Swallowing is a complex function that is often taken for granted. As individuals age, physiologic changes can contribute to increased difficulty in swallowing.1 Healthy older adults as well as those with compromised health can experience this phenomenon.2 Swallowing issues can lead to aspiration, malnutrition, and dehydration. However, it is important to recognize that swallowing problems are most often indicative of an underlying condition.
Nurse practitioners (NPs) and physician assistants (PAs) who see these patients regularly may be the first to identify dysphagia. Patients may struggle to identify swallowing difficulties or do not recognize this as a problem. Nursing staff may report that a patient was coughing or gagging during eating or taking medication. These are common indicators that a patient may have difficulty swallowing and need further evaluation.
Dysphagia does not occur on its own; swallowing difficulties are most often the result of an underlying disease process (Table). For this reason, as clinicians begin an assessment, they should always ask, “What is the reason for this patient’s dysphagia?”5
Patients with dysphagia are at increased risk of developing aspiration pneumonia as a result of food, liquid, or oral bacteria entering the lungs. Although patients may demonstrate symptoms like coughing or choking, some patients may be aspirating silently. This incidence may be particularly widespread in older patients with neurologic disorders.3
Poor oral function can lead to an increase in gram-negative anaerobic bacteria and masticated food residue in the mouth, both of which increase a patient’s risk of developing upper respiratory infections and aspiration pneumonia.6 For these reasons alone, it is important for clinicians to recognize dysphagia and assist patients to provide optimum swallowing. The PASS acronym offers a quick assessment guide for clinicians in the field6:
P: What is the probability that this person has swallowing difficulties based on past history?
A: Account for any previous problems with swallowing
S: Screen for objective signs of swallowing difficulties (eg, coughing, gagging, drooling)
S: Speech language pathologist referral
Another important method for determining patients’ swallowing ability is to ask if they have difficulty swallowing their medications. This question not only establishes possible dysphagia but opens up the door to discuss alternative options for taking medications. When bringing up the issue of dysphagia with patients, start by asking open-ended questions in an attempt to get the patient to discuss how they take their oral medication(s), what time of day, and with what type of liquid. Other important questions include:
- Do you have difficulty swallowing food or medications?
- How often does this happen to you?
- What do you do when you have trouble swallowing?
A number of dysphagia-specific standardized scales are available for clinicians to identify the presence of dysphagia and document changes in status. Scales that have been normed and validated for use at the bedside or in the clinic include the Eating Assessment Tool (EAT-10), Swal-QOL and Swal-CARE, and the Functional Oral Intake Scale.7,8
Creating an accepting environment where patients feel comfortable providing detailed information will serve the clinician well. Patients may have been told that they have dysphagia and may have been referred to a speech-language pathologist (SLP) but may not have had the health literacy to understand the importance of the swallowing regime. Clinicians should speak with their patients using plain language, emphasizing concern for their condition and acceptance of their symptoms.9,10
Much of the research on methods of rehabilitation for dysphagia has been among patients who have experienced stroke.11 Dysphagia is often treatable through rehabilitative exercise, food and liquid texture modifications, and body positioning techniques and strategies. Although most patients with stroke recover their swallowing function over time, this is not the case for patients with other progressive conditions.11
Therefore, there is no single treatment or strategy that will resolve every patient’s dysphagia — a strategy that may work well for 1 patient could in fact make the swallowing problem worse for another patient. An example of this is the pervasive myth in healthcare that the chin tuck works for every patient with dysphagia.12 Although this posture can be helpful for some patients, fluoroscopic or endoscopic imaging of the swallow is required to determine if this posture will be effective. One study demonstrated that 48% of patients with silent aspiration continued to aspirate silently even with the use of the chin down/chin tuck posture.13
NPs and PAs play a critical role in identifying patients with dysphagia and making the appropriate referral to an SLP. The SLP can then determine the safest and most efficient way for patients to eat and drink. Patients with dysphagia are assessed and prescribed graded food textures and drink thicknesses that match their physical and cognitive abilities. Inconsistencies and errors in labeling of texture-modified foods, however, have resulted in deaths attributed to the delivery of inappropriate food textures to patients with dysphagia.7 To help avoid adverse events, the International Dysphagia Diet Standardization Initiative developed standardized terminology and definitions for texture-modified foods and liquids.7
Patients who experience swallowing difficulties are at increased risk for error in their medication administration. A recent study indicated that medication administration errors occur in nearly 60% of drugs administered to residents of long-term care facilities with swallowing difficulties.1 SLPs may recommend texture modifications for medications, such as crushing or cutting pills, and should work with the NP, PA, and pharmacist to ensure the patient’s medications can safely be modified in the recommended manner. The clinicians may rely on the pharmacist to identify alternative medication administration options (eg, liquid medications; smaller pill sizes; and coated vs noncoated pills, capsules, and extended-release granules) as needed.
Medications are often dispensed in solid form because it is the most cost effective method of administration.4 Certain medications, when crushed or scattered over food, could have their therapeutic effectiveness damaged and the likelihood of side effects increased.14 For patients with swallowing difficulties, other avenues of administration including liquid, rectal, or parenteral formulations must be considered.14 It is not only the responsibility of the clinician administering the medications, but it is the obligation of the prescriber to make sure that the patient is able to take the medications as prescribed. If the patient does have difficulty with swallowing, modifications can be made that will increase patient adherence with medication administration.4
One option for patients who struggle to take medications with liquid, but are prescribed medications that cannot be crushed, is to bury the pill in a small amount of pudding or applesauce. This is often more palatable to the patient, and the weight of the solid pudding may carry the medication more efficiently into the esophagus.
For elderly patients taking multiple medications (polypharmacy), the SLP, NP, PA, and pharmacist should work together to cluster medications so that they can all be administered in a similar way. If a patient can take each medication using the same swallowing technique, they are less likely to have errors in medication administration.
Collaboration Key to Success
The management of dysphagia should be a collaborative effort that includes not just the medical team, but the patient as well. Patients are more likely to follow medical recommendations when they are involved in their treatment plan.10 Involving patients in their care will also help to decrease the incidence of poor outcomes as a result of swallowing difficulties. Clinicians should check with patients about their understanding of why the pill “feels stuck” and provide a simple explanation that they can understand. Involve family or significant others in the plan to improve swallowing and foster feelings of self-efficacy, encouraging the patient at all times.9 Use multiple learning strategies to increase patients’ understanding and ability to participate in their own care. All of this can be reinforced by each member of the healthcare team to provide the patient the support necessary to work toward improved swallowing.
NPs, PAs, and nurses can initiate this engagement by asking patients what they are already doing at home to manage taking their medications despite their dysphagia; discuss when it is safe and appropriate to take medications, incorporating the patient’s own strategies into their treatment plan to facilitate adherence. Good communication between the healthcare team and the patient is essential to ensuring that patients are able to eat, drink, and take their medications safely. Better swallowing decreases medication errors, increases patient hydration and nutrition, and puts the patient on the path to favorable outcomes.
Carel Mountain, DNP, RN, CNE, is Director of Nursing at Sacramento City College, Sacramento, California. Kimberlee Golles, MS, CCC-SLP, is a speech language pathologist at Kaiser Permanente Medical Center in Walnut Creek, California.
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