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

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

Prognostic factors of poor outcomes in pneumonia in older adults: aspiration or frailty?

Purpose Little is known about the long-term and functional prognoses of older adults with pneumonia, which complicates their management. There is a common belief that aspiration is a poor prognostic factor; however, the diagnosis of aspiration pneumonia (AP) lacks consensus criteria and is mainly based on clinical characteristics typical of the frailty syndrome. Therefore, the poor prognosis of AP may also be a result of frailty rather than aspiration. This study investigated the impact of AP and other prognostic factors in older patients with pneumonia. Methods We performed a retrospective cohort study of patients aged 75 years and older, admitted with pneumonia in 2021. We divided patients according to their initial diagnosis (AP or non-AP), compared outcomes using Kaplan–Meier curves, and used logistic regression to identify independent prognostic factors. Results 803 patients were included, with a median age of 84 years and 52.7% were male. 17.3% were initially diagnosed with AP. Mortality was significantly higher in those diagnosed with AP than non-AP during admission (27.6% vs 19.0%, p = 0.024) and at 1 year (64.2% vs 53.1%, p = 0.018), with survival analysis showing a median survival time of 62 days and 274 days in AP and non-AP, respectively (χ2 = 9.2, p = 0.002). However, the initial diagnosis of AP was not an independent risk factor for poor prognosis in multivariable analysis. Old age, frailty and cardio-respiratory comorbidities were the main factors associated with death. Conclusion The greater mortality in AP may be a result of increased frailty rather than the diagnosis of aspiration itself. This supports our proposal for a paradigm shift from making predictions based on the potentially futile labelling of AP or non-AP, to considering frailty and overall condition of the patient

Frailty, swallowing and dysphagia

Purpose of Review: This paper is a brief overview of the relationship between frailty, swallowing and dysphagia. Its goal is to explore the interplay between age and sarcopenia in the development of dysphagia, which is known to be linked to aspiration pneumonia. It is postulated that there is growing justification for routine screening for dysphagia in older frail people, to enable rehabilitation of swallowing through exercise and nutritional intervention, after a hospital stay. Recent Findings: The global population is ageing, with a particular increase in the very old and frail. Frail people have a limited functional and physiological reserve and often have sarcopenia. Any subsequent insult (trauma, illness, medication change) frequently results in decompensation and the need for a hospital stay. Often, in these patients, there are changes in the biomechanics of swallowing that can cause impairment and dysphagia. But, many patients adapt the way they eat with subtle compensatory techniques, to bypass this difficulty. It is possible that many more people, than is currently evident, have undiagnosed dysphagia. Pneumonia and respiratory disease are common reasons for hospital admission in the frail elderly population. Dysphagia with aspiration is an important aetiological factor in pneumonia, which is a serious health concern with increasing age. Dysphagia may simply be a consequence of physiological decompensation, related to age, frailty and sarcopenia. Dysphagia is not systematically screened for and may not be identified in many older frail people who have adapted their swallowing, to accommodate their dysphagia. This may be a significant factor in pneumonia-related hospital admissions. Swallow rehabilitation, after such admission to hospital, is also rarely offered in the acute medical setting. This needs to change to reduce recurrent admission, morbidity and mortality. Summary: The population is ageing. Sarcopenia, frailty and dysphagia are common with increasing age. Pneumonia is a common admission to hospital and often, aspiration secondary to dysphagia is a common cause. Proactive identification and intervention has the potential to reduce morbidity, hospital admission, length of hospital stay and mortality

Modified medication use in dysphagia: the effect of thickener on drug bioavailability—a systematic review

Introduction Dysphagia is associated with long-term conditions including strokes, dementia, Parkinson’s disease and frailty. Dysphagia affects 30–40% of the population aged over 65 years-old. Adults with dysphagia often experience long-term conditions requiring multiple medications (often > 5) to manage these. The thickening of liquids is a common compensatory strategy in dysphagia management. Studies suggest that immersion in thickened liquids affects medicines’ solubility in vitro. Clinicians and pharmacists are unaware of the pharmacokinetic/therapeutic effects of thickened liquids on oral medicines. We conducted a systematic review of existing literature on thickeners’ effects on drug bioavailability. Methodology We performed a literature search of MEDLINE & EMBASE. Search terms included: dysphagia/thickened diet (EMBASE only)/ bioavailability or absorption of medicines or pharmacokinetics; excluded: NG feeds/animal studies. Studies included: all genders, countries, > 18 years, community and hospital settings. PRISMA guidance was followed. Results Five hundred seventy results were found, and 23 articles identified following the reference list review. Following an abstract and full-text review, 18 were included. Most articles evaluated thickeners on dissolution profiles in-vitro, with a few investigating in-vivo. Most studies were single-centre prospective studies identifying that thickeners generally affect dissolution rates of medications. Few studies assessed bioavailability or used clinical outcomes. Conclusion Dysphagia and polypharmacy are common in older adults, but little is known about the effects of altering liquid viscosity on the therapeutic effect of most medications. Further larger-scale studies are required to evaluate the therapeutic impact of thickener, on a bigger range of medications, factoring in other variables such as type of thickener, viscosity of thickener and duration of immersion

The diagnosis of aspiration pneumonia in older persons: a systematic review

Purpose Community-acquired pneumonia (CAP) is highly common across the world. It is reported that over 90% of CAP in older adults may be due to aspiration. However, the diagnostic criteria for aspiration pneumonia (AP) have not been widely agreed. Is there a consensus on how to diagnose AP? What are the clinical features of patients being diagnosed with AP? We conducted a systematic review to answer these questions. Methods We performed a literature search in MEDLINE®, EMBASE, CINHAL, and Cochrane to review the steps taken toward diagnosing AP. Search terms for “aspiration pneumonia” and “aged” were used. Inclusion criteria were: original research, community-acquired AP, age≥ 75 years old, acute hospital admission. Results A total of 10,716 reports were found. Following the removal of duplicates, 7601 were screened, 95 underwent full text review, and 9 reports were included in the final analysis. Pneumonia was diagnosed using a combination of symptoms, inflammatory markers, and chest imaging findings in most studies. AP was defined as pneumonia with some relation to aspiration or dysphagia. Aspiration was inferred if there was witnessed or prior presumed aspiration, episodes of coughing on food or liquids, relevant underlying conditions, abnormalities on video fuoroscopy or water swallow test, and gravity-dependent distribution of shadows on chest imaging. Patients with AP were older, more frailer, and had more comorbidities than in non-AP. Conclusion There is a broad consensus on the clinical criteria to diagnose AP. It is a presumptive diagnosis with regards to patients’ general frailty rather than in relation to swallowing function itself