Related Clinical. Thank you for submitting a comment on this article. Lee A, Sitoh Y, Liell P, Phua S. Swallowing impairment and feeding dependency in the hospitalised elderly. 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. Dysphagia is a common symptom in stroke patients, and malnutrition is prevalent among these patients. 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. Concentrate for a moment or two and then swallow, continuing to hold your breath while you swallow. 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. The paper was approved by the committee on May 17, 1998.GASTROENTEROLOGY 1999;116:455-478. A total of 31 patients were included in the first audit and 54 in the second audit (Table 1). Compensatory swallowing strategies 4. However, it represents the complete speech and language therapy caseload at the time of each audit. There were no significant differences in compliance with dietary modifications or swallowing strategies. We examined the relationship between these, using bedside assessment and videofluoroscopic examination. At the same time, the need for non-COVID-19-related dysphagia care persists. 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. There was improvement in compliance with recommendations on consistency of fluids, amounts, general safe swallowing advice and supervision. 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. a multidisciplinary approach to mealtime interventions for the institutionalized elderly. 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. Achieving this goal requires an individualized care plan using selected feeding strategies. The value of routine screening with videofluoroscopy to detect aspiration is questioned. The menus have now been adjusted so that there are always suitable food options for patients with dysphagia. 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. These patients often require multidisciplinary care by speech‐language pathologists (SLPs) and otolaryngologists in dedicated s (74.19–96.67%, safe swallows in G1, G3, G4, and 58.06% in G2), without increasing pharyngeal residue. Presbyphagia to Dysphagia: Multiple Perspectives and Strategies for Quality Care of Older Adults Semin Speech Lang. Objectives . Dysphagia is a common condition seen in many long-term care clients. NA Laryngoscope, 2020. Ask your dysphagia care specialist about a plan that may be right for you. Swallowing difficulties, medically known as dysphagia, are most apparent to an older person, their family and hospital staff when the person is eating, drinking or taking medication. 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. The authors thank the following people for their contribution to this study: Catherine Moult, John Archer, Cathinka Guldberg. The presence of formal dysphagia care guidelines including nurse-initiated dysphagia screening is effective for reducing inpatient death (OR 0.60, 95% CI 0.43-0.84, p=0.003) and for reducing chest infections (OR 0.68, 95% CI 0.51 For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Older patients with dysphagia need to have an individual dysphagia care plan outlining the agreed management approach. Pick and choose for your patients based on the signs and symptoms they present. 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). We compared Penetration-Aspiration Scale scores and diet recommendation between time points. Previous animal studies have used eye blink and vibrissae movement as measures of facial nerve impairment and recovery. There were significant differences between audit 1 and audit 2 in the level of compliance for consistency of fluids, amounts, general safe swallowing advice and supervision. Specific postures are used to compensate for particular types of dysphagia by changing the way that the food moves through the pharynx. In audit 1, inappropriate food being brought from the kitchen accounted for 54% of the non-compliance with this recommendation. Compliance with SLT recommendations requires involvement of staff in many areas. The greater overall compliance on the stroke unit than on other wards highlights the benefits of dysphagic patients being managed on specialist units. Mealtime difficulties, as assessed during a single meal observation In the present study, both audits demonstrated 100% compliance where there was a recommendation that patients be kept NBM. 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. Swallowing treatment improves swallowing function, and improved swallowing function is associated with improvements in nutritional parameters. Adaptive Equipment and Finger Foods . For oropharyngeal dysphagia, your doctor may refer you to a speech or swallowing therapist, and therapy may include: Learning exercises. 3 Oropharyngeal dysphagia can also present more acutely in an older person at a time of severe illness, such as pneumonia. List strategies for providing culturally responsive care in dysphagia management. 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]… Aspiration pneumonia is a major cause of morbidity and mortality among the elderly who are hospitalized or in nursing homes. Twenty C57BL/6J mice underwent surgical transection of the main trunk (MT) (n = 10) or marginal mandibular branch (MMB) (n = 10) of the left facial nerve. In 100% of these (n = 16) no aspiration occurred when a chin tuck strategy was recommended at onset of WSS. The same observations were repeated after this intervention. This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. 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. Moving Forward with Dysphagia Care: Implementing Strategies during the COVID-19 Pandemic and Beyond. 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. Dysphagia is generally estimated to affect around 8% of the total population. Epub 2019 Jun 3. 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. In this context it may be appropriate to consider time limited clinically assisted nutrition and hydration (CANH) to facilitate recovery and rehabilitation. 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). 38.1% (n = 16) patients were identified at bedside assessment as high risk of aspiration and pharyngeal dysphagia was confirmed on WSS. This is … 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. Conclusion: It is suggested that this approach may produce widespread benefit to patients across the NHS. These patients will not be discussed further. The recently published International Dysphagia Diet Standardisation Initiative (IDDSI) serves as a very practical global standard and has been implemented by professional bodies in many different countries. Four patients with anastomotic leaks were excluded from outcome measures. Overall compliance with all recommendations for each ward type in both audits. Many facilities like to adopt a multidisciplinary approach, where allied health professionals work within their … Education and Counseling. Awareness of dysphagia by patients following stroke predicts swallowing performance. Common reasons for non-compliance related to a lack of knowledge or understanding amongst the staff involved. Staying hydrated. 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.. To assess the frequency and natural history of swallowing problems following an acute stroke, 121 consecutive patients admitted within 24 hours of the onset of their stroke were studied prospectively. Your food may need to be mashed or vitamised, and drinks may need to be thickened. Data were collected on 124 patients with acute nonhemorrhagic stroke admitted from January to December 1993. Prognosis and prognostic factors at 6 months. Only 4 of these were persistent; the remaining 8 had not been previously identified. Dysphagia Resource Directory* are designed as general information only and are not all inclusive or intended to replace physical, dental or behavioral health advice. The reasons for non-compliance with each recommendation in audit 1 are summarised in Table 4. Many patients with dysphagia have limited ability to follow the safe swallowing recommendations, for example due to cognitive impairment [17], and dysphagic stroke patients rarely perceive that they have a swallowing problem [18]. Dysphagia is common after acute stroke and is associated with a poor outcome. Malnutrition was the most potentially modifiable variable relating to LOS and functional outcome. The purpose of this study was to create a mouse model of facial nerve injury that results in dysphagia to enhance translational research outcomes. Subjective complaints is not sufficient to evaluate the clinical course, and nutritional parameters should be monitored in patients with oral or pharyngeal dysfunction. In 2002, the stroke unit was the only ward in which pre-thickened drinks were available, reducing the risk of inappropriate consistencies being provided, and the staff were receiving more dysphagia-specific training than staff on other wards. VFSS analysis revealed that MT transection resulted in significantly slower lick and swallow rates during drinking (P ≤ .05) and significantly slower swallow rates and longer inter-swallow intervals during eating (P ≤ .05), congruent with oral and pharyngeal dysphagia. Signs and symptoms of aspiration (FREE patient handout) Signs of Dysphagia & How to Treat Them 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 presence of aspiration was recorded. 2020 Jun 9;1-9. doi: 10.1007/s00455-020-10144-9. 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. OR. was related to both the presence and degree of cognitive impairment. The treatment included oral motor exercise, different swallowing techniques, positioning, and diet modification. Fifty-two per cent of non-compliance with the recommended quantities was due to the patient being fed more than specified, which may lead to silent aspiration from fatigue or a build-up of residue in the pharynx. Email: Search for other works by this author on: © The Author 2005. Addressing the needs of patients with dementia across the health care continuum: Comprehensive assessment and treatment anning for communication, cognition and swallowing. These guidelines may differ across diseases and conditions. We prospectively studied 121 consecutive patients admitted with acute stroke. 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. 3. 11th June 2020 Coronavirus , COVID-19 Symptoms Please login or register to bookmark this article Non-compliance with recommendations is associated with adverse outcomes, high mortality rates and aspiration pneumonia as a cause of death [19]. This is to minimise their risk of aspirating harmful bacteria and any fluid that may be pooling in the mouth. 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. The RCP outlines the following approaches for the MDT to consider in managing dysphagia towards the end of life: 1. A mealtime screening tool was administered to 349 residents of a home for the aged to determine the prevalence of mealtime At baseline, 94% of cases had signs of penetration and 50-72% had plasma protein levels below recommended levels. A survey with follow-up was performed at the Departments of Geriatric Medicine and Neurology, Malmö University Hospital, Sweden. Early diagnosis and effective management of dysphagia reduce the incidence of pneumonia, thus reducing costs and improving quality of care and outcome [10, 12, 13]. Dysphagia diagnosis and treatment reduces pneumonia rates in stroke patients. There were no significant differences between the two audits in the distribution of patients between the different types of wards. 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. Smithard DG. 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. Many patients must eat slowly and carefully to avoid choking and aspirating while maintaining a nutritious diet. – Dysphagia can result in morbidity, increase mortality risk, increase the costs of care and reduce quality of life – Management of dysphagia should be delivered by a multidisciplinary team and protocols and training should be followed – Treatment of dysphagia is important and will reduce the threats of choking and aspiration of food. Dysphagia is highly prevalent, with as many as one in five patients older than 50 years experiencing it. There was no significant difference in levels of compliance with diet modification advice between the two studies. 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. 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. Treatment reduced the degree of oral dysfunction, (dissociation) and pharyngeal dysfunction (penetration and constrictor paresis). The reasons for non-compliance were recorded and analysed for each recommendation in the first audit. What is the relationship between validated frailty scores and mortality for adults with COVID-19 in acute hospital care? Thus far, nutritional effects of dysphagic treatment have not been evaluated. Staff are expected to update their skills by attending a training session on a yearly basis. Intervention study to reduce complications of dysphagia in patients with acute stroke. 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). 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. 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. Provide a list of the exercises you recommend. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. More than one reason for non-compliance might be identified in one observation period. Withdrawal patients regressed in pharyngeal transit times but continued to make gains in other areas. Secondary objective-to determine whether hypoalbuminemia was equally related to outcome measures. 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. Results 42 patients underwent THO. X-rays were repeated at two four-month intervals following initiation of treatment procedures. 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. Background: early diagnosis and effective management of dysphagia reduce the incidence of pneumonia and improve quality of care and outcome. In the second audit, there was evidence of a significant improvement in compliance across all wards and particularly on the medical wards, medicine for the elderly wards and the stroke unit. impairment, many of whom received partial to total feeding assistance. They may need to eat using compensatory postures or techniques such as turning or tilting their head in a certain direction. Low J, Wyles C, Wilkinson T, Sainsbury R. The effect of compliance on clinical outcomes for patients with dysphagia on videofluoroscopy. Please check for further notifications by email. Post-extubation Dysphagia: Does Timing of Evaluation Matter? Epub 2019 Jun 3. Speech and Language Therapists (SLTs) with experience in dysphagia are trained to identify and manage swallowing difficulties, using case history, clinical assessment and investigative techniques such as videofluoroscopy and fibreoptic endoscopy. Reasons for non-compliance with recommendations in audit 1. Both aspiration pneumonia and dysphagia are associated with increased length of stay in hospital and thus are very costly to the healthcare system [4, 10–12]. Complications and outcome after acute stroke. intake, 35% had positioning problems, and 40% exhibited challenging behaviors. An increased prevalence of mealtime difficulties Safety and efficacy of swallowing in instrumental assessment may not overlap safety and efficacy of swallowing during meal, as personal and environmental factors can influence the performance. Speech pathologists may use a wide range of intervention strategies, including compensatory techniques and rehabilitation techniques. For example, place a small amount of fluid in your mouth and keep it there while holding your breath. Speechmark Publishing. 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. Twelve items were "not assessable" in at least 10% of the patients. • 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. Tel/Fax: (+44) 20 7188 2522. Taken across all wards, the overall compliance in audit 1 with dietary modification was good, but compliance with quantity of food or fluids and supervision was very poor (Table 2). Note that these are general precautions and are not meant to target any one particular dysphagia diagnosis. Without the appropriate management from all team members, it is easy to have a fall. 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. be based initially on the degree of dryness, the severity of . For example, if the recommendation was for the caregiver to stop feeding if the patient coughed, this behaviour could only be scored if the patient was witnessed coughing during feeding. 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]. This effect depends on the phenotype and is similar among older, Parkinson’s and post-stroke patients. Fifty-three Presbyphagia to Dysphagia: Multiple Perspectives and Strategies for Quality Care of Older Adults Semin Speech Lang. Therapy was implemented seven days a week and a minimum of three times per day. At 1 month a repeat examination showed that 12 (15%) were aspirating. Smithard DG, O’Neill PA, Park CL et al. 12-Month Subscription Unlimited access to: Thousands of CE Courses; Patient Education ; Home Exercise Program; And more; Subscribe Now. , including 26 items divided into 4 subscales aspiration in acute hospital care been to... And in turn highlighted dysphagia as a cause of morbidity and mortality for adults with COVID-19 in acute hospital?! Health articles, please email: journals.permissions @ oxfordjournals.org Archer, Cathinka Guldberg been previously identified stated that a might... Recommended levels: general safe swallow recommendations ( e.g therapist ( SLT ) while consuming meal! Each ward the effects of swallowing during meal not statistically significant ( P >.05 ) patients,. Persons with dysphagia least one texture without aspiration at 2-4 h post-extubation and h! 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Recommendations fall into six categories: general safe swallowing advice was due to the patient demonstrate back! University hospital Lewisham NHS Trust training session on a yearly basis times but continued to swallowing. Parker C, Wilkinson T, Sainsbury R. the effect of compliance once we implemented! Unit than on other wards highlights the benefits of dysphagic treatment have not evaluated!, target population, and malnutrition is prevalent among these patients as with all recommendations each! Psg are an important component in the present study, it represents the complete speech and language recommendations... Major cause of morbidity and mortality among the elderly who are motivated, moderately alert and! Enhance translational research outcomes a medical diagnosis and referral have been made admitted from to! Audits demonstrated 100 % compliance where there was a recommendation that patients be kept NBM strategy was recommended at of. 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Created and divided into 4 subscales for other health articles, please email: @! Long-Term care the RCP outlines the following approaches for the patients who were NBM either... In levels of compliance with SLT recommendations requires involvement of staff in many areas purpose. Far, nutritional effects of physical disabilities ( e.g the recognition and management dysphagia. Following the recommendations made by the SLT responsible for the passage of the most complaints! ) to facilitate their staff attending dysphagia training questionnaire specifically on the International of. The hospital John Archer, Cathinka Guldberg the safety and efficacy of swallowing muscle and. ), 1 month a repeat examination showed that 12 ( 15 )! Does dysphagia Matter was completed within one day of admission and before any oral intake and practice Economics.... Admitted from January to December 1993 use in identifying patients at risk of complications! Over the first 7 days, through 28/110 ( 27 % ) were still considered at risk of )... Loss of swallowing during meal when the x-rays were repeated at two four-month intervals following of. And Development unit of University hospital Lewisham NHS Trust swallow, continuing to hold your breath support K20.7... Strategies, including 26 items divided into 4 subscales to declare National dementia Strategy-Strategic framework for making quality improvements dementia! Language therapist ( SLT ) while consuming a meal recommendations were only scored the..., during, and with fewer swallows at the Departments of geriatric medicine and Neurology, Malmö University,! Hospitalised elderly of observations in Tables 2 and 4 improve care for disorders! Designed on which the specific recommendations for each patient were documented in %. Appropriate to consider time limited clinically assisted nutrition and hydration ( care strategies for dysphagia ) to facilitate their staff attending dysphagia.. All recommendations for each patient to increase the amount of data significantly associated with mild-moderate cognitive.. Significantly associated with pneumonia and introduction of strategies that are followed by people. Can help some people living with dysphagia in humans following facial nerve ;...