Ingrid Scholten

Intake of thickened liquids by hospitalized adults with dysphagia after stroke

Abstract There is widespread concern that individuals with dysphagia as a result of stroke do not drink enough fluids when they are prescribed thickened liquids. This paper details a retrospective audit of thickened liquid consumption of 69 individuals with dysphagia following stroke in acute and rehabilitation hospitals in Adelaide, South Australia. Hospitalized individuals with dysphagia following stroke drank a mean of 781 ml (SD = 507 ml) of prescribed thickened liquids per day, significantly less in the acute setting (M = 519 ml, SD = 305 ml) than in the rehabilitation setting (M = 1274 ml, SD = 442 ml) (t(67) = −8.34, p < .001). This daily intake of thickened liquids was lower than recommended standards of fluid intake for hospitalized adults. Fluid intake could be increased with definitive protocols for the provision and monitoring of consumption of thickened liquids, by offering more fluid via food or free water protocols or by routine use of non-oral supplementary routes. Future research into the effectiveness of such recommendations needs to evaluate not only the impact on fluid intake but also on health outcomes.

Learning about the Dynamic Swallowing Process Using an Interactive Multimedia Program

The management of dysphagia is the largest recognized subspecialty in the field of speech-language pathology. Practicing speech-language pathologists require a comprehensive theoretical and functional knowledge base to underpin the safe and effective management of people with dysphagia. Students need to develop an understanding of the normal integrated swallow and how it can be affected to appreciate the assessment or treatment of dysphagia. Although students are well motivated to learn this material, assimilating knowledge of the dynamic nature of the swallow has typically been problematic because of its complex character. The limitations of currently available teaching resources have been addressed by the production of an interactive multimedia program that includes integrated presentation of text, graphics, voice-overs, and video and animation sequences to highlight various aspects of the swallowing process. Students can selectively manipulate parts of this process to understand the normal swallow and to simulate different aspects of dysfunction and the consequent effects on swallow safety and efficiency. Feedback from students, faculty, and experts has demonstrated that The Dynamic Swallow would be a valued tool in the teaching of dysphagia.

Primary progressive aphasia: Serial linguistic, neuropsychological and radiological findings with neuropathological results

Abstract Since Mesulam and Weintraubs (1992) original description of six patients with primary progressive aphasia (PPA), there has been considerable debate concerning the quality of the speech and language impairment, the long-term course of the disorder, the existence of syndrome subtypes, and the nature of the underlying pathological process. We report the case of a 60-year-old woman who presented with a 4-year history of word-finding difficulty, and received a diagnosis of PPA. In contrast to a relentless deterioration of word-finding, comprehension and auditory–verbal memory, all other intellectual skills remained well preserved for a considerable period before the onset of dementia, and death. Regular detailed assessments of language, mnestic, intellectual and psychological functioning were performed over a 6-year period, as well as serial radiology and post-mortem neuropathology. We report the findings and discuss them in the context of the theoretical issues.

Pressure-Flow Analysis for the Assessment of Pediatric Oropharyngeal Dysphagia

OBJECTIVES To determine which objective pressure-impedance measures of pharyngeal swallowing function correlated with clinically assessed severity of oropharyngeal dysphagia (OPD) symptoms. STUDY DESIGN Forty-five children with OPD and 34 control children without OPD were recruited and up to 5 liquid bolus swallows were recorded with a solid-state high-resolution manometry with impedance catheter. Individual measures of pharyngeal and upper esophageal sphincter (UES) function and a swallow risk index composite score were derived for each swallow, and averaged data for patients with OPD were compared with those of control children without OPD. Clinical severity of OPD symptoms and oral feeding competency was based on the validated Dysphagia Disorders Survey and Functional Oral Intake Scale. RESULTS Those objective measures that were markers of UES relaxation, UES opening, and pharyngeal flow resistance differentiated patients with and without OPD symptoms. Patients demonstrating abnormally high pharyngeal intrabolus pressures and high UES resistance, markers of outflow obstruction, were most likely to have signs and symptoms of overt Dysphagia Disorders Survey (OR 9.24, P = .05, and 9.7, P = .016, respectively). CONCLUSION Pharyngeal motor patterns can be recorded in children by the use of HRIM and pharyngeal function can be defined objectively with the use of pressure-impedance measures. Objective measurements suggest that pharyngeal dysfunction is common in children with clinical signs of OPD. A key finding of this study was evidence of markers of restricted UES opening.

A Descriptive Study of the Fluid Intake, Hydration, and Health Status of Rehabilitation Inpatients without Dysphagia Following Stroke

Adequate hydration is important for all people, particularly when hospitalized with illness. Individuals with dysphagia following stroke are considered to be at risk of inadequate fluid intake and, therefore, dehydration, but there is little information about the fluid intake or hydration of individuals without dysphagia poststroke. This cohort study measured the average beverage intake, calculated the urea/creatinine ratio as a measure of hydration, and documented specific health outcomes of 86 people without dysphagia poststroke who were inpatients in rehabilitation centers. Participants drank on average 1504 ml per day (SD 359 ml), which typically represented 67% of their estimated daily requirement. Approximately 44% of the participants in the sample were dehydrated based on a blood urea nitrogen/creatinine ratio >20:1. Sixteen percent of participants were diagnosed with one or more of the health outcomes of dehydration/hypernatremia, urinary tract infection, or constipation. A greater level of dependence was associated with poorer beverage intake and higher risk of an adverse health outcome. Those in the older/elderly age range (particularly older women) and those with poor mobility were most at risk of poor hydration. This study highlights that patients in rehabilitation facilities poststroke, even without dysphagia, may be at risk of suboptimal fluid intake and hydration.

Biomechanical Quantification of Mendelsohn Maneuver and Effortful Swallowing on Pharyngoesophageal Function

Objective To quantify the effects of 2 swallowing maneuvers used in dysphagia rehabilitation—the Mendelsohn maneuver and effortful swallowing—on pharyngoesophageal function with novel, objective pressure-flow analysis. Study Design Evaluation of intervention effects in a healthy control cohort. Setting A pharyngoesophageal motility research laboratory in a tertiary education facility. Subjects Twelve young healthy subjects (9 women, 28.6 ± 7.9 years) from the general public, without swallowing impairment, volunteered to participate in this study. Methods Surface electromyography from the floor-of-mouth musculature and high-resolution impedance manometry–based pressure flow analysis were used to assess floor-of-mouth activation and pharyngoesophageal motility, respectively. Subjects each performed 10 noneffortful control swallows, Mendelsohn maneuver swallows, and effortful swallows, with a 5-mL viscous bolus. Repeated measures analyses of variance was used to compare outcome measures across conditions. Results Effortful and Mendelsohn swallows generated greater floor-of-mouth contraction (P = .001) and pharyngeal pressure (P < .0001) when compared with control swallows. There were no changes at the level of the upper esophageal sphincter, except for a faster opening to maximal diameter during maneuver swallows (P = .01). The proximal esophageal contractile integral was reduced during Mendelsohn swallows (P = .001). Conclusion Effortful and Mendelsohn maneuver swallows significantly alter the pharyngoesophageal pressure profile. Faster opening of the upper esophageal sphincter may facilitate bolus transfer during maneuver swallows; however, reduced proximal esophageal contractility during Mendelsohn maneuver swallows may impair bolus flow and aggravate dysphagic symptoms.

Integrating Student Assessment Practices: the significance of collaborative partnerships for curriculum and professional development in a university department

Abstract The purposes and practices of student assessment in all sectors of education are contested. So when the members of a university department decide to collaborate in order to integrate their assessment requirements, what they enter into is a program of personal and collective review that begins to unmask the moral and political dynamics of curriculum and professional development. This article describes such a collaborative project, its processes and its products, as well as the dynamics of collective review as they relate to facilitation, organisational change, and comfortable versus critical collaboration.

Characterization of swallow modulation in response to bolus volume in healthy subjects accounting for catheter diameter

Characterization of the pharyngeal swallow response to volume challenges is important for swallowing function assessment. The diameter of the pressure‐impedance recording catheter may influence these results. In this study, we captured key physiological swallow measures in response to bolus volume utilizing recordings acquired by two catheters of different diameter.

An oral hygiene protocol improves oral health for patients in inpatient stroke rehabilitation

THE OBJECTIVE To determine whether a simple oral hygiene protocol improves the oral health of inpatients in stroke rehabilitation. THE BACKGROUND DATA DISCUSSING THE PRESENT STATUS OF THE FIELD Poor oral health can lead to serious complications, such as pneumonia. The comorbidities associated with stroke, such as dysphagia, hemiparesis and cognitive impairment, can further impede independent oral care. International stroke guidelines recommend routine oral care but stop short of detailing specific regimes. MATERIALS AND METHODS The oral health assessment tool (OHAT) was conducted by speech-language pathologists with 100 patients with and without dysphagia in three metropolitan inpatient stroke rehabilitation facilities. A simple nurse-led oral hygiene regime was then implemented with all participants, which included twice daily tooth brushing and mouth rinsing after lunch, and oral health was measured again one week later. RESULTS Initially, dysphagia was negatively associated with OHAT scores, and independence for oral hygiene was positively associated with oral health. After one week of a simple oral hygiene regime, the OHAT scores available for 89 participants indicated an improvement on average for all participants. In particular, 59% of participants with dysphagia had an improvement of 1 or more points. None of the participants developed pneumonia. CONCLUSION A simple, inexpensive oral hygiene regime resulted in positive outcomes for patients with and without dysphagia in inpatient stroke rehabilitation settings. Oral health assessments and oral hygiene regimes that are simple to implement by the interdisciplinary team can be incorporated into standard stroke care with positive effect.

Coding of significant comorbidities and complications for stroke in rehabilitation

Background: Comorbidities and complications of stroke have implications for level of care and hospital resources. It is critical, therefore, that hospital morbidity data accurately reflect the prevalence of these additional diagnoses. Objective: This study aimed to measure and describe the concordance between stroke clinicians/researchers and medical record coders when recording stroke and related diagnoses. Method: Diagnoses recorded prospectively, according to defined criteria by a clinical research team, were compared with the coding of stroke comorbidities and complications as per the Australian Coding Standards (ACS) from the separations of 100 inpatients from three rehabilitation facilities in South Australia. Percentage agreement, kappa coefficient, sensitivity and specificity values were calculated. Results: Kappa coefficients for agreement of prospective diagnoses with coding ranged from 0.08 to 0.819. The diagnoses with the highest agreement were stroke, aspiration pneumonia (nil cases), aphasia and dysphagia. The diagnoses with the lowest agreement were apraxia, cognitive impairment, constipation and dehydration. Conclusion: Not all stroke comorbidities are represented accurately in hospital morbidity datasets. Education of stroke clinicians about the current ACS may clarify expectations about medical record documentation for coding purposes which in turn may result in more accurate morbidity data and therefore costings for the rehabilitation sector.