Decisions on eating and drinking in older adults admitted with pneumonia and referred for swallowing difficulties.

PURPOSE: Older patients with pneumonia are commonly restricted from oral intake due to concerns towards aspiration. Eating and drinking with acknowledged risks (EDAR) is a shared decision-making process emphasising patient comfort. As part of our project to find the barriers and facilitators of EDAR, we aimed for this initial study to see how frequently EDAR was selected in practice. METHODS: We performed a retrospective cohort study at an acute hospital where EDAR was initially developed, of patients aged ≥ 75 years-old admitted with pneumonia and referred to speech and language therapy. RESULTS: Out of 216 patients, EDAR decisions were made in 14.4%. The EDAR group had a higher 1-year mortality than the modified/normal diet groups (p < 0.001). Pneumonia recurrence rate did not differ significantly between the groups (p = 0.070). CONCLUSION: EDAR decisions were comparatively less common and most were associated with end-of-life care. Underlying reasons for the low EDAR application rate must be investigated to maximise patient autonomy and comfort as intended by EDAR while minimising staff burden.

Decoloniality and healthcare higher education: Critical conversations.

BACKGROUND: We explore the theoretical and methodological aspects of decolonising speech and language therapy (SLT) higher education in the United Kingdom. We begin by providing the background of the Rhodes Must Fall decolonisation movement and the engagement of South African SLTs in the decoloniality agenda. We then discuss the evolution of decoloniality in SLT, highlighting its focus on reimagining the relationships between participants, students, patients and the broader world. OBJECTIVE: The primary objective of this discussion is to fill a gap in professional literature regarding decoloniality in SLT education. While there is limited research in professional journals, social media platforms have witnessed discussions on decolonisation in SLT. This discussion aims to critically examine issues such as institutional racism, lack of belonging, inequitable services and limited diversity that currently affect the SLT profession, not just in the United Kingdom but globally. METHODS: The methods employed in this research involve the engagement of SLT academics in Critical conversations on decolonisation. These conversations draw on reflexivity and reflexive interpretation, allowing for a deeper understanding of the relationship between truth, reality, and the participants in SLT practice and education. The nature of these critical conversations is characterised by their chaotic, unscripted and fluid nature, which encourages the open discussion of sensitive topics related to race, gender, class and sexuality. DISCUSSION POINTS: We present our reflections as academics who participated in the critical conversations. We explore the discomfort experienced by an academic when engaging with decolonisation, acknowledging white privilege, and the need to address fear and an imposter syndrome. The second reflection focuses on the experiences of white academics in grappling with their complicity in a system that perpetuates racism and inequality. It highlights the need for self-reflection, acknowledging white privilege and working collaboratively with colleagues and students toward constructing a decolonised curriculum. Finally, we emphasise that while action is crucial, this should not undermine the potential of dialogue to change attitudes and pave the way for practical implementation. The paper concludes by emphasising the importance of combining dialogue with action and the need for a nuanced understanding of the complexities involved in decolonising SLT education. CONCLUSION: Overall, this paper provides a comprehensive overview of the background, objectives, methods and key reflections related to the decolonisation of SLT higher education in the United Kingdom. It highlights the challenges, discomfort and responsibilities faced by academics in addressing decoloniality and emphasizes the importance of ongoing critical conversations and collective action in effecting meaningful change. WHAT THIS PAPER ADDS: What is already known on this subject Prior to this paper, it was known that the decolonial turn in speech and language therapy (SLT) was a recent focus, building on a history of professional transformation in South Africa. However, there was limited literature on decoloniality in professional journals, with most discussions happening on social media platforms. This paper aims to contribute to the literature and provide a critical conversation on decolonising SLT education, via the United Kingdom. What this paper adds to existing knowledge This paper adds a critical conversation on decolonising SLT higher education. It explores theoretical and methodological aspects of decoloniality in the profession, addressing issues such as institutional racism, lack of sense of belonging, inequitable services and limited diversity. The paper highlights the discomfort experienced by academics in engaging with decolonisation and emphasizes the importance of reflection, collaboration and open dialogue for meaningful change. Notably we foreground deimperialisation (vs. decolonisation) as necessary for academics oriented in/with the Global North so that both processes enable each other. Deimperialisation is work that focuses the undoing of privilege exercised by academics in/with the Global North not only for localising their research and education agenda but checking their rite of passage into the lives of those in the Majority World. What are the potential or actual clinical implications of this work? The paper highlights the need for SLT practitioners and educators to critically examine their practices and curricula to ensure they are inclusive, decolonised and responsive to the diverse needs of communities. The discussions emphasise the importance of addressing institutional racism and promoting a sense of belonging for research participants, SLT students and patients. This paper offers insights and recommendations that can inform the development of more equitable and culturally responsive SLT services and education programmes.

Chin tuck against resistance exercise with feedback to improve swallowing, eating and drinking in frail older people admitted to hospital with pneumonia: protocol for a feasibility randomised controlled study.

BACKGROUND: Swallowing difficulties (dysphagia) and community-acquired pneumonia are common in frail older people and maybe addressed through targeted training of the anterior neck musculature that affects the swallow. We have developed a swallowing exercise rehabilitation intervention (CTAR-SwiFt) by adapting a previously established swallowing exercise to ensure patient safety and ease of execution in the frail elderly population. The CTAR-SwiFt intervention consists of a feedback-enabled exercise ball that can be squeezed under the chin, with real-time feedback provided via a mobile application. The aim of this study is to evaluate the feasibility of assessing the effectiveness of the CTAR-SwiFt intervention in reducing dysphagia and community-acquired pneumonia, prior to a larger-scale multi-centre randomised controlled trial. METHODS: We will recruit 60 medically stable patients over the age of 75 years who have been admitted with a diagnosis of pneumonia to the acute frailty wards at two participating hospitals in the UK. Study participants will be randomised into one of three groups: standard care, low intensity (once daily) CTAR-SwiFt exercise or high intensity (twice daily) CTAR-SwiFt exercises. The intervention period will last for 12 weeks, the final follow-up assessment will be conducted at 24 weeks. We will assess the feasibility outcomes, including rates of participant recruitment and retention, compliance with the exercise regime and adverse incidents. Additionally, we will assess the usability and acceptability of the intervention device and the performance of different clinical outcome measures (e.g. chin tuck strength, Functional Oral Intake Scale, SWAL-QOL, EQ-5D and swallow speed). A sub-sample of study participants will complete videofluoroscopic assessments of swallowing function before and after the intervention to evaluate the physiological changes (e.g. bolus flow rates, laryngeal elevation, base-of-tongue retraction). CONCLUSIONS: By improving the ability to swallow, using our chin tuck exercise intervention, in frail older patients admitted to hospital with pneumonia, it is anticipated that patients' oral intake will improve. It is suggested that this will further impact clinical, patient and healthcare economic outcomes, i.e. reduce the need for supplemental feeding, improve patient satisfaction with oral intake and swallowing-related quality of life, decrease the occurrence of chest infections and reduce hospital admissions and related healthcare costs. TRIAL REGISTRATION: ISRCTN, ISRCTN12813363 . Registered on 20 January 2020.

Inter-Relationships between Frailty, Sarcopenia, Undernutrition and Dysphagia in Older People Who Are Admitted to Acute Frailty and Medical Wards: Is There an Older Adult Quartet?

Introduction: With increasing age the prevalence of frailty, sarcopenia, undernutrition and dysphagia increases. These are all independent markers of outcome. This study explores the prevalence of these four and explores relationships between them. Methods: A convenience sample of 122 patients admitted to acute medical and frailty wards were recruited. Each was assessed using appropriate screening tools; Clinical Frailty Score (CFS) for frailty, SARC-F for sarcopenia, Nutritional Risk Tool (NRT) for nutritional status and 4QT for dysphagia. Results: The mean age of the participants was 80.53 years (65-99 years), and 50.37% (68) were female. Overall, 111 of the 122 (91.0%) reported the presence of at least one of the quartet. The median CFS was 5 (1-9), with 84 patients (68.9%) having a score of ≥5 (moderate or severely frail); The median SARC-F was 5 (0-10), with 64 patients (52.5%) having a score of ≥5; The median NRT was 0 (0-8) and 33 patients (27.0%) scored ≥ 1. A total of 77 patients (63.1%) reported no difficulty with swallowing/dysphagia (4QT ≥ 1) and 29 (23.7%) had only one factor. Sixteen patients (13.1%) had all four. There was a significant correlation between nutritional status and dysphagia, but not with frailty or sarcopenia. There were significant correlations between frailty and both sarcopenia and dysphagia. Conclusions: In our sample of acute medical and frailty ward patients, there was a much higher prevalence than expected (91%) of either: frailty, sarcopenia, undernutrition or dysphagia. The prevalence of all four was present in 13% of patients. We suggest that frailty, sarcopenia, nutritional risk and dysphagia comprise an "Older Adult Quartet". Further study is required to investigate the effect of the "Older Adult Quartet" on morbidity and mortality.

A New Simple Screening Tool-4QT: Can It Identify Those with Swallowing Problems? A Pilot Study.

As people and the population age, the prevalence of swallowing problems (dysphagia) increases. The screening for dysphagia is considered good practice in stroke care, yet is not routinely undertaken in the management of frail older adults. A short swallow screen, the 4QT, was developed following a review of the literature. The screen has four questions relating to swallowing that can be asked by a member of the health care team. A convenience sample of 48 older frail patients on an acute frailty ward was recruited into a Quality Improvement project. Their swallow was screened using the EAT-10 and 4QT. A speech and language therapist assessed for the presence of dysphagia using a standardised assessment for dysphagia. The 4QT was as effective as the EAT-10 in identifying older frail adults with potential swallowing problems (Κ = 0.73). The 4QT has 100% sensitivity, 80.4% specificity and positive predictive value (PPV) 50%, negative predictive value (NPV) 100%. The 4QT is a highly sensitive but not specific swallow screen, only 50% of people reporting swallowing problems were confirmed to have a degree of dysphagia by the SLT. The 4QT is a simple screening tool that could be used by all staff, but requires further research/evaluation before it is widely accepted into clinical practice.

An Acute Model of Care to Guide Eating & Drinking Decisions in the Frail Elderly with Dementia and Dysphagia.

People with dementia frequently develop dysphagia (swallowing impairment), which causes them to be at high risk of aspiration pneumonia, resulting in hospital admissions. These individuals are advised against alternative nutrition and hydration as this does not eliminate the risk of developing chest infections. The purpose of this study was to establish the impact on length of stay by having a protocol to guide eating and drinking despite aspiration risks (risk feeding). A risk-feeding protocol was developed and implemented in a hospital setting. The quality improvement methodology of Plan-Do-Study-Act (PDSA) was employed to evaluate the impact of a protocol on the length of stay in patients with dementia and aspiration pneumonia. Annual audits (2016-2018) on the time taken from admission to when a route of nutrition was established were conducted, with adaptations made to the protocol. There was a reduction in nutrition planning times with each year. On closer evaluation of the data, improved nutrition planning times for this cohort impacted on a shorter length of stay. Having a model of care in place to guide feeding decisions in dementia coordinates care, as demonstrated in timely decision-making. For patients who are admitted with aspiration pneumonia and dementia, a decreased length of stay is evident.

Pilot of a Charter to Improve Management of Medicines and Oral Care for Residents with Dysphagia in Care Homes.

Research in care homes has demonstrated that medication management practices in patients with dysphagia and those receiving medicines covertly may be inappropriate, illegal, and potentially cause harm. This paper presents the results of a feasibility study piloting a resident and healthcare professional best practice charter to improve such practices in care home residents with dysphagia. A charter was developed through a multi-professional expert panel, implemented in one care home, and then piloted in 22 homes in England, Wales, and Northern Ireland. A website was setup and developed iteratively to support the process. Care home staff and residents provided initial feedback on the implementation process and on perceived outcomes six months post implementation. A total of 16 (88.9%) out of 18 respondents from nine homes for six months reported a positive response to the charter. More than 80% of responses regarding the implementation process, impact on staff confidence, and perceived usefulness of the charter were positive. Perceived effectiveness and usefulness could, however, be further improved especially the perceived effect on frequency of medication review, which is reliant on external stakeholder involvement. The charter and supporting website were well received with respondents believing that it was useful, staff showing more confidence, and residents having enhanced care. Approaches to enhancing the charter's effectiveness were identified.