Dysphagia is an all-too common adversary of neuro-rehab patients, and the professionals who care for them.
Some studies suggest the swallowing disorder is experienced in as many as 93 per cent of people admitted to brain injury rehab centres (Hansel et al, 2008).
It will affect around one in two stroke survivors, according to the Stroke Association, and roughly at least a third of people with MS.
Meanwhile, over 80 per cent of people with Parkinson’s may be affected (Suttrup et al, 2016).
Its impact on the patient can be profound. Not only does it reduce life quality and independence – those key indices of rehabilitation – but can also complicate medication intake and cause malnutrition.
It is also implicated in infections such as aspiration pneumonia which can be fatal.
After a brain injury, damage to the main swallowing centres of the brain or to the nerves and muscles controlling swallowing can cause dysphagia.
But the brain injury can influence swallowing in other ways too, as brain injury charity Headway explains in its dysphagia factsheet:
“If the senses of taste and smell are impaired then the oral preparatory stage will be affected and the production of saliva will not be stimulated.
“This stage can also be affected by severe cognitive issues.
People may not understand what food is or have an awareness that they are about to eat.
“The effects of brain injury can also mean that people sometimes aren’t aware of problems such as food going down the wrong way, because their choking reflex doesn’t work.
This is known as silent aspiration and is one of the reasons that aspiration pneumonia can occur.”
Speech and language therapists employ a range of therapy techniques aimed at triggering the swallowing reflex and strengthening muscles needed for chewing and swallowing.
Once the patient is in a residential care or community setting, carers and loved ones may also have a key role to play in minimising the impact of the condition.
“Dysphagia can mean that mealtimes become a struggle,” says Helen Willis, dietitian at Wiltshire Farm Foods.
“Not only is eating a slow process, but it can also be a scary one.
“The risk of choking or aspiration, the inhaling of food into the lungs, is high and can lead to frequent chest infections and pneumonia.”
A texture-modified diet may, therefore, be required to counter these risks.
But home-blended food brings with it its own problems, on top of reduced appetite caused by illness and apprehension about swallowing.
Helen says: “Being presented with a puréed meal that doesn’t resemble food that a patient is used to can make the eating process even harder.
“People with dysphagia still eat with their eyes so if a meal is not visually appealing then it can fail to trigger salivation, further hindering an already-weakened swallowing process.”
Density of nutrition, or rather lack of it, is a major factor too.
“Adding water to aid the blending process of food at home can dilute the nutritional content, meaning patients need to eat a higher volume of food to achieve the same nutritional intake at a time when they are more likely to have a reduced appetite.
“Often patients with dysphagia struggle to get the calories and nutrition they need, meaning each bite they do take needs to be packed with as much protein, calories, vitamins and minerals as possible.
“Serving larger portions with fewer calories does little to improve mealtimes for dysphagia patients since the meal may appear more intimidating and is unlikely to be finished.”
In her role as an in-house dietitian at Wiltshire Farm Foods, Helen is tasked with finding solutions to such problems.
One alternative to home-blended food for dysphagia patients she has influenced is the PuréePetite range, part of the Softer Foods range of texture modified meals.
They provide smaller, and therefore more manageable, portions. Yet deliver the same nutritional value as a standard-sized dish.
They are “energy dense” to serve up a similar calorie and protein content as larger dishes, containing a minimum of 500 calories at least 20g of protein.
They are also suitable for patients requiring a Level 4 Puréed diet in line with the recently introduced IDDSI (International Dysphagia Diet Standardisation Initiative) food and drink texture standards.
Crucially, dishes in the range are shaped to look like a non-blended meal – “making them more appealing, encouraging patients to eat”, says Helen.
Another weapon in the fight to mitigate dysphagia’s impact is the oral nutritional supplement (ONS). Fortifying or adding an ONS to the patient’s diet can deliver high levels of protein or calories in a low volume.
Whichever option is taken, the power of good nutrition in rehabilitation should not be underestimated, or compromised because of swallowing difficulties, says Helen.
“Eating a well-balanced meal that meets the patient’s nutritional needs whilst being at a safe texture can lead to improved recovery times and a better quality of life.
“Healthcare professionals should consider all options when it comes to providing the best diet for their dysphagia patients, and always be aware of the potential challenges of home-blended meals.”
To discover a range of Softer Foods products that are IDDSI compliant and designed to help your patients and residents with dysphagia visit www.specialistnutrition.com to request a brochure or book a tasting session with Wiltshire Farm Foods.
“We refused to furlough and and supported staff like our clients”
Despite the significant pressures caused by the COVID-19 pandemic, Neuro Case Management UK (NCMUK) declined the opportunity to furlough any of its near 100-strong team. Martin Gascoigne, founder of the Sheffield-based business, explains more.
As a family-owned case management company, one of the biggest of our kind in the UK, we have built our reputation on providing a first-rate service in a caring and compassionate way.
Care and compassion are values which run deep for all of us here and we appreciate the great efforts our team go to for our clients. So in times when the going gets tough, we will always show we’ll support them every step of the way.
The furlough scheme was an introduction that many businesses took advantage of, and undoubtedly there are financial benefits in doing so, but for us it was not an option.
Although we have almost 100 staff now across our four offices, covering the whole of England and Wales, and the financial cost of sustaining them all throughout the lockdown period was undeniably a very significant commitment, it was something we wanted to do.
Our team are very loyal and committed and we wanted them to have the security of knowing their full wages would be paid every month.
We are proud to have the ethos of a family business, we look after our own and we’ll continue to do that as we grow further.
That’s the real USP of what we do – we’re not part of a conglomerate, we’re an independent business which knows all of its team personally and are really pleased to back them however we can.
They deliver a fantastic service to our clients, so we support them in the same way.
We pride ourselves not just on the quality of service we offer, but also on the breadth. We’re very unusual for a case management company in that we have the full range of services in-house, so we’re a one stop shop service provider.
I started off NCMUK ten years ago, in September 2010, and at first there was just me.
At that time, we only provided support for adult clients with brain injuries, based on the experience and expertise I’d built up during my time as a senior brain injury social worker and CQC registered manager of a 60-bed neuro rehab hospital.
Over the years, we’ve added more people and capability to the team, and have enhanced our services to support spinal injury clients, including children.
We now offer everything you’d need from a case management company, from start to finish. We also added a sister company which advises on benefits and payroll.
So if a benefits review is needed for someone who is a low earner, we can do that.
Or whether it’s a review under the Mental Capacity Act, we have experts in our team who can do that.
We’ve built up a strong professional network based on the fact we can provide any service within the one company – it’s great from a client’s perspective, but also very appealing to those who appoint us on their behalf from the legal and medical worlds.
They can leave things to us and know they’ll get exactly what they need.
As a business which continues to grow and invest in its future, we’ve just created a new website – ncmuk.co.uk – which was a two-month project for us and is helping us to look to the future of NCMUK and how we will continue to develop.
We are working with clients throughout the country, who are central to everything we do, and are well placed to support more as we enter our second decade.
Bereavement damages – an overview
The thorny issue of bereavement damages in fatal accident cases has recently raised its head again on one of my cases, writes associate solicitor Lauren Haas. Since so few of the families I encounter are aware of bereavement damages it may be useful to summarise the current law in this area and set out what the potential issues are.
What are bereavement damages?
Bereavement damages are a fixed sum of money which can be claimed on the unlawful death of a loved one.
They are separate from any financial dependency claim, which can of course also be brought.
Unlike a lot of other jurisdictions in Europe and the world, within the English jurisdiction we are very restrictive in our approach to bereavement damages.
Who can claim?
The current legal position allows you to claim the bereavement award if you are:
- The spouse or civil partner of the deceased; or if no such eligible claimants exist, then
- In cases involving the death of a child under 18, the parents if the child was “legitimate”, or the mother if the child was “illegitimate” ie mother and father were not married.
The question of who can actually claim this award has caused some controversy and outrage in recent years.
In 2017, a case in the Court of Appeal (Smith v Lancashire Teaching Hospitals NHS Foundation Trust) resulted in the Court of Appeal dragging the rather outmoded position on eligible claimants into a 21st century setting by ruling that cohabitants who have lived together for two years or more (for at least two years immediately prior to death) can claim for bereavement damages.
However – beware! As is the case for parents, where both an eligible cohabitant and spouse are eligible to claim bereavement damages then the award is divided equally between them.
Who cannot claim for bereavement damages?
Despite the fact that some cohabitants are now entitled to bereavement damages, the list of people entitled to a bereavement award remains very restricted.
The following individuals are not entitled to a bereavement award:
- Cohabitants of less than 2 years
- Parents of an adult child who is over the age of 18
- The unmarried father of a child under the age of 18
- Children who have lost a parent (regardless of the child’s age)
How much can be claimed for bereavement damages?
Following a consultation by the Government in reaction to the Smith v Lancashire case mentioned above, the award for bereavement in fatal accident claims was increased from £12,980 to £15,120 in March 2020 (after seven years of no increase at all).
The new award level applies to deaths on or after 1 May 2020.
However, the Ministry of Justice’s reiterated view is that bereavement damages are token in nature and have intentionally been limited in scope to a very restricted pool of individuals.
“What price is a loved one’s life?” is probably one of the most emotive issues lawyers deal with in fatal accident cases.
The answer is of course that no money can ever compensate for the death of a beloved family member, but it adds to the hurt of families already dealing with a loved one’s death to find out what level of bereavement damages are actually set at and how restrictive in scope they are.
As a serious injury lawyer, it has been my experience that this restrictive approach can cause real heartache and anger at a time when families are in an exceptionally emotive state of mind anyway.
Careful and early management of the expectations of the families involved in fatal accident cases in respect of bereavement damages is therefore key.
A multitude of legal commentators have sought to emphasise the inequality and unfairness of the current legal position.
The Association of Personal Injury Lawyers (APIL) carried out consumer research in 2013, in which more than half of the 2,000 people surveyed thought bereavement damages should be more than £100,000, while three-quarters of people wanted the levels set on a case-by-case basis.
In addition, the current legal position does not reflect modern society’s view of and the proliferation of so-called “illegitimate” children ie children not born to a married couple.
It is a fact of life that (depending on the studies one consults) around 30-50% of babies are born out of wedlock.
That means a lot of fathers will fall outside of the scope of bereavement damage.
Children are prevented from claiming bereavement damages for parents in any case, which has caused many an expression of outrage when explaining the law to families.
As a comparison, in Spain or Greece you would likely be able to claim damages of around €80,000-100,000 for a bereavement which is caused by an unlawful act.
In Scotland, every case is looked at on its own merits and this has resulted in awards solely for bereavement damages reaching up to £140,000.
Unfortunately, a policy change by the Government is highly unlikely at the present time.
Lauren Haas is an associate solicitor specialising in serious injury and fatality cases at Irwin Mitchell.
The purrfect way to share my thoughts
A day in the life of Peggy, the resident feline at Stanley House, Elysium Neurological’s care centre in Herefordshire.
Who said ‘cats have it easy’? It’s really not that simple, after all not all the staff and residents here speak or understand ‘Felis catus’. For those who aren’t acquainted with Latin, the language of all well-educated feline divas, it simply means domestic cat.
So you can see how exhausting it can be trying to get my own way, lots of long luxurious rests are the name of this game!
Truth be known, I am actually spoilt rotten. I get to sleep where I want and residents and staff often use activity time to make me fabulous treats to eat and toys to play with, which of course I do deserve.
Even though I am super happy here it’s been a really odd few months and I have felt a bit confused as to what’s really going on, not least because all the staff look the same in their uniforms and masks and then there is the constant hand washing throughout the day.
I can’t see their lovely faces and can only tell them apart by the smell of their feet and that’s certainly not my favourite way of seeking out special friends.
Another really odd thing, there have hardly been any visitors for such a long time although not so very long ago staff put up huge white tents which usually means a special event or party with lots of guests, food, music and what humans call fun.
At such times, I tend to lead my other feline friends off to secret places where we are unlikely to be disturbed, safe in the knowledge that when everything goes back to normal, we will be extra petted and well fed with all sorts of delicacies.
So we waited and waited and nothing happened, no music, no food and no fun until the people who usually bring in the treats started to arrive, but only two at a time. Once they were safely in the tent their relative came to meet them, so many tears of joy were shed at these lovely reunions after many months of separation.
It was clear to see how much they had all missed each other.
The visit didn’t seem to last that long and as soon as it was over the lady who helps with the activities and her new mate ran around like cleaning angels and it all began again.
Yes, it was all a bit mystifying, but perhaps we just have to get used to this way of being and I feel very lucky to have been there to see the happiness and joy that everyone felt; their faces were all smiley, light and beautiful.
It was so moving that even I had to have a little weep into my paws, don’t worry though, it was a great way to earn extra cat cuddles and tidbits.
Time for me to stretch out now and get going with my ground’s sweep, it’s a hard job making sure I keep the humans here safe from other wildlife, especially mice. I can assure you, they will not be moving in.
Meow for now …Peggy
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