Dysphagia Assessment

Dysphagia, or difficulty swallowing, occurs in approximately 55 percent of people with new-onset strokes. Only about 50 percent of those affected recover their normal swallowing ability by six months after onset. Dysphagia may lead to poor nutrition and dehydration^{541, 542} and can result in aspiration leading to pneumonia. Use of a screening tool followed by a detailed swallowing analysis by a trained healthcare professional can enhance early recognition of dysphagia.

• Development and delivery of educational programs to train appropriate staff to perform an initial swallowing screening for stroke patients. This may include staff across the continuum, such as in emergency departments, acute inpatient units, rehabilitation facilities, and community and long-term care settings.
• Access to appropriately trained healthcare professionals such as speech–language pathologists, occupational therapists, and dietitians who can conduct in-depth assessments.

1. Proportion of stroke patients with documentation that an initial dysphagia screening assessment was performed in the emergency department or during hospital admission (core).
2. Proportion of stroke patients with poor results on initial screening who then receive a comprehensive assessment by a speech–language pathologist or other appropriately trained healthcare professional.
3. Median time in minutes from patient arrival in the emergency department to initial swallowing screening by a trained clinician.

Measurement notes

• Data sources include emergency department records, nursing notes, medical notes, and allied healthcare professional notes.

• Ontario Stroke Network OREG Dysphagia Screening Tools Review
• TOR-BSST: www.canadianstrokenetwork.ca/eng/tools/index.php

In 1994, it was estimated that dysphagia was present in approximately 21 000 new stroke patients older than 65 years of age, and that only half of these patients would recover their swallowing ability within the first week.⁵⁴³ Based on a systematic review of the stroke literature, it was estimated that 55 percent of patients demonstrate some degree of dysphagia during their acute care stay.⁵⁴⁴ Dysphagia tends to be less frequent and persistent after hemispheric stroke than in brain stem stroke.⁵⁴⁴ There is evidence for an increased risk for pneumonia in stroke patients with dysphagia (RR 3.17, 95% CI 2.07–4.87) and an even greater risk in stroke patients with aspiration (RR 11.56, 95% CI 3.36–39.77).

There is emerging evidence that a systematic program for screening, diagnosis and treatment of dysphagia in acute stroke patients may yield dramatic reductions in pneumonia rates, feeding tube dependency and length of hospital stay.^543,545-547 Prompt attention to dysphagia screening, followed by appropriate assessment and management, is a deterrent to concomitant problems of aspiration, compromised nutrition and hydration. Westergren (2006) describes the screening activities as “a simple process aiming at identifying those having difficulties with eating” and the assessment process  “as a more complex process involving the use of a multitude of parameters and sometimes invasive measures (such as testing of pharyngeal sensation and gag reflex) or instrumental procedures [such as Videofluoroscopic Study of Swallowing (VFSS) and Fiberoptic Endoscopic Examination of Swallowing (FEES)] to determine functions with a focus on specific details”.⁵⁴⁸

A systematic review by Westergren (2006) examined non-instrumental (besides pulse oximetry) and non-invasive screening methods for bedside detection of eating difficulties among persons with stroke.⁵⁴⁸ Among the 17 articles included in the review, 14 dealt with dysphagia and four with eating difficulties.  The Standardized Bedside Swallowing Assessment was used in the dysphagia studies.  This screening tool involves three stages: general assessment (conscious level, postural control, voluntary cough, voice quality and ability to swallow saliva), sipping water from a spoon, and if safe then proceeding to drink water from a glass. Inter-observer and intra-observer reliability levels for SSA vary between studies, with values of Kappa = 0.24–0.48 between doctors and SLTs, 0.50 between doctors, 0.79 between SLTs, as quoted by Smithard et al. 1997, 1998.^{549, 550} Nurses who completed an education and training program achieved very good agreement (Kappa 0.88, exact agreement 94%) between screening and summative clinical judgment of swallowing function (n = 68, Perry 2001a).

Using the SSA for detection of aspiration shows variable sensitivity (47% to 68%), specificity (67% to 86%), PPV (positive predictive value 38% to 50%) and NPV (negative PV 85% to 88%) when used by SLTs and doctors. ^{549, 550}Using the SSA for detection of dysphagia (‘summative clinical judgment’) showed a sensitivity of 97%, specificity 90%, PPV 92% and NPV 96% and an accuracy of 86% when used by nurses.⁵⁵¹Thus, SSA is more specific for dysphagia in general than for aspiration specifically. SSA has been shown to be a stronger predictor of complication rates and functional outcome than the VFSS.

Bedside screening of each new stroke patient may involve observation of the patient’s level of alertness to participate in the screening process. It should include an evaluation of the patient’s oral motor function and oral sensation, as well as the presence of a cough. It may also include trials of fluid such as that included in the Toronto Bedside Swallow Screening Test (TOR-BSST©) or the Burke test.⁵⁵² These tools recommend that water be administered using a preset protocol and that signs of impaired swallowing be monitored. Coughing during and up to one minute following test completion and/or “wet” or hoarse voice are suggestive of an abnormal swallow. A cautionary note here is that silent aspiration may occur in patients who do not cough or complain of any problems with swallowing or have no wet-sounding voice. If there is silent aspiration, the patient may not display any signs or symptoms on the trial swallows. It is possible for them to not demonstrate obvious problems during the initial screen and still be aspirating. Therefore all stroke patients, regardless of their screening result, should be informally monitored during their hospital stay for symptoms of swallowing problems.

A screening test should be simple to use and have proper psychometric validation before it is implemented as part of the existing stroke care program. The TOR-BSST© has been validated on over 300 patients with stroke and shown to have high reliability and high accuracy in detecting dysphagia, regardless of severity, in both acute and rehabilitation patients with stroke. ⁵⁵²

Patients who have problems identified on the initial swallowing screen should be referred for specialized assessment and management to a speech–language pathologist as soon as possible. A complete assessment of swallowing includes a full bedside (clinical) assessment and, if deemed necessary, an instrumental assessment such as a video fluoroscopic or fibreoptic endoscopic assessment of swallowing.

Results from these assessments assist in determining the severity, type and prognosis of dysphagia and in planning a management program. The management program should include compensatory techniques (such as texture modifications and swallowing postures) and rehabilitative techniques. ⁵⁵³Appropriate dysphagia management reduces the risk of complications of dysphagia such as aspiration, malnutrition and dehydration as well as assists in overall recovery.⁵⁵⁴ Malnutrition as a result of dysphagia is a valid concern, and nutritional status should be assessed in patients with dysphagia.

For more information related to nutrition and dysphagia, refer to recommendation 4.2, “Components of acute inpatient care—Nutrition and Dysphagia.”