STROKE AND DYSPHAGIA
HCS 403/6209 Transition to Professional Autonomy
STROKE
Anyone can have a stroke
http://www.stroke.org.uk/

Stroke occurs approximately 152,000 times a year in
the UK

One in four strokes are fatal within a year

Stroke is the fourth single largest cause of death in the
UK

Britain has 1.16million stroke survivors

It is the largest cause of complex disability

A third of strokes occur in people under 65 years

Stroke costs the British economy around £9billion a
year
The impact of stroke

Communication problems
About a third of stroke survivors have difficulty with
communication
 One third of people who have survived a stroke in the UK
have aphasia
 Aphasia affects your speech, your ability to understand
what is being said, and your reading or writing skills
 Many stroke survivors also have dysarthria - caused when
weakness of the muscles you use to speak, meaning your
voice may sound different and you may have difficulty
articulating your speech
 Dyspraxia of speech happens when you cannot move
muscles in the correct order and sequence to make the
sounds needed for clear speech

The impact of stroke

Cognitive problems
 It is thought that some cognitive loss probably
happens in most stroke survivors
 Some of the most common areas of cognition that
can be affected by stroke are
 Memory
 Attention
 Perception
 Communication
The impact of stroke

Depression
About half of stroke survivors suffer depression in the first
year following their stroke
 Symptoms: losing interest in everyday activities and not
being able to enjoy the things you used to; finding it
difficult to concentrate or make decisions, avoiding people;
losing self-esteem or confidence; becoming isolated from
society


Emotional problems


Including anxiety, anger and personality problems
Fatigue
One of the most common effects of stroke
 The intensity of the tiredness does not seem to be related
to the severity or type of stroke you have had

NICE stroke pathway
http://pathways.nice.org.uk/pathways/stroke#path=view%3A/pathways/stroke/stroke-overview.xml&content=view-index
Further pathways relevant to speech and language therapy include:
 Stroke rehabilitation
 Assessment and therapy in specific areas for people with stroke
National Stroke Strategy 10-point plan
http://www.gmccsn.nhs.uk/files/7413/5246/5915/DH_-_National_Stroke_Strategy_December_2007_Easy_Access_Version.pdf










Awareness
Preventing Stroke
Involvement
Acting on the warnings
Stroke as a medical emergency
Stroke unit quality
Rehabilitation & community support
Participation
Workforce
Service Improvement
Stroke strategy: Life after stroke
http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_081059.pdf

The seven outcomes set out in ‘Out health, our care,
our say’ are relevant to people living with stroke:
Improved health and emotional wellbeing
 Improved quality of life
 Making a positive contribution
 Choice and control
 Freedom from discrimination
 Economic wellbeing
 Personal dignity


Commissioners should commission stroke services
with these outcomes in mind
Support services post-stroke
http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_081059.pdf
National guidelines and information




National clinical guidelines for Stroke, 2nd edition. Royal College of
Physicians, 2004 www.rcplondon.ac.uk
National service framework (NSF) for older people’s services.
Department of Health, 2001 www.dh.gov.uk/PolicyandGuidance
NSF for long-term conditions. Department of Health, 2005
www.dh.gov.uk/PolicyandGuidance
Scottish Intercollegiate Guidelines Network (SIGN):




Guideline 64: Management of individuals with stroke: Rehabilitation,
prevention and management of complications, and discharge planning,
2005.
Guideline 13: Management of patients with stroke part I: Assessment,
investigation, immediate management and secondary prevention,
1997 www.sign.ac.uk
RCSLT Clinical Guidelines, 2005 – section on Aphasia www.rcslt.org
Mental Health Capacity Act. Department of Health, 2005
www.mca2005.co.uk
http://www.stroke.org.uk/

Prevention: Campaign and provide services in support of more effective
primary and secondary prevention

Provide Services: Support as full a life after stroke as possible for all
stroke survivors and their families in the UK

Campaign and influence: To achieve full implementation and
resourcing of the stroke strategies and plans

Education, information and training: The leading UK provider and
facilitator of quality stroke information and training to both the public and
the caring professions

Research: Fund high quality research providing maximum benefit to
people affected by stroke

Awareness: Raise awareness of stroke, research, prevention, treatment
and its consequences
http://www.differentstrokes.co.uk/

Different Strokes is run by younger stroke survivors for younger
stroke survivors, for the purposes of active self-help and mutual
support

The charity provides an important voice for younger stroke
survivors to Government, service providers and funders, fighting
for better standards and improved understanding

Different Strokes currently does this by:

Organising a national network of weekly exercise classes to optimise
recovery, regain independence and play a full role in their communities

Providing practical, easy to use information for the recovering stroke
survivor

Offering a 'StrokeLine' telephone service so that younger stroke
survivors can speak to other younger stroke survivors

Keeping stroke survivors informed of developments relevant to them
http://www.aphasiaalliance.org/

The Aphasia Alliance is a coalition of key organisations from all over
the UK that work in the field of aphasia

The Aphasia Alliance is not an organisation, but an informal union
between different organisations that share a common purpose – to
improve the lives of, and support, people with aphasia and their
families

The purpose of the Aphasia Alliance is:







To maintain communication, good relationships and collaboration
between organisations focused on Aphasia
To keep each other informed
To support and encourage one another
To try to ensure that work is not replicated
To exchange ideas
To make the most of resources available
To highlight shared priorities and to speak with one voice
DYSPHAGIA
Dysphagia
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563739/

Dysphagia affects between 23-50% of stroke
patients

Swallowing difficulties can result in aspiration and
reduced oral intake

This can lead to pneumonia, malnutrition and
dehydration
Oropharyngeal dysphagia

Defined as a disruption in the transition of the
bolus through the mouth and pharynx

This can arise as a result of:
 Muscle
weakness
 Problems with attention and/or concentration
 Balance difficulties and/or poor co-ordination
Application to the ICF Model (WHO, 2001)
ICF DIMENSION
Impairment
FACTORS
Activity
Nutrition and hydration, management of secretions, dietary
preferences, current feeding pattern, positioning, posture, bolus
size, altered food consistencies, pacing and presentation of food
and drink, need to use special utensils, coping strategies
Participation
Environment, mealtime interaction, ability to participate in social
meal times, ability to eat in different locations, cope in different
social settings
Wellbeing
Effects of emotional state, mood and behaviour
General motor skills, structure, vocal tract function, respiratory
status, tracheotomy status, cognitive levels, level of alertness,
effect of medication, oral hygiene and sensitivity, dental health
NICE Guidelines: Dysphagia Following Stroke





Assess swallowing in people after stroke in line
with recommendations in Stroke
Offer swallowing therapy at least 3 times a week
Swallowing therapy could include compensatory
strategies, exercises and postural advice
Ensure that effective mouth care is given to people
with difficulty swallowing after stroke
Healthcare professionals should regularly monitor
and reassess people with dysphagia after stroke
Diet Modification

Dysphagia is commonly managed using diet
modification

Different NHS Trusts use different terminology to
refer to different diet and fluid consistencies

The Sheffield stroke service uses the following diet
and fluid descriptors...
Sheffield descriptors (diet)
Sheffield descriptors (fluid)
Ethics in Dysphagia

It is important to consider the client’s personal
treatment preferences

Modifications must be made to ensure that the
clients nutritional needs are being met

Patients who are unable to meet their nutritional
needs via oral intake will be considered for an NG
tube/PEG
Percutaneous Endoscopic Gastrostomy (PEG)



A PEG is considered when a patient requires long term
nutritional support
The risks and benefits of the procedure need to be
assessed on a patient by patient basis
Factors such as life expectancy should be taken into
account


Prior to placing a PEG, the client will need to consent to the
procedure


For example, a PEG will not be placed if it will prolong the dying
process
A capacity assessment will be carried out if there are concerns
about the patient’s cognitive ability to consent
Family members/carers will also need to be made aware of
the long term implications of a PEG
Other resources for Dysphagia

National Dysphagia Competence Steering Group UK: Interprofessional Dysphagia
Framework on Dysphagia MOLE page

National Patient Safety Agency NHS (2007) - Problems Swallowing? Resource for
healthcare staff www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=7033

NICE (2006) - Nutrition support in adults: Oral nutrition support, enteral tube
feeding and parenteral nutrition
www.nice.org.uk/guidance/cg32/chapter/guidance

RCSLT (2009) – Manual for Commissioning and Planning Resources – Dysphagia
www.rcslt.org/speech_and_language_therapy/commissioning/dysphagia_manu
al_072014

SIGN - Management of patients with stroke: identification and management of
dysphagia www.sign.ac.uk/pdf/qrg119.pdf

Stroke Association (2012) - Swallowing Problems After Stroke
www.stroke.org.uk/sites/default/files/Swallowing%20problems%20after%20str
oke.pdf