Authors: James W. Wheless, Brooke Richardson, Clio Rubinos, Edward Faught, Marry Vuong
Categories: Review, 14, 337, 60, 61
Source: Neurology: Clinical Practice
Dysphagia, or difficulty swallowing, affects several individuals globally and can contribute to a reduced quality of life and partial medication adherence, especially in patients with epilepsy. There is also a lack of awareness and understanding of dysphagia among both health care providers and patients. This review examines the interplay between dysphagia and epilepsy treatment and the potential for optimizing diagnosis and intervention.
Dysphagia, although a prevalent condition, is often underdiagnosed or misdiagnosed. Managing dysphagia involves patient and caregiver education on medication management techniques, lifestyle changes, and collaboration with a multidisciplinary health care team. There are also several modalities to screen and evaluate for dysphagia by using technology, using questionnaires, and asking probing questions. In patients with epilepsy, dysphagia can make swallowing certain formulations of antiseizure medications (ASMs) difficult or impossible—so, there is a need for tailored management strategies if discontinuing the medication is not feasible. Alternative formulations such as soluble, liquid, granular, or powder alternatives have been recognized as valuable options in addressing partial adherence due to dysphagia.
Patients with dysphagia may have varying symptoms, making it challenging for clinicians to accurately identify the condition. To address this issue, various questionnaires and assessments have been developed to uncover swallowing difficulties. Administration of alternate ASM formulations must consider options available for each individual.
Swallowing difficulty, or dysphagia, is a prevalent condition in various age groups and conditions. Dysphagia is typically categorized by clinicians as oropharyngeal dysphagia (OPD) or esophageal dysphagia.^1,2^ The global prevalence of OPD is estimated to be 43.8% and is often attributable to other comorbid conditions. Despite a high global prevalence, several patients do not seek care for their swallowing difficulties and are underdiagnosed or misdiagnosed.
Health care providers may have a limited understanding of dysphagia. A 2021 survey of 396 health care providers (nurses, physicians, auxiliary nursing care technicians) in Spain revealed that only 63.2% of respondents reported that they knew the definition of dysphagia.^3^ The Eating Assessment Tool-10 (EAT-10) score is commonly used as a self-screening tool for OPD (eAppendix 1). Up to 20.8% of respondents have conducted the EAT-10 screening test, with 39.2% of respondents expressing that they do not know what the EAT-10 screening test is. A lack of understanding of the diagnosis, assessment, and clinical management techniques for dysphagia can lead to delayed care, complications, and emergency department visits. There is a lack of data in the literature suggesting whether the understanding or definition of dysphagia is consistent for providers in the United States.
Geriatric patients diagnosed with nonaspiration pneumonia have been observed to receive fewer consults for dysphagia than geriatric patients with aspiration pneumonia.^4^ Although aspiration pneumonia is a possible complication of dysphagia, the absence of aspiration pneumonia in a patient with dysphagia should not preclude referrals to dysphagia specialists, especially considering the effects of dysphagia on quality of life (QoL). Gender disparities were also found to be a factor for a patient receiving a dysphagia consult. Male patients with aspiration pneumonia were significantly more likely to receive a speech-language pathologist (SLP) dysphagia consult (p = 0.022).^4^
Dysphagia poses a significant health concern because it may lead to complications such as partial medication adherence, dehydration, malnutrition, and aspiration pneumonia.^5^ Medication adherence is especially critical in patients with epilepsy because partial adherence can result in lower plasma levels resulting in seizures, accidents, and seizure-related hospitalizations.^6^ It can be difficult to achieve the therapeutic levels for an antiseizure medication (ASM) to be efficacious if patients are not properly taking their medication.
Difficulty swallowing negatively affects several aspects of life. Patients report multiple psychological and social embarrassment when eating with others, reduced ability to eat, food avoidance, and feeling handicapped or limited.^7^ A large survey conducted from 2014 to 2017 assessed the self-reported EAT-10 scores of 2,054 persons aged 18–65 years. In societies with easier access to health care, participants were found more likely to seek help earlier for swallowing difficulties. Despite modifying their lifestyle and having EAT-10 scores consistent with low QoL, participants repeatedly expressed that they did not have swallowing problems. These results suggest that the definition of dysphagia may not be clear for patients and that they do not report difficulties because they were not aware of this medical condition. Several older patients believe dysphagia to be a normal part of aging or adapt their lifestyle habits to accommodate any swallowing difficulties and do not seek care.^8^
Despite the many comorbid diseases and factors that contribute to dysphagia, it is a common and limiting problem that is often underdiagnosed. In this review article, we examine the existing research on dysphagia, assessment methods, and management strategies, with a focus on understanding the complex interplay between the treatment of epilepsy in patients with dysphagia and identifying potential avenues to optimize diagnosis of dysphagia and clinical intervention.
Dysphagia may occur across all age groups, from neonates to older adults. The prevalence of pediatric dysphagia is reported up to 94%, depending on how dysphagia is defined and which subgroup is studied.^9^ Most children with dysphagia present with other disorders, but up to 25% of children with normal development can experience dysphagia.^9^ Patients may present with swallowing complications due to physical/structural abnormalities, abnormalities of the gastrointestinal (GI) tract that may require enteral feeding tubes, or congenital/genetic malformations.^1,2,10,11^ Lennox-Gastaut syndrome is one of the childhood epilepsy syndromes in which patients may develop rapid onset of swallowing difficulties.^12^
In older individuals, OPD often results from comorbidities such as dementia, neurologic and respiratory conditions, brain injuries, surgeries, or cancer.^10,13^ Some of these conditions are also linked to late-onset epilepsy (LOE), which manifests after the age of 60, peaking in incidence beyond 75 years, with structural changes to the brain being the most common causes.^14^ For instance, LOE is found in approximately 30%–50% of patients with cerebrovascular disease, around 25% of those with traumatic brain injuries, 10%–20% of patients with neurodegenerative diseases, and 10%–30% of those with brain tumors.^15-17^ Although the relationship between dysphagia and LOE has not been extensively explored, it would not be surprising to observe both conditions in the same patient. Indeed, neurogenic dysphagia is a common and prominent issue in patients with central/peripheral nervous system, neuromuscular, or muscular diseases.^18^ Dysphagia may be present in at least 50% of patients with ischemic or hemorrhagic stroke and approximately 60% of patients with traumatic brain injury. OPD may also be the result of acute conditions including dehydration, urinary tract infections, congestive heart failure, and pneumonia.^4^ Pneumonia is a leading cause of death in the older population, and dysphagia is frequently associated with pneumonia.
Esophageal dysphagia can be caused by motility disorders, structural abnormalities, or infiltrative and systemic causes.^11^ Examples of esophageal dysphagia include achalasia, diffuse esophageal spasm, and hypercontractile esophagus. Esophageal and gastric cancers may also lead to esophageal dysphagia because tumors can cause mechanical obstructions. Lastly, infiltrative and systemic diseases, such as scleroderma and eosinophilic esophagitis, can cause indirect esophagitis tissue atrophy and fibrosis.
Dysphagia can also stem from nonorganic causes and affect patients of all ages. Phagophobia is a form of psychogenic dysphagia and is characterized by fear/avoidance or perceived difficulty of swallowing food, fluids, or solid medications, despite normal physical and laboratory findings.^19^ Dysphagia in these patients can also be attributed to anxieties surrounding choking or dying from improperly swallowing.^20^ Patients can also have partial medication adherence due to anxiety around pill intake.
Functional dysphagia is a swallowing disorder not caused by anatomical obstructions or lesions, rather due to issues with the functional aspects of swallowing.^21,22^ This type of dysphagia may be more difficult to differentiate and diagnose from other dysphagia types, so patients should be referred to a functional neurology specialist. Functional dysphagia can be caused by neurologic conditions, muscular disorders, psychological disorders, or coordination/lack of muscle strength that facilitates swallowing.
An overview of dysphagia types and examples of commonly associated conditions is presented in Table 1.^2,10,11,21,23^
In addition to dietary restrictions and potential effects on nutrition, several patients can choke on pills, leading to partial adherence and the potential to suffer the consequences of their undertreated disease. An observational study of 118 pediatric patients with epilepsy was conducted to determine adherence barriers on ASM adherence and seizure control.^24^ Results demonstrated that lower adherence was significantly linked to difficulty swallowing ASMs at 25 months after epilepsy diagnosis. At 25 months after epilepsy diagnosis, children with difficulty swallowing reported a 38.8% rate of adherence, whereas children with no difficulty swallowing had a 60.4% adherence rate. Decreased adherence, especially in patients with epilepsy, contributes to uninformed clinical interventions, increased health care costs, and higher incidence of hospitalizations.^25^ Children with lower adherence in the first 6 months of therapy are 3.2 times more likely to have continued seizures for a longer period.^26^
Early identification and intervention for dysphagia can improve QoL and reduce further medical complications and hospital readmission.^27^ Clinicians should carefully evaluate and assess both the patient's presentation and history, in addition to conducting dysphagia-related questionnaires and physical examinations, as part of the process in identifying the need for referrals to dysphagia experts.^23^
Each patient's perception of their symptoms can vary widely.^28^ As a result, patients' self-reporting of their swallowing abilities can sometimes be inconsistent with the results of their clinical evaluations, making it challenging for clinicians to accurately assess swallowing function in a holistic fashion. The potential for limited reliability of reported history and subjective symptoms requires clinicians to use a variety of clinical tests to further assess dysphagia, rule out alternative diagnoses, and definitively diagnose dysphagia.^29^ When possible, it is also recommended for providers to interview family members and caregivers to help uncover any additional information the patient may be too embarrassed to express or is subconsciously adapted not to notice themselves.^29^
Initial screenings are easy to perform and often play an important role in determining the presence, and sometimes etiology, of dysphagia.^29,30^ Observing a patient drinking water or eating solid food may provide the neurologist some information regarding the patient's swallowing function and can be quickly conducted if there are signs pointing to diminished swallowing function. Recognizing limited mental status, dry mouth (xerostomia), coughing, choking, drooling, or goiters can point to potential dysphagia. OPD is commonly caused by chronic neurologic conditions and usually manifests as coughing, choking, or difficulty initiating swallowing.^2,8^ These characteristics can also be secondary to conditions that cause weakening muscles, such as amyotrophic lateral sclerosis, thyroid problems, or oropharyngeal/esophageal dysfunction.^23^ However, there are several more advanced and specialized assessment tools that dysphagia specialists can use to formulate a diagnosis. Referrals to clinicians with dysphagia expertise (such as a SLP and gastroenterologist) for assistance in distinguishing and categorizing each case of dysphagia are essential for providers because each distinct type of dysphagia has a unique etiology, set of symptoms, and management considerations.^23,30,31^
Table 2 presents a list of questions that health care providers may use in dysphagia screening during practice. This screening may also help identify patients who may not have swallowing difficulties but may prefer an alternative ASM formulation because of preference and those who are too young, nonverbal, or unable to provide a primary history.
SLPs are widely considered the preferred professionals for evaluating and managing speech, language, communication, and swallowing disorders for individuals throughout their lifespan. They practice in a variety of health care environments, including acute care facilities, outpatient clinics, inpatient rehabilitation centers, and home health care settings. The fundamental responsibility of an SLP is to align dysphagia assessment and management with the values and needs of each patient, primarily focusing on enhancing the QoL and promoting patient health through appropriate evaluations, individualized treatment, and referrals to other specialists.
SLPs use the clinical swallow evaluation and several questionnaires to better quantify and interpret the common subjective symptoms of dysphagia.^29,32,33^ Because most of the questionnaires aim to gather detailed and relevant disease information, such as chronicity, frequency, and severity of symptoms, health care providers commonly use questionnaires to ensure a thorough dysphagia assessment. The Sydney Swallow Questionnaire and the Mayo Dysphagia Questionnaire are 2 common tools designed for use in the general population.^32,33^ Beyond standardizing and customizing dysphagia assessment, questionnaires have played a crucial role in generating quantitative data related to dysphagia. This has facilitated a more efficient integration of subjective patient symptoms into objective disease studies. Table 3^7,32,33^ provides a summary of questionnaires to aid in identifying dysphagia.
A clinical swallowing evaluation by an SLP is an important first step in determining indications for further evaluation of OPD through instrumental swallow assessments. When evaluating for OPD, a flexible endoscopic evaluation of swallowing (FEES) procedure allows for a superior view of the larynx and pharynx while the patient consumes various consistencies of food and liquid. The modified barium swallow (MBS) study, also known as a videofluoroscopic swallow study, is a videofluoroscopic examination providing lateral and/or anteroposterior (AP) evaluation of the oropharynx and cervical esophagus while the patient consumes various consistencies of barium or foods mixed with barium.^27,29,34,35^
In most cases, the MBS should include a complete esophageal sweep to identify the possibility of esophageal dysphagia, which could affect treatment planning and which may also result in a referral for further GI evaluation.^34^ It is crucial to note that only MBS and FEES—not the clinical swallow evaluation—can identify the presence or absence of aspiration/oropharyngeal dysphagia, and that these examinations provide critical information regarding swallowing physiology that must be used for planning individualized treatment programs and additional management strategies. Clinicians reported a significant difference in the ability to directly visualize anatomical sites, with most sites being better visualized on the FEES than MBS (p < 0.05).^36^ It is suggested that patients are first referred to speech pathology for a clinical swallow evaluation; then, the SLP can determine whether further assessment by FEES or MBS is indicated or whether the patient requires a referral to a GI specialist.^37^
For assessing dysphagia related to esophageal motility disorders, the barium swallow is commonly used, although high-resolution impedance manometry is considered best suited.^29,30^ Esophagogastroduodenoscopy performed by a gastroenterologist can provide accurate information on esophageal anatomy and is commonly the first diagnostic test used in certain types of dysphagia.^35^
Table 4^27,29,34,35^ provides a summary of the diagnostic tools/assessments used to identify dysphagia. A swallowing specialist will determine the candidacy (age and physical ability to perform examinations) for these various evaluations based on the intricacies of each patient.
Treatment plans are tailored to the individual's underlying swallowing pathophysiology and typically include exercises aimed at strengthening musculature or implementing compensatory strategies, in conjunction with ongoing patient and care partner education. SLPs may also provide recommendations for feeding and eating, as well as suggestions for modification to food and liquid to promote the individual's overall health. It is also critical to engage the patient in informed decision making about recommendations for diet modifications, just as clinicians would with other aspects of their care.
Given the acute and dynamic nature of patients' medical states in acute care environments, the SLP's role primarily centers on evaluation and education, prioritizing these important elements of care over the implementation of intensive strengthening exercises. In addition, dysphagia treatment in acute care is influenced by the constraints imposed by the current health care landscape and its abbreviated hospital stays.
After an official dysphagia diagnosis, a multidisciplinary team including physicians, nurses, dietitians, SLPs, pharmacists, and case managers need to continually work as a collaborative unit to provide the best patient-centered and team-based care possible.^38^ The important role of the pharmacist should also not be overlooked, especially when it comes to collaboration on medication formulation selection, administration, dosing, and manipulations (crushing, splitting, diluting) for patients with dysphagia and epilepsy.
Management of dysphagia may include patient and family/caregiver education regarding optimal eating contexts, including positioning, alertness, and the rate of eating, drinking, and/or feeding; strengthening exercises; compensatory strategies; optimizing oral health; and providing patient and caregiver education on modified diets and liquids, along with their limitations and benefits.^39,40^ Clinicians should be aware that there are multiple areas of expertise within SLP, so referrals should be directed to an SLP with expertise in dysphagia.
Some ASMs, such as clobazam, phenytoin, phenobarbital, valproic acid, lamotrigine, oxcarbazepine, and gabapentin, have been found to exacerbate dysphagia.^41^ Activation of dysphagia can be due to movement disorders, myopathy, or disturbance of salivation related to these medications. Management strategies should be tailored to each patient's need, if stopping the exacerbating medication is not feasible.
Patients presenting with dysphagia necessitate the consideration of suitable oral dosage forms, or adaptations thereof, to facilitate the safe administration of oral medications, thus enhancing medication adherence.^42^ For example, although several SLPs are less frequently recommending thickened liquids, thickened liquids are sometimes recommended to diminish the potential for aspiration and/or to increase patient comfort.
Some patients with OPD may drink only thickened liquids. In these cases, thin liquids are thickened to the appropriate level with thickening agents made of ingredients such as starches and gums. There is limited evidence suggesting that thickening liquids can reduce dysphagia-related pulmonary sequelae.^38,43^ Furthermore, it may actually lead to negative effects, including dehydration, malnutrition, decreased drug release and/or bioavailability, and urinary tract infections.^43^
For difficulties in swallowing solid pills, alternative oral formulations prove advantageous.^44,45^ These include liquid solutions or suspensions, orally disintegrating tablet formulations, liquid gels, and dosage form modifications including tablet crushing or the opening/mixing capsules in food/water. Such options may make it easier to swallow for certain patients with OPD and are deemed viable oral formulation options. Additional considerations for using alternative formulations are discussed further.
Crushing oral medications for administration through a feeding tube is a common practice for patients with dysphagia requiring enteral tubes.^46^ Crushing carries risks because it often involves untested vehicles that could potentially alter medication bioavailability, reducing efficacy or posing safety concerns (i.e., clogging the feeding tube). This principle also extends to dietary considerations, in which cohesive and moist foods are sometimes safer to swallow and may be effective in mitigating the risk of choking in certain patients.^40^ Providers should also be aware of food and drug interactions with the material of the feeding tube because certain medications may result in reduced concentrations after delivery into the enteral tubes and either need dose adjustment or should be avoided through this route.^47^ Diazepam was found to have decreased absorption in polyvinyl chloride (PVC)/polyurethane tubing. Cannabidiol should not be used in tubes made with PVC because of its potential to harden and crack the tube.
Botulinum toxin injection and oral smooth muscle relaxants are also treatment options; however, they are less effective and are generally reserved for patients considered poor candidates for dilation or surgical intervention.^21^ Managing distal esophageal spasm and hypercontractile esophagus involves systemic therapy encompassing the use of oral smooth muscle relaxants and pain modulators.^21,48^ For those looking for more conservative approaches before pharmaceutical or surgical approaches, alternative strategies may include behavioral and dietary modifications such as positioning during and after meals, food textures, frequency of eating, and consuming peppermint oil.
Treatment of functional dysphagia may be complex and include discontinuation of motility-altering medications, trialing high-dose acid suppression, and lifestyle modifications (eating upright, avoiding exacerbating foods, thorough mastication).^21^
For patients with dysphagia, the formulations of ASMs are an important aspect that can affect QoL. When considering formulations of ASMs, a clinician should consider other factors, such as the need for special formulations, adherence, feeding tubes, sites of absorption of medications, food-drug interactions, and the use of thickeners. Patients with dysphagia may encounter several barriers to oral medication intake, such as the number and size of the capsules or tablets, presence of rough surfaces, or unpleasant tastes in solid forms, and may, as a result, need special formulations.^46,49^ Difficulties swallowing further exacerbate these challenges. Modified formulations, including soluble, liquid, granular, or powder alternatives, offer potential solutions in patients with dysphagia.
If a nonsolid formulation is not available as a US Food and Drug Administration (FDA)-approved product, prescribers may elect to have a solid ASM compounded into an alternative formulation. Having these specialized ASM formulations may be immensely convenient for caregivers and patients, but it is important to consider the potential limitations of compounded medications. Pharmacy compounding has significantly less regulatory oversight than FDA-approved medications, and product quality can vary interfacility and intrafacility.^50^ In medications with a narrow therapeutic window, such as an ASM, variability in drug concentrations may greatly affect disease control. Compounded medications also have a shorter shelf life and stability data in comparison with manufactured products. Some patients may opt for alternative routes of administrations, such as transdermal systems; nasal sprays; and rectal, orodispersible (oral films and orally disintegrating), effervescent, or intramuscular formulation. However, not all formulation alternatives may be an option because of cost barriers and the condition being treated.
A patient's adherence to their prescribed medication is crucial for its effectiveness, regardless of the disease and its severity.^51^ In addition to financial considerations and medication availability, patient preferences play a significant role in medication adherence. When adult patients were surveyed for their preference for any oral pharmaceutical forms, positive attributes of tablets included ease of handling and swallowing; for granules, attributes such as ease of public consumption and pleasant texture were preferred. On the contrary, negative attributes for tablets included the desire for fewer tablets per day while granules were criticized for requiring the consumption of a large amount of liquid. Table 5^52-59^ presents the different modern-era, FDA-approved antiseizure medications and their pharmacokinetic (PK) and product characteristics.^52-56,60^
When special formulations cannot fully solve the problem of dysphagia, a clinician may introduce the idea of a feeding tube to a patient. Gastrostomy and jejunostomy tubes are a viable solution for patients who cannot meet their daily nutrition and medication needs orally. When administering medications through a feeding tube, it is important to consider the sites of absorption of medication and whether PK properties are altered by crushing. For example, medications such as phenytoin, cannabidiol, and lacosamide should not be given using a jejunostomy tube because they are poorly absorbed in the jejunum.^61,62^ Always consult a clinical pharmacist when switching between feeding tubes because the lack of absorption may lead to adverse effects such as seizures. Some medications, especially those that are extended release or enteric coated, cannot be crushed.
Diluting an ASM can help improve delivery of the medication through the feeding tube, but this can negatively affect the drug bioavailability if performed improperly. Medications should be crushed, diluted, and given immediately because stability may be compromised when these medications are manipulated. Furthermore, when medications are crushed and mixed with food, clinicians should consider food-drug interactions. For example, phenytoin binds to protein components of enteral feeding products; therefore, administration should be taken 30 minutes earlier or 4 hours after enteral feeds. Diazepam should not be mixed with grapefruit juice because grapefruit juice increases the concentrations of diazepam in the body, potentially leading to more adverse effects, such as somnolence.^63^
Dysphagia is a common condition, especially among children and older adults and those with neurologic conditions.^23^ However, it is sometimes not initially recognized. To lower the rate of serious dysphagia-related complications, such as increased rates of long-term care, mortality, malnutrition, incidence of aspiration pneumonia, and medication nonadherence, it is important for clinicians to be alert and proactive in identifying patients who may have undiagnosed dysphagia and referring to an SLP and/or a GI specialist for evaluation.^64^
Early identification of, and intervention for dysphagia can improve QoL and reduce the likelihood of further medical complications.^27^ Prescribers should consider incorporating patient interviews, questionnaires to identify dysphagia, clinical assessments, and obtaining medical history related to any difficulties with swallowing into their initial evaluations. However, standard initial screenings, such as observing a patient swallow, may be limited at best, and it is recommended that nondysphagia clinicians refer patients to an SLP or gastroenterologist.
Clinicians are encouraged to be aware of symptoms that have been strongly associated with dysphagia, including choking, coughing, eating meals at a slower rate, repeated throat clearance during or after meals, feelings of food being stuck in the mid-chest or throat, weight loss, changes in preference of food consistency to liquids and semisolids, and even neurologic changes in some instances.^29,30^ Additional symptoms of dysphagia include difficulty initiating swallowing, difficulty chewing, chest congestion after meals, nocturnal aspiration, and recurrent chest infections (including aspiration pneumonia) without a known cause such as exposure to infectious individuals. Home care providers are often the first health care professionals to observe signs of dysphagia and thus play a pivotal role in identifying, referring, and educating patients with dysphagia.^31^
It is also of clinical relevance to note that several patients with dysphagia have additional concerns of xerostomia, which may arise from a multitude of etiologies, including specific medications and polypharmacy.^65^ By commonly causing pill dysphagia, xerostomia can further exacerbate a patient's symptoms.
In patients with epilepsy and dysphagia, medication management must involve the careful consideration of individualized patient needs and limitations. Prescribing an ASM that comes in a smaller pill size may help with swallowing difficulties, but, in turn, patients might have to inconveniently take a larger quantity to achieve an effective daily dose. The same can be true when switching a patient from a solid to liquid formulation—an increase in the liquid quantity taken may be required. Prescribers should evaluate the benefits and challenges of different formulation types and what may be best to fit a patient's lifestyle needs. In addition to education regarding benefits and possible pitfalls of formulation changes, patients should be thoroughly counseled on how to store a liquid medication at the correct temperature and how to administer and measure the medication (needing to shake a suspension vs a solution). Newer formulations such as oral films and orally disintegrating tablets may be a great solution; however, they may be costly to the patient. Insurance coverage and having nonsolid FDA-approved ASM formulations including liquid solutions or suspensions on an institution's formulary plan can also affect a prescriber's ability to select an ASM appropriate for their patient.
Dysphagia is not solely attributed to the normal aging process but is often linked to comorbidities and various medical conditions across the age spectrum.^1,9^ The perception of dysphagia symptoms can vary significantly among patients because of differences in swallowing function, age, and health literacy level. This variability can sometimes lead to inconsistencies between a patient's self-reported symptoms and objective test results, posing challenges for clinicians in accurately identifying the presence of dysphagia by assessing and using patient-reported symptoms.^29,30^ To address this issue, various questionnaires have been developed to quantify and interpret subjective dysphagia symptoms, aiding health care providers in generating appropriate referrals, conducting comprehensive assessments, and considering relevant clinical factors, including in special populations.^29,30,33^
Partial adherence to medications due to dysphagia remains a prevalent and modifiable factor in managing a patient's disease and is likely to be underidentified and under-reported. Formulations such as soluble, liquid, granular, or powder alternatives have been recognized as valuable options in addressing medication aversion.^46,49,51^ Administration of alternate ASM formulations must consider options available for each individual ASM, and clinicians should consider factors such as special formulations, adherence, feeding tubes, sites of absorption of medications, food-drug interactions, and use of thickeners.
Multidisciplinary care between health care providers and SLPs plays a vital role in managing swallowing and feeding difficulties, especially when optimizing oral diets or changing between oral ASM formulations, in patients with dysphagia. This interdisciplinary teamwork can have a far-reaching positive impact on nutritional goals, hospital stay duration, and patient QoL among individuals with malnutrition or with metabolic-related mentation alterations that can affect safe and adequate oral intake of nutrition and medication. In addition to providing proactive education to susceptible populations (older adults, pediatric patients, patients with relevant comorbid disorders), early referrals to dysphagia experts such as SLPs can increase clinical diagnoses, improve therapeutic strategies, and maximize patient outcomes.
C.R. is a 52-year-old woman with a history of spastic quadriparetic cerebral palsy, with associated seizure disorder and intellectual disability. She was admitted to the medical intensive care unit after being found minimally responsive and with seizure activity by her sister, who is also her caregiver. On admission, C.R. was found to have aspiration pneumonia with metabolic encephalopathy and signs of chronic protein-calorie malnutrition. The sister reported several days of increasing lethargy leading up to admission, with associated difficulty administering zonisamide and levetiracetam XR. Knowing the importance of the ASMs, the sister ultimately emptied capsules and crushed the tablets and then “slurried” the medication in liquid in hopes of improving C.R.'s ease of consumption. She denied any other difficulties with feeding or medication management before this event and conveyed high levels of satisfaction with the effectiveness of C.R.'s ASM.
Given the patient's poor level of alertness and signs of chronic malnutrition, the sister agreed to placement of a short-term nasoduodenal feeding tube for nutrition during C.R.'s acute illness. Neurology was consulted and recommended initiating use of intravenous levetiracetam and liquid zonisamide.
On hospital day 3, an SLP was consulted for a clinical swallow evaluation with the goal of returning C.R. to an oral diet and her usual oral medication. At this time, and on the SLP's attempts over the next several days, C.R.'s poor alertness prohibited completion of an evaluation.
By hospital day 7, C.R.'s alertness had improved, especially when her sister was present. Thus, evaluation was deemed by the SLP to be safe and medically warranted and was timed around the presence of C.R.'s sister. While there were no endorsements of dysphagia during conversations with other members of the medical team, during this interview, C.R.'s sister described a lifelong limited diet consisting only of pureed consistencies such as apple sauce, pudding, and yogurt, citing a fear that more-solid textures would cause C.R. to “choke.” She noted that C.R. coughs when drinking thin liquids about once a day but that these episodes are brief and never associated with an increase in chest congestion or a fever. The sister also shared that C.R. has been dependent for feeding and oral care for her entire life; notably, these are 2 risk factors of aspiration pneumonia.^66^ C.R. had never participated in a swallowing evaluation because her family did not necessarily perceive her swallowing and eating to be problematic (because they simply adjusted her diet as they saw best) and, based on family report, outpatient providers had not expressed concerns about swallowing or recommended referrals for evaluation.
The clinical swallow evaluation revealed signs of OPD consistent with C.R.'s baseline according to her sister, namely reduced head control, anterior bolus loss, and absent rotary jaw movements. Signs of aspiration and reflux were not appreciated on the examination, although it is important to note that the lack of observable symptoms does not guarantee the absence of either of these conditions. C.R.'s sister was clear in her to be able to get C.R. nutrition; to bring her home; and, most importantly, to make sure C.R. was able to swallow her ASMs and prevent further seizures.
Through collaboration with C.R.'s sister, SLP, neurology, and pharmacy, the hospitalist initiated returning C.R. to a pureed and thin liquid diet with oral immediate-release (IR) levetiracetam 500-mg tablets (2 twice daily), administered by crushing and dissolving in apple sauce, and zonisamide liquid. Over the next 3 days, C.R. was able to consume baseline levels of nutrition without increased signs of dysphagia/aspiration while also taking her ASMs without ill effect and no signs of seizure activity. The nasoduodenal tube was removed, and the patient was discharged home, along with a recommendation for consultation with a dietitian for her chronic dysphagia and malnutrition.
This case highlights the importance of a collaborative approach in caring for patients with seizure disorders and dysphagia—previously detected or otherwise.
Medical writing and editorial support were provided by iLuma Medical Communications (Tiffannie Nguyen, PharmD, and Ilona Kravtsova, PharmD, RPh).
Writing support funding from Azurity Pharmaceuticals. Authors were not compensated for development, analysis, or drafting of this manuscript.
J.W. Wheless - Speaker's Bureau: LivaNova, Eisai, Supernus, Jazz, UCB, Neurelis, Biomarin, SKLSI, Azurity. Consulting: Jazz, Neurelis, Marinus, Biomarin, Azurity. Grants: Shainberg Foundation, TSC Alliance, NIH, Neuro Event Labs, Envision, Stoke, Xenon, Neurelis, Marinus, Epiwatch, SKLSI, Longboard, Biohaven; B. Richardson reports no disclosures; C. Rubinos - Speaker's Bureau: Marinus; E. Faught - Grant: UCB. Consultant: Azurity, Biogen, LivaNova, Neurelis, SK Life Science; M. Vuong reports no disclosures. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.