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Research on swallowing problems in the elderly highlights potential for preventing pneumonia in stroke patients

Current research on swallowing problems (dysphagia) suggests that hospital stroke management plans that include programs to diagnose and treat dysphagia may yield dramatic reductions in pneumonia rates, according to a new evidence report produced by ECRI, an Evidence-based Practice Center (EPC), under contract to the Agency for Health Care Policy and Research. The EPC also found that use of comprehensive examinations conducted at the patient's bedside can detect most serious swallowing problems, could improve quality of care, and may help reduce costs.

About 6.2 million Americans over age 60 have dysphagia, a condition that can result in "aspiration"—when food or fluids enter a person's lungs—and lead to pneumonia. The topic for this report was nominated by the Health Care Financing Administration, which sought an evidence-based assessment of methods for diagnosing and treating dysphagia in elderly individuals with neurologic diseases, specifically those methods associated with services provided by speech-language pathologists. Most of the approximately 300,000 to 600,000 new cases of dysphagia each year occur in stroke patients.

In addition to showing that patients benefit from acute stroke management programs that include specific efforts to diagnose and treat swallowing problems, an analysis of the available literature demonstrates the value of full bedside examinations in providing a solid core of information that health professionals and others can use in deciding on a course of treatment. A full bedside examination includes taking a detailed history, performing a physical examination of the mouth and throat, and observing the patient attempting to swallow various consistencies and sizes of foods and liquids. Other findings discussed in the report include:

• Use of full bedside examinations in dysphagia management programs are capable of identifying up to 80 percent of all cases of aspiration. Aspiration often is difficult to detect because about half of patients with dysphagia who aspirate do so silently (without a cough).
• The limitations of available evidence do not allow one to determine the extent to which invasive procedures like videofluoroscopy or fiberoptic endoscopy reduce pneumonia rates more than full bedside examinations.
• The evidence is inconclusive about how the frequency of swallowing therapy sessions affects patient outcomes.
• The only controlled trial that compared a soft diet (some solids) to a traditional pureed diet (liquids only) found that a soft diet resulted in lower pneumonia rates among stroke patients with a history of aspiration pneumonia.

As noted by the developers of the report, there is a great need for more extensive and better designed research in the area of dysphagia, particularly a well-designed trial comparing dysphagia management programs using different diagnostic modalities. ECRI's report provides a detailed description of the design and analysis of a trial that would address several major unanswered questions and would also overcome some of the limitations of current research, such as sample sizes that are too small and the pooling of outcomes data on patients with dysphagia resulting from different causes.

Select to access the summary, Diagnosis and Treatment of Swallowing Disorders (Dysphagia) in Acute-Care Stroke Patients (AHCPR Publication No. 99-E023). Print copies of the summary are available from the AHCPR Publication Clearinghouse. The full report is expected to be available in summer 1999.

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