From the Guidelines
This 62-year-old female stroke patient requires immediate attention to her dysphagia symptoms and assistance with completing her recommended follow-up care, including referrals for mammogram, cardiology Holter monitoring, neurology consultation, thyroid ultrasound, and possible thyroid nodule biopsy. The patient's stroke history (December 19,2023) and speech deficits make completing these follow-ups particularly important, as the Holter monitoring could identify cardiac arrhythmias like atrial fibrillation that increase stroke risk, and the thyroid nodule requires evaluation to rule out malignancy. Her dysphagia symptoms also warrant attention as they could lead to aspiration, especially given her stroke history. According to the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines, update 2015 1, patients should be screened for swallowing deficits as soon as they are alert and ready for trialing oral intake using a valid screening tool by an expert in dysphagia. The guidelines also recommend that abnormal results from the initial or ongoing swallowing screens should prompt a referral to a speech-language pathologist, occupational therapist, dietitian or other trained dysphagia clinician for more detailed bedside swallowing assessment and management of swallowing, feeding, nutritional and hydration status. Additionally, the American Heart Association/American Stroke Association guidelines for adult stroke rehabilitation and recovery recommend early dysphagia screening to identify dysphagia or aspiration, which can lead to pneumonia, malnutrition, dehydration, and other complications 1. I recommend applying for hospital financial assistance programs, Medicare/Medicaid if eligible, or exploring patient assistance programs for her medical needs, and prioritizing her dysphagia management and completion of outstanding referrals. Some key considerations for her dysphagia management include:
- Screening for swallowing deficits using a valid screening tool by an expert in dysphagia 1
- Referral to a speech-language pathologist, occupational therapist, dietitian or other trained dysphagia clinician for more detailed bedside swallowing assessment and management 1
- Implementation of oral hygiene protocols to reduce the risk of aspiration pneumonia after stroke 1
- Consideration of enteral feedings (tube feedings) if the patient cannot safely swallow or meet their nutrient and fluid needs orally 1
- Incorporating principles of neuroplasticity into dysphagia rehabilitation strategies/interventions 1
From the Research
Patient's Condition and Referrals
- The patient is a 62-year-old female with a history of stroke, discharged on 12/29/23, and has been experiencing speech difficulties and dysphagia.
- She was referred for several tests and consultations, including a mammogram, cardiology Holter monitoring, neurology referral, and a repeat thyroid ultrasound, but was unable to complete them due to cost constraints.
- The patient's current symptoms include dysphagia, particularly when sleeping.
Role of Speech-Language Pathologists
- Speech-language pathologists play a crucial role in assessing and treating patients with speech, language, or swallowing difficulties, as noted in 2.
- They can help identify red flags that suggest a referral to a speech-language pathologist is indicated, such as dysphagia or speech difficulties.
Assessment and Management of Dysphagia
- A timed water swallowing test can be a useful tool for assessing swallowing difficulties and determining the need for referral to a speech-language therapist, as seen in 3.
- Oral trials, also known as swallow trials or tasters, are widely used in dysphagia management, but there is a lack of uniformity in their implementation and a need for further research, as highlighted in 4.
- Speech therapy has been shown to be effective in improving dysphagia in hospitalized patients with post-stroke dysphagia, with an average recovery time of 22 days, as reported in 5.