Dysphagia Screening in Patients with Cerebrovascular Accidents (CVA)
General
Jun 28, 2024
A cerebrovascular accident, or stroke, also called a brain attack, happens when blood supply to a region of the brain is blocked or when a blood vessel in the brain bursts. Swallowing disorders, also known as dysphagia, are a common complication of stroke, affecting more than 50% of stroke survivors (Martino R et al., 2005). For the vast majority of the 6.2 million stroke survivors in the US, one of the first hindrances on the course to rehabilitation is a swallowing disorder (Saab R et al., 2023). Most patients recover swallowing function within a week, but 11–13% may still have dysphagia after six months (Martino R et al., 2005). Evidence from experimental and observational research shows the benefits of dysphagia screening in stroke rehabilitation, such as reduced risk of pneumonia, mortality, dependency, and length of stay (Sherman V et al., 2021).
The Importance of Early Screening
Early identification of potential aspiration through screening is crucial to prevent pneumonia after stroke (PAS) and ensure better treatment outcomes. The current article highlights some general screening procedures to identify possible risks of aspiration associated with cerebrovascular accidents. Dysphagia screening protocols, a crucial tool in the hands of healthcare professionals, aid in identifying the potential risk for aspiration. As healthcare professionals, your role in administering these screenings is invaluable. A swallow screening also helps decide the need for a swallow assessment, potential swallow safety precautions, and the necessity of referral related to nutrition and hydration support.
Screening Procedures
Screening procedures may include questionnaires or patient/caregiver interviews focusing on questions such as past and current swallowing difficulties, weight loss, oral hygiene, and medical complications such as fever and a history of pneumonia. The healthcare team could also review the medical history of etiological risk categories for dysphagia. During a bedside dysphagia screening, observation of the patient's alertness and cognitive abilities are crucial to further screening. The procedure includes orientation, self-awareness interview, assessment of volitional cough, secretion management capacity, and gag reflex (pharyngeal sensation). It is not recommended to proceed with further observation-based screening if the patient is not alert or does not exhibit a cough reflex or secretion management capability. If the patient is cognitively stable, a swallow screening protocol can be administered to observe for signs such as cough during or after the swallowing, oral motor weakness, and voice quality change (wet, gurgly voice post-swallow).
Advanced Screening Tests
A water swallow test could be administered while conducting standard screening protocols. If the patient exhibits prerequisite abilities, Water Swallow Test protocols such as the Burke Dysphagia Screening Test (DePippo et al., 1994) and Yale Swallow Protocol (Leder & Suiter, 2014), which includes a 3 oz Water swallow test, could be administered. In addition, Swallowing screening protocols such as the Toronto Bedside Swallowing Screening Test (TOR-BSST; Martino et al., 2009) and Simple Standardized Bedside Swallowing Assessment (SSA; Perry 2001) can be utilized for early identification of aspiration risk. The Gugging Swallow Screen (GSS) is a fast and reliable method to identify stroke patients with aspiration risk (Trapl M et al., 2007).
Conclusion
In summary, a swallow screening is a quick and efficient procedure that can be done at the bedside. It is not limited to speech-language pathologists (SLPs). It can be performed by other qualified healthcare professionals, making it a practical and feasible tool in the early identification of potential dysphagia. Screening allows the healthcare team to make objective decisions about further assessment by quickly and effectively identifying high-risk individuals or early dysphagia assessment and interventions. Delays in screening stroke patients increased the incidence of stroke-after pneumonia (SAP) by 1% per day of delay (Bray et al., 2016). Prompt and coordinated action in conducting swallow screenings can significantly enhance treatment outcomes for individuals with cerebrovascular accidents.
To take your practice to the next level, consider Liri AI, a game-changing tool for speech-language pathologists. It helps SLPs save up to 70% of their time.
References
American Speech-Language-Hearing Association. (2001). Roles of speech-language pathologists in swallowing and feeding disorders: Technical report. ASHA 2002 Desk Reference, pp. 3, 181–199.
Addington, W. R., Stephens, R. E., & Gilliland, K. A. (1999). Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke: An interhospital comparison. Stroke, 30(6),1203–1207.
Bray, B., Smith, C. J., Cloud, G., Enderby, P., James, M., Paley, L., Tyrrell, P. J., Wolfe, C., & Rudd, A. (2016). The association between delays in screening for and assessing dysphagia after acute stroke and the risk of stroke-associated pneumonia. Journal of Neurology, Neurosurgery, and Psychiatry. https://doi.org/10.1136/jnnp-2016-313356
Daniels, S. K., Ballo, L. A., Mahoney, M. C., & Foundas, A. L. (2000). Clinical predictors of dysphagia and aspiration risk: Outcome measures in acute stroke patients. Archives of Physical Medicine and Rehabilitation, 81(8)
DePippo, K. L., Holas, M. A., & Reding, M. J. (1994). The Burke dysphagia screening test: Validation of its use in patients with stroke. Archives of Physical Medicine and Rehabilitation, 75(12), 1284–1286.
DePippo, K. L., Holas, M. A., Reding, M. J., Mandel, F. S., & Lesser, M. L. (1994). Dysphagia therapy following stroke: A controlled trial. Neurology, 44(9), 1655–1660.
Hemorrhage – ActivelyFitSeniors. https://activelyfitseniors.blog/tag/hemorrhage/
Hughes, T. A. T., & Wiles, C. M. (1996). Clinical measurement of swallowing in health
and in neurogenic dysphagia. Quarterly Journal of Medicine, 89(2), 109–116.
https://doi.org/10.1093/qjmed/89.2.109Leder, S. B., & Suiter, D. M. (2014). The Yale Swallow Protocol: An evidence-based approach to decision making. Springer. Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G., Streiner, D. L., & Diamant, N. E.
(2009). The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and
validation of a dysphagia screening tool for patients with stroke. Stroke, 40(2), 555–561.
https://doi.org/10.1161/STROKEAHA.107.510370Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: Incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12):2756–2763. doi: 10.1161/01.STR.0000190056.76543.eb.
Perry, L. (2001). Screening swallowing function of patients with acute stroke. Part two: Detailed evaluation of the tool used by nurses. Journal of Clinical Nursing, 10(4), 474–481. https://doi.org/10.1046/j.1365-2702.2001.00502.x
Recognizing Symptoms of Dysphagia After a Stroke | Thick-It.
https://thickit.com/blog/2020/05/15/recognizing-symptoms-of-dysphagia-after-stroke/Saab, R., Balachandar, A., Mahdi, H., Nashnoush, E., Perri, L., Waldron, A., Sadeghian, A., Rubenfeld, G., Crowley, M., Boulos, M., Murray, B., & Khosravani, H. (2023). Machine-learning assisted swallowing assessment: A deep learning-based quality improvement tool to screen for post-stroke dysphagia. Frontiers in Neuroscience.
Sherman,В., Greco, E., & Martino, R. (2021). The Benefit of Dysphagia Screening in Adult
Patients With Stroke: A Meta‐Analysis. Journal of the American Heart Association.
https://doi.org/10.1161/jaha.120.01875Trapl M, Enderle P, Nowotny M, Teuschl Y, Matz K, Dachenhausen A, Brainin M.Stroke. 2007 Nov;38(11):2948-52. doi: 10.1161/STROKEAHA.107.483933. Epub 2007 Sep 20.PMID: 17885261
A cerebrovascular accident, or stroke, also called a brain attack, happens when blood supply to a region of the brain is blocked or when a blood vessel in the brain bursts. Swallowing disorders, also known as dysphagia, are a common complication of stroke, affecting more than 50% of stroke survivors (Martino R et al., 2005). For the vast majority of the 6.2 million stroke survivors in the US, one of the first hindrances on the course to rehabilitation is a swallowing disorder (Saab R et al., 2023). Most patients recover swallowing function within a week, but 11–13% may still have dysphagia after six months (Martino R et al., 2005). Evidence from experimental and observational research shows the benefits of dysphagia screening in stroke rehabilitation, such as reduced risk of pneumonia, mortality, dependency, and length of stay (Sherman V et al., 2021).
The Importance of Early Screening
Early identification of potential aspiration through screening is crucial to prevent pneumonia after stroke (PAS) and ensure better treatment outcomes. The current article highlights some general screening procedures to identify possible risks of aspiration associated with cerebrovascular accidents. Dysphagia screening protocols, a crucial tool in the hands of healthcare professionals, aid in identifying the potential risk for aspiration. As healthcare professionals, your role in administering these screenings is invaluable. A swallow screening also helps decide the need for a swallow assessment, potential swallow safety precautions, and the necessity of referral related to nutrition and hydration support.
Screening Procedures
Screening procedures may include questionnaires or patient/caregiver interviews focusing on questions such as past and current swallowing difficulties, weight loss, oral hygiene, and medical complications such as fever and a history of pneumonia. The healthcare team could also review the medical history of etiological risk categories for dysphagia. During a bedside dysphagia screening, observation of the patient's alertness and cognitive abilities are crucial to further screening. The procedure includes orientation, self-awareness interview, assessment of volitional cough, secretion management capacity, and gag reflex (pharyngeal sensation). It is not recommended to proceed with further observation-based screening if the patient is not alert or does not exhibit a cough reflex or secretion management capability. If the patient is cognitively stable, a swallow screening protocol can be administered to observe for signs such as cough during or after the swallowing, oral motor weakness, and voice quality change (wet, gurgly voice post-swallow).
Advanced Screening Tests
A water swallow test could be administered while conducting standard screening protocols. If the patient exhibits prerequisite abilities, Water Swallow Test protocols such as the Burke Dysphagia Screening Test (DePippo et al., 1994) and Yale Swallow Protocol (Leder & Suiter, 2014), which includes a 3 oz Water swallow test, could be administered. In addition, Swallowing screening protocols such as the Toronto Bedside Swallowing Screening Test (TOR-BSST; Martino et al., 2009) and Simple Standardized Bedside Swallowing Assessment (SSA; Perry 2001) can be utilized for early identification of aspiration risk. The Gugging Swallow Screen (GSS) is a fast and reliable method to identify stroke patients with aspiration risk (Trapl M et al., 2007).
Conclusion
In summary, a swallow screening is a quick and efficient procedure that can be done at the bedside. It is not limited to speech-language pathologists (SLPs). It can be performed by other qualified healthcare professionals, making it a practical and feasible tool in the early identification of potential dysphagia. Screening allows the healthcare team to make objective decisions about further assessment by quickly and effectively identifying high-risk individuals or early dysphagia assessment and interventions. Delays in screening stroke patients increased the incidence of stroke-after pneumonia (SAP) by 1% per day of delay (Bray et al., 2016). Prompt and coordinated action in conducting swallow screenings can significantly enhance treatment outcomes for individuals with cerebrovascular accidents.
To take your practice to the next level, consider Liri AI, a game-changing tool for speech-language pathologists. It helps SLPs save up to 70% of their time.
References
American Speech-Language-Hearing Association. (2001). Roles of speech-language pathologists in swallowing and feeding disorders: Technical report. ASHA 2002 Desk Reference, pp. 3, 181–199.
Addington, W. R., Stephens, R. E., & Gilliland, K. A. (1999). Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke: An interhospital comparison. Stroke, 30(6),1203–1207.
Bray, B., Smith, C. J., Cloud, G., Enderby, P., James, M., Paley, L., Tyrrell, P. J., Wolfe, C., & Rudd, A. (2016). The association between delays in screening for and assessing dysphagia after acute stroke and the risk of stroke-associated pneumonia. Journal of Neurology, Neurosurgery, and Psychiatry. https://doi.org/10.1136/jnnp-2016-313356
Daniels, S. K., Ballo, L. A., Mahoney, M. C., & Foundas, A. L. (2000). Clinical predictors of dysphagia and aspiration risk: Outcome measures in acute stroke patients. Archives of Physical Medicine and Rehabilitation, 81(8)
DePippo, K. L., Holas, M. A., & Reding, M. J. (1994). The Burke dysphagia screening test: Validation of its use in patients with stroke. Archives of Physical Medicine and Rehabilitation, 75(12), 1284–1286.
DePippo, K. L., Holas, M. A., Reding, M. J., Mandel, F. S., & Lesser, M. L. (1994). Dysphagia therapy following stroke: A controlled trial. Neurology, 44(9), 1655–1660.
Hemorrhage – ActivelyFitSeniors. https://activelyfitseniors.blog/tag/hemorrhage/
Hughes, T. A. T., & Wiles, C. M. (1996). Clinical measurement of swallowing in health
and in neurogenic dysphagia. Quarterly Journal of Medicine, 89(2), 109–116.
https://doi.org/10.1093/qjmed/89.2.109Leder, S. B., & Suiter, D. M. (2014). The Yale Swallow Protocol: An evidence-based approach to decision making. Springer. Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G., Streiner, D. L., & Diamant, N. E.
(2009). The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and
validation of a dysphagia screening tool for patients with stroke. Stroke, 40(2), 555–561.
https://doi.org/10.1161/STROKEAHA.107.510370Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: Incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12):2756–2763. doi: 10.1161/01.STR.0000190056.76543.eb.
Perry, L. (2001). Screening swallowing function of patients with acute stroke. Part two: Detailed evaluation of the tool used by nurses. Journal of Clinical Nursing, 10(4), 474–481. https://doi.org/10.1046/j.1365-2702.2001.00502.x
Recognizing Symptoms of Dysphagia After a Stroke | Thick-It.
https://thickit.com/blog/2020/05/15/recognizing-symptoms-of-dysphagia-after-stroke/Saab, R., Balachandar, A., Mahdi, H., Nashnoush, E., Perri, L., Waldron, A., Sadeghian, A., Rubenfeld, G., Crowley, M., Boulos, M., Murray, B., & Khosravani, H. (2023). Machine-learning assisted swallowing assessment: A deep learning-based quality improvement tool to screen for post-stroke dysphagia. Frontiers in Neuroscience.
Sherman,В., Greco, E., & Martino, R. (2021). The Benefit of Dysphagia Screening in Adult
Patients With Stroke: A Meta‐Analysis. Journal of the American Heart Association.
https://doi.org/10.1161/jaha.120.01875Trapl M, Enderle P, Nowotny M, Teuschl Y, Matz K, Dachenhausen A, Brainin M.Stroke. 2007 Nov;38(11):2948-52. doi: 10.1161/STROKEAHA.107.483933. Epub 2007 Sep 20.PMID: 17885261