Dysphagia Screening in Residential Long Term Care Settings in the Republic of Ireland: A Cross Sectional Survey

Abstract

Dysphagia is a common health concern reported to affect between 15% [1] and 70% [2] of older adults living in residential long-term care settings (RLTCS), who constitute a heterogeneous group with different dysphagia-associated conditions and care needs [3]. Dysphagia may lead to choking, aspiration and aspiration pneumonia due to impaired deglutition safety, and weight loss, malnutrition and dehydration as a result of impaired swallowing efficiency if not identified promptly and adequately managed [4]. Most of the available literature on dysphagia screening refers to patients with acute stroke, with current evidence supporting routine administration of swallow screening tests in this population [5]. However, no clinical guideline has been developed to date for use with older adults with dysphagia living in RLTCS and there is limited empirical evidence to guide practices in relation to dysphagia identification and management in this healthcare setting [3, 6]. In these circumstances, dysphagia screening may occur in an ad hoc fashion depending on the resources available and healthcare setting [7]. Dysphagia screening is a procedure used to identify individuals at risk of dysphagia requiring further assessment, involving administration of swallow screening tests, review of medical history to identify risk factors and conditions known to cause dysphagia, such as dementia or Parkinson’s disease, and observation of the presence of signs and symptoms of dysphagia at mealtimes [8, 9]. Further assessment of swallowing function is indicated in the event of a failed swallow screen or if dysphagia is suspected [10]. Non-instrumental clinical assessment is a systematic procedure, conducted by speech and language therapists (SLTs) in the Republic of Ireland [11], that involves the integration of information from the individual’s medical history, patient report, oro-facial examination and swallow trials [10]. This assessment allows to estimate the risk of aspiration, to inform dysphagia management recommendations and to identify the need for instrumental assessment [8, 10]. Instrumental swallowing assessment, typically videofluoroscopic swallowing study or flexible endoscopic evaluation of swallowing, may be indicated to evaluate the anatomy of the structures involved in swallowing and the physiology of swallowing to obtain a diagnosis of dysphagia and establish its cause and severity, and determine the underlying cause of aspiration or residue and presence of silent aspiration [8]. Nursing-led dysphagia screening does not replace SLT assessment; instead, it allows for early recognition of at-risk individuals and intervention [12]. It is recommended that all older adults are screened for dysphagia or assessed for swallowing difficulties on admission to a RLTCS [3, 13]. Swallow screening tests, such as the Gugging Swallowing Screen [14] or the Volume-Viscosity Swallowing Test [15], have been validated for use in older adults and recommended in RLTCS to screen for dysphagia associated signs and symptoms [16]. However, the Yale Swallow Protocol is the only swallow screening test validated to date for use in post-acute care to date, including older adults living in RLTCS [17]. Studies conducted in other countries found that nurses practising in RLTCS rely on residents’ self-reports of swallowing difficulties [18, 19], observation of signs of dysphagia during mealtimes [16, 19, 20] or relevant past medical history and associated risk-factors [16, 18] to identify residents at risk of dysphagia. The administration of swallow screening tests by nurses is not common practice in RLTCS [21]. Nursing personnel with 24-hour care access to residents in RLTCS are usually the first healthcare professionals to observe for signs and symptoms of swallowing difficulties when assisting with diet and fluid intake. Subsequently, they are often the healthcare professionals to conduct dysphagia screening and refer patients with or at risk of dysphagia to the SLT and implement dysphagia management recommendations [21, 22]. Although it is recommended that residents with suspected dysphagia be referred to the SLT for a clinical assessment of dysphagia [23], SLTs may not be readily available in Irish RLTCS [24, 25]. A survey conducted in the Republic of Ireland found that most Irish RLTCS do not have a SLT onsite and few nurses have received training on how to administer swallow screening tests in RLTCS [24]. Given potential delays in accessing SLT dysphagia services in Irish RLTCS, nurses may implement dysphagia management interventions while waiting for SLT assessment, including initiation or change of modified diets and modified fluids to reduce the risk of aspiration [25]. Current available evidence shows that modified texture diets and fluids contribute to undernutrition and dehydration while not reducing the risk of aspiration pneumonia in older adults with dysphagia [25, 26]. No previous studies have investigated nursing-led dysphagia screening practices in RLTCS in the Republic of Ireland. Furthermore, there are no data available on the prevalence of dysphagia or on the incidence rates of aspiration pneumonia Irish RLTCS. This study aimed to describe the process of nursing-led dysphagia screening in RLTCS in the Republic of Ireland and investigate the need to advance dysphagia screening and evaluation services in Irish RLTCS. Our objectives were: 1) to identify dysphagia screening practices used by nurses; 2) to describe referral patterns and dysphagia management interventions implemented with residents in whom dysphagia is suspected and before a clinical assessment of dysphagia is performed and estimate maximum waiting time (in days) from referral until SLT assessment; 3) to quantify the number of residents with dysphagia, episodes of aspiration pneumonia in the previous twelve months and the number of residents on modified texture diets and fluids; and 4) to determine differences in waiting time for SLT assessment, prevalence of dysphagia, twelve-month incidence rate of aspiration pneumonia and use of modified texture diets and fluids between groups of RLTCS, specifically SLT access (onsite/offsite), administration of swallow screening tests (yes/no), location (urban/rural) and type of RLTCS (public/voluntary/private).