Stroke: Dysphagia & Oral Care
Presented by the Adult Speech-Language
Pathology Team,
Central Zone
23 November 2010
Housekeeping Items
• Sign attendance sheet
– give to site Telehealth contact
• fax to Alison Cronk (403-343-4866) or
• scan & e-mail to Alison
• Complete the evaluation form (sent at same time as
poster)
– send to Megan Terrill, R.SLP (fax, interoffice mail,
scan & e-mail)
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Objectives
• Reinforce the importance of early dysphagia
identification & management
• Discuss practical strategies for acute & chronic stroke
mealtime management
• Demonstrate growing evidence to support need for oral
care guidelines & protocols
• Report on oral care program implemented at Red Deer
Regional Hospital
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What is dysphagia?
• Feeding: The process of getting solids, liquids &
medication up to & in to the mouth
• Swallowing: The entire act of deglutition, a physiological
process that takes solids, liquids, saliva & medication
from the mouth to the stomach
• Dysphagia: The loss or impaired ability to feed, chew
and/or swallow
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Essential Anatomy
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Why do we worry about dysphagia?
• Examples of negative outcomes:
• Aspiration Pneumonia
• Dehydration
• Malnutrition
• Skin Integrity
• Delayed Initiation of Rehab
• Decreased Independence
• Quality of Life Issues
• Death
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Incidence of dysphagia in stroke
• 55% of all acute stroke patients admitted to hospital
• Historical data:
– Patients with dysphagia 3x more likely to develop
pneumonia than stroke patients without dysphagia
– Patients with severe dysphagia (confirmed
aspiration), 11x more likely to develop pneumonia
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Incidence of dysphagia in stroke
• Historical data:
– Mortality significantly higher for patients with
dysphagia, esp. in first 90 days
– As many as 35% still have difficulties after 3 months
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Dysphagia: Stroke Best Practice
• Swallowing ability should be screened using a simple,
valid, reliable tool before initiating oral intake of
medications, fluids or food
• Assess the swallowing ability of all stroke patients who
fail the swallowing screening
– Clinical Bedside Assessment
– Instrumental Assessment (e.g. videofluoroscopy
swallow study, FEES)
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Dysphagia: Stroke Best Practice
• Nutritional status – assess using a validated tool or
measure, to avoid malnutrition
• Explain the nature of the dysphagia, recommendations,
follow-up & re-ax to patients, family & care providers
• Provide client and/or legal decision maker with enough
info to allow informed decision making
• Reassess those receiving modified texture diets or
enteral feeding for changes in swallowing status
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How will we identify dysphagia?
• Team effort
– innovative, flexible approach to the use of regional
resources
– implement a training program - RNs, LPN’s or other
health care providers provide an initial screening
– develop interdisciplinary dysphagia teams to provide
clinical bedside or instrumental ax
• Suggest screening/assessing confirmed or suspected
stroke and TIA (transient ischemic attack)
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Method used to screen/assess for
dysphagia currently dependent on
service location.
Team communication is vital.
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Dysphagia: Tor-BSST
• Toronto-Bedside Swallowing Screening Test
• Validated in acute & rehab facilities
• SLPs take certification & then offer a 4-hour session
– RNs, LPNs, RDs, OTs, other SLPs
• 2 choices: pass or fail
• Training has occurred at: Camrose, Vermilion,
Wainwright, Red Deer & Drumheller Hospitals
– Various stages of implementation
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Dysphagia: Tor-BSST
• FAIL
– Remain NPO
– Team manages hydration, nutrition & medication
needs
• IV? NG-tube? HDC? Comfort measures only?
– Refer for a clinical bedside assessment
• If condition improves in the meantime, repeat the
screen
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Dysphagia: Tor-BSST
• PASS
– Give thin fluids & soft, easy-to-chew solids (old
DTHR)
– Give thin fluids & minced solids for 6 meals/snacks; if
no concerns upgrade to soft solids (old ECH)
– Monitor…any concerns, refer for clinical bedside ax
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Dysphagia: Tor-BSST
Wet, gurgly voice quality:
KEY indicator of swallowing difficulties.
Regardless of setting or discipline, train your ear to listen
for this.
If you hear it, refer for a clinical bedside assessment.
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Dysphagia: TTMD
• Test of Textured Modified Diet (TTMD)
• Available in continuing care locations (old DTHR)
• New residents screened for feeding & swallowing
difficulties
– screen done by LPNs & RNs
– 10 feeding questions
– 10 swallowing questions
• Residents then referred to SLP and/or OT
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Dysphagia: Clinical Bedside Assessment
• When in doubt, refer for this
• In-depth eval yields recommendations, for example:
– Positioning needs
– Feeding methods
– Texture modification
– Environmental adaptations
– Oral care
– Need for instrumental eval
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Mealtime Tips: Setting the Stage
• Glasses on, hearing aids in
• Dentures in, unless very poor fitting (e.g. muscle
tone/weight loss makes them “slide around”)
• In general, TV & radio off
• Normal table
• Prescribed, adapted equipment/utensils available at
every meal
• Prescribed medication delivery adhered to
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Mealtime Tips: Special Considerations
• Neglect: unless told otherwise…
– Put plate, cup, utensils on “good” side
– Approach from the “good” side
– Speak to them on the “good side”
• Hemiplegia (muscle weakening, usually on 1 side)
– Ensure tray is in reach
– Model creativity e.g. rip packages with teeth
– Empathize but don’t dwell
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Mealtime Tips: Special Considerations
• Persons with language changes (aphasia)
– Short, clear directions
– Use ‘do’ statements, rather than ‘don’t’ statements
– Talking louder doesn’t help
– No ‘baby’ talk – they are a competent adult
• Attention/Orientation Challenges
– Say their name & get eye contact before giving directions
– State what meal it is (e.g. “it’s lunchtime”) and what is available
(e.g. “There’s your meat, beans, etc…)
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Mealtime Tips: Special Considerations
• Facilitate independence as much as possible
• Avoid fostering dependence
• Here’s why:
– Dependence for feeding = strongest predictor of
aspiration pneumonia
• Feed when alert
• Ensure mouth is empty between spoonfuls
• Feed at eye level, not standing over the person
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Oral Care: Stroke Best Practice
• All stroke patients should have an oral/dental ax:
– screen for dental disease
– screen for level of oral hygiene
– screen for cleanliness & ability to safely wear/
use dentures & appliances
• Oral care protocols should address:
– frequency of oral care required
– types of products to be used
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Why emphasize oral care?
• Avoid aspiration pneumonia
– All aspiration is not equal
– Aspiration of solids, medication & bacteria-filled
saliva poorly tolerated by the lungs
– Aspiration of water tolerated more easily by lungs
** BUT ONLY IF MOUTH IS CLEAN AND NOT
FULL OF PATHOGENS **
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Why emphasize oral care?
• Avoid airway obstruction
– Residue left in mouth
• Avoid tartar build-up & dental decay while in facility
• Basic comfort
– Refresh
– Moisturize
– Breath odor control
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Red Deer Oral Care Protocol
• Developed by multi-disciplinary team
• Instituted on the Stroke Unit
• One-hour training session in conjunction with Tor-BSST
training
– RNs & LPNs trained
• Use of form
• Proper oral care techniques
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Red Deer Oral Care Protocol: Assessment
Healthy
Fair
Poor
Very Poor
Lips
Gums &
Tissues
Tongue
Mouth Odor
Oral
Cleanliness
Saliva
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Red Deer Oral Care Protocol: Assessment
• Determine if patient is:
– NPO
– Dependent for oral care
– Able to expectorate (i.e. spit)
– Unable to expectorate
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Red Deer Oral Care Protocol: Treatment
** IN NO SITUATION ARE SWABS ALONE ENOUGH **
• Toothbrushes to clean
• Rinses to clean
• Swabs to remove debris, freshen & moisturize
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Red Deer Oral Care Protocol: Treatment
• If NPO …
– NPO often times = significant dysphagia
– Likely aspirating own saliva
– Significant changes in saliva & general condition of
oral cavity found
• Can/Cannot Expectorate …
– CAN: use normal toothbrush & swabs
– CANNOT: use suction toothbrush & swabs
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Red Deer Oral Care Protocol: Treatment
• Dependent for oral care
– likely require heavy care/transfers
– tendency to miss/skip oral care
– oral care necessary to prevent medical
complications leading to even heavier care
• Independent for oral care but hemiparetic
• consider electric toothbrush
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Red Deer Oral Care Protocol: Treatment
• BID
– brush teeth, tongue, gums for 1-2 minutes
– no toothpaste unless non-foaming (e.g. Biotene)
– follow with chlorhexidene soaked swabs
** use suction if indicated
• q2-4h between BID care with
– closer to q2h for NPO patients
– moistened swabs to remove mucous/debris & moisturize
** brushing indicated in some situations
– water based lubricant for lips & oral cavity
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Red Deer Oral Care Protocol: Treatment
• DAILY: floss teeth if able
• PRN: water based lubricant to moisturize lips & oral
cavity (this is in addition to q2-4h between BID)
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Summary: Typical Patient Progression
• Emergency Phase
– Tor-BSST
• Acute Care
– oral care, clinical bedsides & reviews
• Rehabilitation Units
– oral care, clinical bedsides & reviews, feeding &
swallowing therapy
• Community Care (i.e. homecare, continuing care)
– TTMD (continuing care only), oral care, clinical
bedsides & reviews
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Questions?
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Today’s Presenters
Megan Terrill, MSLP, R.SLP, S-LP (C)
Professional Practice Lead – Adult Speech-Language Pathology
megan.terrill@albertahealthservices.ca
Camrose MSK-CRP Clinic
Phone: 780-678-3417
Fax: 780-672-1322
Justin Mutch MS, R.SLP, CCC-SLP
Speech-Language Pathologist
justin.mutch@albertahealthservices.ca
Red Deer Regional Hospital, Unit 35
Phone: 403-343-4445
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References
• Alberta Provincial Stroke Strategy (APSS) (Jan 2010). “Emergency
Management of Acute Stroke”. http://www.strokestrategy.ab.ca
• Alberta Provincial Stroke Strategy (APSS) (Jan 2007).
“Rehabilitation and Community Reintegration”.
http://www.strokestrategy.ab.ca
• Alberta Provincial Stroke Strategy (APSS) (Nov 2009). “Inpatient
Care for Acute Stroke Admissions”. http://www.strokestrategy.ab.ca
• Beck, S.L. (1991). Oral Exam Guide.
• Johnson, V., Chalmers, J. & Titler, M. (2002). “Evidence-based
protocol: oral hygiene for functionally dependent and cognitively
impaired older adults”. Iowa: University of Iowa Gerontological
Nursing Interventions Research Center.
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References
• Langmore, S., Terpenning, M., Schork, A., Chen, Y., Murray, J.,
Lopatin, D., Loesche, W. (1998) “Predictors of Aspiration
Pneumonia: How Important Is Dysphagia?” Dysphagia. 13; 2: 6981.
• Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G.,
Streiner, D., Diamant, N. (2009). “The Toronto Bedside Swallowing
Screening Test: Development & Validation of a Dysphagia
Screening Tool for Patients With Stroke”. Stroke. 40;555-561.
• Martino, R., Foley, N., Bhogal, S., Diamant,N., Speechley, M.,
Teasell, R. (2005). “Dysphagia after stroke: incidence, diagnosis,
and pulmonary complications. Stroke. 36(12):2756-63.
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References
• Martino, R., & Sharpe, K. (2005). “Swallowing Difficulties:
Information for the patient & family”. StrokEngine.
http://www.medicine.mcgill.ca/strokengine/PDF/dysphagia-en.pdf
• Teasell, R., et al (2008). “Canadian best practice recommendations
for stroke care”. CMAJ. 179 (12).
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