by Dr Chile Ogugua

The updated Parkinson’s disease NICE guideline 2017 offers comprehensive advice on best practice in speech and swallowing assessment in patients with Parkinson’s disease.

The guidance states that:

  1. Consider referring people with early Parkinson’s disease (PD) to speech and language therapist (SLT) with experience in PD for assessment, education and advice
  2. Offer SLT for people with PD experiencing problems with communication and swallowing or saliva
  3. For swallowing concerns, interventions may include expiratory muscle strength training
  4. For speech and communication problems, consider attention to effort therapy.

Aims/objectives

To review the process of identification, referral and assessment of swallowing and communication problems in patients with Parkinson’s disease who are admitted in QEH,Woolwich. Who refers?, how quickly they are referred, delays in referral, constraints in identification, referral and assessment and need for standard screening tool.

Method

Retrospective review, over a 6 months study period (January to June 2017). We cross referenced data from referrals to SLT with data for hospital iCare (for all patients coded post discharge with PD). We reviewed;

  1. The total number of patients admitted with PD within the study period,
  2. The total number of patients with PD referred to SLT,
  3. The interval (in days) between admission and referral to SLT,
  4. Indications for referral,
  5. Types of intervention given
  6. Community SLT referral and follow up.

Results

A cohort of 224 patients with PD were admitted within the 6 months study period.

The total number of patients referred to SLT was 45 (20.09%). The average delays (days) before referral to SLT from admission was 2.28, with shortest delay (0), and longest delay (18).

The total number of patients with PD referred for swallowing concerns only was 43 (95.6%), whilst the total number of patients with PD referred for speech/communication problems only was 2 (4.4%).

The total number of patients with PD that required diet modification only as a result of assessment was 21 (46.7%), those that required just fluid modification were 2 (4.4%), whilst those that required both diet and fluid modification were 12 (26.7%).

The total number of patients with PD that required NO intervention after
assessment was 10 (22.2%).

The total number of patients with PD referred for community SLT follow up was 12 (26.7%). Those that required no follow up were 33 (73.3%).

Conclusion/discussion/future plans

Patients with Parkinson’s disease (PD) only get referred when concerns about swallow function/safety and communication problems are noted during admission. Majority of the referrals were mainly for swallow
concerns.

In order to identify appropriate referrals across the in patient population, a generic swallow decision making tool is to be placed on the (hospital/trust) intranet with a prompt in the nursing notes. This will require the nursing staff to only observe the patients whilst eating and drinking for potential dysphagia red flags. The SLT will carry out in hospital training and education for the nurses and medical staff. It is hoped that this will increase the number of appropriate referrals to SLT for assessment, education and advice.

The medical admission booklet in ED (emergency department) has a tick box section for swallow and speech concerns. Unfortunately, these sections are either not completed or marked as not assessed. This will be highlighted in ward/grand rounds, and clinical meetings to ensure medical staff, especially doctors are aware of the importance of completing these tick boxes and facilitate early and appropriate referrals to SLT.

The SLT tend to follow a generic assessment pattern for patients, however, weekly video fluoroscopy clinics are run, which help to objectively assess patients whose bedside assessment do not provide enough information for comprehensive management.

Patients that require ongoing swallowing and communication management on discharge, there is and easily accessible referral system in place to community SLT. Information leaflets explaining speech and swallowing problems and recommendations are also easily available and accessible.

If no impairment is noted on assessment, or if immediate SLT input in not required in the community, the GP (general practitioner), patient, family and carers are made aware of signs to look out for and the referral routes for community SLT if needed.

The SLT service is only commissioned to provide and “assess and advice” communication service to help patients communicate their basic needs to the extent of available resources and refer to community SLT on discharge. Lee Silverman voice therapy, a form of EFFORT therapy is offered by the community SLT in both Bexley and Greenwich.

There is a close working relationship between the SLT and PD specialist nurses to facilitate assessment , education , advice on speech and swallowing concerns in patients with PD.

References

  • Parkinson’s disease in adults/Guidance and guidelines/NICE. http://www.nice.org.uk/guidance/ng71
  • Parkinson’s disease NICE Guideline 2017. www.bgs.org.uk/poerpoimt/2017md/walker_nice.pdf

Special thanks to Hannah Doubleday, SLT team, QEH,Woolwich.

Dr Chile Ogugua, Consultant Geriatrician, Queen Elizabeth Hospital, Woolwich, Lewisham and Greenwich Trust