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44
S
p eech
P
athology
A
ustralia
MULTICULTURALISM AND DYSPHAGIA
Procedure
For all participants, fluid intake would be recorded daily by
nursing and allied health staff on standard daily fluid balance
charts, with thin and thickened fluid consumption recorded
separately. Chest status would be checked weekly by medical
officers. Diagnosis of pneumonia would be based on medical
diagnosis confirmed by X-ray. Weekly blood tests would
provide urea:creatinine ratio, as an indicator of hydration
(Institute of Medicine of the National Academies, 2004). Oral
health examinations would also be conducted weekly. Dysphagic
participants would complete drink satisfaction surveys when
discharged from the study, rating both thick fluids and water.
The survey tool is a 5-point Likert scale, and rates factors such
as taste, feel in the mouth, thirst, and coughing.
All participants would be asked to follow an oral hygiene
protocol and record their compliance with this, with nursing
support as necessary. The protocol is based on the oral health
protocols for residential aged care facilities developed by the
South Australian Dental Service and Australian Dental
Association (South Australian Dental Service, 2004). Please
contact the authors for a copy.
Participants without dysphagia would be discharged from
the study after 21 days or on discharge from the hospital,
whichever occurred earlier. Participants with dysphagia
would be discharged from the study when dysphagia for thin
fluids resolved or on discharge from the hospital, whichever
occurred earlier.
Education would be provided to all staff assisting with data
collection including nursing, medical and allied health staff.
This would be supplemented with written information sheets
and protocols.
The reality
Consecutive admissions (97 in total) to the Medical
Rehabilitation Unit at HRC were screened across a 9-month
period. Of these, 31 (32%) did not satisfy the inclusion criteria,
44 (45%) did not consent and 4 (4%) consented but were
unable to participate in the FEES. Eighteen (19%) participants
were recruited and completed the study. Of these 18
participants, 15 were non-dysphagic controls and 3 were
dysphagic. However, on FEES, the three dysphagic par
ticipants demonstrated airway penetration of thin fluids, but
not aspiration. Therefore, none of the recruited participants
met the eligibility requirements for the treatment groups.
Another 103 stroke admissions were screened at the Royal
Adelaide Hospital over 7 months. Of the 28 eligible patients,
none were recruited into the study: Patients were too unwell,
or overwhelmed by their recent stroke, or excluded because
they were receiving non-oral fluid supplements.
In summary, recruiting participants was a challenge. Of the
200 patients screened across the two stroke units, only 22
were recruited, and 4 of these withdrew. Many refused
consent either because of the invasive nature of the FEES or
because they wanted to concentrate on their recovery and
rehabilitation without distraction. No recruited patients were
eligible for the treatment group, because none were found to
be aspirating on objective assessment.
Future directions
Our intention in embarking on this study was to determine
the best outcomes for dysphagic stroke patients who aspirate
thin liquids, and to obtain evidence for the relative influence
of dysphagia versus thickened fluids on fluid intake and
hydration. Unfortunately, because of recruiting difficulties,
we have not succeeded in gathering sufficient data to date to
draw any conclusive results.
We have not given up. We have found the research process
rewarding, and we consider the question we are attempting
to answer a vital one in our clinical practice. Our study differs
from the outcome data collection being conducted elsewhere
in Australia in that it is a randomised control trial that will
reduced cost, as well as the posited health outcomes. We did
not want to change clinical practice, however, without the
evidence to support these changes. To determine which of
two treatments implemented by speech pathologists results in
the best outcomes for dysphagic stroke patients who aspirate
thin liquids, and to obtain evidence for the relative influence
of dysphagia versus thickened fluids on fluid intake and
hydration, a randomised control trial (RCT) was designed
and ethics approval was sought and granted.
Research design and methodology
The study was designed as a randomised control trial. This
design comprised a treatment group with two treatment
conditions and a control group.
1 The treatment group would comprise stroke patients
aspirating thin fluids, as determined by clinical assessment
and flexible endoscopic evaluation of swallowing (FEES)
(Langmore, 2001). The participants in the treatment group
would be randomly allocated to one of two treatment
conditions, thickened fluids only or thickened fluids plus
access to water, as discussed in more detail below.
2 The control group would comprise stroke patients with no
evidence of dysphagia experiencing the same institutional
and stroke-related conditions. This group was included to
allow comparison to the fluid intake and hydration of
non-dysphagic stroke patients, a unique feature of this
study’s design. This would allow us to determine if the
dysphagia rather than other conditions would influence the
amount of fluid intake as there is currently no evidence
that this population meets average fluid requirements.
Participant selection criteria and initial assessment
For inclusion in the study, the patient had to have experienced
an acute stroke event and be medically stable. Exclusion
criteria were specific medical conditions, i.e., neurode
generative process, neurosurgery, previous head and neck
cancer or surgery, tracheostomy, COPD, pneumonia or com
promised immune status; factors compromising fluid intake
or measurement i.e., supplementary non-oral fluid provision
or renal failure; and known aspiration of pureed food or
thickened fluids. “Aphasia friendly” information sheets and
consent forms were used for communication impaired
patients (Braunack-Mayer & Hersh, 2001; Kagan & Kimelman,
1995). Presence or absence of aspiration would be confirmed
by FEES. All participants would also undergo an initial
clinical assessment of swallowing, a 100ml water test (Wu,
Chang, Wang, & Lin, 2004) and an oral health assessment
(Chalmers, King, Spencer, Wright, & Carter, 2005).
Treatment
Participants in the treatment group would be prescribed the
appropriate thickened fluid consistency and would be randomly
allocated to one of two treatment groups. Treatment group 1
would receive traditional management and would be permitted
to drink only thickened fluids. They would have free access to
these thickened fluids, with a jug at bedside and in the dining
room, and staff assistance as necessary. Treatment group 2
would receive thickened fluid plus access to water according
to the RAH Free Water Protocol (please contact authors for a
copy) which is similar but not identical to the Frazier Water
Protocol. Key features of this protocol include access to water but
not to any other thin liquids, and preclusion of water at meal
times or when taking medication in order to prevent aspiration of
food and tablets along with the water. With these restrictions,
free access to water and thickened fluids is permitted, with
jugs of water and thickened fluids at bedside, thickened fluids
in the dining room, and staff assistance or supervision as
necessary. One point of difference between the RAH Free
Water Protocol and the original Frazier Water Protocol is that
the latter explicitly outlines the need for routine oral care.