The Silent Killer In Stroke

This post was written by Margaret “Pip” Shafer, MA, CCC-SLP/L, Manager Speech Pathology Services at Abington – Jefferson Health.

F-A-S-T.  Face drooping.  Arm weakness.  Speech difficulty.  Time to call 911. The American Heart Association and Stroke Programs throughout the Delaware Valley have done a great job with educating the public in the warning signs of stroke and the message that “time equals brain.”

The patients and families who are unfortunate enough to suffer the more severe consequences of stroke are often surprised and dismayed when beyond the arm or leg weakness, slurred speech and/or word finding problems, they discover difficulty with the most basic of human motor activities- eating and swallowing.

Swallowing safely is rarely discussed in public education and so this side effect- dysphagia- can be even more shocking.

Dysphagia, or difficulty swallowing, can affect the mouth, throat or esophagus- the tube that connects the throat to the stomach.  Symptoms can include difficulty chewing, drooling, food pocketing in the cheek or the more dangerous, food and liquids entering the airway.  This is  commonly referred to as “going down the wrong pipe” and can cause coughing or choking.  Any of these symptoms can be embarrassing, frightening, life-threatening, or socially isolating.  Most dangerous is the absence of coughing when food or liquid is inhaled; this is called silent aspiration.

Many cultures equate food with love and family. The inability to eat safely can remove patients and families from routine celebrations: Halloween candy, Thanksgiving turkey and stuffing, birthday cake!

For someone who has had a stroke, it is standard protocol to perform a nursing screening, and a formal evaluation of swallowing function. A screening is performed in the Emergency Department and looks at mouth muscles and the ability to safely drink water so medications can be administered with minimal risk of choking or inhaling water or pills. An evaluation is performed by a trained Speech Language Pathologist (SLP) who performs a more detailed exam of the mouth, throat muscles and cranial nerves and then examines swallowing safety with various food consistencies. This is to assure the optimal and least restrictive diet. Patients with chewing or breathing problems may eat more comfortably and safely with pudding or ground consistencies. Liquids can be thickened to allow better control when swallowing to prevent the inhaling of liquid into the lungs (aspiration).

SLPs can offer diet modifications and work closely with Registered Dieticians to assure adequate nutrition for recovery from stroke. SLPs can also provide exercises for many people to help them regain the strength and coordination to safely eat again. SLPs work with Physical and Occupational Therapists and Doctors of Physical Medicine and Rehabilitation to assist stroke patients in their recovery.

But what if a severe stroke occurs with a devastating impact on swallowing and communication ability?

This is when an Advance Directive (AD) can provide guidance to families and medical teams as to the patient’s wishes. Some studies show that 60 percent of people do not have Advance Directives. In filling out an AD, “what about artificial nutrition through a tube inserted in the nose or, perhaps more permanently in the stomach?” is asked. If you find this to be a difficult subject to think about now when you are healthy, imagine how your family would feel if such a circumstance were to occur and they were asked to make that decision for you! When you state your own wishes you maintain your personal choice. An AD allows you to have this discussion with your doctor and family to maintain self-determination and lessen the burden on your loved ones in the event of a life-altering situation like a stroke.

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