Impact of delay in early swallow screening on pneumonia, length of stay in hospital, disability and mortality in acute stroke patients

Background/Objectives: Early swallow screening, within 4 h of admission, is required for all acute stroke patients to commence nutritional support, as recommended. We evaluated the impact of delay in early swallow screening on outcomes in patients admitted with acute stroke. Subjects/Methods: Prospective cohort study of 1656 men (mean ± SD age = 73.1y ± 13.2) and 1653 women (79.3y ± 13.0) admitted with stroke to hyperacute stroke units (HASUs) in Surrey. Logistic regression was used to assess the risk (adjusted for age, stroke severity and co-morbidities) of delay in swallow screening on pneumonia, length of stay (LOS) > 3 weeks in HASU or hospital, moderately severe to severe disability on discharge (modified Rankin scale score = 4–5) and mortality during admission. Results: Compared with those who received swallow screening within 4 h of admission, a delay between 4 and 72 h was associated with greater risks of pneumonia: OR = 1.4 (95%CI:1.1–1.9, P = 0.022), moderately severe to severe disability on discharge: OR = 1.4 (1.1–1.7, P = 0.007) and a delay beyond 72 h was associated with even greater risks of pneumonia: OR = 2.3 (1.4–3.6, P < 0.001), prolonged LOS in HASU: OR = 1.7 (1.0–3.0, P = 0.047, median LOS = 6.2 vs. 14.7 days) and hospital: OR = 2.1-fold (1.3–3.4, P = 0.007, median LOS = 6.8 vs. 14.9 days), moderately severe to severe disability on discharge: OR = 2.5 (1.7–3.7, P < 0.001) and mortality: OR = 3.8 (2.5–5.6, P < 0.001). These risks persisted after excluding 103 patients who died within 72 h. Conclusions: Delay in early screening for swallow capacity in acute stroke patients is detrimental to outcomes, possibly due to delaying nutritional provision or through inappropriate feeding leading to aspiration. Routine early screening needs greater attention in HASUs

European Society for Swallowing Disorders – European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

Laura WJ Baijens,1 Pere Clavé,2,3 Patrick Cras,4 Olle Ekberg,5 Alexandre Forster,6 Gerald F Kolb,7 Jean-Claude Leners,8 Stefano Masiero,9 Jesús Mateos-Nozal,10 Omar Ortega,2,3 David G Smithard,11 Renée Speyer,12 Margaret Walshe13 1Department of Otorhinolaryngology – Head and Neck Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; 2Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital of Mataró, Autonomous University of Barcelona, Mataró, 3CIBERehd, Instituto de Salud Carlos III, Barcelona, Spain; 4Department of Neurology, Antwerp University Hospital, University of Antwerp, Born Bunge Institute, Edegem, Belgium; 5Department of Translational Medicine, Division of Medical Radiology, Skåne University Hospital, Malmö, Sweden; 6Clinique Bois-Bougy, Nyon, Switzerland; 7Department of Geriatrics and Physical Medicine, Bonifatius Hospital, Lingen, Germany; 8Long Term Care and Hospice, Ettelbruck, Luxembourg; 9Rehabilitation Unit, Department of Neuroscience, University of Padua, Padova, Italy; 10Department of Geriatric Medicine, Hospital Ramón y Cajal, Madrid, Spain; 11Clinical Gerontology, Princess Royal University Hospital, King’s College Hospital Foundation Trust, London, UK; 12College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia; 13Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland Abstract: This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization’s classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies. Keywords: Swallowing disorders, malnutrition, aged, frail elderly, quality of life, healthy aging, sarcopeni