Dysphagia and Considerations for Nutritional Intervention

Introduction

In healthcare settings, an interdisciplinary approach is applied to management of swallowing disorders (dysphagia) and this collaboration may include a dietetic professional and a speech-language pathologist (SLP), along with the patient, their family, and other members of the healthcare team. Speech-language pathologists are professionals who assess, diagnose and treat dysphagia, as well as a variety of communication and cognitive disorders (ASHA, 2016). This case study chapter discusses the clinical problem of dysphagia from the perspective of a speech-language pathologist practicing in the United States. Dysphagia is identified as a risk factor for malnutrition, (Chen, Li, Fang, Lu, & He, 2019). This supports the need for close collaboration between the SLPs, who address the motor and sensory complications of dysphagia and the dietetic professionals who address the nutritional concerns. Insight into different perspectives on dysphagia and dysphagia management is important to understand the influences of dysphagia on clinical decision-making and patient outcomes.

Dysphagia is a disorder of swallowing that may affect a person’s ability to safely and effectively meet their nutritional needs. A variety of medical conditions may result in dysphagia, including neurological conditions affecting a person’s motor skills, or diagnoses or procedures that can affect function of the swallowing structures. For example, anterior cervical disc fusion (ACDF) procedures may result in a two-week post-surgical dysphagia incidence of up to 71%, with declining incidence over time (Cho, Lu, & Lee, 2013). Dysphagia has been identified through videofluoroscopic evaluation in 64% of patients assessed after acute stroke (Mann, Hankey, & Cameron, 2000). In addition to the effects of dysphagia on one’s ability to adequately obtain nutrition and hydration, presence of dysphagia can influence morbidity, mortality, and quality of life (Gonzales-Fernandez, Ottenstein, Atanelov, & Christian, 2013). Based on an understanding of dysphagia as a disorder with multiple influences, perhaps a better working definition of dysphagia would encompass a broader perspective, such as: dysphagia is a multifactorial swallowing disorder that can affect a person’s overall health and psychosocial well-being. Regardless of the reason for the dysphagia, each case is unique and intervention is dependent upon multiple factors that influence the overall management approach.

For discussion purposes, this chapter introduces a composite clinical case of a 75-year-old male who suffers from dysphagia as a result of a stroke. The American Heart Association reports that in the United States, over 795,000 people have a stroke annually (Go, et al., 2012). The incidence of dysphagia after stroke varies by location and severity of infarct but this diagnosis was selected for the case study due to documented high rates of resulting dysphagia. Research indicates that 64-78% of people post stroke demonstrated dysphagia when they were evaluated with instrumental studies in the acute hospital setting (Martino et al., 2005). Presence of a previous stroke is cited as a risk factor related to higher rates of malnutrition (Chen et al., 2019) with up to 62% of people suffering from malnutrition post stroke (Foley, Salter, Robertson, Teasell, & Woodbury, 2009). To better understand the case study, a basic review of normal swallowing, age-related changes in swallowing, disordered swallowing, swallowing assessments, and dysphagia management are presented.