Identification and nursing management of dysphagia in individuals with acute neurological impairment: a systematic review protocol

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1 Identification and nursing management of dysphagia in individuals with acute neurological impairment: a systematic review protocol Sonia Hines RN, BN, MAppSc (Research) 1,2 Kate Kynoch RN, GradCert(ICN), MN(ICN), PhD (candidate) 1,2 Judy Munday RN, DipEd(Nurs), BA (Hons), Master of Applied Science (Research) (candidate) 1,2 1. Mater Health Services Nursing Research Centre, Brisbane, Queensland 2. The Queensland Centre for Evidence-Based Nursing and Midwifery:a Collaborating Centre of the Joanna Briggs Institute Review question/objective The objective of this review is to undertake an update of the previously updated JBI review, which included articles published between January 1998 to January 2008 inclusive, focussing on the nursing role in recognition and management of dysphagia in adults with acute neurological impairment. 1 The original review was by Ramritu et al. and sourced evidence from 1985 to This new update aims to review all available evidence from February 2008 to March Specifically the review update seeks to find the best available evidence regarding: The nursing role in the recognition and management of dysphagia in adults with acute neurological impairment The evidence on the effectiveness of nursing interventions in the recognition and management of dysphagia. Background Dysphagia, that is, difficulty in swallowing, is a serious and life-threatening medical condition that affects a significant number of individuals with acute neurological impairment, largely from stroke. The WHO estimates that approximately one in six people will experience a stroke at some point in their life 3 and of these around 65% will develop neurogenic dysphagia. 4 Dysphagia is not generally considered a major cause of mortality; however, the complications that result from this medical condition, namely, aspiration pneumonia and malnutrition, are among the most common causes of death in the elderly. 5 Nurses, who are available to patients 24 hours a day in hospital, are in the ideal position to identify individuals with swallowing difficulties and initiate interventions that may prevent further complications until a formal assessment can be undertaken. 6 It is imperative, therefore, that the nurse s role and nursing interventions in the management of dysphagia are understood. The act of swallowing is generally considered to consist of three stages. During the voluntary oral phase, food is chewed, lubricated and formed into a bolus where finally the tongue moves the bolus posteriorly into the oropharynx at the tonsil pillars. The involuntary pharyngeal phase begins when the doi: /jbisrir Page 312

2 swallowing reflex is initiated and continues with peristaltic action propelling the bolus through the pharynx until it reaches the opening of the upper oesophageal sphincter. The oesophageal phase begins once the upper oesophageal sphincter opens and the bolus enters the oesophagus. Peristaltic action continues to move the bolus to the lower oesophageal sphincter where it enters the stomach Cranial nerves, along with the brain stem, cerebral cortex, and numerous muscles, are essential mediators of sensation and movement in the swallowing process. 11 Disruption to any of these processes can result in impaired or altered swallowing ability. It is vital, therefore, that nurses have an understanding of the anatomical and physiological processes involved in the act of swallowing. Only with possession of this knowledge will nurses be able to advise physicians and speech-language pathologists of the symptoms they observe in their patients that are associated with dysphagia. 8,12 Also important to nursing knowledge is an understanding that the causes of dysphagia can occur in the absence of a pathological process and in individuals with subclinical neurological impairment. 13 Certain prescribed medications, such as sedatives and antipsychotics, may also alter the normal processes of swallowing, 7 as may age-related physiological changes. 9 The signs and symptoms of dysphagia by medical diagnosis may not present in any predictable manner. 12 It is recommended that all individuals presenting with neurological impairment receive appropriate screening of swallowing function as soon as possible after admission. 7,12,14 Screening and assessment for swallowing problems are distinct procedures with the former being for the initial identification of at-risk patients, while the latter is more comprehensive. 15 Assessment of swallowing function is essential to the accurate identification and diagnosis of deficits in swallowing and to the effective management of dysphagia. Initial screening of swallowing function includes a review of the patient s chart, an interview, physical examination, and a clinical bedside evaluation, most often in the form of a water swallow test. 9,10,16,17 It has been suggested that 80% of patients with dysphagia can be diagnosed by taking a thorough history. 7 Detection of swallowing difficulties in the initial screening may be further evaluated with specific swallow studies (eg. videofluoroscopy swallow study (VFSS)) to provide a conclusive diagnosis. 12,17 A collaborative team approach including physicians, radiologists, speech-language pathologists, dieticians, and nurses is ideal in the assessment and management of the patient with dysphagia. 6,9 Management protocols following the diagnosis of dysphagia will vary depending on the specific type and cause of dysphagia; however, the main goals in managing dysphagia are to maintain hydration and nutritional support, limit the possibility of aspiration of food and fluids into the respiratory tract, and re-establish oral intake. 18 Specific interventions for maintaining nutrition include changing the texture, frequency and amount of food offered, positioning of the patient during and after feeding, and feeding the patient via a nasogastric tube or percutaneous endoscopic gastrostomy (PEG) tube. 8,10,19 There have been numerous physical and psychological problems associated with non-oral methods of feeding reported in the literature. 8 Early identification of risk factors and initiation of interventions may be essential not only to help prevent complications associated with dysphagia 20 but also to assist in maintaining and restoring an individual s ability to sustain oral intake and thereby improve long term health outcomes and quality of life. 21 Nurses, who are available on a 24-hour basis and to all members of the multidisciplinary team, are in a prime position to undertake an initial screening and initiate interventions. 6 Nurses specifically trained in undertaking dysphagia screening have an important role in reducing adverse outcomes associated with doi: /jbisrir Page 313

3 dysphagia. Clinical screening is not intended to replace the more formal assessments by physicians and speech-language pathologists but rather to quantify the observable signs of swallowing difficulty and provide a basis for referral for further assessment. 22 Additionally, nurses are often in the position of explaining and educating family members on the patient s management plan, 8 and have an important impact on the patient and family adherence to treatment for dysphagia. 12 Overall, dysphagia is a complex disorder that is best managed by a multidisciplinary team and through client-family partnership. Early identification and initiation of appropriate interventions may reduce complications associated with dysphagia and improve the quality of referrals, health outcomes and quality of life for patients with dysphagia. Nurses are central to a patient's care and are thus in a position to assess and intervene early with patients who have swallowing difficulties. It is vital, therefore, that evidence is developed which describes the nurse s role in the identification and recognition of individuals with swallowing difficulty and provides support for the effectiveness of nursing interventions. The evidence from the previously updated review 1 indicates that nurses are well placed to conduct dysphagia assessments and that there are several tools available that may be suitable for them to use. It is important that formal dysphagia screening protocols are in place and that nurses are trained to use them. If nurses screen patients with an acute neurological impairment within 24 hours of admission, it may reduce the time that patients spend without appropriate methods of nutrition and hydration, and improve clinical outcomes. Dysphagia screening by nurses does not replace assessment by other health professionals; instead it enhances the provision of care to patients at risk allowing for early recognition and intervention to occur. The level of evidence in the previous iteration of this review was overall moderate to low, with only one randomised controlled trial able to be included, with most being of lower quality observational or descriptive designs. It is hoped that this version of the review is able to find a higher level of evidence to answer this question. Keywords dysphagia, stroke, nursing, systematic review Definitions Dysphagia refers to difficulty in swallowing. 23 Acute neurological impairment in this context refers to limited functioning of the nervous system following stroke, cerebral haemorrhage or other brain injury. 4 Inclusion criteria Types of participants This review will consider studies that include adults over the age of 18 years with neurogenic dysphagia. This review will include adults whose neurological impairment is considered acute (predominantly stroke patients). Populations with neurological impairment resulting from a long term disease process (eg. Huntington s disease) will not be included as their assessment needs are considered different to the focus of this review and largely the purview of speech and language professionals, not nurses. doi: /jbisrir Page 314

4 The original review included children over the age of 12 months. 2 The previous update and this review are limited to adults due to the vast differences in clinical assessment and management of dysphagia in children. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate interventions which focus on the nursing role in the recognition and screening for dysphagia; any formal observation of the ability to swallow undertaken/documented by nurses, clinical/bedside swallowing screening undertaken by nurses, pulse oximetry monitoring for the purposes of detecting aspiration, and other interventions concerned with the nursing management of dysphagia, either in comparison to usual care or other interventions. Exclusion criteria Studies focussing on diagnostic procedures ordered or undertaken by either medical or speech-language pathologists (such as VFSS) are not of interest to this review. Studies focussing on dysphagia without a diagnosed neurological impairment will be excluded. Any studies with participants with dysphagia resulting from cancer, radiotherapy, surgery, infection or congenital abnormalities will also be excluded, unless these participants form the control group. Studies of the effectiveness of thickened fluids have already been the subject of other systematic reviews, 24,25 and so are considered outside the scope of this review. Types of outcomes This review will consider studies that measure any outcomes related to the following areas: Early recognition by nurses of those with difficulty swallowing Clinical screening by nurses of any patient with suspected swallowing difficulties Timely referral by nurses to speech-language pathologists for formal assessment Any outcome measures from interventions that aimed to prevent aspiration, choking episodes and/or associated morbidity. Types of studies This review will consider both experimental and epidemiological study designs including randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross-sectional studies for inclusion. This review will also consider descriptive epidemiological study designs including case series and descriptive cross-sectional studies for inclusion. doi: /jbisrir Page 315

5 Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Only studies published in English will be considered for inclusion in this review. Studies published between February 2008 to March 2013 will be considered for inclusion in this review. The databases to be searched include CINAHL, Medline, Cochrane CENTRAL, Web of Science, Embase and Mednar. The search for unpublished studies will include OpenSIGLE, New York Academy of Medicine Library Gray Literature Report and Dissertations Abstracts International. Initial keywords to be used will be: dysphagia (text word and MH) or gag reflex or swallow problem or impair or difficult neurological and impair or stroke or bedside swallowing assessment MH "Brain Diseases+" or neurological and impair* or disorder* disease* or malfunction MH "Deglutition Disorders" or MH "Gagging" or bedside swallowing assessment or swallowing assessment. Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. If necessary, study authors will be contacted to attempt to clarify details or retrieve any missing data. doi: /jbisrir Page 316

6 Data synthesis Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest None known Acknowledgements We would like to acknowledge the work of all our previous co-authors on prior versions of this review. doi: /jbisrir Page 317

7 References 1. Hines S, Wallace K, Crowe L, Finlayson K, Chang AM, Pattie M. Identification and nursing management of dysphagia in individuals with acute neurological impairment (update). International Journal of Evidence-Based Healthcare. 2011;9(2): Ramritu P, Joanna Briggs Institute for Evidence Based N, Midwifery. Identification and nursing management of dysphagia in individuals with neurological impairment: Joanna Briggs Institute for Evidence Based Nursing and Midwifery; Thorvaldsen P, Asplund K, Kuulasmaa K, Rajakangas A-M, Schroll M, Project ftwm. Stroke incidence, case fatality, and mortality in the who monica project. Stroke March 1, 1995;26(3): Daniels SK. Neurological disorders affecting oral, pharyngeal swallowing. GI Motility online Wieseke A, Bantz D, Siktberg L, Dillard N. Assessment and early diagnosis of dysphagia. Geriatric Nursing. 2008;29(6): Davies S. An interdisciplinary approach to the management of dysphagia. Professional Nurse. [Paper]. 2002;18(1): Blackington E, McCormick T, Willson B, Lowenstein A, Gilbert R. Oropharyngeal dysphagia in the elderly - identifying and managing patients at risk. Advance for Nurse Practitioners July;9(7): Davies S. Dysphagia in acute strokes. Nursing Standard April;13(30): Lefton J. Dysphagia: Etiologies, risk identification, and assessment methods. Support Line. 1999;21(6): Randolph GW. Dysphagia. In: Wilson WR, Nadol JB, Randolph GW, editors. The clinical handbook of ear, nose and throat disorders. Manchester: The Parthenon Publishing Group; Couriel JM BR, Miller R, Thomas A, Clarke M. Assessment of feeding problems in neurodevelopmental handicap: A team approach. Arch Dis Child 1993;69(5): Perlman AL. Dysphagia: Populations at risk and methods of diagnosis. Nutrition in Clinical Practice. [Presentation]. 1999;14(5):S Emick-Herring B, Wood P. A team approach to neurologically based swallowing disorders. Rehabilitation Nursing. 1990;15(3): O'Neill PA. Swallowing and prevention of complications. British Medical Bulletin. 2000;56(2): Chang A, Pattie M, Finlayson K. Early detection of swallowing problems in patients with neurological conditions. Final Report to QLD Nursing Council - Funding body. Brisbane: QUT2005December Shanley C, O'Loughlin G. Dysphagia among nursing home residents: An assessment and management protocol. Journal of Gerontological Nursing August 2000;26(8): Smith HA, Connolly MJ. Evaluation and treatment of dysphagia following stroke. Topics in Geriatric Rehabilitation Jan-Mar 2003;19(1): Daniels SK. Optimal patterns of care for dysphagic stroke patients. Seminars in Speech and Language. 2000;21(4): Dorner B. It's tough to swallow: A practical approach to nutritional care of dysphagia. The Director. 2002;10(3): Davies S. Problem solved. Nursing Standard October-5 November 2002;17(7): Gauwitz DF. How to protect the dysphagic stroke patient. American Journal of Nursing. 1995;95(8): Lambert HC, Gisel EG, Wood-Dauphinee S. The functional assessment of dysphagia: Psychometric standards. Physical and Occupational Therapy in Geriatrics. 2001;19(3): World Health Organization. Who steps stroke manual: The who stepwise approach to stroke surveillance. Geneva: World Health Organization; Loeb MB, Becker M, Eady A, Walker-Dilks C. Interventions to prevent aspiration pneumonia in older adults: A systematic review. Journal of the American Geriatrics Society July;51(7): Hines S, McCrow J, Abbey J, Gledhill S. Thickened fluids for people with dementia in residential aged care facilities. International Journal of Evidence-Based Healthcare. 2010;8(4): doi: /jbisrir Page 318

8 Appendix I: Appraisal instruments MAStARI appraisal instrument this is a test message Insert page break doi: /jbisrir Page 319

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11 Appendix II: Data extraction instruments MAStARI data extraction instrument Insert page break doi: /jbisrir Page 322

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