Post-Stroke Dysphagia Stroke Master Class

Mary McFarlane BSc Hons MSc

Northwick Park Hospital Principal Speech and Language Therapist Adult Acute/Stroke

Aims

�  Provide an overview of the incidence of dysphagia, associated risks and dysphagia recovery

�  Highlight the limitations of current practice and benefits of instrumental assessment

�  Review treatment and management of post-stroke dysphagia

Dysphagia an Overview

Stages of Swallowing 1 Oral Preparatory stage 2 Oral stage 3 Pharyngeal stage 4 Esophageal stage

Incidence of Post-Stroke Dysphagia

�  The most reliable videofluoroscopic evidence reports the incidence of dysphagia in the acute phase as 78% (Daniels and Foundas, 1999) and 71% (Hamdy et al. 1998)

�  Aspiration is reported in 38% (Daniels and Foundas, 1999) and 42% (Kidd, Lawson, Nesbitt and MacMahon 1993) of dysphagic patients

�  67% of post-stroke patients that aspirated did so silently, Daniels et al. (1998)

Silent Aspiration

Risks associated with post-stroke dysphagia �  Increased risk of poor nutrition, hydration and aspiration-

related pneumonia (Martino, et al. 2005)

�  Increased length of hospital admission, increased mortality, co-morbidities, institutionalization and health care costs (Smithard, et al. 1996)

�  Increased medication administration errors (Haw, et al 2007)

�  Up to one-third of stroke patients will develop pneumonia (Sellars, et al. 2007)

�  Pneumonia is the leading cause of death post-stroke (Heuschmann et al. 2004)

�  Pneumonia in the post-stroke population is often due to aspiration ( Armstrong and Mosher (2011)

Risks associated with post-stroke silent aspiration

�  5.5 times greater risk for developing pneumonia for stroke patients that aspirated silently, compared with those who audibly aspirated or those that did not aspirate (Holas et al. 1994)

�  Patients with aspiration during swallow had a fourfold increased risk of pneumonia. Those with profound aspiration had a tenfold increased risk and those with silent aspiration had a thirteen fold increased risk of pneumonia (Pikus et al. 2003)

Limitations of Current Practice

�  The traditional dysphagia assessment is not reliable for detecting silent aspiration (Ramsey et al 2003)

�  CSE identified 42% of the aspirating patients; more concerning, 70% of patients with profound aspiration on VFS were not identified as aspirating during their CSE (Splaingard et al 1988)

Instrumental Assessment

VFSS FEES®

VideoFluoroscopic Swallow Study Fiberoptic Endoscopic Evaluation of Swallowing

Screening tools for silent aspiration �  Cough Reflex Testing (CRT) a quick, cost effective, validated

method to identify those at risk of silent aspiration (Miles et al 2013)

�  CRT paired with a water swallow test. Sensitivity for detection of aspiration was 89% and specificity was 89% (Wakasugi et al., 2008)

�  CRT has been in use for over 50 years and has been specifically designed to assess reflexive, as opposed to voluntary cough

�  Over the past 20 years researchers have used cough reflex testing to specifically test cough in the stroke population

�  CRT is used as part of routine clinical practice in many institutions

CRT Strong pass

CRT Fail

Dysphagia cause and recovery

�  Central and peripheral causes can result in absence of function, weakness or incoordination of swallow musculature

�  Post-stroke dysphagia is typically transient and spontaneously resolves. 71% of patients initially presented with dysphagia this reduced to 46% one month post (Hamdy et al. 1998)

�  Recovery in the acute stage is often attributable to the resolution of oedema and return of circulation to the ischemic penumbra (Dombovy, 1991)

�  Hamdy et al (1998) suggest reorganisation of the intact hemisphere as a mechanism for dysphagia recovery

Management of Dysphagia •  Compensatory:

-  Typically used in the acute stages -  Address the symptoms of dysphagia but not underlying

impaired swallow physiology

�  Rehabilitative: -  Rehab is necessary for those whose swallowing problems

do not resolve spontaneously -  Therapy programmes have shown positive returns to total

oral feeding even in patients with chronic dysphagia (Crary 1995, Huckabee & Cannito 1999)

Diet restrictions & modification

�  NBM non oral feeding NGT & PEG

�  Puree diet

�  Water Protocols

�  Medication administration in patients with dysphagia after stroke should be managed as a team (McFarlane et al 2014)

Summary �  Dysphagia post-stroke is common, early identification and management is

crucial to avoid aspiration pneumonia, dehydration and malnutrition

�  Dysphagia management needs to be approached as an inter-disciplinary team

�  Speech-Language Therapists provide objective diagnostic information about a patient’s swallowing abilities and provide recommendations for rehabilitation of swallowing physiology, while also providing short-term compensatory advice

�  Diet modification has consequences for nutrition, hydration and quality of life and this should be taken into consideration by the stroke team. Medication administration in patients with dysphagia is complex and poses pharmaceutical and legal challenges

�  Pharmacists should be consulted and patient care plans should be individualised to provide safe and effective pharmaceutical support

Thank you

References Armstrong, J. R., and Mosher, B. D. (2011). Aspiration Pneumonia After Stroke: Intervention and prevention. The Neurohospitalist, 1(2), 85-93.

Crary, M.A. (1995) A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke. Dysphagia, 10, 6-18

Daniels, S. K., Brailey, K., Priestly, D. H., Herrington, L. R., Weisberg, L. A., & Foundas. A. L. (1998). Aspiration in patients with acute stroke. Archives of Physical Medicine and Rehabilitation,79, 14-19.

Daniels, S. K., & Foundas, A. L. (1999). Lesion localization in acute stroke patients with risk of aspiration. Journal of Neuroimaging, 9, 91-98.

Dombovy, M. L. (1991). Stroke: Clinical course and neurophysiologic mechanisms of recovery. Critical Reviews in Physical and Rehabilitation Medicine, 2(17), 171-188.

Hamdy, S., Aziz, Q., Rothwell, J, C., Power, M., Singh, K.D., Nicholson, D.A., Tallis, R.C., & Thompson, D.G. (1998). Recovery of swallowing after dysphagic stroke relates to functional reorganization in the intact motor cortex. Gastroenterology, 115, 1104-1112.

Haw, C, Stubbs, J, & Dickens, G. (2007). An observational study of medication administration errors in old-age psychiatric inpatients. International Journal of Quality in Health Care, 19(4), 210-216.

Heuschmann, P. U., Kolomonsky-Rabas, P. L., Misselwitz, B., Hermanek, P., Leffmann, C., Janzen, R. W., Rother, J., Buecker-Nott, H. J., and Berger, K. (2004). Predictors of in-hospital mortality and attributable risks of death after ischemic stroke: the German Stroke Registers Study Group. Archives of Internal Medicine, 13(16), 1761-8.

References Holas, M. A., DePippo, K. L., & Reding, M. J. (1994). Aspiration and Relative Risk of Medical Complications Following Stroke. Archives of Neurology, 51, 1051-1053.

Huckabee, M-L. & Cannito, M.P. (1999) Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation. Dysphagia, 14, 93-10

Kidd, D., Lawson, J., Nesbitt, R., and MacMahon, J. (1993) Aspiration in acute stroke: A clinical study with Videofluoroscopy. Quarterly Journal of Medicine, 86(12), 825-9

Martino, R., Foley, N., Bhogal, S., Diamant, N., Speechley, M., & Teasell, R. (2005). Dysphagia after stroke: Incidence, diagnosis, and pulmonary complications. Stroke, 36, 2756-2763.

Miles, A., Moore, S., McFarlane, M., Lee, J., Allen & Huckabee, M, L. (2013). Comparison of cough reflex test against instrumental assessment of aspiration. Physiology and Behaviour. 118 25-31

McFarlane M, Miles A, Atwal & Parmar P. (2014) Inter-disciplinary management of dysphagia following stroke. British journal of Neuroscience Nursing. (In press).

Pikus L, Levine M, Yang Y, Rubesin S, Katzka D, Laufer I, Gefter WB. (2003) Videofluroscopic studies of swallowing dysfunction and the relative risk of pneumonia. AJR Am J Roentgenol. 180 (6): 1613-1616.

Ramsey, D, Smithard, D & Kalra L. (2003). Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke 34, 1252–7.

References Sellars, C., Bowie, L., Bagg, J., Sweeney, P., Miller, H., Tilston, J., Langhorne, P., & Stott, D.J. (2007). Risk Factors for Chest Infection in Acute Stroke A Prospective Cohort Study. Stroke, 38 (8), 2284-2291.

Smithard, D., Parks, C., Morris, J., Wyatt. R., England, R., and Martin, D. (1996). Complications and outcome after acute stroke: Does dysphagia matter? Stroke, 27, 1200-1204.

Splaingard, M, Hutchins, B, Sulton, L & Chaudhuri, G. (1988). Aspiration in rehabilitation patients: Videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil, 68, 637- 40.

Wakasugi, Y., Tohara, H., Hattori, F., Motohashi, Y., Nakana, A., & Goto, S. (2008).Screening test for silent aspiration at the bedside. Dysphagia, 23 (4), 364-370.