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

Abstract

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 1998.2 This new update aims to review all available evidence from February 2008 to March 2013. 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 life3 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 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.7-10 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 dysphagia20 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 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 review1 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.