What is the best course of action for an elderly female patient with a history of Transient Ischemic Attack (TIA) and psychosis, who is experiencing on and off orientation and is opening her mouth and spitting out food, indicating potential dysphagia and aspiration risk?

Immediate NPO Status and Urgent Dysphagia Evaluation Required

This elderly female patient with TIA history exhibiting mouth opening and spitting behavior must be made NPO (nothing by mouth) immediately and undergo urgent instrumental swallowing assessment with videofluoroscopy or FEES to prevent aspiration pneumonia and death. 1

Critical Context: Why This is a Medical Emergency

This patient's behavior of opening her mouth and spitting out food represents overt dysphagia with active food rejection, which in the context of TIA history and altered orientation indicates:

• 40-78% of acute stroke/TIA patients develop dysphagia, with the highest risk in those with neurological impairment 1
• Aspiration pneumonia mortality rates reach 20-65% in stroke patients with dysphagia 2
• Up to 55% of patients with dysphagia have silent aspiration without protective cough reflex, meaning the visible spitting may represent only part of the problem 3
• Altered mental status (on/off orientation) combined with dysphagia dramatically increases aspiration risk and indicates potential recurrent cerebrovascular events 1, 4

Immediate Actions (Within Hours)

1. Make Patient NPO Immediately

• Stop all oral intake including medications until dysphagia screening is completed 1
• Initiate IV maintenance fluids to prevent dehydration 1
• Do not rely on preserved gag reflex as indicator of swallowing safety - this is unreliable 1

2. Perform Bedside Dysphagia Screening

• Use a validated screening tool performed by trained healthcare provider or speech-language pathologist 1
• Assess for wet/gurgly voice quality, weak voluntary cough, and ability to manage oral secretions 5
• Document that screening was performed before any oral intake 1

3. Urgent Instrumental Swallowing Assessment

Proceed immediately to videofluoroscopy (modified barium swallow) or FEES (fiberoptic endoscopic evaluation of swallowing) because: 1, 3

• Bedside evaluation alone cannot detect aspiration - clinical examination misses silent aspiration in over half of cases 3
• The combination of TIA history, psychosis, altered orientation, and active food rejection represents extremely high aspiration risk requiring objective assessment 1, 3
• Instrumental evaluation is the only way to determine if oral intake is safe and identify specific biomechanical swallowing impairments 1

4. Neurological Re-evaluation

• Assess for new or recurrent stroke - altered orientation with new dysphagia may indicate evolving cerebrovascular event 1
• TIA patients remain at highest stroke risk in first 2 weeks, and dysphagia can be the presenting sign 1

Nutritional Support Decision Algorithm

If Patient Cannot Swallow Safely (Determined by Instrumental Assessment):

Initiate enteral nutrition within 7 days to prevent malnutrition while maintaining aspiration precautions: 1

• Days 1-21: Nasogastric tube feeding is the preferred initial route 1
• After 3 weeks: Convert to PEG tube if dysphagia persists, as PEG is associated with fewer treatment failures, better nutritional delivery, and improved albumin concentration 1
• Do NOT place early PEG (within first 2-3 weeks) - this is not supported by evidence 1

Critical Caveat for This Patient:

Given the psychosis history and altered orientation, goals of care discussion is essential before PEG placement, as: 5

• Dysphagia in elderly patients with neurological disease carries approximately 50% mortality at 6 months 5
• Tube feeding does not improve survival in patients with advanced dementia or end-stage neurological disease 1, 5

Interprofessional Team Assembly (Within 24 Hours)

Coordinate immediate consultations: 1, 5

• Speech-language pathologist: Instrumental swallowing assessment and dysphagia therapy recommendations 1, 5
• Registered dietitian: Nutritional assessment and tube feeding regimen if needed 1, 5
• Neurology: Evaluate for recurrent TIA/stroke given altered orientation 1
• Psychiatry: Assess whether food refusal has psychiatric component vs. true dysphagia 6

Monitoring for Aspiration Pneumonia

Watch for development of: 1, 2, 4

• Fever, cough, increased respiratory rate
• Oxygen desaturation
• New infiltrates on chest imaging
• Aspiration pneumonia is the leading cause of death in nursing home residents and elderly stroke patients 4

Common Pitfalls to Avoid

• Do NOT continue oral feeding with "modified diet" or thickened liquids without instrumental confirmation - this is guessing and puts patient at lethal aspiration risk 3, 5
• Do NOT assume spitting behavior is purely psychiatric without ruling out true dysphagia - psychotic patients can have medication-induced or neurological dysphagia 6
• Do NOT delay instrumental assessment while trying compensatory strategies - every meal represents aspiration risk 3, 5
• Do NOT rely on "trial feeding" to assess safety - silent aspiration occurs without clinical signs 3
• Do NOT place PEG tube in first 2-3 weeks unless unable to pass nasogastric tube 1

If Instrumental Assessment Shows Safe Swallowing with Modifications

Implement specific compensatory strategies identified by speech-language pathologist: 1, 5

• Postural techniques (chin tuck, head rotation)
• Diet texture modifications based on objective findings
• Swallowing maneuvers targeting identified impairments
• Intensive swallowing therapy to restore function 3

Quality of Life Consideration

Dysphagia profoundly impacts quality of life through malnutrition, social isolation, fear of eating, and loss of eating pleasure. 5 The decision between aggressive nutritional support vs. comfort-focused care should involve patient/family values, particularly given this patient's complex medical history with TIA, psychosis, and fluctuating orientation. 5