Dysphagia Knowledge Hub — 吞嚥困難知識庫
Case Study 2: Post-Stroke Dysphagia in an 85-Year-Old Man
Patient Presentation
Mr. K is an 85-year-old retired accountant admitted via the emergency department with sudden-onset left-sided facial droop, arm weakness, and dysarthria. CT brain confirms right middle cerebral artery (MCA) territory infarct. NIHSS score at admission: 16 (moderate-severe stroke).
Past medical history: Atrial fibrillation (on warfarin — sub-therapeutic INR at admission), type 2 diabetes mellitus, mild cognitive impairment (MMSE 22/30 six months prior).
Pre-stroke function: Independent ADLs; lived alone in a housing estate flat with daily carer visits for meals. Family reports “slight choking on water” on some occasions pre-stroke (retrospective mild pre-existing dysphagia).
Nutrition on admission: Weight 58 kg; estimated BMI 20.5 kg/m². MNA-SF score: 9 (at risk of malnutrition).
Acute Assessment (Day 1)
GUSS administered by ward nurse within 3 hours of admission:
Part 1 (indirect):
- Vigilance: Alert for >15 min — 1
- Cough/throat clear: Weak but present — 1
- Saliva swallow: Present — 1
- No drooling — 1
- Voice quality: Wet/gurgly — 0
- Part 1 score: 4/5
Because Part 1 < 5, direct swallowing test was not performed. GUSS total: 4/20 — Severe dysphagia
Decision: Nil by mouth. Nasogastric (NG) tube inserted on Day 1. IV fluids initiated; SLT urgent review requested.
FEES Assessment (Day 3)
With acute phase partially stabilised (NIHSS now 13), FEES was performed at bedside.
Findings:
- Significant pharyngeal residue after semi-solid trials (yoghurt × 5 mL)
- Thin water (5 mL × 3 trials): aspiration on 2 of 3 trials — PAS 8 (material below vocal folds, no ejection attempt = silent aspiration)
- Mildly thick liquid (IDDSI Level 2): penetration only — PAS 3
- Purée (IDDSI Level 4): mild residue, no penetration or aspiration — PAS 1
FEES interpretation: Silent aspiration of thin liquids; safe swallowing of purée with mild pharyngeal residue.
RAPIDS Score
| Variable | Present? | Score |
|---|---|---|
| Age ≥70 | Yes (85) | +1 |
| Brainstem/bilateral | No (unilateral MCA) | 0 |
| NIHSS ≥13 | Yes (16) | +1 |
| Pre-stroke dysphagia | Yes (mild) | +1 |
| Absent gag reflex | Absent | +1 |
| Total | 4 |
RAPIDS 4 = approximately 85% probability of persistent dysphagia at 6 months. PEG discussion initiated with family on Day 7.
Management Plan
Nutrition:
- Continue NG feeding (Ensure Compact 1.5 kcal/mL, 1500 mL/day = 2250 kcal/day; protein target 1.3 g/kg/day)
- Commence dysphagia rehabilitation concurrently with NG feeding (not mutually exclusive)
- Schedule PEG assessment discussion at Day 14 if NG feeding continues
Dysphagia rehabilitation (commencing Day 4):
- Active range-of-motion tongue and lip exercises
- Effortful swallow on saliva (every waking hour)
- Thermal-tactile stimulation to anterior faucial pillars
- Small oral trials: purée consistency (IDDSI Level 4) × 2 tablespoons, twice daily, under SLT supervision (not for nutrition — for rehabilitation and oral pleasure)
Family meeting:
- Explained silent aspiration and the significance of FEES findings
- Counselled on RAPIDS prognosis
- Discussed NG vs. PEG; family and patient wished to continue NG initially with PEG review at Day 14
- Goal: maintain some oral pleasure (supervised purée trials) while ensuring nutrition and hydration via NG
Week 6 Discharge Outcome
After 6 weeks of rehabilitation in a stroke unit:
- FOIS improved from Level 1 (tube only, Day 1) to Level 4 (total oral diet of single consistency)
- Progressed to IDDSI Level 4 (Purée) diet — full oral intake, no NG supplement
- IDDSI Level 2 (Mildly Thick) liquids — no further silent aspiration on repeat FEES at Week 5 (PAS 3 for thin, PAS 1 for mildly thick)
- No aspiration pneumonia during inpatient stay
- Discharged to residential care facility with written dysphagia management plan, IDDSI prescription, and 3-month outpatient SLT review scheduled
Learning Points
- RAPIDS guides prognosis conversations: A score of 4 justifies early PEG planning discussions; avoiding this conversation until Day 28 is a missed opportunity.
- Oral trials during NG feeding are appropriate: Small supervised oral trials maintain oral motor function and quality of life without compromising nutrition.
- Silent aspiration requires FEES: The patient showed no cough response to aspiration — FEES (not WST) was the appropriate tool to characterise his true swallowing physiology.
- Discharge planning begins on Day 1: Stroke units function best when dietitian, SLT, nursing, and family are aligned on the nutritional and swallowing management plan from admission.
References
- Broadley S, et al. (2003). Predictors of prolonged dysphagia following acute stroke. J Clin Neurosci, 10(3):300–5. PMID: 12748046
- Martino R, et al. (2005). Dysphagia after stroke. Stroke, 36(12):2756–63. DOI: 10.1161/01.STR.0000190056.76543.eb
- Leder SB, et al. (2012). Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients. Dysphagia, 13(4):208–12. DOI: 10.1007/PL00009573