Dysphagia, or difficulty swallowing, is a serious and life-threatening medical condition that affects a significant number of individuals with acute neurological impairment, largely from stroke.. Finestone HM, Greene-Finestone LS, Wilson ES, Teasell RW. Presbyphagia to Dysphagia: Multiple Perspectives and Strategies for Quality Care of Older Adults Semin Speech Lang. Other covariates were not significant. Interventions for persons with dysphagia often include restrictions in types of food and consistency of liquids. The number of observations per patient varied because of discharges or deaths and because of the frequency with which a particular behaviour could be observed. Thank you for submitting a comment on this article. Results: presented by Pamela Masters-Farrell, MSN, RN, CRRN and Cindy Nehe, MS, CCC-SLP. Over a 6-month period, most problems had resolved, but some patients had persistent difficulties (6, 8%), and a few (2, 3% at 6 months) had developed swallowing problems. We were able to access a large number of staff involved in the care of patients with dysphagia, from the catering staff preparing meals to the health care assistants feeding the patients, by developing different levels of training appropriate to each professional group. A dependency upon others for feeding emerged as the dominant risk factor, with an odds ratio of 19.98 in a logistic regression model that excluded tube-fed patients. 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. After MMB transection, these same VFSS metrics were not statistically significant (P > .05). Design: sequential observational study before and after targeted intervention. Sally K. Rosenvinge, Ian D. Starke, Improving care for patients with dysphagia, Age and Ageing, Volume 34, Issue 6, November 2005, Pages 587–593, https://doi.org/10.1093/ageing/afi187. There was a significant improvement in the overall levels of compliance across all wards between the two studies (P≤ 0.01) and in the levels of compliance on the stroke ward (P ≤ 0.01), the medical wards (P ≤ 0.01) and the medicine for the elderly wards (P ≤ 0.01) individually (Table 3 and Figure 2). Oxford University Press is a department of the University of Oxford. The use of videofluoroscopy in detecting aspiration did not add to the value of bedside assessment. Whelan K. Inadequate fluid intakes in dysphagic acute stroke. Close attention to nutrition status may help to optimize stroke patients' rehab potential and use of health care resources. After item revision, the Mealtime Assessment Scale (MAS) was created, including 26 items divided into 4 subscales. Setting: an acute general and teaching hospital in an inner city area. Patients with an abnormal swallow (dysphagia) on bedside assessment had a higher risk of chest infection (P=.05) and a poor nutritional state (P=.001). A working group discussed the latent construct, target population, and purposes of the scale. Within participants, there was a significant decrease in penetration/aspiration at 24 h and 79% showed improvement in airway protection on at least one bolus type, suggesting an improvement in swallow function over the first day following extubation. It is considered a new common geriatric syndrome in the elderly population. Each quarterly training session, run by the speech and language therapy department, lasted between 1 and 2 h and was booked through the training department of the hospital. We examined the relationship between these, using bedside assessment and videofluoroscopic examination. It has come to be described as a new geriatric syndrome and an emerging pandemic, which is why it is considered one of the main challenges of geriatric medicine. The presence of aspiration was recorded. Each individual’s medical situation is unique. National Dementia Strategy-Strategic framework for making quality improvements to dementia services and addressing health inequalities. 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. The overall level of compliance in audit 1 for all recommendations was 51.9% (95% CI 46.8–57.1). However, in order to prevent any change in behaviour of the nursing staff at the time of the study, ward managers were not contacted. Complications and Outcome After Acute Stroke: Does Dysphagia Matter? Verbal consent was obtained from the patients. was related to both the presence and degree of cognitive impairment. 2019 Jun;40(3):227-242. doi: 10.1055/s-0039-1688837. To determine the relative risk of pneumonia, dehydration, and death associated with videofluoroscopic evidence of aspiration, silent aspiration, aspiration of 10% or greater on one or more barium test swallows, and aspiration of thick liquid or more solid consistencies in the subacute phase after stroke. • 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. Fifty-three There were no significant differences for recommendations regarding dietary modification or strategies (Table 2 and Figure 1). 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). Marks E, Rainbow D. Working with Dysphagia. There was no significant difference in levels of compliance with diet modification advice between the two studies. 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. Note that these are general precautions and are not meant to target any one particular dysphagia diagnosis. An increased prevalence of mealtime difficulties From these findings seven regional priorities were identified that would directly improve the care of individuals with swallowing difficulties in Northern Ireland. Improvement in compliance was demonstrated in medical and geriatric wards and the stroke unit, but not in the surgical wards. Chadwick DD, Joliffe J, Goldbart J. Adherence to eating and drinking guidelines for adults with intellectual disabilities and dysphagia. Dysphagia (difficulty in swallowing) can result from a wide variety of medical conditions including acute or progressive neurological conditions, trauma, disease or surgery . This included patients on the specialist stroke unit, medicine for the elderly wards, general medical wards and surgical wards and included both nil by mouth (NBM) patients and those receiving oral intake. Ask your dysphagia care specialist about a plan that may be right for you. These patients often require multidisciplinary care by speech‐language pathologists (SLPs) and otolaryngologists in dedicated Therapy was implemented seven days a week and a minimum of three times per day. Dysphagia instrumental evaluations, videofluoroscopic swallow study (VFSS) and flexible endoscopic evaluation of swallowing (FEES), are used to diagnose the impairment and determine treatment planning via any combination of exercises to improve swallowing physiology (i.e., strength, timing, coordination of swallowing events/movements), compensations to improve bolus flow for … Published work and observations in our own Trust indicated that patients with dysphagia may be fed in a manner which places them at significant risk of aspiration, despite SLT advice for safe swallowing. Specific strategies will need to be added for individual cases. The world's population is ageing, and elderly people have become one of the most important target groups for the food industry due to their specific diet requirements. Dysphagia is a common symptom in stroke patients, and malnutrition is prevalent among these patients. A clinical exam is conducted on day two post surgery and an SLT assisted water soluble swallow (WSS) is conducted on day three, enabling evaluation of deglutitive biomechanics, effectiveness of postural strategies in eliminating aspiration, in conjunction with assessment of anastomic integrity. Thus far, nutritional effects of dysphagic treatment have not been evaluated. The audit was registered with the Clinical Governance and Audit Department in the Research and Development Unit of University Hospital Lewisham NHS Trust. Thirty-nine percent of all patients (p < .05) failed the initial swallow screen and required altered dietary texture and intervention. Observations were made at all mealtimes and of drinks throughout the day. More than one reason for non-compliance might be identified in one observation period. 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. There were no significant differences in compliance with dietary modifications or swallowing strategies. 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. The reason for non-compliance was documented but was only documented as ‘patient non-compliance’ if that patient was deemed able to take responsibility for following the advice by the SLT who had made the recommendations. Following a plan can help you manage your dysphagia. 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. 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. be based initially on the degree of dryness, the severity of . Logistic regression analyses then identified the significant predictors of aspiration pneumonia. of each resident, were documented in 87% of these individuals. LOS and MRI at admission (T1), 1 month (T2), and discharge (T3). With a dysphagia diagnosis, all water and drinks must be thickened. Only 4 of these were persistent; the remaining 8 had not been previously identified. The idea behind an interdisciplinary approach to dysphagia management is that all parties are working together to achieve the ultimate goals. Additionally, the magnitude of problems A checklist was designed on which the specific recommendations for each patient were documented under these six headings. The presence of dysphagia was associated with an increased risk of death (P=.001), disability (P=.02), length of hospital stay (P<.001), and institutional care (P<.05). Healthy hydration is key for anyone providing care for an older adult. Previous animal studies have used eye blink and vibrissae movement as measures of facial nerve impairment and recovery. Guidance on the Management of Dysphagia in Care Homes 1 This paper has been developed to assist speech and language therapists who are finding that their services are stretched with increasing numbers of patients /clients /residents being referred for dysphagia assessment and management from community settings and care homes. identified has implications for both resource and staff-training requirements in long-term care facilities. Investigation and management of chronic dysphagia. At baseline, 94% of cases had signs of penetration and 50-72% had plasma protein levels below recommended levels. Hypoalbuminemia was unrelated to LOS and MBI scores. A similar study has been reported, but in that study, the carers knew they were being observed, which may have altered their behaviour . For oropharyngeal dysphagia, your doctor may refer you to a speech or swallowing therapist, and therapy may include: Learning exercises. Workers are balancing resident safety, nutrition and hydration, and quality of life. Dysphagia has been identified as an independent predictor of mortality in stroke patients  and is an important risk factor for aspiration pneumonia and malnutrition [2, 4, 7–11]. Each ward was visited 16 times over each 5-day period, and patients were observed eating and drinking. Encourage daily practice, at least twice a day. Multiple risk factors for pneumonia have been identified, but no study has effectively compared the relative risk of factors in several different categories, including dysphagia. AGA technical review on management of oropharyngeal dysphagia. Dysphagia (difficulty in swallowing) can result from a wide variety of medical conditions including acute or progressive neurological conditions, trauma, disease or surgery . Sixty percent of cases showed an improved overall VSBE score, and improved levels of albumin and total iron-binding capacity were restricted to this group. 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. Urban community hospital. These guidelines may differ across diseases and conditions. Oropharyngeal dysphagia is defined as the difficulty for the passage of the food bolus from the mouth to the lower esophagus. A mealtime screening tool was administered to 349 residents of a home for the aged to determine the prevalence of mealtime 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. There were no significant differences between the two audits in the distribution of patients between the different types of wards. Published by Oxford University Press on behalf of the British Geriatrics Society. advice on alertness, posture, advice to stop the patient eating or drinking if showing signs of aspiration). Muscle wasting, cachexia, and asthenia affect the coordination and muscle strength needed for swallowing, which in turn, can lead to poor appetite and inefficient oral intake. This means that the patients’ carers have to take responsibility for following the recommendations made by the SLT. The swallowing mechanism was felt to operate more quickly, more efficiently, and with fewer swallows at the end of the 18-month study. These results from mice provide novel insight into specific VFSS metrics that may be used to characterize dysphagia in humans following facial nerve injury. 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. Diabetics (p=.005) and right hemispheric lesion patients(p=.015) had lower T1 MBI scores. A further 10 patients aspirated on WSS; a chin tuck strategy was recommended and this was effective in eliminating aspiration in 80% (n = 8). Direct and indirect strategies for treating dysphagia have been described. A total of 31 patients were included in the first audit and 54 in the second audit (Table 1). Smithard DG, O’Neill PA, Park CL et al. This SLT then took appropriate action, for example by informing the relevant nursing and medical teams and reiterating recommendations. Older patients with dysphagia need to have an individual dysphagia care plan outlining the agreed management approach. Below is a list of common compensatory swallowing strategies. cognitive impairment, pointing to a need for more aggressive intervention with this group. These are modifications of food and fl… They may need to eat using compensatory postures or techniques such as turning or tilting their head in a certain direction. An inter-item correlation r >0.7 was found in 2 cases and a discrimination index equal to 0 in 7/22 items. The results clearly demonstrate Managing patients with dysphagia Management strategies for dysphagia may involve food and/or fluid modification, swallow rehabilitation and compensation strategies. Low J, Wyles C, Wilkinson T, Sainsbury R. The effect of compliance on clinical outcomes for patients with dysphagia on videofluoroscopy. A pilot test was conducted on 40 patients, assessed by a speech and language therapist (SLT) while consuming a meal. If your swallowing is gradually becoming worse, discuss this with a health care professional (eg your doctor or nurse). Dysphagia management in elderly patients is complex and involves multiple disciplines. The establishment of specific training packages reduced the time demands on trainers by reducing the preparation required for individual sessions. Furthermore, 27% of non-compliance with the general safe swallowing advice was due to the patient continuing to eat/be fed when coughing. Staying hydrated. Soft & Bite Sized Diet (aka, Dysphagia Advanced Diet) Minced & Moist Diet (aka, Dysphagia Ground/Mechanically Altered Diet) Pureed Diet (aka, Dysphagia Pureed Diet) Oral intake was best among residents with severe cognitive 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. The value of routine screening with videofluoroscopy to detect aspiration is questioned. 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 … It is suggested that this approach may produce widespread benefit to patients across the NHS. 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