Published: 08/01/2004, Volume II4, No. 5886 Page 27
The term dysphagia is used to describe an abnormality of swallowing and may include problems positioning food in the mouth, chewing, delayed swallow reflex, escape of the bolus into the airway and choking. Dysphagia is a common and serious problem following a stroke, but problems can also arise from a wide range of neurological, structural or psychological conditions, including dementia, Parkinson's disease, multiple sclerosis, head injury, cancers and general degenerative conditions.
The precise incidence of dysphagia is unknown because it is frequently under-diagnosed.However, Department of Health figures for 2001-03 record more than 23,000 primary diagnoses of dysphagia in England and Wales, associated with almost 76,000 bed days. Some 40-60 per cent of nursing home residents may have dysphagia to some degree.
There is a need for early detection and management of dysphagia in both hospital and primary care to reduce the serious risks associated with this condition, which may be severe and include aspiration pneumonia, malnutrition, dehydration, increased susceptibility to infection and reduced tissue viability.
Amber Valley primary care trust's speech and language therapy service has created 256 dysphagia-trained nurses (DTNs) to identify and manage the condition, referring on severe, complex and persistent cases. Nurses now manage 40 per cent of dysphagic clients in acute, rehabilitation, mental health and residential settings. The scheme has been extended into nursing homes and primary care over the last year.
Consider the case of Mrs X, an 88-year-old woman with moderate dementia who lived in a nursing home.Her medical condition suddenly deteriorated over three days with a chest infection; she became confused and stopped eating and drinking.
The DTN in the nursing home was able to assess Mrs X on the first day she started to deteriorate and recommend thickened fluids and a smooth diet. She requested a GP visit for Mrs X and antibiotics were prescribed as she was at high risk of aspiration.
An emergency referral to speech and language therapy was made; the therapist visited two days later to assess Mrs X, found she was at risk of aspiration and made recommendations about diet and feeding needs.
The DTN agreed to monitor Mrs X and contact the speech and language therapist if she had any concerns.
Two weeks later the SLT phoned the nursing home to arrange a review appointment for Mrs X. The DTN had monitored and reassessed Mrs X, who had improved significantly and had progressed to syrupy fluids and a 'fork-mashable' diet. It was not necessary for the SLT to visit Mrs X and the DTN agreed to contact her as required.
In this case the DTN detected and assessed Mrs X for dysphagia and made an interim management plan, referring to the appropriate professionals immediately. This facilitated a prompt specialist assessment and prescription of antibiotics. An admission to hospital was prevented and Mrs X survived.
Where admission to local or acute hospitals is required, we have found that the DTNs are consistently assessing the patients sooner than SLT. The scheme has been audited and the number of nil-bymouth days for patients in acute beds has reduced by 40 per cent.
Mary Heritage is professional lead and Holly Froud is specialist speech and language therapist for Southern Derbyshire speech and language therapy services, Amber Valley PCT.