Identification and nursing management of dysphagia in individuals with acute neurological impairment (update)
Results Forty-two quantitative studies were retrieved and, of these, 17 met the inclusion and quality criteria, representing a wide range of quantitative research methodologies. The evidence from this updated review indicates that nurses are well placed to conduct dysphagia screening and that there are several tools available that may be suitable for them to use. It is important that formal dysphagia screening protocols are in place and that nurses are trained to use them. If nurses screen patients with an acute neurological impairment within 24 h of admission, it may reduce the time that patients spend without appropriate methods of nutrition and hydration and improve clinical outcomes. Dysphagia screening by nurses does not replace assessment by other health professionals; instead it enhances the provision of care to patients at risk by allowing for early recognition and intervention to occur. Dysphagia screening by nurses is an important initial step in the care of patients with acute neurological impairment, but in order to achieve the best outcomes, it needs to be followed up with careful, consistent management of food and fluid intake.
We previously reported that foetal valproate exposure impairs intelligence quotient. In this follow-up investigation, we examined dose-related effects of foetal antiepileptic drug exposure on verbal and non-verbal cognitive measures. This investigation is an ongoing prospective observational multi-centre study in the USA and UK, which has enrolled pregnant females with epilepsy on monotherapy from 1999 to 2004. The study seeks to determine if differential long-term neurodevelopmental effects exist across four commonly used drugs (carbamazepine, lamotrigine, phenytoin and valproate). This report compares verbal versus non-verbal cognitive outcomes in 216 children who completed testing at the age of three years. Verbal and non-verbal index scores were calculated from the Differential Ability Scales, Preschool Language Scale, Peabody Picture Vocabulary Test and Developmental Test of Visual-Motor Integration. Verbal abilities were lower than non-verbal in children exposed in utero to each drug. Preconceptional folate use was associated with higher verbal outcomes. Valproate was associated with poorer cognitive outcomes. Performance was negatively associated with valproate dose for both verbal and non-verbal domains and negatively associated with carbamazepine dose for verbal performance. No dose effects were seen for lamotrigine and phenytoin. Since foetal antiepileptic drug exposure is associated with lower verbal than non-verbal abilities, language may be particularly susceptible to foetal exposure. We hypothesize that foetal drug exposure may alter normal cerebral lateralization. Further, a dose-dependent relationship is present for both lower verbal and non-verbal abilities with valproate and for lower verbal abilities with carbamazepine. Preconceptional folate may improve cognitive outcomes. Additional research is needed to confirm these findings, extend the study to other drugs, define the risks associated with drug treatment for seizures in the neonates, and understand the underlying mechanisms.