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Management of patients with stroke: identification and management of dysphagia

Evaluating swallowing and nutrition after stroke

  • Dysphagia affects a large proportion of stroke patients. Swallowing difficulties can result in aspiration and reduced oral intake, leading to the potentially serious complications of pneumonia, undernutrition, and dehydration
  • All stroke patients should be screened for dysphagia before being given food or drink

Aspiration pneumonia

  • The water swallow test should be used as part of the screening for aspiration risk in stroke patients
  • Clinical history taking should take into account comorbidities and other risk factors (e.g. smoking, respiratory disease) to identify increased risk of developing aspiration pneumonia

Swallow screening

  • Patients with dysphagia should be monitored daily in the first week to identify rapid recovery. Observations should be recorded as part of the care plan
  • Patients not fit for assessment should be screened daily to avoid delay in referral for full clinical assessment
  • A typical swallow screening procedure should include:
    • initial observations of the patient's consciousness level
    • observations of the degree of postural control
  • If the patient is able to actively cooperate and is able to be supported in an upright position the procedure should also include:
    • observations of oral hygiene
    • observations of control of oral secretions
    • if appropriate, a water swallow test
  • Patients on nil-by-mouth or modified diet should continue to receive clinically essential medication by an appropriate route as advised by a pharmacist

Diet modification

  • Advice on diet modification and compensatory techniques (postures and manoeuvres) should be given following full swallowing assessment
  • Texture-modified food should be attractively presented and appetising. Patients should have a choice of dishes
  • Texture-modified meals may be fortified to enable patients to meet nutritional requirements
  • Food and fluid intake should be monitored and, if indicated, a referral made to the dietitian

Nutritional screening

  • Assessment of nutritional risk should be carried out within the first 48 hours with regular re-assessment thereafter during the patient's recovery and be recorded prior to any discharge
  • Assessment of a patient's nutritional risk should include an assessment of their ability to eat independently and a periodic record of their food consumption
  • Ongoing monitoring of nutritional status should include a combination of the following parameters:
    • biochemical measures (i.e. low pre-albumin, impaired glucose metabolism)
    • swallowing status
    • unintentional weight loss
    • eating assessment and dependence
    • nutritional intake
  • Nutritional screening should cover, body mass index (BMI), ability to eat, appetite, physical condition, and mental condition

Assessment

  • A standardised clinical bedside assessment (CBA) should be used by a professional skilled in the management of dysphagia
  • The CBA developed and tested by Logemann, or a similar tool, is recommended
  • The modified barium swallow (MBS) test and fibreoptic endoscopic evaluation (FEES) of swallow are both valid methods for assessing dysphagia. The clinician should consider which is the most appropriate for different patients in different settings
  • Hospital and community pharmacists or medicines information centres should be consulted on the most appropriate method of administering medication

Dysphagia therapy

  • All patients who have dysphagia for more than one week should be assessed to determine their suitability for a rehabilitative swallowing therapy programme. Consideration should be given to:
    • the nature of the underlying swallowing impairment
    • patient suitability in terms of motivation and cognitive status
  • Patients with dysphagia should have an oropharyngeal swallowing rehabilitation programme that includes restorative exercises in addition to compensatory techniques and diet modification

Nutritional interventions

  • Following nutritional screening, those identified as undernourished, and those at risk of becoming undernourished, should be referred to a dietitian and considered for prescription of oral nutritional supplements as part of their overall nutritional care plan
  • Patients with dysphagia who are unable to meet their nutritional requirements orally should be considered for initial nasogastric (NG) feeding as soon as possible, within one week of onset. This decision should be made by the multidisciplinary team in consultation with the patient and their carers/family
  • Patients in the early recovery phase should be reviewed weekly by the multidisciplinary team to ascertain if longer term (>4 weeks) feeding is required
  • Feeding via percutaneous endoscopic gastrostomy (PEG) is the recommended feeding route for long term (>4 weeks) enteral feeding. Patients requiring long term tube feeding should be reviewed regularly
  • Patient's and carer's perceptions and expectations of PEG feeding should be taken into account and the benefits, risks, and burden of care fully explained before initiating feeding

Role of regular review

  • Patients with persistent dysphagia should be reviewed regularly, at a frequency related to their individual swallowing function and dietary intake, by a professional skilled in the management of dysphagia

Oral hygiene

  • Good oral hygiene should be maintained in patients with dysphagia, particularly in those with PEG or NG tubes, in order to promote oral health and patient comfort
  • An appropriate oral care protocol should be used for every patient with dysphagia, including those who use dentures

Caring for patients with dysphagia

  • Staff, carers, and patients should be trained in feeding techniques. This training should include:
    • modifications of positioning and diet
    • food placement
    • management of behavioural and environmental factors
    • delivery of oral care
    • management of choking

Example swallow screen

Algorithm of example swallow screen

Algorithm of example swallow screen

full guideline available from…
Scottish Intercollegiate Guidelines Network, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB (Tel – 0131 623 4720)
www.sign.ac.uk/sign-119-management-of-patients-with-stroke-identification-and-management-of-dysphagia.html

Scottish Intercollegiate Guidelines Network. Management of patients with stroke: identification and management of dysphagia. Edinburgh: SIGN; 2010. (SIGN Guideline No. 119).
First included: March 2016.