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 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

We conducted a systematic literature review and analysis of programs for evaluating swallowing in order to prevent aspiration pneumonia. This article derives from an evidence report on diagnosis and treatment of swallowing disorders (dysphagia) in acute-car stroke patients prepared by us as an Evidence-based Practice Center (EPC) under contract to the U.S. Agency for Healthcare Research and Quality (AHRQ). Available evidence on the diagnosis and treatment of dysphagia for preventing pneumonia is limited. We found reported pneumonia rates in one historical controlled study of a program using bedside exams (BSE) for acute stroke patients; one uncontrolled case series study of acute stroke patient-reporting of swallowing difficulty; one controlled case series study of videofluoroscopic study of swallowing (VFSS) for acute stroke patients; and one historical controlled study of fiberoptic endoscopic examination of swallowing (FEES) for patients referred for swallowing evaluation in rehabilitation centers. Comparing these results with historical controls indicates that implementation of dysphagia programs is accompanied by substantial reductions in pneumonia rates. While all these methods appeared effective, the small sizes of available studies did not allow determination of the relative efficacy of BSE, VFSS, or FEES.
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PMID:Prevention of pneumonia in elderly stroke patients by systematic diagnosis and treatment of dysphagia: an evidence-based comprehensive analysis of the literature. 1172 Apr 4

Stroke is a major cause of acute and chronic disability in the developed world, producing a wide range of impairments, including dysphagia, which impact upon eating. Dysphagia affects between one and two thirds of patients with acute stroke, with the potential for life-threatening airway obstruction, aspiration pneumonia and malnutrition. Whilst associated with increased impairment, dysphagia may present in isolation or accompanied by minimal disability; universal screening of swallowing function is recommended. This study describes the process undertaken to review the evidence for dysphagia screening methods in patients with acute stroke. It also identifies, implements and establishes sensitivity and specificity of a screening tool (the Standardized Swallowing Assessment, SSA) for use by nurses. Not all ward staff had completed training to use the SSA by conclusion of the patient audit. Nonetheless 123 out of 165 assessable patients (74.5%) had their swallow function screened, 64 by SSA (52%). Based on 68 completed screening episodes by independently competent nurses, a comparison with summative clinical judgement of swallow function revealed a sensitivity of 0.97 and specificity of 0.9 for detection of dysphagia, with positive and negative predictive values of 0.92 and 0.96. This was significantly better than gag reflex performance, supporting the use of the SSA by competent ward nurses.
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PMID:Screening swallowing function of patients with acute stroke. Part one: Identification, implementation and initial evaluation of a screening tool for use by nurses. 1182 94

The objective of this study was to examine the frequency of dysphagia symptoms and related consequences in medullary stroke patients admitted to a stroke rehabilitation unit. A chart review of a cohort of 563 stroke patients admitted to a rehabilitation unit was used to identify patients with evidence of predominantly medullary lesions. The results of both initial and followup videofluoroscopic modified barium swallowing (VMBS) studies were also reviewed for evidence of aspiration and residuum in patients with dysphagia. Twenty of the 563 patients (3.6%) were diagnosed with a medullary stroke. Eleven of the 20 (55%) patients were identified clinically with dysphagia and nine had at least one (VMBS) study. All dysphagic patients demonstrated some degree of either aspiration or residuum on both initial and final swallowing studies and received some form of dietary modification. Comparisons between patients with and without dysphagia demonstrated significant differences with regard to length of hospital stay and the development of pneumonia (p < 0.05). More than half of the patients with medullary strokes presented with clinical indications of dysphagia, were more likely to develop aspiration pneumonia, and experienced longer hospital stays. Aspiration pneumonia appeared to be an early complication of stroke and dietary modifications did not prevent its development.
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PMID:The incidence, management, and complications of dysphagia in patients with medullary strokes admitted to a rehabilitation unit. 1195 36

Aspiration pneumonia is a serious problem for the elderly institutionalized person, often requiring transfer to a hospital and a lengthy stay there. It is associated with a high mortality rate and is very costly to the health care system. The current study sought to determine the key predictors of aspiration pneumonia in a nursing home population with the hope that health care providers could identify those residents at highest risk and focus more efforts on prevention of this serious disease. A cross-sectional, retrospective analysis was done, using the Minimum Data Set (MDS) nursing home assessment data for three states (New York, Mississippi, Maine) from 1993 to 1994 (N = 102842). Nursing home residents were aged 65+. Standardized MDS summary scales and their component items were used, including: the Activities of Daily Living (ADL) scale, the cognitive performance scale (CPS), and the Resource Utilization Groups (RUGs). Results of these analyses showed the prevalence of pneumonia among this population was 3% (n = 3118). Results from the logistic regression models indicated 18 significant predictors of aspiration pneumonia. The strongest to weakest predictors of pneumonia were, respectively, suctioning use, COPD, CHF, presence of feeding tube, bedfast, high case mix index, delirium, weight loss, swallowing problems, urinary tract infections, mechanically altered diet, dependence for eating, bed mobility, locomotion, number of medications, and age, while both CVA and tracheotomy care were inversely predictive of pneumonia. The emergence of these significant predictors suggested a different pathogenesis of pneumonia in the elderly nursing home resident from the acute care patient or the outpatient. Nursing home residents have chronic medical conditions that gradually lead to "decompensation" in functional status, nutritional status, and pulmonary clearance. Dysphagia and aspiration are common complications of their medical conditions and may slowly worsen as their status deteriorates. Alternatively, a sudden adverse event may dramatically increase the amount aspirated or the ability to resist infection and lead to sudden decompensation. Clinical staff must identify residents with dysphagia and aspiration and work to prevent decline in functional status in all residents. They must be aware of the dangers of adverse events that lead to sudden inactivity or illness and increase the risk of aspiration pneumonia. Prevention of this disease whenever possible will reduce costs, improve health outcomes, and improve our quality of care.
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PMID:Predictors of aspiration pneumonia in nursing home residents. 1235 45

All stroke patients ideally should be admitted to a stroke unit in which personnel are familiar with strategies for taking care of stroke patients. Prevention of worsening cerebral ischemia by appropriate blood pressure and serum glucose management, fever control, and supplemental oxygen for hypoxemic patients is recommended. Recognition of common complications, such as aspiration pneumonia and deep venous thrombosis, highlights the need for swallowing evaluation and the use of pneumatic compression devices or subcutaneous heparin. Patients should be monitored closely for deterioration in their neurologic status and should have complications appropriately addressed. After evaluation of stroke etiology, appropriate secondary stroke prophylaxis should be selected and initiated before hospital discharge.
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PMID:Post-emergency department management of stroke. 1237 68

Percutaneous endoscopic gastrostomy (PEG) is a popular technique for long-term enteral nutrition. However it is not beneficial in all cases, and may even prolong the process of dying. The present article discusses the main indications for PEG insertion, and the ethical considerations involved. Three main questions need to be answered: (1) for what purposes should PEG be used; (2) for what type of patients, and (3) when should PEG be inserted in the natural history of the patient's illness? PEG is used in patients unable to maintain sufficient oral intake. It has been found to improve quality of life and/or to increase survival in patients with head and neck cancer, acute stroke, neurogenic and muscle dystrophy syndrome, growth failure (children) and gastric decompression. It led to no improvement in nutritional or functional status in patients with cachexia, anorexia, aspiration (and aspiration pneumonia), and cancer with a short life expectancy. Several court decisions have stipulated that PEG need be offered in patients in a persistent vegetative state or patients with senile dementia who have lost the ability for self-determination. Since the 30-day mortality after PEG insertion is very high for patients hospitalized in a general medical center, a 'cooling off' period of 30-60 days should be scheduled from the time of the PEG request to actual insertion.
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PMID:Indications for percutaneous endoscopic gastrostomy insertion: ethical aspects. 1256 9

Problems with swallowing (dysphagia) occur in association with numerous illnesses. In many cases, however, they are either not recognized or considered not to require clarification, since other symptoms are of greater importance. In elderly, often multimorbid patients, neurodegenerative diseases, such as apoplexy, are the most common causes of dysphagia, but medications with central nervous side effects may also impair swallowing. The difficulty may be localized either in the oropharyngeal region or in the esophagus. There is considerable danger that such complications as aspiration pneumonia and malnutrition may occur and thus increase morbidity and mortality. In addition, the quality of life of the patient may also be diminished. The family doctor has the important task of initiating a differentiated diagnosis based on careful history-taking and a clinical examination that should include an inspection of the oral cavity and the nerves supplying the brain. Early treatment, for example, involving a logopedist, can be effective.
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PMID:[Apoplexy, diverticulum or Alzheimer disease? Deglutition disorders in seniors must always be evaluated!]. 1261 34

Dysphagia is a common complication after stroke, being reported in 30-50% in acute stage patients. It is also critical that dysphagia may occur 3 to 5 days after onset because of brain edema, so clinicians must be careful to treat stroke patients with close observation. Especially elderly patients with dysphagia have a high risk of aspiration pneumonia, which might be life threatening condition for them. Dysphagia generally recovers spontaneously and frequency of the chronic stage cases is thought to be less 6%. The 30 ml water swallow test is used to screen dysphagia. If cough or some symptom of aspiration such as wet voice or breathing difficulties are seen, dysphagia is strongly suspected. Oral care is essential and diet modification and rehabilitation techniques are applied. Fiberoptic evaluation or fluoroscopic examination is recommended for severe dysphagia. The treatment plan should be established according to the pathological conditions. The goal of dysphagia management is to prevent aspiration pneumonia, dehydration and malnutrition. If swallowing difficulties continue, alternative nutrition. PEG or intermittent tube feeding, could be helpfull. Multidisciplinary team approach should be adopted for dysphagia management.
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PMID:[Evaluation and management of dysphagia after stroke]. 1270 45

Dysphagia following acute stroke frequently necessitates prolonged enteral feeding. There is evidence that early enteral feeding via percutaneous endoscopic gastrostomy (PEG) is both beneficial and safe. The aim of this study was to identify predictors of prolonged dysphagia. The subjects were 149 consecutive patients admitted with acute stroke. Clinical findings and imaging results were prospectively collected, and subsequent progress recorded. Subjects were divided into 3 groups for analysis: no dysphagia; transient dysphagia (< or =14 days); or prolonged dysphagia (>14 days). Validity of the water swallow test as a predictor of aspiration pneumonia was confirmed. Significant associations for prolonged dysphagia were seen with stroke severity, dysphasia and lesions of the frontal and insular cortex on brain imaging. These results indicate that it may be possible to predict patients who will develop prolonged significant dysphagia following acute stroke thereby facilitating referral for insertion of PEG at an earlier time point.
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PMID:Predictors of prolonged dysphagia following acute stroke. 1276 32

Dysphagia occurs in up to half of patients after an acute stroke and may cause dehydration, undernutrition, and aspiration pneumonia. Current evidence suggests that a systematic program of diagnosis and treatment of dysphagia in an acute stroke management plan may yield dramatic reductions in aspiration pneumonia rates. There is also some evidence that nutritional supplementation and proper hydration may reduce morbidity and mortality in acute stroke patients. This article focuses on the recent advances in the evaluation and management of dysphagia, undernutrition, and dehydration related to acute stroke. A summary of pertinent studies in the area of stroke dysphagia and nutrition is also included.
Top Stroke Rehabil 2002
PMID:Swallowing, nutrition, and hydration during acute stroke care. 1452 15


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