Difficulties in Treatment of Dysphagia - Case Study Example

Case study on management of dysphagia after stroke Introduction In the cases of dysphagia and dysarthria during and after stroke, the patient observes difficulties regarding swallowing, sleeping, writing and speaking. It is observed by number of physicians that the patient's speech also may worsen during the period. They generally slur and mumble words. They observe difficulties regarding swallowing and sight. They find it difficult to write and have to contact ophthalmologist. The patients will observe the episodes of syncope. They feel fainting while they are doing their work and daily chores. General effect that has been observed in these patients is the chronic fatigue that cannot be removed by ordinary diet or medication. The appetite will be decreased. They feel depressed and it will be expressed on their faces. (Tyler Reimschisel, MD, 2002) 1 In the two pairs of vessels that supply blood to the brain, they deliver 20 percent of cardiac output. These are observed joined on the ventral surface of the brain and are called as intracranial vessels. It was observed that the isolated infarction of the anterior cerebral artery is uncommon. The highest risk of recurrence of the stroke occurs within the first month after the initial stroke or symptoms. This compels the physicians to evaluate the patients presenting with TIA or suspected stroke. The prophylactic therapy begins immediately at presentation. In the patients with recent cerebral ischemia, the first step is to localise the lesion. The evaluation of heart, extracranial carotid arteries and intracranial circulation strokes is necessary for the patients who undergo recent stroke. The extracranial carotid circulation and the intracranial anterior circulation can be observed using MRA and CTA.( National guideline clearing house, 2007)2 Subcortical infarctions or lacunae are observed in a diameter greater than 1.5 cm. they are thromboembolic in nature. (Scott E. Kasner, MD; Lewis B. Morgenstern, MD, 2005)3 2. After Stroke guidelines and rehabilitation The American Heart Association endorsed stroke rehabilitation guidelines by VA. Effective rehabilitation interventions started immediately after stroke are capable of enhancing the recovery process. Though the stroke is a cause for disability in survivors, the multidisciplinary rehabilitation procedures when started in time can reduce functional impairment. The level I evidences recommend that the delivery of post stroke care is multidisciplinary rehabilitation. Evaluation of swallowing can be a screen for dysphagia, recognising that impairment may cause in severe pneumonia and death. The guidelines also call for standardised assessment that tailor complete treatment procedure.( Harold P. Adams, Jr, MD, 2003) 4 This should be patient specific addressing his needs and medical therapy for depression and emotions. The goal of rehabilitation will be to prevent complications and minimise the impairments. This is possible by maximising the functional activities of the organs. The multidisciplinary rehabilitation will be undertaken by a multidisciplinary team that contain physician, nurse, physical therapist, occupational therapist, kinesiotherapist, speech and language pathologist, psychologist, recreational therapist, patient and family members of care givers. The team should educate the family and care givers before the process of rehabilitation initiates. The patient specific recommendations should be based on clinical problems or resources unique to the medical system. 5 According to a study the bilateral pallidal surgery can be highly effective in case of primary dystonia. In case of DYT-1 patients with primary dystonia and with the patients with negative with DYt-1, the pallidal surgery is recommended. The gene positive patients have improved their condition by 90 to 100 percent to the burke fahn Mrsden dystonia. In case of secondary patients a 30 percent improvement has been observed. A self resolving sysarthria has been observed in the case of a patient after the surgery. The less response in the patients has been analysed is due to the lack of the second side surgery. (Kilgore SM, Bronte-Stewart H, 2002) 6 3. Radio Surgery In case of disorders, the stereotactic radio surgery can be a minimally invasive treatment modality that allows delivery of a large dose of radiation. This is intracranial specific that sparing the surrounding tissue. This will not depend on fractionated radio therapy. The stereotactic radio surgery focuses on non parallel beams of external radiation on a stereotactically defined target. If the doses are less there is a chance of reaching the non targeted tissues. There is an alternate radio surgical solution, LINAC radio surgery that has been modified in various ways since its inception 1985. This also is based on collimated x ray beam that is focussed stereo tactically on intracranial target.( Timothy C. Ryken, M.D, 2001) 7 The above figure is adopted from http://www.medscape.com/content/2003/00/45/61/456126/art-nf456126.fig1.gif The target dose distribution can be decided by changing collimator sizes and eliminating undesirable arcs. There are number of reports published on the patients treated with LINAC based radio surgery for VSs. According to the Martens of university hospital in Ghent, Belgium, a mean marginal dose of 19.4 Gy was delivered to 70 percent with a single iso center. The follow up duration was 19 months for 14 patients. During this short follow up complete tumor control has been achieved. 71 percent of the part is stabilized and did not enlarge. In another report for treating 23 patients with LINAC based surgery in Rome was published by Valentino and Raimondi. Out of them 5 people suffered with NF and 7 of them have undergone previous surgery. The total radiation dose to the tumor margin ranged from 12 to 45 Gy in five sessions. The results derived from the non conventional methods of radio surgery that involves multi sessions can be compared to the radio surgical techniques. 96 percent of patients are observed to be in control of tumor. In a research that observed the patients treated in an interval of 10 years, the extensive experience with GKS and VSs are documented. The minimum dose to the tumor margin was 17 Gy during the early part of the series. Radio graphic tumor control was observed in 93 percent of patients and only 2 percent developed symptoms that need surgical intervention. In case of 44 cases reported by kobayashi et al, the gamma knife centre in Komaki city, Japan, the mean marginal dose of 14.8 Gy was delivered to the 50 percent iso dose line. The mean follow up duration was 12 months. Complete tumor control was reported. The radiological regression occurred in 25 percent and stabilization occurred in 75 percent. The majority of cranial nerve deficits were resolved and pre operative hearing has been preserved in 48 percent of the patients. (William A. Friedman, M.D., Kelly D. Foote, M.D.2003) 8 4. Case Study 4.1 Introduction: A 51 year old man suffering with AIDS has right sided weakness, diplopia, dysarthria and gait disturbance. The patient was reported to emergency 8 days after he woke up with numbness of the right side of his face, arm and leg. He used to veer right side while walking. After that when he developed horizontal diplopia and dysarthria within a few days he was referred to emergency. He was HIV positive for 10 years. His history is significant with pneumocystic caninji pneumonia and hepatitis. The patient was divorced and resided with ex wife and a friend. He has 30 plus pack year of smoking history and no alcohol. The patient was admitted as an inpatient with a provisional diagnosis of acute ischemic stroke. He was administered with pyrimethamine and sulfadiazine empirically for toxoplasma encephalitis. The erythrocyte sedimentation rate, rapid plasma region, non reactive, thyrotropin, HgbA1c are studied. On the basis fo these results the patient started on a aspirin and pravastatin. This resulted in finding negative of Toxoplasma antibodies. As a result the toxoplasma therapy was discontinued. After that he improved his gait muscle strength in rehabilitation centre. He recovered his mental status in 8 days in rehabilitation centre but other neuron conditions did not improve. (W. Bryan Burnette, MD, MS, 2007)9 4.2 Managing and Identifying dysphagia When the patient needs the optimal stroke care it includes the identification and manageing the dysphagia. The identification of dysphagia may be after the stroke or it may even develop during the first month after the stroke. It is evident by the studies that the 50 percent of the acute stroke patients have some degree of dysphagia within the period immediately after the stroke. If this was left undetected may lead to potentially serious complications. These complications include dehydration, malnutrition and aspiration pneumonia. The importance of identifying and managing the dysphagia in stroke increases the chance of surviving according to the research evidences. The identification and managing it can reduce the complications in the stroke treatment. This is also capable of increasing the length of the hospital stay. This requires institutional care and if not results in increased mortality. If the dysphagia was detected in time and addressed accordingly, the time of staying in the hospital can be reduced. The management of dysphagia can be done as follows. The patients need to be active in timely swallowing and screening of it to minimize the complications. In case of stroke survivors, the screening process needs the access to a rapid and timely comprehensive dysphagia assessment by an expert. This compels every hospital treating neuron patients and cerebral stroke patients to develop a dysphagia unit. They have to maintain all acute stroke survivors The management of dysphagia prohibits oral administration of medications, water and ice chips. This requires intravenous fluids. (Rosemary Martino, MA, MSc, PhD et al, 2006) 10 4.3Decision Making If a person was admitted in the hospital with severe dysphagia and dysarthria and aspiration pneumonia, the lateral medullary infarction may be detected. This can be known as wallenberg's syndrome. The abnormality of swallowing should be assessed after the patient has recovered from pneumonia. This can be done on the basis of provocation test and video fluorography. In case of a 65 year patient it was observed that the swallowing reflex has been improved after the swallowing training and the vdieofluorography showed the magnitude of aspiration to the trachea had decreased. The patient started to take food by mouth. These tests will help in quantitative assessment of dysphagia. This will decide the time at which the in take need to be started by elderly patients. (Nippon Ronen Igakkai Zasshi, 1997) 11 In order to the evaluate the predictive value of a complete clinical screening of aspiration in patients suffering with neurological diseases require clinical assessment. The patients suffering with dysphagia taking video fluoroscopy also need clinical assessments to estimate the changes occurred. The cost benefit of radiological examination also can be estimated using clinical observations and assessments. Consecutive patients meeting the criteria of neurological disease generally have a risk of swallowing malfunctions. This dysphagia may be due to the cerebrovascular accidents, brain injury, parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, myotonic dystrophy, and abiotrophic diseases should under go clinical assessment using 25 item form to check for symptoms regarding dysphagia and dysarthria. The dysarthria dyspagia involve oropharyngereal swallowing mechanism. This needs the performance of water swallow test that assesses the aspiration risk. This assessments will bring out the sensitivity, specificity, positive predictive and negative predictive values of the symptoms. The symptoms are dysphagia and dysarthria. History of cough on swallowing and water test positivity versus video fluoroscopy documented aspiration. These are taken as gold standards. These are measured in all the patients and in the sub groups also. These sub groups patients contain various neurological disorders. This can result in non specific complaints of dysphagia showing a very poor predictive value. The symptoms of cough on swallowing proved to be the most reliable in estimating the risk of aspiration with 74 percent accuracy and specificity. The 71 percent are positive predictive and 77 percent negative predictive values. Compared to these the standardized the three oz water test has a higher potential regarding the prediction. They predict the clinical signs but have lesser sensitivity. If the cough is associated with cough on swallowing with the 3 oz test gives a positive prediction of 84 percent. The negative prediction is 78 percent. In case of failure of the clinical tests to detect the impairment, the video fluoroscopy can document the low risk of about 20 percent if there is mild aspiration. The aspiration like history of cough on swallowing and 3 oz positivity is capable of providing the useful screening tool. The cost benefit ratio seems very competitive in comparison with videofluorocsopy in case of calculation of aspiration risk. (J Neurol Neurosurg Psychiatry 1997) 12 5. Artificial Nutrition Artificial nutrition and hydration will take place in the people having controversial therapies for life threatening diseases. This is widely used phenomenon without scientific backing. This plays an important role in palliative care for patients and their families. The hospice nurses should understand the importance of artificial nutrition and hydration in the patients suffering with dysphagia. The fundamental care giving activity for the patients suffering with dysphagia is provision of food and fluids. As the dysphagia avoids oral nourishment, the artificial nutrition is important for them. Some health care providers will be guided by personal biases and have weak empirical basis. This leads to the shift in attitudes and practices in end of life care. As the acute care focus has moved to hospice and palliative care, the use of artificial nutrition and hydration has changed remarkably. Similarly people suffering with dysphagia need artificial nutrition. The acute care model of universal hydration, changed to universal non hydration. This is not suitable for dysphagia patients. The palliative and rehabilitation care in dysphagia patients need the appropriate use of artificial nutrition and hydration. As it is inhuman to starve people suffering with dysphagia, the support for artificial nutrition is gaining momentum. The clinical experience and research suggested that the artificial nutrition and hydration are best for the patients suffering with dysphagia during illness and after stroke. (Mary Ersek, PhD, RN, 2003,) 13 In the patients suffering with dysphagia cough is one of the common symptom observed. In case of some patients with dysphagia cough, the elevation of the head of the bed can be prescribed. In case of dysphagia the proton pump inhibitor was less successful than expected. In case of failure of empiric approach, the 24-h esophageal testing can be employed. (Editorial, 2003) 14 5.1 Partial seizures and hemiparesis: The association between seizures and encephaloceles was well established. The motor cortex encephalocele that presented the progressive hemiparesis and simple partial seizures was successfully treated at our institution. Though the patient's medical history did not reveal no concussion, birth complications, febrile seizures and central nervous system infection, stroke or brain tumor, he/she may be suffering with seizures that cause dysarthria. This needed the operation with motor mapping. The stalk of encephalocele has been transected en bloc by using bi polar cautery. Then it was sent for examination. After that the hemostasis was obtained and the dura matter has been closed. The polysorbate mesh was secured with absorbable screws. There after the bone putty has been used to fill the cranial defect. The second outer plate of polysorbate mesh has been secured over the bone putty with 4 mm screws that are absorbable. The anatomical layers are used to close the surgical wound. The pathological examination of the resected specimen revealed the gliotic and edematous cerebral cortex consistent with encephalocele. After the surgery the patient was observed for 24 hours in the intensive care. He was then transported to the neurosurgical ward for 48 hours. After that she was discharged home. After that it was observed that she was seizure free and free of dysarthria. There are no evidences of focal neurological deficits. The other symptoms regarding the neurological deficits are also absent. 15 References: The references are given in the following format according to Harvard style. Author, year of publishing, title, publisher, edition information if available, type of media, date retrieved, website address. 1. Tyler Reimschisel, MD, 2002, two sides of same coin, Medscape.com, ,electronic, 21-5-07, http://www.medscape.com/viewarticle/442145 2. National guideline clearing house, 2007, guidelines, guidelines.com, ,electronic, 21-5-07, http://www.guideline.gov/summary/summary.aspx'doc_id=8952 3. Scott E. Kasner, MD; Lewis B. Morgenstern, MD, 2005, Cerebrovascular Disorders: Ischemic Stroke, Medscape.com, ,electronic, 21-5-07, http://www.medscape.com/viewarticle/534586 4. Laurie Barclay, MD, 2006, American Heart and American Stroke Associations Endorse New Stroke Rehabilitation Guidelines', Medscape.com, ,electronic, 21-5-07, http://www.medscape.com/viewarticle/511995 5. Harold P. Adams, Jr, MD, 2003, Acute Ischemic Stroke: Future Options for an Unmet Medical Need, medscape.com, ,electronic, 21-5-07, http://www.medscape.com/viewprogram/2514 6. Kilgore SM, Bronte-Stewart H, 2002, Movement Disorder Highlights From the 54th Annual Meeting of the American Academy of Neurology, Medscape.com, ,electronic, 21-5-07, http://www.medscape.com/viewarticle/433375 7. Timothy C. Ryken, M.D, 2001, Ultrasonographic Guidance for Spinal Extracranial Radiosurgery: Technique and Application for Metastatic Spinal Lesions, medscape.com, ,electronic, 21-5-07, http://www.medscape.com/viewarticle/421514 8. William A. Friedman, M.D., Kelly D. Foote, M.D.2003, Linear Accelerator-Based Radiosurgery for Vestibular Schwannoma, Medscape.com, ,electronic, 21-5-07, http://www.medscape.com/viewarticle/456126 9. W. Bryan Burnette, MD, MS, 2007, Case 15: When a Stroke Is Not a Stroke, Medscape.com, ,electronic, 21-5-007, http://www.medscape.com/viewarticle/550613 10. Rosemary Martino, MA, MSc, PhD et al, 2006, An Educational Manual for the dysphagia Screening Professional, Heart and stroke foundation of Ontario, ,electronic, 21-5-07, http://profed.heartandstroke.ca/ClientImages/1/dysphagia%20Manual%20FINAL%2020060123.pdf 11. Nippon Ronen Igakkai Zasshi, 1997, Swallowing rehabilitation in an elderly patient with Wallenberg's syndrome--role of videofluorography and the swallowing provocation test, Medscape.com, ,electronic, 21-5-07, http://www.medscape.com/medline/abstract/9212689 12. J Neurol Neurosurg Psychiatry 1997, Predictive value of clinical indices in detecting aspiration in patients with neurological disorders, jnnp online, ,electronic, 21-5-07, http://jnnp.bmj.com/cgi/content/abstract/63/4/456 13. Mary Ersek, PhD, RN, 2003, Artificial Nutrition and Hydration: Clinical Issues, Medscape.com, ' ,electronic, 21-5-07, http://www.medscape.com/viewarticle/464009 14. Editorial, 2003, Chest, medscape.com, ,electronic, 21-5-07, http://www.medscape.com/viewarticle/450758 15. Kostas N. Fountas, M.D., Ph.D et al, 2005, Spontaneous Motor Cortex Encephalocele Presenting With Simple Partial Seizures and Progressive Hemiparesis, medscape.com, ,electronic, 21-5-07, http://www.medscape.com/viewarticle/513326 Read More