Invited Review

Nutrition in Clinical Practice

Volume 34 Number 1
Dysphagia: Interprofessional Management, Impact, February 2019 80–95

C 2018 American Society for

and Patient-Centered Care Parenteral and Enteral Nutrition

DOI: 10.1002/ncp.10239
wileyonlinelibrary.com

Carol Marie McGinnis, DNP, APRN-CNS, CNSC; Kimberly Homan, MS,

CCC-SLP; Meghan Solomon, MS, CCC-SLP; Julia Taylor, MS, CCC-SLP;
Kimberly Staebell, MSN, RN, CRRN; Denise Erger, MBA, RDN, LN;
and Namrata Raut, MD, PM & R

Abstract
Dysphagia affects a multitude of people worldwide with tremendous impact on the affected individual, families, and caregivers.
Understanding dysphagia, as well as the status of screening, evaluation, and treatment, aids in the knowledge required by a
interprofessional team to holistically care for patients with dysphagia and their caregivers. The impact of dysphagia includes
potential associated risk and a cascade of effects. Conversations regarding meeting nutrition and fluid needs with consideration
for quality of life need to be integrated into the plan of care for individuals with dysphagia. (Nutr Clin Pract. 2019;34:80–95)

Keywords
aspiration; deglutition disorders; dysphagia; interdisciplinary communication; speech-language pathology

Introduction and esophageal dysphagia. It is critical that medical

Providing nutrition through oral intake (OI) and the joy
of eating is often taken for granted. It is hard to disagree
with the importance of adequate nutrition and fluid intake.
When swallowing becomes inefficient, uncomfortable, or is
deemed unsafe, additional care and consideration regarding
OI and the many factors related to this change must occur.
Dysphagia is a swallowing disorder that impacts oral, pha-
ryngeal, and/or esophageal function because of anatomic
or physiological insult.1 Repercussions of dysphagia can
impact quality of life (QoL), hydration, nutrition, and
medication administration, and there may be increased risk
for or an association with further medical complications.
The realm of dysphagia is vast and impacts a variety of
individuals around the globe. The collaboration of an In-
terprofessional team, including providers, speech language
pathologists (SLPs), occupational therapists, registered di-
etitian nutritionists, nursing staff, respiratory therapists,
pharmacists, social services, and a variety of others, is
essential for the most sensitive and effective care. Functions
of each discipline working with individuals with dysphagia
may vary and can overlap from area to area. Communica-
tion between the disciplines and a united plan of care is
vital.
This discussion will emphasize oropharyngeal dysphagia
(OD), as the scope does not allow the thoroughness
required to cover other phases of or causes for dysphagia,
though many points of discussion also apply to pharyngeal
professionals have a working awareness of dysphagia and
the impact it can have on individuals, especially regarding
nutrition, hydration, and QoL, to more comprehensively
serve them.
Causes
There are many causes for dysphagia, and in some cases,
etiology may be difficult to ascertain. Neurologic disorders
such as stroke can cause dysphagia, which may occur in
37%–55% of stroke patients.2 Stroke severity as assessed
by the National Institutes of Health Stroke Scale; ࣙ5 is
a reliable predictor of dysphagia.1 Severity of dysphagia
may vary according to the region affected by the stroke.
Brainstem strokes, especially lateral medullary, tend to
have the most severe and longest lasting dysphagia.3-5
Among the hemispheric strokes, strokes with insular region
From the Sanford USD Medical Center, Sioux Falls, South Dakota,
USA.
Financial disclosure: None declared.
Conflicts of interest: None declared.
This article originally appeared online on December 23, 2018.
Corresponding Author:
Carol Marie McGinnis, DNP, APRN-CNS, CNSC, Sanford USD
Medical Center, 1308 West 18th Street, Sioux Falls, SD 57117-5039,
USA.
Email: carol.mcginnis@sanfordhealth.org
McGinnis et al
involvement present with more severe dysphagia.3 Dyspha-
gia also may result from traumatic or nontraumatic brain
injury, depending on the area and extent of injury.6 Spinal
cord injury can cause dysphagia as well.7-9
Neurodegenerative diseases and neuromuscular diseases,
including but not limited to Parkinson’s disease, multi-
ple sclerosis, amyotrophic lateral sclerosis, muscular dys-
trophies, poliomyelitis, myasthenia gravis, and dementias,
are other causes of dysphagia.10 Dysphagia may be the
result of structural lesions (eg, thryomegaly, cervical hy-
pertosis/osteophytes, etc).11,12 Connective tissue disorders
(eg, polymyositis, dermatomyocytis),13-15 iatrogenic causes
(eg, endotracheal intubation,16 anterior cervical discec-
tomy and fusion17 ), and cancer of the oral cavity, phar-
ynx, or esophagus and related treatment (eg, surgical
resection and radiation) are other possible etiologies for
dysphagia.
Medication use has been associated with dysphagia.
Although most studies assessing the relationship between
medications and dysphagia have been case reports or small-
scale studies, it is important to be aware of these when no
other cause can be identified. Medications such as central
nervous system depressants (neuroleptics/antipsychotics or
anesthetics) may depress brainstem function and control
of swallowing. Additionally, antipsychotics have anticholin-
ergic properties that may induce salivary changes and
impair esophageal peristalsis.18-20 Furthermore, dopamine
antagonists can result in dystonia and dyskinesia,21,22 and
fat-lowering agents may have a side effect of myopathy,
according to case and anecdotal reports.23 Esophageal
dysphagia can be related to medications such as nons-
teroidal anti-inflammatory agents, potassium salts, bispho-
sphonates, and medications that relax the lower esophageal
sphincter and can lead to injury and acid reflux with
damaging effects.24
Age and frailty have been associated with dysphagia.24-26
Presbyphagia, or frailty in swallowing, may be due to age-
related loss of swallowing muscle mass or sarcopenia. El-
derly persons with sarcopenia and dysphagia may not only
have disease-related dysphagia but also sarcopenic dyspha-
gia identified by reduced calf circumference, grip strength,
and trunk muscle mass.27,28 Socioeconomic challenges have
also been identified as a cause of malnutrition leading
to sarcopenia.29 Physiological changes in oropharyngeal
swallowing begin to manifest in individuals over age 60
years of age,30 and in a study by Robbins, Humpel, Ba-
naszynski, Hind, and Rogus-Pulia, the decreased pressure
reserve noted with aging was suggested to put the older
population at greater risk for dysphagia.31 Changes related
to aging also include altered cough reflex, lowered immu-
nity, decreased lung elasticity, decreased saliva production
leading to changes in microbial flora, decreased muscle
tone impacting the chest wall (cough strength, airway
clearance), tongue (oral clearance), and intestinal motility
81
(reflux, increased use of proton pump inhibitors), which
all can lead to a decrease in the body’s ability to fight
infection.32
Statistics
Incidence and Prevalence
To appreciate the significance of dysphagia, a brief discus-
sion of the incidence/prevalence is shared. Bhattacharyya33
analyzed the 2012 National Health Interview Survey and
found that annually, 1 in 25 adults was reported to be af-
fected by swallowing problems. According to The National
Foundation of Swallowing Disorders, 10 million Americans
are evaluated for swallowing difficulties each year, and
22% of those over 50 years of age may have dysphagia.34
According to estimates, about 8% of the world’s population
have difficulty eating and drinking because of dysphagia.35
Defining the prevalence of dysphagia within the general
population has its challenges. Instead, studies have been
conducted on the incidence/prevalence within specific pop-
ulations, including older adults39 and individuals who have
experienced mechanical ventilation,36,37 acute stroke,38 an-
terior cervical fusions,40 and more. Ickenstein et al41 report
an incidence of OD >50% within 72 hours of a new stroke.
A systematic review by Valenzano et al42 found small case
studies and definitions of dysphagia to be inconsistent for
individuals who have experienced traumatic spinal injury,
indicating the need for further research with a specific
definition of dysphagia, as the broad definition of dysphagia
implies impact along various sections or phases of the
swallow. Further exploration can lend insight relevant to
prevalence or incidences, given various medical conditions
or factors. As further studies are conducted regarding the
prevalence of dysphagia, the impact dysphagia has on
nutrition, hydration, and QoL must not be lost.
Economic Impact
In addition to morbidity and mortality, there is monetary
cost to dysphagia that affects healthcare systems and indi-
viduals worldwide. A systemic review of OD on healthcare
costs and length of stay by Attrill et al43 found “the
presence of dysphagia added 40.36% to healthcare costs
across studies.” A study by Westmark, Melgaard, Reth-
meier, and Ehlers44 looked at costs in and out of the hospital
setting and found that in the geriatric dysphagia population,
costs were significantly higher for those with a dysphagia
diagnosis. As per Bhattacharyya’s analysis of the National
Health Interview Survey, it was noted that a minority of
the number of persons with self-reported dysphagia sought
healthcare, and adults with reported swallowing difficulties
indicated 11.6 ± 2.0 missed workdays compared with 3.4 ±
0.1 missed days per year for individuals without reported
swallowing difficulty.33
82
Screening and Evaluation
Screening and Clinical Swallow Evaluation
(CSE)
Dysphagia is an indicator for morbidity and mortality in
the medical setting, and early identification and treatment
of dysphagia and aspiration is imperative for lessening
potential negative outcomes for patients and medical care
facilities.41,45 Underlying neuromuscular abnormalities fre-
quently warrant OD screening. The World Gastroenterol-
ogy Organization (WGO) Guidelines46 state that “stroke
patients should be screened for dysphagia within the first 24
hours after the stroke and before oral intake.” They report
that this screening guideline has the potential to significantly
reduce the risk for dysphagia-related complications after
acute stroke. The WGO also recommends screening for pa-
tients with weight loss and repeated chest infections.46 Other
mechanical abnormalities or obstructions may require OD
screening, including abscesses, diverticulum, myositis, fi-
brosis, head/neck malignancies and treatment sequalae,
post-cervical surgery, osteophytes, and others.46 Nurse-
performed screening is frequently done in the critical care
setting;47 however, post-extubation screening lacks specific
guidelines.
Swallow screening performed by a registered nurse (RN)
is a common practice for those with overt symptoms of
dysphagia, such as pocketing of food, a wet gurgly voice, or
coughing after eating or drinking; however, there is a need
for further standardization of swallow screening for those
with the less common etiological factors of dysphagia. In
addition, silent aspiration, which is aspiration without overt
symptoms, is undetectable in screenings and subsequently
not referred for an instrumental assessment to identify
dysphagia. Cough reflex testing, inducing a cough with
citric acid and evaluating the strength of that cough, has
been suggested as a means to identify those who might
be at risk of silent aspiration.48,49 At this time, there is
no evidence-based practice for detecting silent aspiration
without imaging. The bedside RN plays an important role
in identifying overt dysphagia symptoms and referring for
further evaluation by an SLP, as access is available.
Screening, evaluation, and treatment for dysphagia is a
universal concern. Ickenstein et al41 assert that although nu-
merous tools exist, the worldwide medical community lacks
a universal protocol with both high specificity and sensitiv-
ity for predicting aspiration. The bedside practitioner needs
effective yet simple tools for initial assessment. Screening
tools in the literature include questionnaires, mealtime
observations, and/or various administration techniques for
swallowing water and/or food boluses.50-53 Some studies in-
volved swallowing a single volume of water, whereas others
involved subtests with gradually increasing volumes.45,50 It
is beyond the scope of this article to cover the numerous
Nutrition in Clinical Practice 34(1)
techniques that have been developed, as many are offered.
Systematic reviews provide an overview of related research
and publications relative to many techniques.45,50,54 In ad-
dition to screenings, the breadth and depth of the CSE,
administration of food and/or liquid by an SLP to assess
overt signs and symptoms of dysphagia, has been covered
by others, including Coyle.55
Screening tools and the CSE or bedside swallow eval-
uation are an important initial step in dysphagia diagnos-
tics; however, screening and bedside evaluation methods
alone are insufficient for thorough evaluation of swal-
lowing anatomy and physiology and/or the detection of
aspiration.56 Two recent studies reviewed evidence of the
effectiveness of dysphagia screening for reducing associated
risks, such as pneumonia. Teuschl et al completed an obser-
vational study of 993 screened and 401 unscreened patients
and found similar rates of stroke-associated pneumonia:
5.0% for the screened group and 5.5% for the unscreened
group.57 Of 216 patients with a nothing-by-mouth sta-
tus, 13.9% still developed pneumonia. A systematic review
concluded that there is insufficient evidence that current
dysphagia screening protocols reduce risk for pneumonia,
death, or dependency after stroke.58 Therefore, ideally,
bedside screening measures should lead to supplemental
evaluation with instrumental assessment for a comprehen-
sive, thorough examination of oropharyngeal anatomy and
physiology, as indicated and available.
Instrumental Assessment
Instrumentation is widely regarded as the gold standard
in dysphagia diagnostics. This includes videofluoroscopy
(VFS)/modified barium swallowing studies (MBSS),
fiberoptic endoscopic evaluation of swallowing (FEES),
high-resolution manometry (HRM), and upper
endoscopy.39,46,59,60 Instrumentation provides the opportu-
nity for quantitative, reliable evaluation of oropharyngeal
anatomy and physiology when using an established clinical
protocol. See Table 1 for further information. Protocols for
VFS/MBSS are well established and include numerous
standardization efforts, including the penetration-
aspiration scale,61 Modified Barium Swallow Impairment
Profile, oropharyngeal swallow efficiency,59 and Dynamic
Imaging Grade of Swallowing Toxicity.61 Advantages of
the VFS/MBSS are that it provides more information about
the physiology of the pharyngeal phase, and it also allows
for visualization of the oral and esophageal phases.62 FEES
provides direct visualization without radiation exposure, is
more accessible to patients who are immobile or in critical
care because it can be completed at the bedside, and allows
for immediate biofeedback training.59,63 When compared
with VFS, penetration, aspiration, and pharyngeal residues
were perceived as more severe with FEES.64,65 Upper
McGinnis et al 83

Table 1. Instrumental Dysphagia Assessments. mining the appropriateness for and preliminary groundwork
prior to further instrumental evaluation and therapeutic
Assessment Pros Cons
intervention trials during instrumental assessment.55 The
VFS/MBSS r Standardization r Must be incorporation of the CSE also initiates the establishment
efforts for completed in of the therapeutic alliance and the educational founda-
assessments radiology tion needed for patient-centered care and further decision
r Visualization of r 2-dimensional making.
oral, pharyngeal, view
and esophageal r Radiation
phases exposure
r Visualization of r Barium-based Treatment
physiology of PO products By identifying persons with dysphagia and subsequently
pharyngeal phase providing thorough diagnostics for underlying impairments
FEES r Direct r No
involving oropharyngeal anatomy and physiology, SLPs
visualization of visualization
the pharynx of oral or are equipped to develop specific, individualized care plans
r No radiation esophageal tailored toward patients’ specific goals. Clinical manage-
r Immediate phases ment of dysphagia is a relatively new field; however, the
biofeedback r No standard- field of speech language pathology has made significant
training ization of progress since the early 1980s, when pioneering clinical
r Can be completed assessment researchers made strides developing clinical dysphagia prac-
at bedside
r Swallowing r Further tice patterns.59 Nonetheless, the literature consistently ac-
High-resolution
manometry muscles are research to be knowledges that the field of dysphagia has a paucity of
measured for conducted evidence and needs much more research.
pressure The American Speech Language Hearing Association
production (ASHA)66 defines treatment goals to optimize safety and
Upper r May be able to r Does not efficiency and target feeding methods and techniques. Con-
endoscopy identify a assess swallow sideration for minimizing pulmonary risk and reducing the
structural etiology physiology burden of care while optimizing the patient’s QoL must
for dysphagia
also be considered. Dysphagia treatment must strive to
FEES, fiberoptic endoscopic evaluations; MBSS, modified barium provide support for adequate nutrition and hydration in
swallowing study; VFS, videofluroscopy. order to allow for the return to safe and efficient OI as
soon as possible while incorporating patients’ preferences.
From an SLP perspective, treatment is generally divided into
endoscopy evaluates structural reasons for dysphagia and
2 categories: compensations and restorative/rehabilitative
visualizes the pooling of secretions and/or food/liquid
approaches.
residuals in the oropharynx; however, endoscopy is not
sensitive for evaluating swallowing physiology.46 HRM
directly quantifies pressures of muscle activations involved
with swallowing and has promising applications in the
Compensations
future, as the field of dysphagia evolves.59 Several other Swallowing compensations alter and/or improve the swal-
applications combine various evaluation techniques to low but do not facilitate a lasting functional change in the
provide a more comprehensive examination and increase physiological swallow when the technique is not used. The
knowledge of swallowing mechanics. most commonly implemented techniques are alterations
In the SLP community, controversy exists regarding the of diet and liquid consistency, postural changes (eg, chin
necessity of the CSE because of its inability to evaluate tuck, head turns, etc), timing/coordination techniques (eg,
oropharyngeal anatomy and physiology against the gold oral preparatory set), laryngeal maneuvers (eg, supraglottic
standard of instrumental assessments. Coyle55 argues that swallow), environmental changes (eg, bolus presentation
the CSE is indeed necessary as an initial step prior to methods, reducing distractions, etc) sensory modifications
instrumental evaluation or when instrumental testing is not (eg, thermo-tactile stimulation, carbonation, dissolvable
feasible. Feasibility is multifactorial, and the most common flavored films, etc), and others.59,67-69 Throughout the years,
reasons for its use include accessibility/availability (often there have been a variety of clinical practice patterns in
a function of clinical setting), necessity (the instrumental use for compensations. Some compensations are contraindi-
study should provide new information that a CSE cannot), cated in specific cases. For example, a chin tuck position may
and patient refusal. Certainly, the CSE has incredible value contribute to airway entry in some people, so following the
for building patient rapport, offering diagnostics, and deter- treating clinician’s recommendations is vital.
84
Food and Liquid Modification
Diet modification by changing the texture or consistency
of foods and/or liquids is a common practice in medical
settings for compensation of dysphagia. Diet modifications
are assistive in improving an individual’s efficiency of OI
and potentially reducing the risk of aspiration. ASHA
recognizes diet modification as compensatory, since it is
used as a tool to improve swallowing but does not create
a lasting functional change to the swallow physiology itself.
For liquid and food texture modification, various diet levels
are established to facilitate safer, more efficient swallowing.
Thickened liquid boluses have increased viscosity, which in
turn slows food bolus movement through the oropharynx,
as compared with a thinner bolus, which moves more
quickly. The speed of the thinner bolus may place the patient
at higher risk for timing and coordination issues leading to
potential aspiration.70 It is important to consider the impact
of thickened liquids on patients with oropharyngeal weak-
ness, as this can lead to increased retention and aspiration
after the swallow. Additionally, lack of willingness for pa-
tients to take thickened liquids is a common problem when
managing dysphagia. Although modified diets compensate
for some types of dysphagia immediately, patients have
reported a dislike of altered textures and thickened liquids,
which can lead to reduced fluid OI and dehydration.71,72
Global efforts have been made to standardize food and
liquid modifications.
Dysphagia Diet Standardization
Healthcare facilities have been using the National Dys-
phagia Diet: Standardization for Optimal Care (NDD)
since its inception in 2002. At the time of its introduction,
many care facilities had their own set of diets with varying
degrees of texture modification that were used for patients
with swallowing difficulty. The NDD was designed to help
mitigate some of the discrepancies when transferring from
one facility to another.73 However, challenges remained
globally with varying levels, descriptions of food and liquid,
and labels that led to further safety risks for patients.74
In pursuit of global standardized international terminol-
ogy for dysphagia foods and liquids, a multidisciplinary task
force from around the world met in June of 2012; from their
meeting, The International Dysphagia Diet Standardization
Initiative (IDDSI) was formed.74,75 Primary reasons for
the establishment of the international initiative included
improving patient safety by increasing consistent commu-
nication and standards and striving for better treatment
outcomes as the field of dysphagia continues to evolve using
evidence-based practice.76,77
Components of the IDDSI were released in steps be-
tween September and November 2015.76 The IDDSI frame-
work consists of 8 levels with 2 inverted pyramids. Visit
Nutrition in Clinical Practice 34(1)
the IDDSI website to see the model in color and with
explanations.78 Each level has a distinct color and number
label. Transitional foods are shown on the outside of the
food pyramid. Transitional foods are foods that change
texture with the addition of moisture or temperature. The
IDDSI Syringe Flow Test and Pressure Fork Test are meth-
ods that were developed to allow professionals, caregivers,
and patients to assess the appropriate consistency of liquids
and foods.76 Specific guidelines on how to perform the
Pressure Fork Test and the Syringe Flow Test can be found
on the IDDSI web site at http://www.iddsi.org/framework.79
The IDDSI website provides useful resources that are free
and readily available.77 The IDDSI model and its outcomes
will be formally reviewed in 2020 by the international
committee that developed the framework.76
Restorative and Rehabilitative
Restorative and rehabilitative techniques are aimed at im-
proving physiologic swallow function. These techniques
include skill and/or strength training. Skill training fo-
cuses on coordination and timing of swallowing. This is
a relatively recent area of clinical practice, and future
directions with biofeedback (eg, surface electromyogra-
phy) are promising.59,67 Strength training utilizes exercise
physiology for striated muscle building to combat mus-
cle weakness due to sarcopenia or other neuromuscular
causes.67,80 Some evidence supports the effectiveness of
exercise-based therapy compared with the use of behav-
ioral compensations.80 Rehabilitative approaches include
maneuvers such as Mendelsohn and effortful swallow and
strengthening exercises targeting lingual muscles, suprahy-
oid muscles, pharyngeal constrictors, etc.59,67 Some other
specific examples include expiratory muscle strength train-
ing, the McNeill Dysphagia Therapy Program, and neu-
romuscular electrical stimulation.59,67,80 Another emerging
concept in rehabilitation is preventative swallowing therapy,
particularly for patients with head and neck cancer who
are undergoing radiotherapy.59,81,82 Again, many of these
philosophies and techniques have at least some support in
the literature; however, much more research is needed.
Individualization
SLPs lack a uniform concept of “usual care practices,”
according to Carnaby and Harenberg.80 They surveyed
Special Interest Group 13 (Swallowing and Swallowing Dis-
orders), which includes ASHA members, with the majority
of members having at least 15 years of experience from a
variety of work settings. When given a single hypothetical
patient case, responses generated 47 different treatment
techniques. Most concerning, only 6 of the 47 (13%)
techniques proposed were exercise-based, which literature
supports for making a functional change to the underlying
McGinnis et al
physiologic impairments. Additionally, respondents com-
monly reported use of techniques that did not directly
correspond to the specific symptoms of physiological
abnormalities.80 Ciucci et al also discuss this “one-size-fits-
all” approach as the status quo but also suggest that SLPs
are moving in a positive direction toward more individual-
ized therapy approaches.59 SLPs need an increased aware-
ness of evidence to support treatment while maintaining
holistic, patient-centered, and individualized therapy.
Dysphagia, Aspiration, and Pneumonia
Definitions
The definitions of dysphagia and aspiration are established;
pneumonia and/or pneumonitis due to aspiration is less
clearly defined. Son et al completed a literature review
covering the most recent evidence on aspiration, aspiration
pneumonitis, and aspiration pneumonia.83 To clarify ter-
minology, dysphagia is a swallowing disorder characterized
by underlying impairment, impacting normal swallowing
anatomy and/or physiology; aspiration is the entry of mate-
rial from the oropharynx or gastroesophageal tract through
the larynx into the trachea. Aspiration pneumonitis results
from aspiration of noxious contents, usually sterile refluxed
gastric contents with a pH of 2.4 or lower. Aspiration pneu-
monia results from aspiration of oropharyngeal or gastric
contents because of colonized bacterial load introduced
from the large volume aspirated. According to Son et al, this
material is usually not acidic enough (>2.5 pH) to lead to
pneumonitis. It is difficult to differentiate pneumonitis and
pneumonia; however, these conditions are distinct diseases
with differing pathophysiology.
Complex Relationship
The relationship between dysphagia, aspiration, and as-
piration pneumonia is not fully understood or defined.
Although it may seem obvious, dysphagia and aspiration
are not the same, nor do they always lead to the development
of aspiration pneumonia or pneumonitis. The consequences
of aspiration can range from normal physiology to seri-
ous medical complications, including mortality. In a 2010
normative study evaluating healthy, ambulatory adults aged
61–90 years, laryngeal penetration occurred in 83%, and
aspiration occurred in 28% of these adults.84 In a 2017
study that included normal, healthy adults aged 20–90
years, laryngeal penetration occurred in 50% and aspiration
occurred in 18% at some point. Out of the adults that
aspirated, 75% aspirated silently or without a sensorimotor
response.85 These studies, therefore, indicate that aspiration,
even silent aspiration, can happen occasionally in normal,
healthy adults. However, Butler et al acknowledge that
differentiation between normal and pathological aspiration
in healthy adults remains unclear in view of a paucity
85
of evidence in this area; therefore, the healthcare team
must incorporate critical thinking and synthesize relevant
information while being cognizant of the holistic aspects in-
volving the patient as well as utilizing instrumentation for a
comprehensive evaluation.85 Son et al describe the potential
manifestations of aspiration and 3 important characteristics
to consider: infectiousness of inoculum, volume of inocu-
lum, and acuity of onset. Aspiration pneumonia is thought
to result from infectious inoculum, macro-aspiration, and
acute onset.83
Literature does not currently support an absolute causal
relationship between aspiration and pneumonia.86,87 In a
study of 152 patients post video swallow evaluation followed
for 3 years, Feinberg found a lack of support between
prandial liquid aspiration and pneumonia. They suggest
that the relationship between aspiration, including volume
and frequency of aspiration, as well as gastroesophageal
reflux and pneumonia is unclear. It is well known that
food and liquid aspirated can cause pneumonia, but several
factors were unclear: volume of aspiration, frequency of
aspiration, and oropharyngeal versus gastric reflux aspira-
tion. Interestingly, the study found that individuals with “ar-
tificial feeding” (or more sensitively termed non-OI [NOI]
or enteral nutrition [EN]) had the highest frequency of
pneumonia; therefore, nothing by mouth with an alternate
means of providing nutrition is not necessarily successful for
preventing pneumonia.86
Clinical Considerations
The complexity of these relationships poses a challenge to
the healthcare team to integrate input from the SLP in
terms of providing the most appropriate level of manage-
ment for patients. As Butler et al point out, appropriate
management is a challenge because the lack of normative
data on “what constitutes normal swallowing?”.85 Over-
management of dysphagia is a reality. Because of liability
concerns, healthcare providers often operate under a conser-
vative “risk” mentality with the assumption that aspiration
always leads to pneumonia. To be clear, aspiration certainly
must occur for aspiration pneumonia to develop. However,
the relationship is multifactorial, complex, and remains
largely unknown. Therefore, recommendations often strive
to prevent aspiration related to OI and reduce risk; however,
aspiration of saliva and reflux is unavoidable, and research
and experience have shown that some aspiration can pos-
sibly be a normal variant. Unfortunately, this overman-
agement approach can contribute to unintentional negative
health outcomes, such as decreased hydration, nutrition,
and potential for subtherapeutic medication levels.74,88,89
QoL is another factor impacted by overmanagement.
Smith’s findings showed that a significant amount of both
SLPs’ and nurses’ knowledge of clinical practices regarding
dysphagia and aspiration is inconsistent with current
86
medical literature and may have the potential to cause
unintended harm.87 Alternatively, if swinging too far on
the other end of the spectrum, patients can be under
managed and at a higher risk for developing serious respi-
ratory illnesses. Clinical judgment integrating observation,
comorbidities, ambulatory status, oral cares, and ability to
handle oral secretions, as well as other factors, is essential
to appropriate management of patients. SLPs, providers,
and other members of the healthcare team must consider
these multiple factors in conjunction with patient views,
wishes, and goals when making safe, appropriate, patient-
centered recommendations based on patient-centered dis-
cussion. Elements of patient-centered care include that it
is holistic, collaborative, and includes responsive care.90
Ethical principles, including nonmaleficence (do no harm),
should provide a framework in guiding discussion.91,92 Pal-
liative care input can be helpful in identifying and discussing
short-term and long-term goals, needs, and wishes with
the patient and their family and should be included as
important decisions are made, as indicated.
Risk Factors
Poor oral hygiene has been linked to pneumonia with
chronic and/or large-volume aspiration of colonized bac-
teria from oropharyngeal or gastric sources providing an
infectious source for aspiration-induced lung injury.93,94
The oral risk is due to microflora in patients with intact
teeth as well as those who are edentulous, with the re-
lated organisms differing,94 though with similar risk for
pneumonia. According to Son, Shin, and Ryu, risk factors
for pneumonia include altered mental status, gastrointesti-
nal disorders, intervention factors (enteral tube feeding,
endotracheal tube), dysphagia, and esophageal motility
disorders.83 Langmore et al95 investigated predictors of
aspiration pneumonia in elderly patients from outpatient,
inpatient acute care, and nursing home settings and found
that dysphagia alone is insufficient to cause pneumonia, un-
less other risk factors are also present. The most significant
predictors of pneumonia included being dependent for oral
care, being dependent on tube feeding before pneumonia,
being dependent on others for feeding, taking a number
of medications, currently smoking, and having multiple
medical diagnoses and a number of decayed teeth.95 Lang-
more et al96 conducted a subsequent study on predictors
of aspiration pneumonia for nursing home residents with
results supportive of their prior findings.96 Completing
thorough oral hygiene, maintaining oral moisture, and
ensuring oropharyngeal clearance after OI are crucial to
reducing the risk for aspiration pneumonia,83 and the
importance of this simple hygiene task cannot be overstated.
Certainly, more research is needed in this area, as the signif-
icance of findings can inform recommendations for clinical
practice.
Nutrition in Clinical Practice 34(1)
Nutrition, Hydration, and Medication
Nutrition
Sarcopenia (loss of muscle tissue because of the aging
process) has been linked to impaired nutrition status
and increased malnutrition risk,27,97 which may contribute
to weakness in swallowing and further impair existing
OD. Sarcopenic dysphagia or difficulty swallowing due to
sarcopenia of skeletal and swallowing muscles can be dif-
ferentiated from presbyphagia, which refers to age-related
swallowing changes associated with frailty.27 In looking at
82 hospitalized patients with restricted OI without dys-
phagia who exhibited sarcopenia, 26% developed dyspha-
gia with evidence for sarcopenic dysphagia.98 In a study
monitoring nutrition intake, those with a caloric intake
<22 kcal/kg/d exhibited significantly poorer recovery from
dysphagia than those with an intake >22 kcal/kg/d,99
suggesting the importance of nutrition status maintenance
relative to effective swallowing. Optimal nutrition must be
part of the rebuilding or therapeutic process for regaining
strength and safety in swallowing; it is indispensable for
sarcopenic rehabilitation.27
Feeding Tube Use for Providing Nutrition,
Hydration, and Medication
The need for feeding tube use is usually indicated when one
is unable to consume adequate nutrition by mouth and/or
consuming nutrition and/or fluid orally is deemed unsafe
and the use of a feeding tube is consistent with a person’s
goals of care. Prevalence of feeding tube use related to dys-
phagia may be increasing as screening for and detection of
dysphagia increases. Discussion of research related to tube
use and related outcomes is difficult to generalize because
of multiple factors in reported studies, including tube size,
type, and delivery site feeding regime, including feeding and
fluid provision plan and multiple patient-specific factors.
The nutritionDay Project, a 1-day prevalence study of
191 nursing homes from 14 countries in Europe and the
United States between 2007 and 2012 reflected that tube
feeding was reported in 14.6% of residents with dysphagia.
In this study, the mortality of residents with dysphagia
receiving tube feeding was not statistically different from
those who were not receiving tube feeding (21.4% vs 25.3%,
P = 0.244).100 A descriptive, cross-sectional population-
based study of 4920 nursing home residents between 1994
and 1998 with severe and irreversible cognitive impairment
reflected feeding tube use in 10.1% of White subjects and
38.9% for Black subjects (P < 0.001). Tube use was strongly
associated with swallowing difficulties,101 and the role of
ethnicity in end-of-life decisions was suggested for further
study.
Nasogastric feeding tubes are often used to deliver
nutrition support when length of need is unknown or
McGinnis et al
anticipated to be of short duration, though definition of
short duration is subjective, as small-bore tubes have been
used successfully for months. Estimated duration of need
is helpful in determining the best tube choice. Additionally,
estimated duration of need is often an important factor in
criteria for reimbursement when providers such as Medicare
are involved, as length of need of >3 months and serving
as primary source of nutrition must be documented.102,103
The smallest diameter and softest tubes possible are obvious
choices for nasogastric tubes for patient comfort, safety,
and, when secured as discreetly as possible, for patient
dignity. Tube flushing after use and before and after each
appropriate form of medication is administrated can help
prevent clogging of small-bore tubes to enhance their use.
As alluded in the section on medication administration,
research and education are called for in this area.
Percutaneous abdominally placed tube choice should
also be patient specific. Aspiration risk due to gastric
reflux (vs OD) may prompt discussion of need for jejunal
access, but gastric tube use, whenever possible, provides
more patient feeding options. Gastric feeding tubes (G
tubes) may be placed in methods other than endoscopically
(percutaneous endoscopic gastrostomy tubes), including
direct surgical placement and placement using fluoroscopy,
which is often done without general anesthesia, increasing
this as an option for some who are not candidates for general
anesthesia.
Gastric feeding regimens can be helpful for the patient
with dysphagia who will socialize where food is involved by
suggesting administering a feeding prior to a food-related
event to dampen hunger, which may help some socialize
more easily, though this does not necessarily reduce the
desire for food. On the other hand, postmeal gastric feeding
can be used to promote OI where this is safe to allow best
appetite for the oral meal. The feeding can be adjusted
according to how well the meal was eaten (eg, half of a
good meal, with 1 carton of feeding needed instead of 2,
all, or none) on a meal-by-meal basis to help transition back
to OI and reduce dependency on feeding via tube, when it
is deemed safe. Nocturnal feeding may require professional
guidance in adjusting feeding to promote appetite during
the daytime as OI becomes safe.
Fluid provision is a critical component of enteral tube
feeding to ensure adequate hydration, even when oral fluid
intake is possible, until there is consistent adequate oral fluid
intake. Comparison to usual terms, such as recommending
4 or 6 cups of water per day, is often more helpful than
suggesting milliliters of fluid. Normalizing feeding regimens
are not only helpful for comprehension of the suggested
regimen but also for comparison to usual meal-like routines,
which can assist with the now significantly altered QoL
aspects. When EN is used, it is the responsibility of the
healthcare team to promote an administration and care
regimen that best meets patient needs, considering efficacy,
87
simplicity, comfort, safety, and cost effectiveness, in con-
junction with patient goals and wishes. Research regarding
means to help meet patients’ nutrition and fluid needs using
enteral feeding tubes while preserving QoL, as possible, is a
suggested area of need.
Removal of G tubes was associated with a variety of
factors, as found in a review of literature by Wilmskoetter,104
with the strongest predictor being the absence of aspiration
on modified barium swallow. This reflects the importance
of ongoing monitoring for improvement in the safety of
swallowing so that OI can resume as quickly as it is deemed
safe and efficient. Wojner and Alexandrov105 looked for
clinical indicators to help predict tube feeding dependency
in stroke patients with dysphagia to help enhance the timing
of medical interventions, such as tube feeding initiation,
and optimize outcomes while reducing risk in a poorly
reimbursed diagnostic group. In addition to being older with
higher stroke severity scores, 4 independent risk factors were
identified, including wet voice after swallowing water, hy-
poglossal nerve dysfunction, NIHSS score, and incomplete
oral labial closure.
Hydration
Dehydration or insufficient fluid may be viewed as a
form of malnutrition.106 Adequate fluid is critical for nu-
merous essential functions, including homeostasis, waste
elimination, maintaining perfusion, and thermoregulation,
for healing and for general well-being. Dehydration in
healthy young adults has been linked to fatigue, anxi-
ety, and headaches, as well as effects on concentration
and memory;107 effects in the elderly can be more severe.
With increased age and fragility, dehydration may increase
thromboembolic complications and can be predisposing
to recurrent stroke in addition to kidney dysfunction and
delirium.107
Crary108 looked at hydration status of acute ischemic
stroke patients with dysphagia in a retrospective review of
67 patients, according to serum urea nitrogen/creatinine
(BUN/Cr) ratio as a hydration marker. Modification of
solid diets or thickened liquids resulted in significantly
elevated BUN/Cr values at discharge, and liquid or diet
modifications were felt to impair hydration status. In a
prior report,89 they indicated that acute stroke patients with
dysphagia demonstrated significantly higher BUN/Cr levels
than those without dysphagia. In a study by Murray88 of 69
participants post stroke in acute care (65% of participants)
and rehab setting, the mean thickened liquid consumption
was 781 mL, or only half the intended consumption for
hospital inpatients and well below general recommenda-
tions of 2100 mL for women and 2600 mL for men per the
Australian National Health and Medical Research Council.
Of note, according to The Institute for Medicine, 2011,
recommendations are 3700 mL for men and 2700 mL for
88
women over the age of 19, including >70 years of age,
with only 19% of this fluid coming from food.109 In the
study by Murray et al,88 fluid intake was higher in the
rehab vs acute setting and in younger vs older participants.
The authors, who reinforce the importance of adequate
hydration, suggest that free water protocols may be a way of
increasing total fluid intake for individuals with dysphagia
in rehab settings.
The Frazier Free Water Protocol is an option for opti-
mizing hydration for those who are at risk for aspirating or
are aspirating thin liquids.110 The protocol allows regular,
thin water 30 minutes following meals after aggressive oral
care for patients who are carefully selected. Appropriate
candidates include those who can maintain alertness, are
relatively mobile, have reasonably intact cognition, and are
independent with feeding or have adequate supervision.
Candidates not appropriate for the protocol are those who
have degenerative neurological conditions, are impulsive,
or have an excessive cough reflex to thin liquids. In a
systematic review involving 8 studies with 215 rehab and
30 acute patients with OD,111 low-quality evidence reflected
that the protocol did not result in increased odds of lung
complications and that the protocol may increase fluid
intake.88,110 All other fluid intake includes the prescribed
thickened liquids, including during mealtimes and medica-
tion administration.
It is imperative that aggressive oral cares are completed
prior to drinking thin water. When other liquids, foods,
or bacteria from the oral cavity are aspirated, the patient
may be at risk for developing aspiration pneumonia. When
the oral cavity is adequately cleaned and pure water is
potentially aspirated, the risk of developing aspiration
pneumonia is less because pure water may be considered
benign to nonacute or chronically ill lungs.112 Adequate oral
cares include brushing teeth/dentures, brushing the tongue,
and using mouthwash as appropriate in order to reduce
the oral cavity of remaining bacteria. Patient perception of
swallow-related QoL appeared to improve with the use of
the Frazier Free Water Protocol.
Medication Administration
In addition to altering the texture of fluid and food intake
for OI, medication administration must also be considered
when the need for adjustment to OI is considered necessary,
as well as when alterations to pills, capsules, and other
meds must be made for administration via feeding tube.
Those who have difficulty swallowing or need to administer
medications via tube may need to crush or suspend them
or open capsules and liquefy them. Improper modification
could have unintended or adverse effects. Some medications
cannot be crushed because of their extended-release formu-
lation, enteric coating, or carcinoid properties. Patients may
refuse to take certain medications crushed because of the
Nutrition in Clinical Practice 34(1)
taste. Certain medications do not dissolve into fine particles
when crushed, increasing the risk of clogging a feeding tube.
Some medications come in liquid formulations; however, the
cost of liquid formulations is often much higher, which is
not always feasible.113
The intended dose of a medication is impacted by
many factors when a patient requires thickened liquids or
when administered via enteral feeding tube. Viscosity, ionic
charge, particle size, thickener formulation, and enteral
feeding formulation all can impact the bioavailability of
medications.74,114-116 Some studies have shown that thick-
ened liquids can impact gastric emptying rate and therefore
the absorption rate.117
Precautions need to be taken when thickening some
medications for oral ingestion. Xanthan gum will have
a different impact than starch-based thickeners on some
medications. When combining starch-thickened products
with polyethylene glycol (eg, Miralax), the mixture imme-
diately thins out, but it can remain thick when mixed with
xanthan-based thickeners.118 A review of a popular nursing
drug handbook does not describe the interaction that can
occur, and the prescriber, administrator, or recipient of
the medication may not be aware that this mixture may
no longer follow the recommended dietary consistency
for OI.
Consistencies administered during MBSS are also con-
sidered a form of medication because of the barium content.
Mixing barium sulfate powder with thickening agents may
change consistency within the oral cavity,119 whereas there
are other products that are developed that are prethickened
and fall within the current IDDSI framework.119 Of note,
aspiration of barium sulfate powder versus iohexol during
MBSS was explored by Sun and Li,120 with a higher occur-
rence of pneumonia in the group administered consistencies
with barium sulfate powder products; however, there was no
statistical significance with the incidence rate of pneumonia
between the 2 groups.
Lohmann et al121 assessed the knowledge and training
needs of 373 nurses and 75 physicians regarding unsuit-
able drugs for patients with dysphagia or feeding tubes
and found knowledge gaps, which could possibly result in
erroneous medication administration. In a systematic review
of medication administration for those with dysphagia by
nurses in aged care facilities, Forough et al122 found a
scarcity of information, suggesting the need for more infor-
mation in this area. The need for enhanced knowledge in
this area also emphasizes the importance of interprofesional
collaboration, including between acute and community care
pharmacists, nurses, providers, dietitians, SLPs, radiology
staff, and others. The American Society for Parenteral and
Enteral Nutrition has offered a useful resource in this area:
a guidebook on enteral medication administration123 that
covers a variety of issues related to medication delivery via
feeding tube.
McGinnis et al
QoL
Dysphagia has physical, psychological, social, and financial
impact124 and can profoundly affect QoL. According to the
World Health Association, QoL is defined as an individual’s
perception of his or her position in life in the context of
the culture and value systems in which he or she lives and
in relation to his or her goals, expectations, standards, and
concerns.125
Dysphagia is an example of a chronic condition with
significant impact because of its effect on OI, in addition
to the fact that is it often considered a symptom of another
disease, such as cancer or a neurological or neuromuscular
condition.126 Dysphagia can not only lead to dehydration,
malnutrition, weakness, and aspiration pneumonia but also
feelings of suffocation, anxiety,127 and the potential to
choke. It can cause embarrassment as well as a loss of meal
time pleasure, leading to changes in socialization, including
refusing to eat around others or be around others who eat
when one can no longer partake.
An examination of the perceived effects of dysphagia
on patients, their families, and caregivers is helpful for
those caring for them to try to understand what this
experience may be like for them. Various tools exist to guide
this exploration, as evidenced by a systematic review to
assess the most effective tools.126 Specific tools are available
to assess QoL, including the swallowing QoL question-
naire, or SWAL-QOL, for assessing QoL in stroke patients
with dysphagia,128 validated through studies in multiple
countries.129,130
A systematic review of studies of patients with OD131
highlighted the feelings of depression as well as anxiety (eg,
will this get better and if so, when?) associated with the
diagnosis of dysphagia. In a systematic review reduced to
8 studies that met criteria, food bolus modification (cutting,
pureeing, or mashing food, thickening fluid) was more fre-
quently associated with worse QoL for those with OD.107 In
assessing the impact of OI vs NOI for 79 patients diagnosed
with stroke and dysphagia, a significant association was
noted between swallowing function (those with OI) and
QoL. This suggested that as swallowing function improves,
so does QoL, as this is satisfying a basic human need on
Maslow’s hierarchy of needs.129
Dysphagia affects not only patients or those who experi-
ence it but also those who care for and about them. Nund et
al132 explored the effects on caregivers of persons with dys-
phagia who were not dependent on gastrostomy tubes. They
reported disruptions in daily life and the need to adapt as
well as a disconnection between expectations and reality and
experiences with services and support. They reported feeling
ill prepared. In exploring survivors’ experiences, these same
authors also noted the theme of entering the unknown and
uncertainty about life after treatment for patients with head
and neck cancer. In 2016, they explored the impact of the
89
effects of dysphagia on caregivers of head and neck cancer
patients using a semistructured interview linking this with
the International Classification of Functioning.133 They
posit that the associated levels of distress and reduced QoL
can be understood as a third-party disability.
In the assessment of care assistant perceptions of helping
those with dysphagia, the realm of helping could be labeled
in 3 categories: recognizing dysphagia, making adjustments,
and facing the dilemma of dysphagia management. Sixteen
care assistants interviewed about their work in this area134
included comments noting that patients had decreased
social interaction and depression related to dysphagia.
Feeding them was time-consuming and exhausting. They
noted the benefit of sitting at the same height (level) as the
patient to better interact and watch him or her. They also
suggested the need for training in this area.
In a qualitative study by Brockbank135 of 24 head and
neck cancer patients, patients reported wanting information
about the impact and prognosis for their swallowing ability,
preferably in verbal format by someone knowledgeable
about dysphagia with individual preference for the manner
and pace in which this information is presented. LaDonna
et al136 suggest that “healthcare providers need to balance
issues of clinical concern with those of importance to
individuals and their families,” and they recommend an
assessment of their knowledge and burden at each clinic
visit.
Of 14 caregivers interviewed regarding their perception
of dysphagia in a palliative care setting,137 themes that
emerged included caregiver knowledge and meaning of
dysphagia, the symbolic role of food, emotional responses,
and tension leading to discordance. Caregivers had little
knowledge of dysphagia and correlation with the dying
process as well as lack of awareness of means to assist. Per-
ceptions about dysphagia and struggles with OI may impact
the patient-caregiver relationship. They suggest using a risk
management, conservative approach to dietary alteration in
the palliative care setting, offering information as well as
support to deal with conflicting emotions in this difficult
time.
Caregivers may project their own food-related beliefs,
attitudes, and values in situations involving others.137 An
example of this is exhibited in the following case study. A
young adult nonverbal female with a history of cerebral
palsy was admitted to acute care for a second occurrence
of aspiration pneumonia. A dysphagia workup, including
a video swallow, revealed a strong tendency for her to
aspirate all textures, and a percutaneous gastric feeding tube
was recommended. In discussing this life change with the
nutrition support nurse, her mother shared her reluctance to
take away OI, one of her few remaining pleasures in life. In
discussing the experience of eating, her mother shared that
meals often took about 1–2 hours and required coaching.
Her daughter reflected signs of anxiety with OI, which
90
her mother began to see as possibly fear of choking and
that though OI is pleasurable for most, it may not be any
longer for her daughter. She reluctantly agreed to have a
gastrostomy tube placed but said she would then focus on
providing other forms of stimulation and pleasure for her
daughter, such as backrubs and reading to her more to
replace what she viewed as loss of pleasure related to eating.
A follow-up phone call to her care facility several weeks later
revealed the excitement that she demonstrated when staff
would assemble the equipment for her meal-like feeding via
the G tube, as she seemed to equate feeding via her tube as
satisfying hunger and therefore pleasurable without the fear
of choking that she may have previously experienced.
Transition (the process of moving from one life phase
to another) or the process of moving to textured food or
nothing by mouth status may be perceived as abrupt, char-
acterized by lack of communication and awareness of the
need for change, according to Ullrich and Crichton.138 They
suggest that the approach should be person-centered, re-
specting not only the fundamental physiologic need for food
and water but also for belonging, esteem, self-actualization,
and trust. Instead of using a punitive or risk aversive
approach (promoting fear of choking, pneumonia, and
possible death), they suggest a focus on connection between
food and QoL, easing the transition with a person-centered
approach. Kenny139 discussed the professional obligation
to minimize harm balanced with upholding autonomy; “a
complex relationship exists between food and emotional
wellbeing.” She explores the ethical implications of restrict-
ing patient autonomy in exercising food preferences. In the
discussion of ethical concerns, food culture, and patient
preferences, she suggests the use of a shared decision-
making model (SDM) in helping prepare those who are
encouraged to modify their usual eating patterns to guide
critical decision-making. This model includes thorough
patient/family education, open communication, and clear
documentation of plans and decisions.
Ultimately, at the forefront of dysphagia management
is the individual. From an ethical standpoint, medical
professionals, especially SLPs, face challenging situations
when making treatment recommendations. Dysphagia not
only impacts hydration and nutrition but also poses psy-
chosocial and QoL challenges.138,139 Morley suggests that
competent patients with dysphagia in nursing homes should
be given the choice regarding modified diets after thorough
education of risks and benefits.24 Ullrich and Crichton
highlight the need for care facilities to revise protocol
and language to promote a person-centered approach to
dysphagia management with clearer communication that
fosters improved understanding, readiness, and willingness
to transition to modified diets.138 A systematic review in
2018 looking at patient adherence to treatment recommen-
dations revealed an average range of 21.9 (“fully adherent”)
to 51.9% (“average adherence”), though further research
Nutrition in Clinical Practice 34(1)
would enlighten this topic as well.140 Patient preferences,
ethical considerations, and adherence are all factors when
considering individualized patient care based on the SDM
model.
Although diet recommendations are ultimately imple-
mented based on provider order, SLPs often initiate rec-
ommendations to providers and the care staff based on
an underlying sense of responsibility for determining the
safest, most efficient, least restrictive diet that optimizes
hydration, nutrition, and QoL. This decision is rarely
simple; it is multifactorial in nature with many potential
consequences. An SLP’s role is to evaluate the individual
situation from an oropharyngeal perspective and make
recommendations based on multiple factors, synthesizing
these factors with multidisciplinary input regarding nu-
trition status, mental health, medical comorbidities, etc.
Smith87 acknowledges the uncomfortable position of an
SLP to make recommendations for patients with dysphagia,
especially individuals known to aspirate. Often, this clinical
decision making is confounded by insufficient familiarity
with limited evidence, an unrealistic pressure to eliminate
or prevent aspiration pneumonia, patient-family dynamics,
and liability concerns. It is important to recognize that, at
times, waivers of liability have been attempted to be used
if patients decline certain recommendations; however, these
waivers have been unenforceable within the courts.141 The
interprofessional team in general is challenged by the need
to provide safe, effective recommendations for OI as well
to provide for nutrition, fluid, and medication delivery bal-
anced with the goals and wishes of the patient, especially if
they differ.
Providing Care Currently With a View Toward
the Future
In large epidemiologic studies, Leder et al142,143 reported
marked increases for swallow evaluation with a 63% increase
for 60–90+ year old geriatric hospitalized participants,
despite only a 23% increase in hospital discharges for the
year 2007 vs 2014. They suggest that “more dysphagia
specialists are needed through 2060 and beyond because
of projections of continued population ageing resulting in
ever increasing referral rates for swallow assessments.”143
Dysphagia experts are underrepresented, and there is need
for additional resources, administrative support, train-
ing, and interprofessional communication as the synergy
of collaboration can enhance the science in conjunction
with quality research. This requires funding and other
resources as well as engagement with industry, including the
pharmaceutical industry.124 Dysphagia is a universal topic,
as evidenced by research and discussion on this topic from
around the globe, as well as the call to unite in this area.144
Access to highly qualified healthcare personnel to detect,
assess, and treat persons with symptoms of dysphagia may
McGinnis et al
be limited in many settings, including rural and long-term
care facilities.59,124 Periodic monitoring throughout the con-
tinuum of care for changes in patient status has the potential
for improvement, including having adequate healthcare
resources and increasing awareness of dysphagia impact
both personally and economically. Suggestions to help meet
residents’ needs include virtual consultation and collabo-
ration with experts via telehealth,59 training care staff in
early detection and prevention of aspiration and mobile in-
strumentation evaluation. Integral to this consultation and
collaboration is the need to base dialogue within an ethical
framework based on principles of patient-centered care.
Virtual consultation may involve increased challenges in
the establishment of the therapeutic relationship. Research
related to outcomes and means to overcome barriers, such as
through patient reporting outcome research, may be very in-
formative for future models of consultation, collaboration,
and care in this area. Ongoing research is needed to provide
evidence to guide practice. Park et al50 describe the benefit
of an evidence-based nursing care algorithm for dysphagia
management in Korean settings with likely application to
other settings. Much can be learned from colleagues across
the globe.
Future research challenges include a lack of standard-
ized definitions of dysphagia and malnutrition, as system-
atic review could not clearly determine prevalence of both
conditions individually or their co-occurrence.106 Cause-
and-effect relationships between the incidence of dysphagia
and ill effects or the lack thereof could lend insight to guide
recommendations for potentially life-altering therapies. A
recurrent theme also includes the need for improved stan-
dardization of screening and evaluation across healthcare
settings. There may be exploration and potential for use
of bioinformatics for predictive modeling.145 Potential new
treatments may include items such as transcranial direct
current stimulation, transcranial magnetic stimulation, and
acupuncture.146,147 There is a lack of consensus for support
of items such as these, and further research is needed.
Research in the area of medication related to the
development or exacerbation of dysphagia, as alluded to
previously, as well as for possible beneficial effects in the
treatment of dysphagia, could be helpful. Morley suggests
the need for randomized trials of angiotensin-converting en-
zyme inhibitors and dopamine agonists, which may increase
the cough reflex, comparing benefit vs potential harm and
looking at dose effects. He also discussed the reported use
of amantadine, a dopamine agonist, for dysphagia related
to stroke24,148,149 and rotigotine transdermal patches to
improve swallowing for patients with Parkinson’s disease.150
Huang concluded that fluoxetine (Prozac) may be useful
in improving swallowing function in a retrospective review
of 159 stroke patients, though they suggest the need for
a placebo controlled, randomized clinical trial to confirm
their finding.151 Further research regarding medication use
91
may impact the treatment of dysphagia, especially in specific
conditions.
In discussing what is on the horizon and further out,
Ciucci et al59 point out that therapy has been reactive. The
focus will increase in the area of preventative therapy, such
as during irradiation, and extend to other areas; rapidly
advancing technology and science will enhance research,
and focus will be on further individualizing treatment.
Enhanced use of telehealth can help in underserved areas;
wearable technology will be increasingly useful, but barriers
to this practice must be reduced, including in reimbursement
and state licensure.59,124 Another opportunity for improving
the field of dysphagia would be to increase advocacy and
field entry knowledge of practicing clinicians.87,124 Ciucci
et al also suggest continuation of investigation into the
neurophysiological basis for dysphagia with a potential
for noninvasive brain stimulation. They recommend an
appreciation of a more holistic approach, including the
consideration of complementary medicine. Reinforcing the
benefit of interdisciplinary, united academic, medical, and
advocacy efforts is also stressed. Bedside clinicians play a
role in enhancing the science while serving as important
patient advocates in the area of dysphagia that affects
millions worldwide.59
Conclusion
Dysphagia awareness has increased and is likely to
continue,130 placing emphasis on the need for efficient and
accurate screening in various settings with potential for re-
ferral to experts who will further evaluate and offer sugges-
tions to guide best practice. Knowledge of the relationship
between dysphagia, aspiration risk, and pneumonia or other
ill effects must be balanced with awareness of the impact
of dietary modification or feeding via tube as well as QoL.
Healthcare professionals must balance safety and efficiency
with patient goals and wishes, which can create moral
and ethical challenges. They also have a responsibility to
remain abreast of and contribute to research as it evolves. A
patient-centered approach based on nonjudgmental, caring
dialogue with patients and families can help promote the
best, mutually agreeable outcomes. Practical approaches
and tips have been integrated in this dialogue for enhance-
ment of current practice and questions raised for future
practice in this issue, which impacts healthcare around the
globe.
Acknowledgements
We would like to acknowledge the invaluable contributions
of the University of South Dakota Medical School Librar-
ians Molly Youngkin, MLS, and Anna Gieschen, MALS,
Outreach Librarians, Wegner Health Science Information
Center.
92
Statement of Authorship
C. M. McGinnis, K. Homan, M. Solomon, J. Taylor, K. Stae-
bell, and N. Raut equally contributed to the conception and
design of the work; C. M. McGinnis, K. Homan, M. Solomon,
J. Taylor, K. Staebell, D. Erger, and N. Raut contributed to
the acquisition and analysis of the data; C. M. McGinnis, K.
Homan, M. Solomon, J. Taylor, K. Staebell, D. Erger, and N.
Raut contributed to the interpretation of the data; and C. M.
McGinnis, K. Homan, M. Solomon, J. Taylor, K. Staebell, and
N. Raut drafted the manuscript. All authors critically revised
the manuscript, agree to be fully accountable for ensuring the
integrity and accuracy of the work, and read and approved the
final manuscript.
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