No gag, no food

David Smithard

No gag, no food

2003, Age and Ageing

Age and Ageing Vol. 32 No. 6  British Geriatrics Society 2003; all rights reserved Age and Ageing 2003; 32: 674–680 Research Letters No gag, no food Table 1. Responses to questionnaire N (%) Ashford Medical New Zealand doctors (A) students (M) doctors (NZ) 39 20 47 DAVID G. SMITHARD1, DAVID SPRIGGS2 1 East Kent Hospitals NHS Trust, UK Email: david.smithard@ekht.nhs.uk 2 Auckland District Health Board, New Zealand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Absent gag reXexa Can not swallow safely Can swallow safely Protection of the swallowb Gag reXex alone Cough reXex alone Both ConWdent to assess swallow Yes No Initial assessment (a) Doctor (b) Nurse (c) SLT (d) Any (e) Doctor and SLT a 18 (46) 18 (46) 11 (55) 5 (25) 10 (21) 33 (70) 12 (31) 16 (41) 8 (21) 9 (45) 9 (45) 2 (10) 1 (2) 19 (40) 24 (51) 12 (30) 26 (67) 2 (10) 18 (90) 4 (9) 33 (70) 7 (18) 3 (8) 13 (33) 14 (36) 2 (5) 6 (30) 0 (0) 9 (45) 5 (25) 0 (0) 5 (11) 0 (0) 17 (36) 20 (42) 4 (9) M vs NZ, χ2 = 10.528, P < 0.001; A vs NZ, χ2 = 6.125, P < 0.025. M vs NZ, χ2 = 19.041, P < 0.0000; A vs NZ, χ2 = 14.036, P < 0.0000. b 674 References 1. Mann G, Hankey J, Cameron D. Swallowing function after stroke. Stroke 1999; 30: 744–8. 2. Smithard DG, O’ Neill PA, Park C et al. Complications and outcome after acute stroke: Does dysphagia matter. Stroke 1997; 27: 1200–4. 3. Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reXex in healthy subjects. Lancet 1995; 345: 487–8. 4. Bleach NR. The gag reXex and aspiration: a retrospective analysis of 120 patients assessed by videoXuoroscopy. Clin Otolaryngology 1993; 18: 303–7. 5. McCullough GH, Wertz RT, Rosenbeck JC. Sensitivity and speciWcity of clinical/bedside examination signs for detecting aspiration in adults subsequent to stroke. J. Commun Disord 2001; 34: 55–72. Downloaded from https://academic.oup.com/ageing/article-abstract/32/6/674/12775 by guest on 25 May 2020 Sir—Following an acute stroke, as many as 60% of patients will have difWculty swallowing [1, 2]. Anecdotally, medical staff often use the gag reXex as a quick bedside swallowing assessment, at the time of admission. However, half of Wt elderly people and one third of Wt young do not have a gag reXex yet swallow safely [3], and many studies have failed to Wnd any relationship between the presence of dysphagia and the absence of a gag reXex [4, 5]. We have undertaken a questionnaire survey, using a clinical scenario of an acute stroke patient with dysphagia, of 39 junior doctors from England, 48 doctors from New Zealand, and 20 Wnal year medical students. The following questions were asked: (i) whether or not the absent gag reXex meant that the patient could swallow safely, (ii) whether either the gag or cough reXex protects the airway, (iii) whether they were conWdent in their own ability to assess the ability to swallow and (iv) which professional group should conduct the initial swallowing assessment. Many medical staff think that the gag reXex has a role to play in the swallowing process. Medical staff in New Zealand appeared less likely to consider an absent gag as a reason to stop patients swallowing (Table 1). Doctors and medical students from England were more likely to consider the gag reXex alone to be protective of the swallow when compared to Doctors from New Zealand. Medical staff in New Zealand were more likely to consider that both the gag and cough reXex protect the airway than their English counterparts. Both groups had little conWdence in their ability to assess swallowing. There was no difference between groups and no consensus as to which professional group should conduct the initial swallowing assessment of acute stroke patients, 39/106 thought that speech and language therapists should do all initial assessments and an equal number thought it was the role of the nurse. Published evidence clearly shows that there is little or no relationship between the gag reXex and the ability to swallow safely. These results, however, suggest that many medical staff, particularly in England continue to consider the presence of the gag reXex as indicating a safe swallow. There appears to be little difference between medical students and doctors, suggesting that the role of the gag reXex in assessing the ability to swallow commences during the time of undergraduate training. This misconception is then perpetuated throughout medical training. It is worrying that despite the wealth of research evidence, doctors continue to consider the gag reXex to be useful in the assessment of the swallow reXex and this considerable knowledge gap may adversely affect the well-being of our patients.

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