. 10. Hydration and nutrition 10.2 Assessment of swallowing function

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1 . 10. Hydration and nutrition 10.2 Assessment of swallowing function NUTRI 1b: In patients with acute, what is the accuracy of a) bedside swallowing assessment b) video fluoroscopy c) fiberoptic endoscopic evaluation of swallowing for detecting clinically significant aspiration? b) How do the results of these assessments affect clinical outcomes? Reference Hamidon BB, Nabil I, Raymond AA. Risk factors and outcome of dysphagia after an acute ischaemic. Medical Journal of Malaysia. 2006; 61(5): Ref ID: 2666 Study type Evidence level e cohort 2+ single centre, Kuala Lumpur Number of patients characteristi cs N=134 s with acute firstever ischemic (CT confirmed) Exclusion criteria included: haemorrhagi c, impaired level of consciousne ss, previous history of, history of previous swallowing Intervention Comparison Length of follow-up Bedside swallowing assessment (BSE) Day 3 to 7 post NA One month Outcome measures Mortality Source of funding Mean age

2 64 yrs, 47.8% Chinese, diabetes 53.7%, hypertension 77.6%, MCA infarct 39.6% and lacunar infarct 44.7% Dysphagia at presentation was an independent predictor of death at one month (OR 5.28; 95%CI 1.51 to 18.45; p=0.01). Mann G, Hankey GJ, Cameron D. Swallowing function after : Prognosis and prognostic factors at 6 months. Stroke. 1999; 30(4): Ref ID: 129 e cohort, single centre Australia 2++ N=128 Hospitalreferred patients with acute first BSE median 3 days from onset BSE Swallowing 65/128 (50%) BSE aspiration 64/128 (50%) Video fluoroscopy (VF) median 10 days post BSE 63/128 (49%) BSE no aspiration 65/128 (50%) VF swallowing N= 46/128 (36%) VF aspiration 100/128 (78%) 6 months Chest infection Mortality Public sector grant VF swallowing 82/128 (64%) Aspiration 28/128

3 (22%) *Incidencd BSE identified a swallowing disorder in 65/128 (51%) and aspiration in 64/128 (50%) patients. VF detected a swallowing disorder in 82/128 (64%) and aspiration in 28/128 (22%) patients. *Association between swallowing disorder and outcomes Multiple regression analysis identified delayed or absent swallowing disorder (detected by VF) as the single independent predictor of chest infection during the six month follow up (hazard ratio HR 9.8; 95%CI 2.9 to 33). Independent predictors of the combined outcome event of swallowing, chest infection, or aspiration at six months included VF evidence of delayed oral transit and penetration of contrast into the laryngeal vestibule. Paciaroni M, Mazzotta G, Corea F et al. Dysphagia following. European Neurology. 2004; 51(3): Ref ID: 2527 e, single site UK 2++ N=406 s with acute-first ever mean time to first assessment and presentation was 330 mins, mean age 73 yrs, 54% male, haemorrhagi c 16% There was a significant difference in the mean ages of s with possible/probabl e/definite dysphagia CBE Performed blind to imaging findings s without dysphagia 3 months Mortality Disability

4 patients with and without dysphagia 104/406 (34.7%) patients had dysphagia at initial clinical examination. 64/34 patients had died in three month follow up, 55/343 in the dysphagic group and 9/343 in the non dysphagic group (OR 0.05; 95%CI 0.02 to 0.11; p<0.0001). *Disability At three month follow up, 69.5% of the patients with dysphagia had a mrs > 3 compared with 15.5% of the patients without dysphagia (OR 0.07; 95%CI 0.04 to 0.12; p<0.0001). *Association between dysphagia and outcome Multiple regression analysis identified dysphagia at baseline as an independent predictor of disability (SE β 0.331, t=6.409, p<0.0001) and mortality (SE β 0.474, t=9.787, p<0.0001) at three month follow up. Power (in press, awaiting notification from author) e cohort 2++ N=140 (N=31 removed due to incomplete data) Hemispheric patients. Previous included if no swallow Exclusion: brain stem population Aspirating: 41 male, Video Fluoroscopy (VF) Performed blind to results of the clinical assessment Aspirators N=71 Non-aspirators N=69 6 months Mortality Length of hospital stay Pneumonia

5 mean age 73 yrs Non aspirating: 42 male, mean age 65 yrs* *Significant baseline difference Whilst in hospital, there were 48 deaths and of these 15 were aspirations compared with 4 non-aspirators (OR 4.35; 95%CI 1.37 to 13.88). Aspirating patients were twice as likely to die within the first six months following (OR 2.00; 95%CI 0.93 to 4.31). Age was not a confounding variable. Cox proportion hazard analysis (adjusted for age) showed higher mortality for aspirating patients (p<0.001) *Length of hospital stay Aspirating patients remained in hospital 6 days longer (51 vs 45 days) than non-aspirators (p<0.05) *Pneumonia Aspirators were twice as likely to have an episode of pneumonia than non-aspirators (26 (35%) vs 13 (19%); p<0.05). More aspirating patients developed pneumonia in hospital during their acute admission (12 vs 4; OR 3.31; 95%CI 1.01 to ). The risk of developing pneumonia was almost four times higher for young aspirating patients compared with young non-aspirating patients. This reduced to 1.75 times for old aspirating patients compared with old non-aspirating patients. Reynolds PS, Gilbert L, Good DC et al. Pneumonia in dysphagic patients: on outcomes and identification of high risk patients. Journal of Neurologic Rehabilitation. 1998; 12(1): Ref ID: Retrospec tive case review, single centre USA 3+ N=102 s with acute ischemic who were referred for a swallowing assessment. Exclusion: brain stem s, silent Swallowing or aspiration by clinical bedside examination (CBE) (median 3 days from admission) 56/ 102 (55%) Videofluroscopy (VF) ((median /as piration CBE 45% VF 67% To discharge Pneumonia Accuracy

6 2514 aspiration and patients without VF one day from CBE) 34/102 (33%) 13/34 silent aspiration 56/102 (55%) had swallowing as detected by CBE and 34/102 (33%) aspirated on VF. CBE (p<0.05) and VF (p<0.01) correlated with the development of pneumonia. Out of the 34 patients who aspirated on VF, 12 (35.3% developed pneumonia compared with 9/68 (15%) of non-aspirators (difference (p<0.01). The combination of CBE and VF had the highest sensitivity and negative predictive values (S=0.86, NVP=0.91). Smithard DG, Smeeton NC, Wolfe CD. Long-term outcome after : does dysphagia matter? Age & Ageing. 2007; 36(1): Ref ID: 372 e cohort, multicentr e UK 2++ N=1188 s with first ever mean age 72 yrs and 58% male There were significant baseline differences of age and female gender Swallowing detected using CBE (N=567) Performed within the first week post (M=621) 5 yrs Mortality Residence Disability At three month follow up, significantly more patients with swallowing had died compared with those with no (OR 2.03; 95%CI 1.12 to 3.67; p<0.05). The difference was no longer statistically different for follow up years one to five. *Residence Significantly more patients with swallow compared with those with no were living in a nursing home at three month (OR 1.73; 95%CI 1.02 to 2.95; p<0.05), four year (OR 3.35; 95%CI 1.37 to 8.19; p<0.05) and at five years (OR 3.06; 95%CI 1.06 to 8.83; p<0.05).

7 *Disability (Barthel Index 15) At four year follow up, a statistically significant proportion of patients with swallowing had a Barthel index 15 compared to those without an (OR 2.44; 95%CI 1.08 to 5.51; p<0.05) Smithard DG, O'Neill PA, Park C et al. Complications and outcome after acute : Does dysphagia matter? Stroke. 1996; 27(7): Ref ID: 2513 e, single site, UK 2++ N=121 s with acute within 24 hrs of onset median 79 yrs, 58% female No significant baseline differences BSE Swallowing 60/121 (50%) VF within 3 days of onset and median time from BSE of 24hrs Aspiration 20/94 (21%) 61/121 (50%) Aspiration 74/94 (89%) 7 days Mortality Functional outcome Length of stay Place of discharge Chest infection Nutritional status Hydration Charity and NHS grant There was a higher of mortality in those with dysphagia compared to those without dysphagia (6 vs 37%; χ²=12.2; p<0.01).aspiration on VF was not associated with a statistically difference (NS). *Chest infections Statistically significant more patients with a swallowing had a chest infection compared with those with no swallowing (33% vs 16%, χ²=3.9; p<0.05). Aspiration on VF was not associated with a statistically significant difference in chest infections between the groups (NS) *Length of hospital stay s with dysphagia stayed in hospital significantly longer than those without dysphagia (44.8 vs 24.5 days; p<0.01) *Disability Dysphagia was associated with a statistically significant lower mean Bathel Index score at 6 months after (15 vs 18; p=0.02) but aspiration on VF was not. s with dysphagia were statistically more likely to be discharged to institutional care (45 vs 21%; p<0.05) *Multivariate analysis

8 The presence of dysphagia was an independent predictor of mortality (χ²=6.4; p=0.01), but not aspiration on VF. Odderson IR, Keaton JC, McKenna BS. Swallow management in patients on an acute pathway: Quality is cost effective. Archives of Physical Medicine & Rehabilitation. 1995; 76(12): Ref ID: 2512 e, single centre USA 2- N=124 s with acute nonhaemorr hagic Who had a swallow screening within 24 hrs of admission 49/124 male BSE Swallowing N=48 (39%) N=76 (61) NA Length of hospital stay Residence *Length of hospital stay The length of hospital stay was significantly longer in patients with dysphagia compared to those without dysphagia (8.4 vs 6.4 days; p<0.05). *Residence s with dysphagia were less likely to be discharged home than those without dysphagia (27% vs 55%; p<0.05)