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SIGN Guideline 119: Management of Patients with Stroke: Identification and Management of Dysphagia
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Dysphagia is a frequent and potentially serious complication of stroke,1 and in some cases may be the sole or overriding symptom.2-5 Reports of incidence vary according to the definition of dysphagia and the timing and method of assessment. Videofluoroscopic evidence indicates the presence of dysphagia in 64-90% of conscious stroke patients in the acute phase, with aspiration confirmed in 22-42% of cases.6-8
Dysphagia is associated with excess morbidity and increased mortality rates. It gives rise to a risk of aspiration and associated bronchopulmonary infections, fluid depletion and undernutrition.9-13 Whilst it is recognised that the development of undernutrition is multifactorial, nutritional problems may be exacerbated by decreased swallow function following stroke. Patients with acute stroke who are undernourished may take significantly longer to recover and have a higher mortality than those who are well nourished.14,15
Most dysphagia resolves within the first few weeks,1,9,11-13,16 but in some cases it may persist 1,6,17 with resulting long term consequences for nutrition management and psychosocial adjustment.
Implementation of a systematic programme of diagnosis and management of dysphagia within an acute stroke management plan can reduce the occurrence of pneumonia.18 Despite this evidence, the detection and management of swallowing problems in acute stroke is inadequate in many hospitals.19 The aim of this guideline is to assist practitioners in reducing the morbidity associated with dysphagia by early detection of swallowing disorders in stroke patients and application of appropriate methods to support food and fluid intake.
Although much has been written on the subject, there is a paucity of good, high level evidence to support the management of this aspect of stroke. There is an ongoing need for healthcare professionals to evaluate their practice in relation to outcomes and to consider carrying out audit and research in the field.
This guideline is an update of SIGN 78 Management of patients with stroke: identification and management of dysphagia and supersedes it.
Since the publication of SIGN 78 in 2004, new evidence has been published in areas covered by the recommendations in that guideline resulting in the need for this selective update. Where this evidence was thought likely to significantly change the content of these recommendations, it has been identified and reviewed.
The guideline development group based its recommendations on the evidence available to answer a series of key questions, listed in Annex 1. This guideline was updated in conjunction with SIGN 118 Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning.20 The guideline development group, specialist peer reviewers and others involved in consultancy, and the details of the systematic literature review are detailed within that guideline.
Where new evidence does not update existing recommendations, no new evidence was identified to support an update or no key question posed to update a section, the guideline text and recommendations are reproduced from SIGN 78. The original supporting evidence was not re-appraised by the current guideline development group.
This guideline provides recommendations based on current evidence for best practice in the identification and management of dysphagia after stroke.
The guideline does not apply to people with neurological conditions other than stroke, or to people with subarachnoid haemorrhage.
The guideline complements SIGN 118 Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning.20 and SIGN 108 Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention.21
The guideline is relevant to all personnel in contact with stroke patients throughout the care pathway from initial primary care response, through hospital admission, on to continuing care in the community. As the evidence base is strongest for patients in the acute setting, the emphasis is on this context.
2 |
Initial clinical evaluation of swallowing and nutrition after stroke |
Minor update |
3 |
Assessment |
Unchanged |
4 |
Training for screening and assessments |
Unchanged |
5 |
Effect of therapy on patient outcome |
New |
6 |
Nutritional interventions |
Minor update |
7 |
Other management issues |
Unchanged |
8 |
Provision of information |
Minor update |
The World Health Organisation defines stroke as a clinical syndrome of rapidly developed clinical signs of focal or global disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than vascular origin.22
Dysphagia, a difficulty in swallowing, can be caused by many pathologies including stroke. In patients with stroke, it is characterised by difficulty in safely moving food or liquids from the mouth to the stomach without aspiration. It may also involve difficulty in oral preparation for the swallow, such as chewing and tongue movement.
This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgement should only be arrived at following discussion of the options with the patient, covering the diagnostic and treatment choices available. It is advised, however, that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken.
Recommendations within this guideline are based on the best clinical evidence. Some recommendations may be for medicines prescribed outwith the marketing authorisation (product licence). This is known as “off label” use. It is not unusual for medicines to be prescribed outwith their product licence and this can be necessary for a variety of reasons.
Generally the unlicensed use of medicines becomes necessary if the clinical need cannot be met by licensed medicines; such use should be supported by appropriate evidence and experience.23
Medicines may be prescribed outwith their product licence in the following circumstances:
‘Prescribing medicines outside the recommendations of their marketing authorisation alters (and probably increases) the prescribers’ professional responsibility and potential liability. The prescriber should be able to justify and feel competent in using such medicines.’23
Any practitioner following a SIGN recommendation and prescribing a licensed medicine outwith the product licence needs to be aware that they are responsible for this decision, and in the event of adverse outcomes, may be required to justify the actions that they have taken.
Prior to prescribing, the licensing status of a medication should be checked in the current version of the British National Formulary (BNF).23
NHS QIS processes multiple technology appraisals (MTAs) for NHSScotland that have been produced by the National Institute for Health and Clinical Excellence (NICE) in England and Wales.
The Scottish Medicines Consortium (SMC) provides advice to NHS Boards and their Area Drug and Therapeutics Committees about the status of all newly licensed medicines and any major new indications for established products.
No relevant SMC advice or NICE MTAs were identified.
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Edinburgh EH7 5EA
Tel. 0131 623 4720 Fax. 0131 623 4503 Web contact duncan.service@nhs.net
Last modified
27/02/12
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