Advances in medical care combined with an ageing population have led to an increase in the number of individuals living for longer and with multiple health conditions (NHS England, 2014; 2019). A focus on delivering care closer to home driven by the 5 year forward view (NHS England, 2014) and more recently the NHS Long term plan (NHS England, 2019) has placed a growing emphasis on admission avoidance and supporting early discharges. A consequence of this is a growing number of people requiring health and social care provision in their own homes, on an increasingly frequent basis and for more complex health needs. Such care often involves multiple disciplines providing input to the same individual. Some teams host several disciplines, such as the integrated care teams, and thus are able to provide fully integrated care to an individual. Conversely, in other services, different disciplines may be based in places that are geographically disparate and hosted by multiple organisations. Such disciplines have to integrate ‘virtually’ into the care that is delivered around the patient (King's Fund, 2018).
Effective methods of note sharing, communication and efficient onward referrals between and across teams are therefore vital (King's Fund, 2018; NHS England, 2019). The pressure and demands on community frontline staff have grown, and they increasingly need to be aware of and alert to factors that put individuals at risk of clinical deterioration. Key frontline staff, such as community and district nurses, will have an overview of an individual that allows them to be aware of changes or warning signs and to respond quickly. They are in the position of providing care to people who can be increasing frail or vulnerable to deterioration from a variety of risk factors, such as frailty, dehydration, malnutrition and chronic respiratory conditions. One such risk factor is dysphagia (swallowing problems).
What is dysphagia?
Swallowing is a complex activity required to move food from the mouth to the stomach, involving different muscles and nerves working together, and it requires close coordination between digestive and respiratory systems (Royal College of Speech and Language Therapy (RCSLT), 2019a). The oral cavity, larynx, and pharynx have multiple functions—breathing, speaking and swallowing. Safe and effective swallowing, therefore, requires a complex interaction of cranial nerve and muscle function, and in people with frailty, older adults and those with long-term conditions, there is a greater risk of dysphagia being present (RCSLT, 2019a).
Dysphagia involves difficulties with chewing and/or swallowing. It may result in poor ability to chew more textured food or to clear the mouth of residue after the swallow. The pharyngeal stage of the swallow may be compromised with a reduced ability to close off the airway, resulting in food and/or fluid entering the airway (aspiration). There may also be a reduced ability to clear the pharynx of food and fluids during the swallow, leaving residue within the throat, which is at further risk of being aspirated. Such aspiration increases the risk of chest infections and pneumonias developing (Cabre et al, 2010; Connolly, 2010). In addition, dysphagia increases the risk of airway occlusion and choking events.
Causes and consequences of dysphagia
The complexity of nerve and muscle function involved in swallowing means that individuals with neurological disorders, such as motor neurone disease, Parkinson's and brain injury, carry an increased risk of dysphagia (RCSLT, 2019a). The estimated prevalence of dysphagia is 40–78% in people with stroke (Mann et al, 1999; Martino et al, 2005; Connolly, 2010) and 33% in those with multiple sclerosis (Hartelius and Svensson, 1994). Dysphagia may also be present in 60% of people with head and neck cancers (Shune et al, 2012), as a result of both the primary tumour as well as the treatment effects from surgery and radiotherapy. Respiratory disorders such as chronic obstructive pulmonary disorder (COPD) can lead to poor airway closure or incoordination during the swallow, with an increased risk of aspiration, particularly of fluids and particularly during exacerbations of the condition. It is estimated that up to 27% of people with COPD will present with dysphagia (McKinstry et al, 2010). Dysphagia is a known consequence of the dementia syndromes, especially with progression of the condition (NHS Digital, 2015).
There is generally an increased risk of dysphagia associated with age and frailty (RCSLT, 2019b), and dysphagia is associated with poor clinical outcomes overall (Smithard et al, 1996; Langmore et al, 1998; Roy et al, 2007; Smithard et al, 2007; Teramoto et al, 2008Cabre et al, 2010, Connolly, 2010; Serra-Prat et al, 2011) and can lead to dehydration and malnutrition, with obvious negative impacts on health status (Teramoto et al, 2008; Serra-Prat et al, 2012; RCSLT, 2019a). Choking is a risk, but the development and recurrence of respiratory infections requiring antibiotics and, potentially, hospital admissions is more common (Langmore et al, 1998; Baine et al, 2001; Kawashima et al, 2004; Martino et al, 2005; Teramoto et al, 2008; Cabre et al, 2010, Connolly, 2010; Almirall et al, 2013).
The community nursing caseload generally includes a frail, older population with long-term conditions and often complex co-morbidities. With such a presentation, care is best delivered when the complexity of interacting factors is considered. Nutrition, wound healing, diabetes, frailty, hydration, medications and cardiac and respiratory functions are factors that interact with and affect each other. For example, a deterioration in respiratory status due to a chest infection may lead to impairment in cardiac function; poor nutrition may lead to poor diabetes management and poor wound healing; low fluid intake can increase the risk of urinary tract infections. This demonstrates why factors such as dysphagia cannot be considered, assessed or managed in isolation. There is a known correlation between dysphagia and age, with dysphagia affecting up to 27% of the older population (Roy et al, 2007; Cabre et al, 2010; Connolly, 2010; Serra-Prat et al, 2011). It is, therefore, vital that key community staff are alert to the signs and symptoms of this disorder and act quickly to make the appropriate onwards referrals.
Signs and symptoms of dysphagia
Individuals may self-report difficulties with swallowing, including coughing, choking or sensations of food/drink sticking in the throat. Coughing associated with eating and drinking is a strong indicator of dysphagia. However, it must be noted that the cough is a reflexive function requiring a sensory stimulus, and in certain disorders with sensory or neurological impairments, there may be blunting or even absence of the coughing response. It is, therefore, important to be alert to more subtle signs of aspiration. In the short term, these may be a wet voice, persistent throat clearing, upper airway sounds and changes in breathing patterns. Longer-term signs may be recurrent chest infections, reduced oral intake and weight loss.
Onward referral
Having identified concerns with swallowing, it is useful to consider which health or social care professionals need to be involved. Speech and language therapists (SLTs) play a key role in the assessment and management of dysphagia (RCSLT, 2019b). SLT teams across the UK generally offer an open referral system, whereby any health or social care practitioner, carer or individual can request a referral for a swallowing assessment. When making a referral, it is useful to include the following holistic information to enable effective triage and prioritisation:
Impact of SLT intervention
Early identification and intervention for dysphagia can improve quality of life and avoid further medical complications or death (RCSLT, 2019a). Up to 15% of hospital admissions of people with dementia who have dysphagia can be prevented by contributions from an SLT at an earlier point (NHS Digital, 2015). Further, a study in the stroke population demonstrated that investment in SLT more than doubled healthcare savings by preventing respiratory infections. SLTs support adults with dysphagia to eat and drink safely. This is achieved through working directly with individuals or indirectly through enabling families and the wider health and care workforce, to recognise and cope effectively with problems (RCSLT, 2019b).
The SLT will take an in-depth case history and carry out a detailed oro-motor examination, followed by functional assessment of ability and safety on both diet and fluid consistencies. SLT intervention for dysphagia aims to identify and reduce the risks of aspiration, choking, dysphagia-related malnutrition and dehydration. This may be through modifying diet and fluid consistencies or by teaching appropriate swallow strategies that improve the safety of swallowing, such as a chin tuck posture or effortful swallow. Other strategies that may improve swallow function are related to changes in posture and pacing or size of food or drink mouthfuls. SLTs are skilled in trialling different swallowing methods, such as via straws or specialised cups, and the appropriate use of these can often circumvent the need to use a fluid thickener.
SLTs may offer swallow therapy if they feel the individual will benefit from it, and this will work on improving overall muscle function, particularly those related to laryngeal elevation, tongue base function and airway closure. Where swallow therapy is employed, an objective assessment of the swallow will usually be arranged before and after treatment through the use of videofluoroscopy, which provides detailed and objective information on swallow function, impairment and the presence or absence of aspiration.
In the community setting, the SLT team will liaise closely with other health and social care professionals and will make appropriate onward referrals where indicated. SLTs also offer advice and support to individuals with dysphagia and their carers, whether this is family members or paid care agencies. Education offered is likely to include strategies around:
A further benefit of SLT intervention is when working with individuals who choose not to follow swallowing recommendations. SLTs are experts in assessing communication function and are able to carry out a mental capacity assessment to determine whether someone has the capacity to make their own decisions around eating and drinking. In situations where capacity is present, SLTs are able to support the individual and their family/carers to be fully informed in the decisions made. Where capacity is lacking, the SLT will liaise with the GP and key health and social care professionals in carrying out a best interests meeting.
Multidisciplinary team contribution to dysphagia management
The SLT will organise onward referrals where necessary, but equally, these can be organised by other health professionals alongside the referral to the SLT.
Where there are concerns about how the person is managing their medications, community nurses should consider asking the GP to rationalise medications and change preparations where appropriate. Community pharmacy teams, where available, can carry out a comprehensive review of medications and the appropriate means of delivery, for example, tablets, liquids and suspensions. They can also give accurate advice about altering the means of delivery, such as taking with food, opening capsules and crushing tablets. Such actions mean that a medication is being given ‘off licence’, and it is the pharmacist who will advise whether such an action is in the best interests of the individual.
Concerns regarding a person's nutritional status may indicate that a referral to the dietetic team is required. This will be particularly useful for individuals with very low intake or health conditions such as diabetes, digestive disorders or renal impairment. Seating and postural issues can often be effectively addressed by involvement of the physiotherapy team, and the ability to effectively self-feed may be further enhanced through occupational therapy assessment and advice regarding eating and cutlery adaptations.
Finally, an important consideration is whether new eating and drinking recommendations require the introduction or review of a package of care. Individuals with dysphagia may need assistance both in the safe preparation of food and drink and during mealtimes, to be aided and encouraged to maintain nutrition, hydration and safety of swallowing.
Conclusion
Community and district nurses are key professionals in the drive to keep individuals safely cared for in the home setting, be that their own home or residential care. They are perfectly placed to have an early awareness of developing problems with swallowing function and to make timely and effective referrals to other members of the community team. Such awareness and action will contribute to the prevention and reduction of risk to people living in their own homes with chronic health conditions or those in recovery.