Optimising medicines administration for patients with dysphagia in hospital:Medical or nursing responsibility?

Dysphagia is common—not only associated with stroke, dementia, Parkinson’s but also in many non-neurological medical problems—and is increasingly prevalent in ageing patients, where malnutrition is common and pneumonia is frequently the main cause of death. To improve the care of people with dysphagia (PWD) and minimise risk of aspiration and choking, the textures of food and drinks are frequently modified. Whilst medicines are usually concurrently prescribed for PWD, their texture is frequently not considered and therefore any minimisation of risk with respect to food and drink may be being negated when such medicines are administered. Furthermore, evidence is starting to emerge that mixing thickeners with medicines can, in certain circumstances, significantly affect drug bioavailability and therefore amending the texture of a medicine may not be straightforward. Research across a number of hospital trusts demonstrated that PWD are three times more likely to experience medication administration errors than those without dysphagia located on the same ward. Errors more commonly seen in PWD were missed doses, wrong formulation and wrong preparation through medicines alteration. Researchers also found that the same patient with dysphagia would be given their medicines in entirely different ways depending on the person administering the medicine. The alteration of medicines prior to administration has potential for patient harm, particularly if the medicine has been designed to release medicines at a pre-defined rate or within a pre-defined location. Alteration of medicines can have significant legal implications and these are frequently overlooked. Dispersing, crushing or mixing medicines can be part of, or misconstrued as, covert administration, thus introducing a further raft of legislation. Guidance within the UK recommends that following identification of dysphagia, the ongoing need for the medicine should be considered, as should the most appropriate route and formulation, with medicines alteration used as a last resort. The patient should be at the centre of any decision making. Evidence suggests that in the UK this guidance is not being followed. This article considers the clinical and legal issues surrounding administration of medicines to PWD from a UK perspective and debates whether medicines optimisation should be the primary responsibility of the prescriber when initiating therapy on the ward or the nurse who administers the medicine

Assessment and management of dysphagia in acute stroke: an initial service review of international practice

The international approach to the assessment and management of dysphagia in the acute phase post stroke is little studied. A questionnaire was sent to clinicians in stroke services that explored the current practice in dysphagia screening, assessment, and management within the acute phase post stroke. The findings from four (the UK, the US, Canada, and Australia) of the 22 countries returning data are analysed. Consistent approaches to dysphagia screening and the modification of food and liquid were identified across all four countries. The timing of videofluoroscopy (VFS) assessment was significantly different, with the US utilising this assessment earlier post stroke. Compensatory and Postural techniques were employed significantly more by Canada and the US than the UK and Australia. Only food and fluid modification, tongue exercises, effortful swallow and chin down/tuck were employed by more than fifty percent of all respondents. The techniques used for assessment and management tended to be similar within, but not between, countries. Relationships were found between the use of instrumental assessment and the compensatory management techniques that were employed. The variation in practice that was found, may reflect the lack of an available robust evidence base to develop care pathways and identify the best practice. Further investigation and identification of the impact on dysphagia outcome is needed

Targeting Fatigue in Stroke Patients

Symptoms of fatigue are often reported by patients in both the acute and chronic stages of recovery following a stroke. It is commonly associated with low mood and sleep disturbances, but can arise in their absence. However, it has also been associated with poorer long-term outcome and, as such, its aetiology warrants a greater understanding. There is convincing evidence that inflammatory cascades and cytokine signalling precipitated by the infarct promote fatigue, and these pathways may harbour therapeutic targets in its management

Acupuncture for stroke: perceptions and possibilities

Objective: To investigate perceptions and acceptability of, and attitudes towards, acupuncture for post-acute stroke and rehabilitation care by exploring the views of different stakeholders. Methods: Three electronic surveys were conducted to gauge the breadth of knowledge and acceptance of acupuncture in post-acute stroke and rehabilitation care among three stakeholder groups: (1) traditional acupuncturists registered with the British Acupuncture Council (BAcC); (2) National Health Service (NHS) professionals attending the 2017 UK Stroke Forum conference; and (3) the UK network of Stroke Club co-ordinators. Results: Of 278 NHS respondents, 31% were doctors. Over half (52%) of all NHS respondents reported they had insufficient knowledge about acupuncture, its effectiveness (23%) or how to refer (21%). Only 12% had previously referred stroke patients for acupuncture but 46% thought that there was role for acupuncture in post-acute stroke care (50% were unsure). Two thirds of BAcC acupuncturist respondents had treated at least one stroke patient, with 70.1% having treated 1–5 stroke patients and 71% having provided treatment in the last year, most commonly for motor impairment (88.2%). Of 99 Stroke Club coordinators who responded, only seven had ever been asked about acupuncture by patients, but most felt there would be interest. Conclusion: Interest in the provision of acupuncture for post-acute stroke care was expressed by both NHS practitioners and acupuncturists. Further research is required on the acceptability of acupuncture to patients as well as evidence of its clinical and cost effectiveness

The risk feeding model of care: impact on length of stay readmissions

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Is dysphagia under diagnosed or is normal swallowing more variable than we think? Reported swallowing problems in people aged 18 – 65 years.

PURPOSE: Dysphagia prevalence in younger community dwelling adults and across nations is sparse. We investigated the prevalence of swallowing problems in an unselected cohort of people aged 18-65 years. METHODS: The EAT-10 Assessment Tool was converted into an anonymized online survey. Invitations were emailed to author contacts and onwards dispersal encouraged. Analysis was performed using non-parametric test for group comparison (Mann-Whitney U) and Spearman’s rho correlation. RESULTS: From March 2014 to October 2017: 2,054 responses (32 reported ages outside of 18-65 or undeclared) from Africa, Asia, Australasia/Oceania, Europe, and North and South America. Responses: 1,648 female, 364 male, (10 reported as both), median age 34, (range 18-65, mean 37.12, SD 12.40) years. Total EAT-10 scores: median 0 (range 0-36, mean 1.57, SD 3.49). EAT-10 score ≥3 (337) median 5 (range 3-36, mean 7.02 SD 5.91). Median age 36 (range 19-65, mean 37.81, SD 13.21) years. Declared sex was not statistically significantly associated with non-pathological vs. pathological EAT-10 score (p=.665). Female scores (median 0.00, mean 1.56, SD 3.338) were significantly higher than for males (median 0.00, mean 1.62, SD 4.161): U (Nfemale=1648, Nmale=364) = 275420.000, z=-2.677, p=.007. Age and EAT-10 score were not associated: females rs=-0.043, p=.079, N=1648, males rs=-0.003, p=.952, N=364. Considerable impact on people: “I take ages to eat a main course … This is embarrassing and I often leave food even though I am still hungry.” (no diagnosis, EAT-10=17). CONCLUSION: Concerns regarding swallowing exist in people undiagnosed with dysphagia, who may feel uncomfortable seeking professional help. Dysphagia may be under reported resulting in a hidden population. Subtle changes are currently seen as subtle markers of COVID-19. Further work is required to ensure that what is an essentially normal swallow does not become medicalized

A paradigm shift in the diagnosis of aspiration pneumonia in older adults

In older adults, community-acquired pneumonia (CAP) is often aspiration-related. However, as aspiration pneumonia (AP) lacks clear diagnostic criteria, the reported prevalence and clinical management vary greatly. We investigated what clinical factors appeared to influence the diagnosis of AP and non-AP in a clinical setting and reconsidered a more clinically relevant approach. Medical records of patients aged ≥75 years admitted with CAP were reviewed retrospectively. A total of 803 patients (134 APs and 669 non-APs) were included. The AP group had significantly higher rates of frailty, had higher SARC-F scores, resided in institutions, had neurologic conditions, previous pneumonia diagnoses, known dysphagia, and were more likely to present with vomiting or coughing on food. Nil by mouth orders, speech therapist referrals, and broad-spectrum antibiotics were significantly more common, while computed tomography scans and blood cultures were rarely performed; alternative diagnoses, such as cancer and pulmonary embolism, were detected significantly less. AP is diagnosed more commonly in frail patients, while aspiration is the underlying aetiology in most types of pneumonia. A presumptive diagnosis of AP may deny patients necessary investigation and management. We suggest a paradigm shift in the way we approach older patients with CAP; rather than trying to differentiate AP and non-AP, it would be more clinically relevant to recognise all pneumonia as just pneumonia, and assess their swallowing functions, causative organisms, and investigate alternative diagnoses or underlying causes of dysphagia. This will enable appropriate clinical management

Evaluation of the prevalence of screening for dysphagia among older people admitted to medical services – An international survey

Background: With the increasing age of the world population, the number of old and frail people is increasing. Respiratory disease is a common reason for hospital admission for older people. Aspiration of saliva, which is probably infected, is the likely etiological agent. The incidence of an abnormal swallow is high in frail older people. Despite the high incidence of swallow problems among older people, many hospital services do not routinely screen older people for dysphagia. Methods: A survey, using Research Electronic Database Capture (REDCap), was carried out via email for a convenience sample of contacts working in hospitals worldwide. They were asked; 1) type of medical services, 2) does your service screen older (>80 years) people for swallowing problems, 3) have nursing staff and medical staff trained to administer a swallow screen, 4) is a swallowing rehabilitation program offered to older people, and 5) which elements of a rehabilitation program are offered and used. Results: One hundred and fifty people with consent from 29 countries responded to the survey. Of them, 75% work in an acute hospital, 15% in rehab, and 10% in community. In total, 62% responded that they do not or only occasionally screen older people for swallowing difficulties; 50% of the medical staff and 27% of the nursing staff were not trained to administer a swallowing screen. A rehabilitation swallowing program was offered in 63% cases, with chin tuck against resistance (83%), tongue strengthening (87%), and shaker maneuver (79%) being more common than electric stimulation (21%). Conclusions: The results of this study suggest that most health facilities do not routinely screen older people for swallowing problems, and the majority of them do not train their staff. The majority of facilities were offering a rehabilitation program. In addition, it is likely that many people are not receiving the appropriate proactive intervention because swallowing problems are not being proactively sought