Odderson IR, Keaton JC, McKenna BS. OR. There was improvement in compliance with recommendations on consistency of fluids, amounts, general safe swallowing advice and supervision. 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). The distribution of the patients in the studies between ward types and whether advice applied to oral intake or patients were nil by mouth. Dysphagia is common following facial nerve injury; however, research is sparse regarding swallowing-related outcomes and targeted treatments. 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]. The original white swallowing advice sheets for each patient were replaced by new, clearly written bright red swallow advice sheets placed behind the patient’s bed. A ’Dysphagia/Nutrition Link Nurse’ programme was established, in which specific nurses in each ward received quarterly 2-h training sessions, run jointly by speech and language therapy and dietetics, to qualify to supervise the care of patients with dysphagia in their ward. 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-nine items were created and divided into 4 subscales. We ensured that we targeted as many staff as possible and acknowledged the high turnover of staff, which resulted in a need for ongoing training. It is also important to remove any food debris from the teeth and mouth after meals that could pose a choking risk. We prospectively studied 121 consecutive patients admitted with acute stroke. Dysphagia diagnosis and treatment reduces pneumonia rates in stroke patients. Dysphagia is highly prevalent, with as many as one in five patients older than 50 years experiencing it. Whelan K. Inadequate fluid intakes in dysphagic acute stroke. This effect depends on the phenotype and is similar among older, Parkinson’s and post-stroke patients. It is suggested that this approach may produce widespread benefit to patients across the NHS. Bedside assessment of swallowing is of use in identifying patients at risk of developing complications. 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]. After item revision, the Mealtime Assessment Scale (MAS) was created, including 26 items divided into 4 subscales. Provide a list of the exercises you recommend. They may need to eat using compensatory postures or techniques such as turning or tilting their head in a certain direction. Investigation and management of chronic dysphagia. Epub 2019 Jun 3. Multivariable logistic regression models were created to investigate associations between age, reason for admission, reason for intubation, and a history of COPD and outcomes of aspiration or silent aspiration at either FEES exam. Criteria for identification of items candidate for exclusion or revision were defined. We are currently using this surgical mouse model to explore promising treatment modalities such as electrical stimulation to hasten recovery and improve outcomes following various iatrogenic and idiopathic conditions affecting the facial nerve. These are modifications of food and fl… Despite this, an audit of adherence to swallowing advice for inpatients with dysphagia revealed that 54% of patients demonstrated non-adherence [20]. 3. Mayo Clinic also offer… Level of evidence: Thirty-nine percent of all patients (p < .05) failed the initial swallow screen and required altered dietary texture and intervention. Presbyphagia to Dysphagia: Multiple Perspectives and Strategies for Quality Care of Older Adults Semin Speech Lang. Signs and symptoms of aspiration (FREE patient handout) Signs of Dysphagia & How to Treat Them A further 10 patients aspirated on WSS; a chin tuck strategy was recommended and this was effective in eliminating aspiration in 80% (n = 8). 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. Rockville MD. The training programme was made as interactive and stimulating as possible, and certificates were provided to reward attendance. The authors have no conflicts of interest to declare. modifications, oral motor treatment, and thermal stimulation. 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. 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. Subjective complaints is not sufficient to evaluate the clinical course, and nutritional parameters should be monitored in patients with oral or pharyngeal dysfunction. The results clearly demonstrate Though 68% exhibited signs of dysphagia, 46% had poor oral Important practice points for managing patients with dysphagia: As with all patients, check vital signs regularly. Dysphagia is generally estimated to affect around 8% of the total population. The work was done at University Hospital LewishamLewisham High StreetLondon SE13 6LHUK. Changing the colour of the swallow advice sheets to make them more visible was another very low-cost, simple measure which instantly heightened awareness of SLT recommendations. Forty-nine patients completed FEES at 2-4 h post-extubation and 24-26 h post-extubation. Furthermore, 27% of non-compliance with the general safe swallowing advice was due to the patient continuing to eat/be fed when coughing. Predictors of Aspiration Pneumonia: How Important Is Dysphagia? The most common reason for non-compliance with consistency recommendations for thickened fluids was that drinks were thickened inappropriately by the domestic (32%) or nursing (38%) staff. Specific strategies will need to be added for individual cases. The IDDSI framework consists of a continuum of 8 levels (0-7), where drinks are measured from Levels 0 … Direct strategy usually refers to treatment that involves food, whereas indirect strategy refers to an exercise regimen performed without a food bolus. The audit was registered with the Clinical Governance and Audit Department in the Research and Development Unit of University Hospital Lewisham NHS Trust. A priori hypothesis-LOS and MRI are adversely related to malnutrition. a multidisciplinary approach to mealtime interventions for the institutionalized elderly. The presence of aspiration was recorded. This group met quarterly and was responsible for overseeing measures to improve care for patients with dysphagia. To determine associations between the nutritional status of inpatient rehabilitation (rehab) unit stroke patients and (1) length of stay (LOS) and (2) functional outcome using Modified Barthel Index (MBI). Treatment. SLTs will advise on compensatory swallowing manoeuvres and/or diet or fluid modification. be based initially on the degree of dryness, the severity of . Clinically 51% (61/121) of patients were assessed as being at risk of aspiration on admission. HANDOUT-ABLE: Strict Nothing by Mouth – Aggressive NPO Oral Care Instructions; HANDOUT-ABLE: NPO Has Been Uttered; What Does This Mean for Me; HANDOUT-ABLE: NPO Holiday Survival Guide for Patients & Families ; HANDOUT-ABLE: Dysphagia Holiday Survival – for the Patient on Modified Consistencies; HANDOUT-ABLE: List of Letter Forms for SLP Referrals — Send with Patient … Items were generated based on the International Classification of Functioning framework. 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. Bivariate analyses identified several factors as significantly associated with pneumonia. Speech pathologists may use a wide range of intervention strategies, including compensatory techniques and rehabilitation techniques. Several observations were made of each patient to increase the amount of data. These patients often require multidisciplinary care by speech‐language pathologists (SLPs) and otolaryngologists in dedicated Smithard DG, O’Neill PA, Park CL et al. Related Clinical. 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. A mealtime screening tool was administered to 349 residents of a home for the aged to determine the prevalence of mealtime • Healthcare professionals with relevant skills and training in the diagnosis, assessment and Overall compliance with all recommendations for each ward type in both audits. This accounts for the inconsistencies in the total number of observations in Tables 2 and 4. 2019 Jun;40(3):227-242. doi: 10.1055/s-0039-1688837. Managing dysphagia in aged care is a little like walking a tightrope. Methods: observations were made on compliance with the recommendations of SLTs regarding consistency of fluids, dietary modifications, amount to be given at a single meal/drink, swallowing strategies, general safe swallow recommendations and whether supervision was required. Many patients must eat slowly and carefully to avoid choking and aspirating while maintaining a nutritious diet. Aspiration pneumonia is a major cause of morbidity and mortality among the elderly who are hospitalized or in nursing homes. Secondary objective-to determine whether hypoalbuminemia was equally related to outcome measures. Flushing, NY: Northern Speech Neurologically Impaired Dysphagic Patients, Asymptomatic Swallowing Disorders in Elderly Patients with Parkinson's Disease: A Description of Findings on Clinical Examination and Videofluoroscopy in Sixteen Patients, Oropharyngeal dysphagia in an elderly post-operative hip fracture population, Nursing staff thickening fluids to an inappropriate consistency, Domestic staff thickening to inappropriate consistency, Number of episodes where reason for non-compliance was not identified, Patient continuing to eat/be fed when coughing, Copyright © 2021 British Geriatrics Society. Mayo Clinic is a leader in treatments such as esophageal dilation for narrowing (strictures) and stent placement for blockages. Artificial nutrition using non-oral methods “Speech and language therapists can advise on strategies to minimise aspiration risk, facilitate eating and drinking, and improve nutritional status. Dysphagia and functional independence measure (FIM) scores on admission, occurrence of aspiration pneumonia, LOS, outcome disposition and cost effectiveness analysis. Increased awareness of as … Moving Forward with Dysphagia Care: Implementing Strategies during the COVID-19 Pandemic and Beyond Dysphagia. Patients who are motivated, moderately alert, and have some degree of deglutition are appropriate candidates for dysphagia therapy. Objective: We included all inpatients with dysphagia on the speech and language therapy caseload at the time of the audit. An inter-item correlation r >0.7 was found in 2 cases and a discrimination index equal to 0 in 7/22 items. 2020 Jun 9;1-9. doi: 10.1007/s00455-020-10144-9. Predictors of aspiration pneumonia in nursing home residents. Guy's and St Thomas' NHS Foundation Trust, Negotiating The Maze: Confronting Dysphagia Together With My Stroke-Afflicted Family Member, Therapeutic Effect, Rheological Properties and α-Amylase Resistance of a New Mixed Starch and Xanthan Gum Thickener on Four Different Phenotypes of Patients with Oropharyngeal Dysphagia, Chapter 19: Food Structure Development for Specific Population Groups, What Makes it Hard for Caregivers of Stroke Patients for Preventing Dysphagia? Oxford University Press is a department of the University of Oxford. Below is a list of common compensatory swallowing strategies. An observational audit was undertaken at University Hospital Lewisham on five consecutive days in May 2002 (audit 1) and was repeated on five consecutive days in September 2003 (audit 2). Thermal stimulation was withdrawn on three of the subjects and after four months, when the x-rays were repeated. Our aim is to develop these seven regional priorities that will make a difference to individuals with swallowing difficulties, their carers and the healthcare systems, processes and services that impact their care. Conclusion Results suggest that involvement of SLT in ERP helps identify patients at risk of aspiration and introduction of strategies e.g. Thank you for submitting a comment on this article. When it was specifically stated that a patient needed direct supervision during all meals/drinks, compliance was only 36%. Leslie P, Paul N, Carding PN, Wilson JA. 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. Holas MA, De Pippo KL, Reding MJ. Others have shown that pre-thickened drinks improve hydration levels in patients with dysphagia [22], and this is a cost-effective measure to improve patient care. A validation process should be conducted. 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). 2019 Jun;40(3):227-242. doi: 10.1055/s-0039-1688837. There was no significant difference in levels of compliance with diet modification advice between the two studies. Further research is indicated to determine the effect of SLT input on patient outcomes. Oropharyngeal dysphagia. It is usually sub-classified into oropharyngeal dysphagia (affecting the mouth and pharynx) and esophageal dysphagia (affecting the esophageal body and esophagogastric junction) (2, 3). This was marked according to whether the recommendation was adhered to. At the same time, the need for non-COVID-19-related dysphagia care persists. Percentage compliance scores were calculated for each recommendation on each ward. Malnutrition was the most potentially modifiable variable relating to LOS and functional outcome. Disclosure of interest None Declared. inception cohort study. An increased prevalence of mealtime difficulties Aspiration, silent aspiration, and aspiration of 10% or greater on one or more barium test swallows during videofluoroscopic evaluation are associated with an increased risk of pneumonia, but not dehydration or death, during the subacute phase after stroke. Note that these are general precautions and are not meant to target any one particular dysphagia diagnosis. Prognosis and prognostic factors at 6 months. Oral care strategies for patients with xerostomia should . AGA technical review on management of oropharyngeal dysphagia. There were no significant differences for recommendations regarding dietary modification or strategies (Table 2 and Figure 1). Results suggest that the profoundly retarded cerebral palsied patient is capable of making gains in swallowing function based upon a passive treatment paradigm. In the meantime, see below for some examples of strategies that are followed by some people living with dysphagia. Healthy hydration is key for anyone providing care for an older adult. When other factors were taken into account, dysphagia remained as an independent predictor of outcome only with regard to mortality. The RCP outlines the following approaches for the MDT to consider in managing dysphagia towards the end of life: 1. Although malnourished and adequately nourished functionally dependent patients improved equally in MBI scores by discharge, prolonged LOS in the malnourished lowered their functional improvement rate ([T3 MBI - T1 MBI]/LOS) (p=.047). Dysphagia is a common condition seen in many long-term care clients. Elmstahl S, Bulow M, Ekberg O, Peterson M, Tegner H. Treatment of dysphagia improves nutritional conditions in stroke patients. Non-compliance with management strategies for swallowing difficulties, by both patients and their carers, is common; Adults with learning disability may find it hard to understand the implications of their swallowing difficulties; it is, therefore, important that their carers recognise the need to follow management guidance in order to reduce the risk of aspiration ; Care plans. All patients were able to commence sips of clear fluid on day three if anastomotic leak was excluded despite pharyngeal dysphagia and aspiration risk with implementation of postural techniques. Dysphagia management in elderly patients is complex and involves multiple disciplines. Intervention Strategies This chapter will provide a discussion of the evidence base for treatment strategies for dysphagia in COPD. We examined the relationship between these, using bedside assessment and videofluoroscopic examination. Steele CM, Greenwood C, Ens I, Robertson C, Seidman-Carlson R. Mealtime difficulties in a home for the aged: not just dysphagia. Data were collected on 124 patients with acute nonhemorrhagic stroke admitted from January to December 1993. The value of routine screening with videofluoroscopy to detect aspiration is questioned. All patients with dysphagia have a clearly written ‘Swallow Advice Sheet’ placed behind their bed, which contains all the key recommendations made by the SLT looking after that patient. Chadwick DD, Joliffe J, Goldbart J. Adherence to eating and drinking guidelines for adults with intellectual disabilities and dysphagia. In our own Trust, we had noted a high incidence of patients with dysphagia being fed in a manner which placed them at significant risk of aspiration, despite SLT advice for safe swallowing. More than one reason for non-compliance might be identified in one observation period. scoliosis) K20.8 effects of surgical interventions K20.9 effects of radiotherapy, chemotherapy and brachytherapy The idea behind an interdisciplinary approach to dysphagia management is that all parties are working together to achieve the ultimate goals. 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. Maintaining good oral hygiene is critical; poor oral health is one of the leading risk factors of aspiration pneumonia in individuals with dysphagia. X-rays were repeated at two four-month intervals following initiation of treatment procedures. Moving Forward with Dysphagia Care: Implementing Strategies during the COVID-19 Pandemic and Beyond Dysphagia . LOS and MRI at admission (T1), 1 month (T2), and discharge (T3). Conclusion: Without the appropriate management from all team members, it is easy to have a fall. Drinking thickened liquids takes longer than drinking non-thickened ones, so managing healthy hydration requires patience and … Practice Standards and Guidelines (PSGs) are necessary to ensure quality care by speech-language pathologists (SLPs) to the people of Ontario who require services for dysphagia (swallowing disorders). 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 paper was approved by the committee on May 17, 1998.GASTROENTEROLOGY 1999;116:455-478. 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. 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. Esophageal dysp… 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). Compensatory swallowing strategies 4. 11th June 2020 Coronavirus , COVID-19 Symptoms Please login or register to bookmark this article If unsafe practice was noted, the SLT responsible for the care of the affected patient was informed. In 100% of these (n = 16) no aspiration occurred when a chin tuck strategy was recommended at onset of WSS. Of those with dysphagia, 21% recovered intact swallowing by discharge; 19% required gastrostomy tube placement. compensatory strategies, exercises and postural advice. Swallow management in patients on an acute stroke pathway: quality is cost effective. 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. The main finding of this study was that transection of the facial nerve MT leads to oral and pharyngeal stage dysphagia in mice; MMB transection does not. What is the relationship between validated frailty scores and mortality for adults with COVID-19 in acute hospital care? 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. Methods: Results: thirty-one patients were observed before and 54 after the intervention. This study collected data via a questionnaire specifically on the knowledge of oral hygiene and the current oral care practices for patients with dysphagia. Setting: an acute general and teaching hospital in an inner city area. The dysphagia evaluation begins with a bedside examination that is sometimes followed by a video-fluoroscopic study. 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]… These strategies can include short-term adjustments to the patient, food and liquid changes, or environmental changes. Each individual’s medical situation is unique. The subjects were followed for up to 4 years for an outcome of verified aspiration pneumonia. A limitation of this study is the small number of patients included. A dysphagia link nurse programme was established, together with modification of an in-house training scheme, use of pre-thickened drinks and modification of swallowing advice sheets. Does dysphagia matter? 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. Full oral feeding using a range of compensatory strategies 2. Non-compliance with recommendations is associated with adverse outcomes, high mortality rates and aspiration pneumonia as a cause of death [19]. Dysphagia care at Mayo Clinic; Esophageal manometry; Upper endoscopy; X-ray; Show more related information. Each ward was visited 16 times over each 5-day period, and patients were observed eating and drinking. 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). There may have been other factors leading to the improvement in care in the 18 months between the two audits—for example, changes in personnel and new national initiatives to improve care for older people. For example, place a small amount of fluid in your mouth and keep it there while holding your breath. The establishment of specific training packages reduced the time demands on trainers by reducing the preparation required for individual sessions. 38.1% (n = 16) patients were identified at bedside assessment as high risk of aspiration and pharyngeal dysphagia was confirmed on WSS. 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). Specific postures are used to compensate for particular types of dysphagia by changing the way that the food moves through the pharynx. Lower T1 MBI scores was related to T2 malnutrition (p=.032). This number can vary depending on the setting. A standardized bedside assessment was performed by a physician. Aims: Compensatory Swallowing Strategies. Adaptive Equipment and Finger Foods . Weigh the patient on admission to obtain a baseline weight. advice on alertness, posture, advice to stop the patient eating or drinking if showing signs of aspiration). Nursing Care Plan for Dysphagia : Impaired Swallowing is one of the nic health articles nursing frequently sought. In cases with unchanged or decreased VSBE score, body weight was reduced and a negative correlation to total iron-binding capacity was noted (r = -0.60, p < 0.05). 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]. Previous animal studies have used eye blink and vibrissae movement as measures of facial nerve impairment and recovery. After MMB transection, these same VFSS metrics were not statistically significant (P > .05). T1 malnutrition was related to lower T2 MBI scores(p=.038). Compliance with ‘nil by mouth’ instructions was 100% throughout. Langmore SE, Kimberley A, Skarupski MPH, Park PS, Fries BE. Close attention to nutrition status may help to optimize stroke patients' rehab potential and use of health care resources. This article will familiarize clinicians with feeding and swallowing techniques, as well environmental and physical recommendations to facilitate assessment and management of individuals with dysphagia and dementia. Intervention techniques … In this context it may be appropriate to consider time limited clinically assisted nutrition and hydration (CANH) to facilitate recovery and rehabilitation. There was no significant difference in the levels of compliance on the surgical wards between the two studies. Increasing shear-viscosity with FCT causes a strong viscosity-dependent therapeutic effect on the safety of swallow. 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. 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