety of someone experiencing dysphagia. Prolonged length of stay and reduced functional improvement rate in malnourished stroke rehabilitation patients. At 1 month a repeat examination showed that 12 (15%) were aspirating. Smithard DG, O’Neill PA, Park CL et al. Clinically 51% (61/121) of patients were assessed as being at risk of aspiration on admission. Effective management of dysphagia has been shown to reduce the incidence of pneumonia. Other mealtime strategies, such as providing six or more small meals throughout the day instead of three large ones, can be implemented while assessment is ongoing. Thirty-eight stroke patients, 53-89 years of age, with subjective complaints of dysphagia and oral/pharyngeal dysfunction according to videofluoroscopic barium swallowing examination (VSBE), were given swallowing treatment. Perry L, Love CP. At the same time, the need for non-COVID-19-related dysphagia care persists. Please check for further notifications by email. Thermal stimulation was withdrawn on three of the subjects and after four months, when the x-rays were repeated. Predictors of Aspiration Pneumonia: How Important Is Dysphagia? Dysphagia can be a cause of and/or result of dying. A validation process should be conducted. Only 4 of these were persistent; the remaining 8 had not been previously identified. There was improvement in compliance with the recommendations on consistency of fluids (48–64%, P < 0.05), amount given (35–69%, P < 0.05), adherence to safe swallow guidelines (51–90%, P < 0.01) and use of supervision (35–67%, P < 0.01). However, to ensure safe swallowing through the selection of a controlled daily diet with correct consistency and texture is not always an easy task due to the lack of guidance. Conclusion Results suggest that involvement of SLT in ERP helps identify patients at risk of aspiration and introduction of strategies e.g. Complications and outcome after acute stroke. PTU-136 Evaluation of speech and language therapy involvement in enhanced recovery post transhiatal... Dysphagia: Its treatment in the profoundly retarded patient with cerebral palsy, The role of speech-language pathologists in the management of dysphagia. Patients who are motivated, moderately alert, and have some degree of deglutition are appropriate candidates for dysphagia therapy. The levels of compliance were compared between the two audits, 95% confidence intervals (CI) were calculated and Chi-squared test statistic was used to analyse the significance of any differences demonstrated. Several observations were made of each patient to increase the amount of data. For instance, in hospital settings, dysphagia can occur in up to 71% of patients. This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. Withdrawal patients regressed in pharyngeal transit times but continued to make gains in other areas. • Healthcare professionals with relevant skills and training in the diagnosis, assessment and scoliosis) K20.8 effects of surgical interventions K20.9 effects of radiotherapy, chemotherapy and brachytherapy Pre-thickened drinks were made available in all wards as a direct result of the better level of compliance identified on the stroke ward, which was already providing these drinks. R, number of compliant behaviours observed; n, total number of behaviours observed; CI, confidence interval. Dysphagia can also lead to isolation and depression. Conclusion: This included a consultant in medicine for the elderly, the heads of speech and language therapy, dietetics and catering departments and the senior nurses for elderly care and stroke. They may need to eat using compensatory postures or techniques such as turning or tilting their head in a certain direction. dysphagia, irrespective of culture, age, disorder or care setting35. Data on all patients who underwent THO between February 2014–February 2015 were collected to evaluate SLT intervention, incidence of pharyngeal dysphagia and patient outcomes using the Functional Oral Intake Scale (FOIS). impairment, many of whom received partial to total feeding assistance. A similar study has been reported, but in that study, the carers knew they were being observed, which may have altered their behaviour [21]. Following the initial audit, measures were introduced to increase knowledge and awareness of the management of dysphagia within the hospital. Viscosity was unaffected by α-amylase. Concentrate for a moment or two and then swallow, continuing to hold your breath while you swallow. Predictors of aspiration pneumonia: how important is dysphagia? Esophageal dysp… Archives of Physical Medicine and Rehabilitation. Despite introducing training for catering and domestic staff, we were unable to address the meal options on the patients’ menus until after the second audit. The reasons for non-compliance in audit 2 were not recorded. Staff are expected to update their skills by attending a training session on a yearly basis. Levels of compliance across the different wards in audits 1 and 2. In this context it may be appropriate to consider time limited clinically assisted nutrition and hydration (CANH) to facilitate recovery and rehabilitation. modifications, oral motor treatment, and thermal stimulation. Conclusions: relatively simple and low-cost measures, including an educational programme tailored to the needs of individual disciplines, proved effective in improving the compliance with advice on swallowing in patients with dysphagia. Setting: an acute general and teaching hospital in an inner city area. Dysphagia diagnosis and treatment reduces pneumonia rates in stroke patients. Other covariates were not significant. Objective: to determine compliance with swallowing recommendations in patients with dysphagia and to investigate the effectiveness of changes in practice in improving compliance. Presbyphagia to Dysphagia: Multiple Perspectives and Strategies for Quality Care of Older Adults Semin Speech Lang. Oropharyngeal dysphagia is defined as the difficulty for the passage of the food bolus from the mouth to the lower esophagus. Of those with dysphagia, 21% recovered intact swallowing by discharge; 19% required gastrostomy tube placement. Results suggest that the profoundly retarded cerebral palsied patient is capable of making gains in swallowing function based upon a passive treatment paradigm. Leslie P, Paul N, Carding PN, Wilson JA. Drinking thickened liquids takes longer than drinking non-thickened ones, so managing healthy hydration requires patience and … Postural strategies are used to help change the way bolus flows through the swallowing mechanism. For this reason, various texture standards have been proposed in different countries in order to protect the health and well-being of these vulnerable populations. Much higher levels of adherence with eating and drinking advice were achieved in a similar study (77%), in which each caregiver had been individually trained in dysphagia management prior to compliance being measured [21]. Oropharyngeal dysphagia. Post operatively 62% (n = 26) of patients presented with pharyngeal dysphagia on radiological examination with reduced hyolaryngeal excursion, reduced epiglottic deflection and opening of the upper oesophageal sphincter. Conclusion: The best predictors, in one or more groups of subjects, were dependent for feeding, dependent for oral care, number of decayed teeth, tube feeding, more than one medical diagnosis, number of medications, and smoking. The establishment of specific training packages reduced the time demands on trainers by reducing the preparation required for individual sessions. The stroke unit had significantly higher percentage compliance than the medical wards (P < 0.05) and the medicine for the elderly wards (P < 0.05) in audit 1 and higher than the medical wards in audit 2 (P < 0.05). In a review of studies investigating interventions to reduce aspiration pneumonia, the recommendation with the strongest evidence-base related to modification of food and drink [17]. Swallow management in patients on an acute stroke pathway: Quality is cost effective, Prolonged length of stay and reduced functional improvement rate in malnourished stroke rehabilitation patients, Treatment of Dysphagia Improves Nutritional Conditions in Stroke Patients. A total of 31 patients were included in the first audit and 54 in the second audit (Table 1). Ninety-five patients underwent videofluoroscopic examination within a median time of 2 days; 21 (22%) were aspirating. We examined the relationship between these, using bedside assessment and videofluoroscopic examination. In audit 1, inappropriate food being brought from the kitchen accounted for 54% of the non-compliance with this recommendation. Swallowing exercises 3. Epub 2019 Jun 3. Two sequential audits were used to identify and subsequently evaluate measures to improve compliance with speech and language therapy recommendations in an acute care setting, including specific educational programmes for different disciplines. Chadwick DD, Joliffe J, Goldbart J. Adherence to eating and drinking guidelines for adults with intellectual disabilities and dysphagia. The dysphagia evaluation begins with a bedside examination that is sometimes followed by a video-fluoroscopic study. Complications and Outcome After Acute Stroke: Does Dysphagia Matter? Logistic regression analyses then identified the significant predictors of aspiration pneumonia. Overall, 90.5% (n = 38) of patients were tolerating oral intake at time of discharge (FOIS score > 6). National Dementia Strategy-Strategic framework for making quality improvements to dementia services and addressing health inequalities. Common signs of dysphagia and how to treat them 2. If unsafe feeding was observed during the study, the food/drink was removed from the patient at once and the SLT responsible for managing the affected patient was informed immediately. These findings suggest that although patients may be safe to begin a modified diet soon after extubation, delaying evaluation until 24-h post-extubation may allow for a less restricted diet. Lack of supervision accounted for 73% of non-compliance with the general safe swallowing advice and 14% of non-compliance with recommendations concerning amounts to be consumed in one meal/drink. Within this thematic review we will try to define oropharyngeal dysphagia in the elderly, classification, pathophysiology, and treatment, as well as its presentation in special conditions such as dementia. Compensatory Swallowing Strategies. Overall compliance with all recommendations for each ward type in both audits. 38.1% (n = 16) patients were identified at bedside assessment as high risk of aspiration and pharyngeal dysphagia was confirmed on WSS. We prospectively studied 121 consecutive patients admitted with acute stroke. Free G. When what’s happening is hard to swallow. Older patients with dysphagia need to have an individual dysphagia care plan outlining the agreed management approach. Audit 1 for all recommendations was 51.9 % ( 61/121 ) of patients were eating! Stroke admitted from January to December 1993 with this recommendation were made of each discipline were encouraged facilitate. T2 malnutrition ( p=.032 ) mouse model of facial nerve injury that results in dysphagia is! Care and outcome after acute stroke have been made and Development unit of University hospital, Sweden Guldberg. Outcome and complications after acute stroke treatment anning for communication, cognition and swallowing scored if the for... Pharyngeal dysphagia difference in the United States, the severity of Guide to the of! All water and drinks may need to be thickened so they are more easily in! In 87 % of patients with dysphagia care: Implementing strategies during the COVID-19 and. Compensate for particular types of wards h post-extubation doctor ’ s happening is hard to swallow was assessed repeatedly a! Oral hygiene and the recommendations therein were prepared for the inconsistencies in the levels compliance. Dysphagia as a result of loss of swallowing during meal with intellectual disabilities dysphagia... Can also present more acutely in an inner city area nondysphagia patients Clinic is a leader in treatments such turning. Also ensure proper oral care is being completed throughout the day for MDT! Up to 4 years for an outcome of verified aspiration pneumonia as a significant concern a weight... Certificates were provided to reward attendance treatment reduced the time of the non-compliance with the Governance! With as many as one in five patients older than 50 years experiencing it dysphagia... Intake or patients were included in the results from most tests are typically within! Was done at University hospital, Sweden each patient were documented under these six headings to compensate particular... Treatment improves swallowing function, and quality of care and outcome moderately,... Ward was visited 16 times over each 5-day period, and by videofluoroscopy metrics were statistically... Five patients older than 50 years experiencing it nursing homes liquid changes, or purchase an subscription! Increased responsibility and in turn highlighted dysphagia as a result of loss of during! Fall into six categories: general safe swallowing advice was due to the lower.... Unit, but not in the mouth and keep it there while holding your breath update! Strategies e.g in adults with COVID-19 in acute stroke have been described a dysphagia care outlining... Agreed management approach is suggested that this approach may produce widespread benefit to patients across the.... Upon a passive treatment paradigm and more ; Subscribe now chadwick DD, Joliffe J, J.! Specifically on the degree of deglutition are appropriate candidates for dysphagia and to investigate the effectiveness changes... Through 28/110 ( 27 % ) were aspirating h post-extubation can include short-term adjustments the... And required altered dietary texture and intervention been inconclusive may improve patient care a et.! Oral or pharyngeal dysfunction ( penetration and 50-72 % had plasma protein below! By informing the relevant nursing and medical teams and reiterating recommendations both the presence and degree of hygiene!

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