The Rehabilitation and Management of Dysphagia

A special issue of Geriatrics (ISSN 2308-3417). This special issue belongs to the section "Geriatric Rehabilitation".

Deadline for manuscript submissions: closed (30 November 2019) | Viewed by 64726

Special Issue Editor


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Guest Editor
1. Geriatric Medicine, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, Woolwich SE18 4QH, UK
2. Centre for Exercise and Active Rehabilitation (CEAR), University of Greenwich, London SE9 2UG, UK
Interests: dysphagia; frailty; care homes; stroke; swallowing rehabilitation
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Special Issue Information

Dear Colleagues,

I am acting as the Guest Editor for a Special Issue of the journal Geriatrics (https://www.mdpi.com/journal/geriatrics, ISSN 2308-3417) on the subject of "The Rehabilitation and Management of Dysphagia". It is my pleasure to invite you to submit an article on this topic.

Dysphagia is a common problem occurring in many medical problems. The frequency/prevalence is variable, with some progressive neurological problems having a prevalence up to 100% as the disease progression occurs. The prevalence will be higher in different settings, with care homes including the most vulnerable in society and having a larger number of people with dysphagia with the least experienced staff. The management and rehabilitation of dysphagia is unclear, with little evidence available outside of stroke, and any studies are small and frequently conducted in people who are either young or do not have clinical dysphagia. This Special Edition will focus on the management of dysphagia across the medical spectrum. Topics could include new research or reviews and cover the full spectrum of medical conditions from frailty, learning disorders to end of life.

Dr. David G. Smithard
Guest Editor

Manuscript Submission Information

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Geriatrics is an international peer-reviewed open access semimonthly journal published by MDPI.

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Keywords

  • Dysphagia
  • Rehabilitation
  • Neurology
  • Learning disability
  • Frailty

Published Papers (10 papers)

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Research

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14 pages, 694 KiB  
Article
First-Hand Experience of Severe Dysphagia Following Brainstem Stroke: Two Qualitative Cases
by Annette Kjaersgaard and Hanne Pallesen
Geriatrics 2020, 5(1), 15; https://doi.org/10.3390/geriatrics5010015 - 4 Mar 2020
Cited by 3 | Viewed by 4951
Abstract
Background: Dysphagia has profound effects on individuals, and living with dysphagia is a complex phenomenon that touches essential areas of life. Dysphagia following a brainstem stroke is often more severe and the chances of spontaneous recovery are less likely as compared with dysphagia [...] Read more.
Background: Dysphagia has profound effects on individuals, and living with dysphagia is a complex phenomenon that touches essential areas of life. Dysphagia following a brainstem stroke is often more severe and the chances of spontaneous recovery are less likely as compared with dysphagia following a hemispheric stroke. Objective: To explore how two individuals with brainstem stroke experienced severe dysphagia during their inpatient neurorehabilitation and how they experienced their recovery approximately one month following discharge. Methods: An explorative study was conducted to evaluate the first-hand perspective on severe eating difficulties. A qualitative case study was chosen to collect data during two face-to-face semi-structured interviews. Phenomenological perspectives shaped the interview-process and the processing of data. Results: Analysis of the empirical data generated the following main themes regarding experiences of: (i) the mouth and throat; (ii) shared dining; and (iii) recovery and regression related to swallowing-eating-drinking. Conclusion: Participants expressed altered sensations of the mouth and throat, which affected their oral intake and social participation in meals. Good support for managing and adapting their problems of swallowing, eating, and drinking in daily activities is essential. Knowledge and skills of professionals in relation to dysphagia is a significant requirement for recovery progress in settings within the municipality. Full article
(This article belongs to the Special Issue The Rehabilitation and Management of Dysphagia)
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9 pages, 947 KiB  
Article
A New Simple Screening Tool—4QT: Can It Identify Those with Swallowing Problems? A Pilot Study
by Karwai Tsang, Esther SY Lau, Mariyam Shazra, Ruth Eyres, Dharinee Hansjee and David G Smithard
Geriatrics 2020, 5(1), 11; https://doi.org/10.3390/geriatrics5010011 - 27 Feb 2020
Cited by 15 | Viewed by 5635
Abstract
As people and the population age, the prevalence of swallowing problems (dysphagia) increases. The screening for dysphagia is considered good practice in stroke care, yet is not routinely undertaken in the management of frail older adults. A short swallow screen, the 4QT, was [...] Read more.
As people and the population age, the prevalence of swallowing problems (dysphagia) increases. The screening for dysphagia is considered good practice in stroke care, yet is not routinely undertaken in the management of frail older adults. A short swallow screen, the 4QT, was developed following a review of the literature. The screen has four questions relating to swallowing that can be asked by a member of the health care team. A convenience sample of 48 older frail patients on an acute frailty ward was recruited into a Quality Improvement project. Their swallow was screened using the EAT-10 and 4QT. A speech and language therapist assessed for the presence of dysphagia using a standardised assessment for dysphagia. The 4QT was as effective as the EAT-10 in identifying older frail adults with potential swallowing problems (Κ = 0.73). The 4QT has 100% sensitivity, 80.4% specificity and positive predictive value (PPV) 50%, negative predictive value (NPV) 100%. The 4QT is a highly sensitive but not specific swallow screen, only 50% of people reporting swallowing problems were confirmed to have a degree of dysphagia by the SLT. The 4QT is a simple screening tool that could be used by all staff, but requires further research/evaluation before it is widely accepted into clinical practice. Full article
(This article belongs to the Special Issue The Rehabilitation and Management of Dysphagia)
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13 pages, 1070 KiB  
Article
Assessment and Management of Dysphagia in Acute Stroke: An Initial Service Review of International Practice
by Carol A. Fairfield and David G. Smithard
Geriatrics 2020, 5(1), 4; https://doi.org/10.3390/geriatrics5010004 - 21 Jan 2020
Cited by 12 | Viewed by 6667
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue The Rehabilitation and Management of Dysphagia)
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12 pages, 215 KiB  
Article
Variation in Dysphagia Assessment and Management in Acute Stroke: An Interview Study
by Sabrina A. Eltringham, Craig J. Smith, Sue Pownall, Karen Sage and Ben Bray
Geriatrics 2019, 4(4), 60; https://doi.org/10.3390/geriatrics4040060 - 25 Oct 2019
Cited by 10 | Viewed by 7340
Abstract
(1) Background: Patients with dysphagia are at increased risk of stroke-associated pneumonia. There is wide variation in the way patients are screened and assessed. The aim of this study is to explore staff opinions about current practice of dysphagia screening, assessment and clinical [...] Read more.
(1) Background: Patients with dysphagia are at increased risk of stroke-associated pneumonia. There is wide variation in the way patients are screened and assessed. The aim of this study is to explore staff opinions about current practice of dysphagia screening, assessment and clinical management in acute phase stroke. (2) Methods: Fifteen interviews were conducted in five English National Health Service hospitals. Hospitals were selected based on size and performance against national targets for dysphagia screening and assessment, and prevalence of stroke-associated pneumonia. Participants were purposefully recruited to reflect a range of healthcare professions. Data were analysed using a six-stage thematic process. (3) Results: Three meta themes were identified: delays in care, lack of standardisation and variability in resources. Patient, staff, and service factors that contribute to delays in dysphagia screening, assessment by a speech and language therapist, and delays in nasogastric tube feeding were identified. These included admission route, perceived lack of ownership for screening patients, prioritisation of assessments and staff resources. There was a lack of standardisation of dysphagia screening protocols and oral care. There was variability in staff competences and resources to assess patients, types of medical interventions, and care processes. (4) Conclusion: There is a lack of standardisation in the way patients are assessed for dysphagia and variation in practice relating to staff competences, resources and care processes between hospitals. A range of patient, staff and service factors have the potential to impact on stroke patients being assessed within the recommended national guidelines. Full article
(This article belongs to the Special Issue The Rehabilitation and Management of Dysphagia)
7 pages, 389 KiB  
Communication
Primary Healthcare Professionals Experience of Transfer and Meaning According to Screening for Dysphagia
by Alexia Andersen Fortes, Jeff André-Brylle, Signe Westmark and Dorte Melgaard
Geriatrics 2019, 4(4), 54; https://doi.org/10.3390/geriatrics4040054 - 27 Sep 2019
Cited by 2 | Viewed by 5260
Abstract
Transfer is a well-known theory about learning in practice contexts. This concept, combined with the need to implement screening for dysphagia in the nursing homes, has led to this project describing the experienced transfer effect and meaning among healthcare professionals after participation in [...] Read more.
Transfer is a well-known theory about learning in practice contexts. This concept, combined with the need to implement screening for dysphagia in the nursing homes, has led to this project describing the experienced transfer effect and meaning among healthcare professionals after participation in a practice-orientated workshop focusing on implementing the Minimal Eating Observation Form-II (MEOF-II). Fifty-eight healthcare professionals participated in a 2.5-h facilitated practice-orientated workshop in the period from March to September, 2018. Before and after the workshop, they filled out a questionnaire that focused on the healthcare professional’s experience of skills related to dysphagia. The study documented that, after the workshop, more healthcare professionals felt competent to perform the MEOF-II to identify signs of dysphagia and know their role in screening for dysphagia. Nine months after the workshop, 80% of the residents in the nursing home had been screened for dysphagia by using the MEOF-II. This study documented that practice-orientated workshops and systematic follow-up encouraged the healthcare professionals to use the MEOF-II to contribute to the early detection of dysphagia in the nursing home. Workshops based on the transfer theory may also be relevant for implementation and application of other new skills in similar settings. Full article
(This article belongs to the Special Issue The Rehabilitation and Management of Dysphagia)
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17 pages, 1302 KiB  
Article
Neuromuscular Electrical Stimulation Plus Rehabilitative Exercise as a Treatment for Dysphagia in Stroke and Non-Stroke Patients in an NHS Setting: Feasibility and Outcomes
by Nicola Martindale, John Stephenson and Sue Pownall
Geriatrics 2019, 4(4), 53; https://doi.org/10.3390/geriatrics4040053 - 24 Sep 2019
Cited by 5 | Viewed by 7017
Abstract
Dysphagia is a debilitating condition with significant consequences in terms of physical and mental health. This study demonstrates that it is feasible to provide an intensive therapy program combining neuromuscular electrical stimulation (NMES) with exercise against resistance in the treatment of dysphagia in [...] Read more.
Dysphagia is a debilitating condition with significant consequences in terms of physical and mental health. This study demonstrates that it is feasible to provide an intensive therapy program combining neuromuscular electrical stimulation (NMES) with exercise against resistance in the treatment of dysphagia in a public healthcare setting. Thirty-one patients (17 stroke, 14 non-stroke) who experienced dysphagia with reduced laryngeal elevation completed the therapy program. After checking the data sets for comparability, it was deemed appropriate for the outcome data from these patients to be combined with that of 12 stroke patients previously reported to enable statistical analysis on a larger data set (n = 43). A repeated-measures ANOVA revealed a statistically significant increase in amount and variety of food a patient was able to take orally (FOIS) following completion of treatment (p < 0.001). There was no significant between-subject effect of stroke status (p = 0.43), or interaction between treatment and stroke status (p = 0.68). There was a significant improvement in secondary outcome measures of swallow safety with fluids (PAS) (p < 0.001) and swallow-related quality of life (Swal-Qol (p < 0.001). These findings indicate that the therapy program may be associated with reduced impairment in a subset of patients with dysphagia resulting from stroke and non-stroke atiologies, and the data will inform the design of future research to address unanswered questions. Full article
(This article belongs to the Special Issue The Rehabilitation and Management of Dysphagia)
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15 pages, 772 KiB  
Article
The Development of a Digital Dysphagia Guide with Care Homes: Co-Production and Evaluation of a Nutrition Support Tool
by Susan Pownall, Elizabeth Barnett, Julie Skilbeck, Angel Jimenez-Aranda and Sally Fowler-Davis
Geriatrics 2019, 4(3), 48; https://doi.org/10.3390/geriatrics4030048 - 15 Aug 2019
Cited by 8 | Viewed by 9172
Abstract
Good nutrition is a recognised outcome in the health and well-being of older care home residents and dysphagia is a known risk factor associated with under nutrition and poor outcomes. The study co-produced a digital Dysphagia Guide with Care Homes using a consensus [...] Read more.
Good nutrition is a recognised outcome in the health and well-being of older care home residents and dysphagia is a known risk factor associated with under nutrition and poor outcomes. The study co-produced a digital Dysphagia Guide with Care Homes using a consensus method with interviews and focus groups to prioritise the need for information and explore acceptability of an educational tool for care home workers. Evaluation of use, acceptability of design, and content of the guide were completed via remote monitoring. The workforce prioritised the need for training as well as the knowledge and skills in relation to planning resident-centred care and advice on textured diets. The technology was a means of offering ‘bite-size’ learning to enhance planning for nutrition across the whole organisation including managers, kitchen staff, and care workers. The Guide to Dysphagia was produced on a tablet and piloted in four care homes over 12 weeks, by 57 staff. Integrated analytics allowed user activity to be monitored. Findings showed that 73% of respondents reported the guide helped them in their job. Additionally, 88% of respondents stated they would recommend the guide to other staff, with 90% reporting it was easy to use. Engagement with staff and managers in four homes resulted in a co-designed, dysphagia guide. Full article
(This article belongs to the Special Issue The Rehabilitation and Management of Dysphagia)
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13 pages, 904 KiB  
Article
Natural History of Swallow Function during the Three-Month Period after Stroke
by Viridiana Arreola, Natàlia Vilardell, Omar Ortega, Laia Rofes, Desiree Muriana, Ernest Palomeras, Daniel Álvarez-Berdugo and Pere Clavé
Geriatrics 2019, 4(3), 42; https://doi.org/10.3390/geriatrics4030042 - 9 Jul 2019
Cited by 13 | Viewed by 6547
Abstract
Oropharyngeal dysphagia is a prevalent complication following stroke (PS-OD), and one that is sometimes spontaneously recovered. This study describes the natural history of PS-OD between admission and three months post-stroke, and the factors associated with its prevalence and development. PS-OD was assessed with [...] Read more.
Oropharyngeal dysphagia is a prevalent complication following stroke (PS-OD), and one that is sometimes spontaneously recovered. This study describes the natural history of PS-OD between admission and three months post-stroke, and the factors associated with its prevalence and development. PS-OD was assessed with the volume-viscosity swallow test (V-VST) in all stroke patients on admission and at the three-month follow-up. We analyzed clinical, demographic, and neuroanatomical factors of 247 older post-stroke patients (National Institute of Health Stroke Scale (NIHSS) = 3.5 ± 3.8), comparing among those with PS-OD the ones with and without spontaneous recovery. PS-OD prevalence on admission was 39.7% (34.0% impaired safety; 30.8%, efficacy) and 41.7% (19.4% impaired safety; 39.3%, efficacy) at three months. Spontaneous swallow recovery occurred in 42.4% of patients with unsafe and in 29.9% with ineffective swallow, associated with younger age and optimal functional status. However, 26% of post-stroke patients developed new signs/symptoms of ineffective swallow related to poor functional, nutritional and health status, and institutionalization. PS-OD prevalence on admission and at the three-month follow-up was very high in the study population. PS-OD is a dynamic condition with some spontaneous recovery in patients with optimal functional status, but also new signs/symptoms can appear due to poor functionality. Regular PS-OD monitoring is needed to identify patients at risk of nutritional and respiratory complications. Full article
(This article belongs to the Special Issue The Rehabilitation and Management of Dysphagia)
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Review

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17 pages, 1621 KiB  
Review
An Overview of Systematic Reviews and Meta-Analyses on Acupuncture for Post-Acute Stroke Dysphagia
by Zi-Yu Tian, Xing Liao, Ying Gao, Shi-Bing Liang, Chong-Yang Zhang, De-Hao Xu, Jian-Ping Liu and Nicola Robinson
Geriatrics 2019, 4(4), 68; https://doi.org/10.3390/geriatrics4040068 - 8 Dec 2019
Cited by 7 | Viewed by 5732
Abstract
Background: Many randomized controlled trials (RCTs) and systematic reviews (SRs) on acupuncture treatment for post-acute stroke dysphagia have been published. Conflicting results from different SRs necessitated an overview to summarize and assess the quality of this evidence to determine whether acupuncture is effective [...] Read more.
Background: Many randomized controlled trials (RCTs) and systematic reviews (SRs) on acupuncture treatment for post-acute stroke dysphagia have been published. Conflicting results from different SRs necessitated an overview to summarize and assess the quality of this evidence to determine whether acupuncture is effective for this condition. The aim was to evaluate methodological quality and summarizing the evidence for important outcomes. Methods: Seven databases were searched for SRs and/or meta-analysis of RCTs and quasi-RCTs on acupuncture for post-acute stroke dysphagia. Two authors independently identified SRs and meta-analyses, collected data to assess the quality of included SRs and meta analyses according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the revised Assessment of Multiple Systematic Reviews (AMSTAR 2). Results: Searches yielded 382 SRs, 31 were included. The quality of 22 SRs was critically low, five SRs were low, and four Cochrane SRs were moderate when evaluated by AMSTAR2. A total of 17 SRs reported 85.2–96.3% of PRISMA items. Five SRs included explanatory RCTs, 16 SRs included pragmatic RCTs, and 10 SRs included both. Conclusion: Currently, evidence on the effectiveness of acupuncture on post-acute stroke dysphagia is of a low quality. The type of study appeared to have no direct influence on the result, but the primary outcome measures showed a relationship with the quality of SRs. High quality trials with large sample sizes should be the focus of future research. Full article
(This article belongs to the Special Issue The Rehabilitation and Management of Dysphagia)
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Other

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10 pages, 211 KiB  
Discussion
Optimising Medicines Administration for Patients with Dysphagia in Hospital: Medical or Nursing Responsibility?
by David J. Wright, David G. Smithard and Richard Griffith
Geriatrics 2020, 5(1), 9; https://doi.org/10.3390/geriatrics5010009 - 19 Feb 2020
Cited by 13 | Viewed by 5605
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue The Rehabilitation and Management of Dysphagia)
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