Screening and management of Dysphagia

Step 1 : Evaluate for swallowing difficulty: Identify dysphagia problems early in vulnerable patients


The first step in the process of dysphagia patient care is recognizing the vulnerable patient.  The patient’s clinical history, physical examination and results of a basic screening test are useful at this stage7.  The patient’s clinical history and specifically the presence of a certain medical condition (e.g., acute stroke, head and neck cancer, head trauma, Alzheimer’s disease, Parkinson’s disease) is adequate basis for predicting high-risk and the need for evaluation8.  As noted in the ACCP clinical practice guidelines, it is also important to screen patients with pneumonia or bronchitis for dysphagia risk.8  Be aware that older adults are more vulnerable to dysphagia, as the swallowing mechanism is altered among otherwise healthy older adults, what is termed ‘presbyphagia’.  With additional stressors such as acute illness and use of certain medications, an older individual can begin to experience dysphagia9.

Step 2: Evaluate for oral-pharyngeal dysphagia: Identify aspiration risk and appropriate diet prescription


Based on the evidence obtained by clinical history, physical examination, and a basic screening test (e.g., EAT-10), oral-pharyngeal dysphagia may be suspected and subsequently, the physician will order evaluation by the multidisciplinary healthcare team.  The dietitian may conduct a comprehensive nutrition assessment, determining the nutritional risk and needs of the individual.  The nurse will provide direct patient care and may conduct relevant procedures (e.g., record daily fluid intake).  The dysphagia specialist (specially-trained speech-language pathologist, logopedist, etc.) will determine aspiration risk and identify the appropriate diet prescription (the texture of solids, and the volume and viscosity of liquids).  The volume-viscosity swallow test (V-VST) is a sensitive clinical method to identify patients with oral-pharyngeal dysphagia whose swallowing could be improved by intervention with liquids of specific volume and viscosity6.   An important feature of the V-VST, is that it can help improve the detection of swallowing dysfunction, including silent aspiration.  Widespread use of this evidence-based method will facilitate appropriate early management oral-pharyngeal dysphagia.

 

 

Step 3: Evaluate pathophysiology of swallowing dysfunction: Identify appropriate therapeutic strategies


Based on the clinical evaluation of oral-pharyngeal dysphagia and aspiration (e.g. positive V-VST results), diagnostic tests may be ordered.  Videofluoroscopic swallowing study is the gold standard method for identifying the pathophysiology of the dysfunction and appropriate therapeutic strategies (e.g., direct swallowing exercises).  Members of the multidisciplinary team work together to assure the comprehensive needs of the patient are met2.

Step 4: Re-evaluate regularly: Continue to assess, monitor, and adjust interventions accordingly


Regularly assess dysphagia severity, monitoring the effects of treatment and adjusting interventions accordingly.  Regular use of the EAT-10 (e.g., on each patient visit) is a practical way to assess changes in symptom severity and guide patient care 2.

 

7. World Gastroenterology Organization Practice Guidelines; Dysphagia 2007. http://www.worldgastroenterology.org/assests/downloads/en/pdf/guidelines/08_dysphagia.pdf.


8. American College of Chest Physicians (ACCP), Smith Hammond CA, Goldstein LB: Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines. Chest 2006;129(suppl 1): 154S-168S.


9. Ney DM et al. Senescent swallowing: impact, strategies, and interventions. Nutr Clin Pract. 2009 Jun-Jul;24(3):395-413.