Medication Intake of Solid Dosage Forms: A Risk Factor for Patients With Stroke-induced Dysphagia?

Study Overview
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Brief Summary
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In a prospective, quantitative explorative study, the risk of aspiration and penetration when swallowing solid pills (placebo) compared to a crushed placebo pill will be evaluated during a routine Fiberoptic Endoscopic Evaluation of Swallowing (FEES). The study design is thus a quasi-experimental study design with repeated measurements in the sense of a pre-posttest. Each patient undergoes a baseline examination (routine procedure) followed by the intervention (administration of three different solid pills and a crushed pill).

Detailed Description
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In the research landscape, the topic of medication intake in patients with dysphagia has generally received very little attention, which is why hardly any recommendations can be found in the current guidelines. In the national guidelines of the National Institute for Health and Care Excellence (NICE), the following paragraph was added in 2019: People with acute stroke who are unable to take adequate nutrition, fluids and medication orally should have their oral medication reviewed to amend either the formulation or the route of administration. In the studies by Kelly and colleagues, dysphagia patients were up to three times more likely to receive an erroneous medication administration than patients without dysphagia. It is therefore currently completely unclear how solid medications can be administered safely in patients with acute dysphagia. There is a complete lack of scientific research in this area which means that the way solid medications are administered to patients with dysphagia is based solely on medical and/or nursing experience. In everyday clinical practice, solid medications are often delivered in a crushed form to make them easier for patients to swallow. This practice is not evidence-based and has no scientific foundation. There is not a single study known to the author that has systematically investigated the swallowability of crushed medications using an instrumental procedure. Thus, there is an urgent need for research to investigate whether crushed pills can be swallowed better than solid medications by using semisolid textures. This research focuses mainly on the stroke population. Research questions: Based on the current state of research and the research gap presented, an overarching research question emerges: Do patients with acute stroke and recent dysphagia also have a swallowing dysfunction for solid medications? Two subprojects are planned to answer the overall research question: A questionnaire analysis and a clinical experimental study. The questionnaire analysis serves as a first orientation on how the topic is handled on the stroke units. One question in the questionnaire is aimed at finding out which bolus is most frequently used for the administration of medication. The clinical trial is then conducted with this result. In a clinical quasi-experimental study, the swallowing ability of placebo medication in patients with dysphagia will be assessed using Fiberoptic Endoscopic Evaluation of Swallowing (FEES). Primary research question Questionnaire study How is medication administration on stroke units, based on dysphagia screening currently performed? Primary research questions Clinical study Is there a different aspiration-penetration risk when swallowing solid medication and when swallowing crushed medication? Methods: In a prospective, quantitative explorative study, the risk of aspiration and penetration when swallowing solid pills (placebo) compared to a crushed placebo pill will be evaluated during a routine Fiberoptic Endoscopic Swallowing Examination (FEES). The study design is thus a quasi-experimental study design with repeated measurements in the sense of a pre-posttest. Each patient undergoes a baseline examination (routine procedure) followed by the intervention (administration of three different solid pills and a crushed pill). Randomisation is not foreseen in a quasi-experimental study or in an evaluation study. Inclusion/exclusion criteria In this part of the study, 60 patients between 50 and 90 years of age who are admitted to the stroke unit of the neurology department at the University Hospital Tulln with an acute first insult, who have a GUSS result of less than 20 points, and who give written consent to participate in the study, are consecutively included. In addition, there must be a need for endoscopy, based on the screening result and the clinical swallowing examination. All patients with additional neurodegenerative diseases, with re-insult, all patients in the time window of 2 hours after extubation, tracheotomy, COPD, patients with pre-existing dysphagia and with pre-existing swallowing problems with tablet swallowing are excluded. All patients who are not eligible for swallow endoscopy are also excluded.

Official Title
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Medication Intake of Solid Dosage Forms: A Risk Factor for Patients With Stroke-induced Dysphagia?

Conditions
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Cerebral Infarction, Stroke, Acute, Stroke, Dysphagia

Intervention / Treatment
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* Other: Solid Medication intake vs. crushed medication intake


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All patients between 50 and 90 years of age who are admitted to the stroke unit of the neurology department at the University Hospital of Tulln with an acute first stroke, who have a Gugging Swallowing Screen (GUSS) result of less than 20 points, and who give written consent to participate in the study, are consecutively included. In addition, there must be a need for endoscopy (FEES), based on the screening result and the clinical swallowing examination. Exclusion Criteria: All patients with additional neurodegenerative diseases, with re-stroke, all patients in the time window of 2 hours after extubation, tracheostomy, chronic obstructive pulmonary disease (COPD), patients with pre-existing dysphagia and with pre-existing tablet swallowing problems are excluded. All patients who are not eligible for FEES (Fiberoptic Endoscopic Evaluation of Swallowing) are also excluded. This includes the following diagnoses: Skull base fractures / facial fractures, severe, life-threatening epistaxis in the last 6 weeks, nasal cavity trauma, nasal and paranasal surgery, nasal and paranasal injury in the last 6 weeks, sinus nasal tumours, skull base tumours / surgery, nasopharyngeal stenoses, craniofacial anomalies, Osler's disease (hereditary haemorrhagic telangiectasia), known vasovagal episodes.

Ages Eligible for Study
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Minimum Age: 50 Years
Maximum Age: 90 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Intervention Model: Single Group Assignment
Interventional Model Description: Quasi-experimental study
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Ability of Swallowing solid placebos vs. a crushed placebo<br>During routine FEES examination, patients are sequentially being given 3 different solid placebos pills and one crushed placebo mixed with semisolid texture. | Other: Solid Medication intake vs. crushed medication intake<br>* The swallowing ability for solid and crushed medications in stroke patients is evaluated.<br>* Other names: Medication Intake of Solid Dosage Forms;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Penetration Aspiration Scale (PAS) ≥ 3 for each solid placebo and for the crushed placebo in comparison. | Penetration Aspiration Scale (PAS) is measured during the Swallow endoscopy (FEES). The PAS is a measure of the penetration and aspiration of a bolus. Scala ranges from 1-8. Material does not enter the airway Material enters the airway, remains above the vocal folds, and is ejected from the airway Material enters the airway, remains above the vocal folds, and is not ejected from the airway Material enters the airway, contacts the vocal folds, and is ejected from the airway Material enters the airway, contacts the vocal folds, and is not ejected from the airway Material enters the airway, passes below the vocal folds and is ejected into the larynx or out of the airway Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort Material enters the airway, passes below the vocal folds, and no effort is made to eject | Immediately after the intervention | 
| Penetration Aspiration Scale (PAS) ≥ 3 for the accompanying bolus | Penetration Aspiration Scale (PAS) is measured during the Swallow endoscopy (FEES). The PAS is a measure of the penetration and aspiration of a bolus. Scala ranges from 1-8. Material does not enter the airway Material enters the airway, remains above the vocal folds, and is ejected from the airway Material enters the airway, remains above the vocal folds, and is not ejected from the airway Material enters the airway, contacts the vocal folds, and is ejected from the airway Material enters the airway, contacts the vocal folds, and is not ejected from the airway Material enters the airway, passes below the vocal folds and is ejected into the larynx or out of the airway Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort Material enters the airway, passes below the vocal folds, and no effort is made to eject | Immediately after the intervention | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| FEES-based graduation of ability to swallow oral solid medication | This is a 4 point severity rating scale modified after Buhmann et al. 2019 | Immediately after the intervention | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Stroke, Acute, Cerebral Infarction, acute first insult, medication intake in dysphagia, Dysphagia, pill dysphagia