Cookies at Dysphagia.ie

At Dysphagia.ie we use cookies to ensure that you get the best user experience. If you continue without changing your settings, we'll assume that you are happy to receive all cookies used by website. However, if you wish to, you can find out how to block cookies here.

Continue

Careline: (ROI) 1800 923 404 (NI) 0800 783 4379 | www.nutricia.ie | Contact

The premier source of information for the management of patients with Dysphagia

Dysphagia and Malnutrition in Stroke Patients

What is stroke?

A stroke or cerebrovascular accident (CVA) is defined as a loss of function caused by a disruption of the blood supply to a part of the brain. This can lead to brain damage and possibly death (RCP, 2012).

There are two main causes of strokes:

  • Ischaemic: the blood supply/ flow is stopped due to a blood clot. The mechanism of ischaemic stroke is similar to that of a myocardial infarction (heart attack). Ischaemic stroke accounts for 85% of all cases.
  • Haemorrhagic: a weakened blood vessel supplying the brain bursts and causes brain damage. It includes primary intracerebral and subarachnoid haemorrhages and accounts for 15% of all cases (RCP, 2012).

Types of stroke

Prevalence of stroke

There are approximately 152,000 cases of stroke in the UK per year, more than one every 5 minutes. It is estimated that there are approximately 1.1 million stroke survivors living in the UK. Stroke incidence is approximately 25% higher in men than women. However, although stroke incidence is higher for men, there are more strokes in women since women generally live longer than men (Stroke Association Statistics, 2013)

Stroke remains the fourth most common cause of death in the UK, after cancer, heart and respiratory disease, accounting for more than 55,000 deaths in 2010 (Townsend et al, 2012), with implications on healthcare resources (RCP Audit, 2010). One in five strokes is fatal. Stroke causes about 7% of deaths in men and 10% in women.

In Ireland, there are approximately 10,000 strokes each year. Of these, five out of six strokes happen in people over the age of 60. Each year, approximately 2,000 Irish people die from stoke which accounts for more deaths than breast cancer, prostate cancer and bowel cancer combined. An estimated 30,000 people are living in the community with disabilities as a result of a stroke. This makes stroke the third biggest cause of death in Ireland and the biggest cause of acquired disability (Irish Heart Foundation, 2014).

Malnutrition is prevalent in stroke patients

The overall prevalence of malnutrition in stroke patients ranges from 6.1% to 62% (Foley et al. 2009a). A recent study carried out in UK hyper acute stroke units found that the prevalence of patients at high risk of malnutrition is 29% (Gomes et al. 2014). This value agrees with the proportion of stroke patients at risk of malnutrition previously reported by Stratton and colleagues of 30% for those in the acute and community setting (Stratton et al. 2003).

Dysphagia and dehydration

There are a number of clinical consequences of stroke, one of which is dysphagia (difficulty swallowing). Dysphagia is common following stroke and it is present in 40-50% of patients who survive the first few days (Stroke Association, 2012; Bogaardt et al. 2009). Dysphagia after stroke may involve difficulties with both the oral and pharyngeal phases of swallowing and increases the risk of respiratory complications and aspiration pneumonia (Sura et al. 2012) and mortality (Singh & Hamdy 2006).

It can add an average of 1.6 days to a typical hospital stay (Cichero & Altman, 2012) and prolong length of stay 13 days due to associated complications such as infections e.g. pneumonia, urinary tract infections (Ingeman et al.2011).

Dysphagia is also a strong predictor of malnutrition risk (Sura et al. 2012) and dysphagic stroke patients are 2.4 times more likely to be malnourished compared with those who have normal swallowing (p <0.008) (Foley et al. 2009b). The serious consequences of malnutrition and dysphagia in stroke mean that it is extremely important to identify those patients who are at risk.

Dysphagia has also been associated with dehydration; it is estimated that 62% of stroke patients suffer from dehydration at some point during their admission (Rowat et al. 2012). Patients often limit their drinking, probably due to concerns about choking and may need enteral or intravenous fluids to meet their requirements (Vivanti et al. 2009). Dehydration is a predictor of poor outcomes including discharge to long term-care (Lakshminarayan et al. 2010; Finlayson et al. 2011, Crary et al. 2013).

Dysphagia and Dehydration

Identifying Malnutrition and Dysphagia in Stroke

The NICE Clinical Guideline for Stroke (NICE CG68, 2008) and the Royal College of Physicians (RCP) National Clinical Guideline for Stroke (RCP, 2012) support the identification and management of malnutrition and dehydration in stroke patients. They recommend that:

  • All patients should be screened for malnutrition at the time of admission and weekly thereafter
  • Stroke patients should also have their hydration assessed on admission, reviewed regularly and managed so that normal hydration is maintained
  • People with dysphagia should be given food, fluids and medications modified in a form that can be swallowed without aspiration
  • People unable to take adequate nutrition and fluids orally should receive tube feeding with a nasogastric tube within 24 hours of admission and be referred for detailed nutritional assessment, individualised advice and monitoring
  • Nutrition support should be initiated for people with stroke who are at risk of malnutrition. This may include oral nutritional supplements (ONS), specialist dietary advice and/or enteral tube feeding (ETF).

Early assessment of nutritional risk, with appropriate nutritional management, may improve survival of stroke patients (Yoo et al. 2008). Delays in assessment, treatment and rehabilitation of stroke patients will increase the risk of secondary complications, hinder recovery, increased likelihood of malnutrition and dehydration, and lead to long-term disability or even death.

The Evidence for Nutrition Intervention

Diet Modification

Texture modification of food and fluids is widely used for the management of dysphagia (Stoke Association, 2012). Guidelines have been produced based on best available current evidence and a consensus of expert opinion, which support the use of thickeners to thicken fluid and foods (Dysphagia Diet Food Texture Descriptors, 2012; Irish Consistency Descriptors for Modified Fluids and Fluids Consensus Document 2009).

There is evidence to suggest that increasing the bolus viscosity improves swallowing function in neurological patients (including stroke survivors) which can lead to a significant reduction in aspiration (Clavé et al. 2006). Food and fluids need to be modified with a thickener to a consistency which provides patients with best control over the rate at which foods and fluids pass through the pharynx (Thomas and Bishop, 2007). If consistency recommendations are not followed, patients may consume food/fluids which they do not have sufficient control over and thus put them at risk of aspiration (Garcia et al. 2010).

Modified texture diets are often nutritionally deficient due to the need to add liquid to reduce the consistency of the meal for certain consistencies (Wright et al. 2005; Foley et al. 2006; Keller et al. 2012). If these diets, which are deficient in energy and protein, are administered for prolonged periods without appropriate nutrition support, they in themselves can lead to dehydration and malnutrition.

Nutrition Support

A randomised control trial by Ha et al. examined whether individualized nutrition support (including ONS in the acute stage of stroke) could prevent or minimize weight loss at 3 months in patients at risk of malnutrition. The nutritional intervention provided was energy- and protein fortified meals, or ONS (0.8-1.5 kcal/ml, 0.04-0.1 g/ml protein), or enteral tube feeding (1-4 kcal/ml) based on nutritional needs. The study showed that weight loss (≥5%) was significantly lower in patients receiving ONS during the first week in hospital (p = 0.013). Moreover, there is a trend towards decreased weight loss at 3 months with ONS however this was not statistically significant (Ha et al. 2010a). Energy and protein supplementation (via fortified diet, ONS or ETF) was also linked with a significant improvement in handgrip strength (Ha et al. 2010b).

Nutritional Management of Stroke Patients

When managing people with stroke, ONS, ETF, texture modified diets and thickened fluids should be considered as per NICE CG32 and RCP guidelines (NICE, 2006; RCP, 2012).

Nutritional management of stroke patients

There are a variety of products which may be suitable for patients following a stroke. These include enteral tube feeds for patients who are unable to meet their nutritional requirements through oral diet alone or have an unsafe swallow; powdered thickeners for patients who require texture modified food or fluids and/or pre thickened oral nutritional supplements for those that are at nutritional risk and oral nutritional supplements patients who can tolerate normal consistency fluids but require nutritional support.

The management of stroke patients by a multidisciplinary team, which includes a Speech and Language therapist and Dietitian, is key to successful outcomes for the stroke patient with dysphagia.


REFERENCES:

Bogaardt HCA et al. The use of biofeedback in the treatment of chronic dysphagia in stroke patients. Folia Phoniatr Logop, 2009; 61: 200-205.

Cichero JA, Altman KW. Definition, prevalence and burden of oropharyngeal dysphagia: a serious problem among older adults worldwide and the impact on prognosis and hospital resources. Nestle Nutr Inst Workshop Ser, 2012; 72; 1-11.

Clavé P et al. The effect of bolus viscosity on swallowing function in neurogenic dysphagia. , 2006; 24(9): 1385-1394.

Crary MA et al. (2013) Dysphagia, nutrition, and hydration in ischemic stroke patients at admission and discharge from acute care. Dysphagia, 2013; 28: 69-76.

Dysphagia Diet Food Texture Descriptors, 2012. http://www.bda.uk.com/publications/statements/NationalDescriptorsTextureModificationAdults.pdf

Finlayson O et al. Risk factors, inpatient care, and outcomes of pneumonia after ischemic stroke. Neurology, 2011; 77(14): 1338–1345.

Foley N et al. Energy and protein intakes of acute stroke patients. J Nutr Heath Aging, 2006; 10: 171-175.

Foley NC et al. Which reported estimate of the prevalence of malnutrition after stroke is valid? Stroke, 2009a; 40: e66-74.

Foley NC et al. A review of the relationship between dysphagia and malnutrition following stroke. J Rehabil Med, 2009b; 41: 707-713.

Garcia MJ et al. Quality of care Issues for dysphagia: modifications involving oral fluids. J Clin Nurs, 2010; 19: 1618-1624.

Gomes F et al. Risk Of Malnutrition On Admission Predicts Mortality, Length Of Hospital Stay And Hospitalisation Costs At 6 Months Post Stroke. Stroke, 2014; 45: A63.

Ha LT et al. Body composition in older acute stroke patients after treatment with individualized, nutritional supplementation while in hospital. BMC Geriatr, 2010a; 10: 75.

Ha LT et al. Individual, nutritional support prevents undernutrition, increases muscle strength and improves QoL among elderly at nutritional risk hospitalized for acute stroke: a randomized, controlled trial. Clin Nutr, 2010b; 29(5): 567-573.

Ingeman A et al. In-hospital medical complications, length of stay, and mortality among stroke unit patients. Stroke, 2011; 42: 3214-3218.

Intercollegiate Stroke Working Party. National clinical guideline for stroke, 4th edition. London: Royal College of Physicians (RCP), 2012.

Irish consistency Descriptors for Modified Fluids and Fluids Consensus Document ,2009. http://www.iaslt.ie/docs/public/information/Irish%20consistency%20descriptors%20for%20modified%20fluids%20and%20food.pdf

Irish Heart Foundation, 2014. http://www.irishheart.ie/iopen24/facts-heart-disease-stroke-t-7_18.html

Keller H et al. Issues associated with the use of modified texture foods. J Nutr Health Aging, 2012; 16(3): 195–200.

Lakshminarayan K et al. Utility of dysphagia screening results in predicting post stroke pneumonia. Stroke, 2010; 41(12): 2849–2854.

NICE Diagnosis and initial management of acute stroke and transient ischaemic attack (Clinical Guideline 68), 2008.

NICE Nutrition Support in Adults: Oral Nutritional Support, enteral tube feeding, and parenteral nutrition (Clinical Guideline 32), 2006.

Royal College of Physicians National Sentinel Stroke Clinical Audit 2010. Round 7 Public report for England, Wales and Northern Ireland. Prepared on behalf of the Intercollegiate Stroke Working Party. P43, 2011.

Rowat et al. Dehydration in hospital-admitted stroke patients: detection, frequency, and association. Stroke, 2012; 43(3): 857-859.

Singh S, Hamdy S. Dysphagia in stroke patients. Postgrad Med J, 2006; 82(968): 383–391.

Stratton RJ et al. Disease-related malnutrition: an evidence-based approach to treatment. Cabi Publishing; 2003.

Sura L et al. Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging, 2012; 7: 287-298.

Stroke Association. Swallowing problems after stroke, 2012. http://www.stroke.org.uk/sites/default/files/Swallowing%20problems%20after%20stroke.pdf

Stroke Association. Statistics, 2013. www.stroke.org.uk/sites/default/files/Stroke%20statistics.pdf

Thomas B, Bishop J (Eds) Manual of Dietetic Practice. 4th ed. Oxford; Blackwell Publishing, 2007.

Townsend N et al. Coronary heart disease statistics, 2012 edition. British Heart Foundation: London. P20, 2012.

Vivanti AP et al. Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalised patients with dysphagia. J Hum Nutr Diet, 2009; 22(2):148-155.

Wright L et al. Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. J Hum Nutr Diet, 2005; 18: 213-219.

Yoo SH et al. Undernutrition as a predictor of poor clinical outcomes in acute ischemic stroke patients. Arch Neurol, 2008; 65: 39-43.

Stages of a Swallow

Eating and drinking belong to the basic necessities of mankind. A healthy adult swallows between 800 and 2400 times a day (1). Although swallowing seems easy, in reality it requires an extremely complicated interaction between various muscles. Timing, coordination, feeling and muscular strength all play a significant role. When one or more of these conditions for swallowing are disturbed, this is called dysphagia. Dysphagia can have a severe social and psychological impact on patients’ life (2). The normal swallowing process can be divided into the following four phases (1,3):

Oral phase

In this first phase the mouth is opened and a piece of solid food or liquid is taken in. The mouth closes, and with intake of a hard consistency, chewing follows. The cheek muscles are tightened to prevent remnants of food remaining in the cheek pouches. Chewing mixes the food with saliva and prepares it for swallowing. When the chewing process is completed, the food (or bolus) is collected in the centre of the tongue and the person is ready to swallow. This first phase of the swallowing process is entirely voluntary (1).

Transport phase

The second phase in the swallowing process is the transport phase. When the bolus has been collected in the centre of the tongue, the tip of the tongue is placed behind the teeth creating a groove in the tongue. This allows the bolus to slide into the pharynx (the throat). The sliding into the pharynx is not an entirely automatic process. The tongue makes a wave-like movement, thus propelling the food bolus into the back of the mouth. When the bolus reaches certain receptors in the pharynx, the swallowing reflex is triggered. From this point on swallowing is an entirely reflexive action (1,3).

Pharyngeal phase

The third phase in the swallowing process is the pharyngeal phase. When the swallowing reflex is triggered, the pharyngeal phase starts. This phase is the most complex phase of swallowing, because it involves many events which occur in a rapid sequence. The soft palate closes the nasopharynx to ensure that the food does not enter the nasal cavity. The vocal folds close and the larynx moves upwards, which results in tilting of the epiglottis and closure of the larynx. This ensures that the food cannot enter the trachea during swallowing. The three pharyngeal constrictor muscles (m. constrictor pharyngis superior, m. constrictor pharyngis medius, m. constrictor pharyngis inferior) contract from top to bottom and transport the bolus into the oesophagus (1,3).

Oesophageal phase

In this last phase of the swallowing process, the bolus enters the oesophagus and is transported further down towards the stomach by peristaltic contractions. In this final phase, the muscles in the neck relax, the larynx is lowered and the vocal folds open, allowing the patient to take a breath (1,3).


REFERENCES:

1. Matsuo, K., Palmer, J.B. (2008). Anatomy and physiology of feeding and swallowing: normal and abnormal. Phys Med Rehab Clin N Am 19, 691-707.

2. Ekberg, O., Hamdy, S., Woisard, V., Wuttge-Hannig, A., Ortega, P. (2002). Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia 17,139-146.

3. Logemann, J. (1999). Evaluation and treatment of swallowing disorders. 2nd ed. Austin: Pro-Ed.

 

Dysphagia in different patient groups

In general, patients with either acute or chronic dysphagia can be divided into three groups (7):
    1. neurogenic dysphagia,
    2. head-and-neck cancer related dysphagia,
    3. dysphagia due to aging (presbyphagia).

Neurogenic dysphagia

The neurological condition of a patient might lead to sensory problems in the oral cavity or pharynx which may lead to dysphagia. Some neurological disorders can induce weaknesses of specific muscles and muscle groups, causing food to get stuck in the pharynx. Other neurogenic disorders can induce diminished laryngeal closure resulting in (silent) aspiration. In addition, coordination of the swallowing process can be affected by certain neurological conditions negatively influencing the motor planning of swallowing. Neurogenic dysphagia can be caused by a range of neurological disorders, such as (1):
  • Stroke
  • Alzheimer’s disease
  • Parkinson’s disease
  • Multiple sclerosis
  • Amyotrophic lateral sclerosis (ALS)
  • Huntington’s disease
  • Guillain-Barré syndrome
  • Poliomyelitis
  • Sensory problems are frequently found in stroke patients, but also occur frequently in other neurological conditions (4). Due to decreased pharyngeal sensitivity, the coordination between swallowing and closure of the larynx is disrupted. As a result, the bolus enters the pharynx before the pharyngeal phase of swallowing has been triggered. In general, these patients will aspirate thin liquids (1).

    Other neurogenic disorders might cause motor problems (i.e. on the level of the pharyngeal and laryngeal muscles). Due to general muscle weakness, chewing can be difficult and the pharyngeal muscles might no longer be able to propel the bolus into the oesophagus. Food gets stuck in the pharynx and patients are at risk of choking. These patients often have less problems drinking thin liquids. In some patients, lip closure is insufficient due to facial paralysis, or the bolus cannot be collected in the centre of the tongue due to paralysis of the tongue musculature. This results in food residue in the oral cavity (1,3,4).

    Swallowing requires motor planning and coordination. It is known that some neurological conditions, e.g. stroke and dementia, can influence the motor planning of swallowing. In these cases an apraxia of swallowing can occur: a patient puts food in his mouth but seems to have forgotten what to do with it.

    Problems in the coordination of swallowing can result in a situation where certain structures (like pharyngeal constrictor or the upper oesophageal sphincter) might have a good motor response to swallowing, but this response is out of sequence. In some neurological patients for instance, the lower pharyngeal constrictors might contract before the middle pharyngeal constrictors contract, resulting in a propulsion force which directs the bolus into the direction of the oral cavity instead of the oesophagus (1,8).

    Dysphagia in patients with head-and-neck cancer

    Dysphagia can also occur after head-neck surgery. The severity of dysphagia depends on the location of the tumour and the extent of surgery. Dysphagia will be negatively influenced by postoperative (chemo-) radiation due to fibrotic changes (9). Apart from these problems, exposure of the pharynx to radiation might lead to a decreased sensitivity, which can lead to residue in the pharynx and a possible concomitant aspiration or choking (3,9). Swallowing rehabilitation in this patient group is mainly targeted on teaching compensation techniques (10).

    Presbyphagia

    The third patient group consists of patients with ‘presbyphagia’; dysphagia as a result of normal ageing. Elderly people often have more problems with thin fluids (due to the slowing down of the swallowing process) and hard consistencies (less strength for chewing). One in three of elderly people in European nursing homes experience dysphagia (2). In 70% of these cases, there is no professional treatment provided for these symptoms. Half of these patients say they eat less and 44% say they have involuntarily lost weight over the previous twelve months. It was shown that 41% of these patients are afraid of choking at mealtimes, and a large group of patients (36%) avoids eating in a group due to their frequent choking (2). Apart from (patho-)physiological problems influencing the severity of dysphagia, problems with correct posture and behavioural problems also appear to play a role (11). Staff shortages, resulting in decreased patient care, can also contribute to eating and feeding problems (2,4).


    REFERENCES:

    1. Matsuo, K., Palmer, J.B. (2008). Anatomy and physiology of feeding and swallowing: normal and abnormal. Phys Med Rehab Clin N Am 19, 691-707.

    2. Ekberg, O., Hamdy, S., Woisard, V., Wuttge-Hannig, A., Ortega, P. (2002). Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia 17, 139-146.

    3. Logemann, J. (1999). Evaluation and treatment of swallowing disorders. 2nd ed. Austin: Pro-Ed.

    4. Rofes, L., Arreola, V., Akmirali, J., Cabré, M., Camins L., García-Peris, P., Speyer, R., Clavé, P. (2011). Diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly. Gastroenterology Research and Practice Volume 2011, Article ID 818979, 13 pages.

    7. Bogaardt, H. (2009). Current aspects of assessment and treatment of dysphagia. PhD-thesis, University of Amsterdam, The Netherlands.

    8. Easterling E.A. and Robbins, E. (2008). Dementia and dysphagia. Geriatric Nursing 29, 275-285.

    9. Kuhnt, T., Becker, A., Bloching, M., Schubert, J., Klautke, G., Fietkau, R., Dunst, J. (2006). Phase II trial of a simultaneous radiochemotherapy with cisplatinum and paclitaxel in combination with hyperfractionated-accelerated radiotherapy in locally advanced head and neck tumors. Medical Oncology 23, 325-334.

    10. Simental, A.A., Carrau, R.L. (2004). Assessment of swallowing function in patients with head and neck cancer. Current Oncology Reports 6, 162-165.

    11. Steele, C., Greenwood, C., Robertson, C. (1997). Mealtime difficulties in a home for the aged: not just dysphagia. Dysphagia 12, 45-50.

     

    Treating dysphagia

    Apart from surgical interventions for restoring swallowing function, swallowing function might be restored through functional rehabilitation (dysphagia therapy). Functional swallowing rehabilitation can be divided into three different approaches: swallowing rehabilitation, compensatory strategies, and the use of dietary adjustments (3).

    Swallowing rehabilitation

    Swallowing rehabilitation consists of exercises targeted to train specific muscles or muscle groups. This can be, for example, exercises which improve the function of the tongue muscles, so that the patient is able to make a better, more homogeneous bolus in the mouth prior to swallowing. There are also exercises to improve laryngeal excursion and pharyngeal contraction (3,4,5).

    Compensatory strategies

    Compensatory strategies allow patients to swallow safely even though their underlying physiology is impaired. The patient learns how he can avoid problems during eating and drinking (such as choking, coughing). Compensatory strategies are mainly aimed at changing the position of the head during swallowing or using special swallowing techniques. An example of a compensatory strategy is swallowing with a ‘supraglottic swallow’ (3). The patient learns to hold his breath prior to swallowing and is taught to close both true and false vocal folds when swallowing. After swallowing the patient deliberately coughs to clear any possible residue. Aspiration cannot occur as the larynx is fully closed and possible residue is cleared (3).

    Dietary adjustments

    A third therapy option is changing the consistency of a patient's diet in the patient’s diet. A Speech and Language Therapist examination, flexible endoscopy or videofluoroscopy is used to determine which consistencies and which quantities the patient is able to swallow without problems. In stroke patients there is a significant chance that aspiration will occur with thin liquids. When a videofluoroscopy shows that thicker liquids are not aspirated, the thin liquids in the patient’s diet can be thickened with commercially available thickening powders. These products are manufactured by many different commercial companies. These companies also provide ready-made ‘thickened’ drinks and puddings for patients with dysphagia. Apart from changing the consistency of the food, the temperature can also be adjusted. It is well-known that receptors in the oral cavity and pharynx that trigger the swallowing reflex are more sensitive to colder stimuli. Therefore it is often advised to start oral feeding with cold food, such as ice water, cold custard, etc. (3).


    REFERENCES:

    3. Logemann, J. (1999). Evaluation and treatment of swallowing disorders. 2nd ed. Austin: Pro-Ed.

    4. Rofes, L., Arreola, V., Akmirali, J., Cabré, M., Camins L., García-Peris, P., Speyer, R., Clavé, P. (2011). Diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly. Gastroenterology Research and Practice Volume 2011, Article ID 818979, 13 pages.

    5. Schindler, A., Vincon, E., Grosso, E., Miletto, A.M., Rosa di, R., Schindler, O. (2008). Rehabilitative management of oroopharyngeal dysphagia in acute care settings: data from a large Italian teaching hospital. Dysphagia 23, 230–236.

     

    Incidence of dysphagia

    As dysphagia is not a single disease, but a symptom of an underlying medical problem (3,4), it is difficult to estimate how many patients are suffering from dysphagia. Any estimation of the incidence of dysphagia is highly influenced by the definition of dysphagia. As there is no standardized definition for dysphagia, an estimation of the incidence will vary from publication to publication. It is probable, however, that dysphagia is under diagnosed in many patients (2,4).

    Incidence and outcome of dysphagia in stroke patients

    Stroke is considered to be one of the major causes of dysphagia. In 2002 the World Health Organisation calculated that about 15 million people worldwide suffer from a stroke every year. Swallowing problems occur in about half of these patients (12, 13). In many patients, the swallowing function will recover within two months. In a small group, recovery of swallowing function may take many months to several years (12, 13). In several cases of stroke patients this recovery does not occur. It is not known exactly how many patients receive long term tube feeding after stroke. It is estimated that in England 1.7% of all stroke patients are long term tube dependent (14). Generally, stroke patients are discharged from swallowing rehabilitation six to twelve months after a stroke, because no further recovery is to be expected. When there are still swallowing problems at the end of the treatment period, the patient often requires (partial) tube feeding for an extended period of time.

    Incidence and outcome of dysphagia in patients with other neurological disorders

    A prospective study into recovery of dysphagia in patients with other neurological conditions shows that the average duration of swallowing rehabilitation for patients who are (partially) dependent on tube feeding prior to therapy is two months. Of this patient group, only 55% returns to an oral diet (15).

    In many degenerative neurogenic disorders, swallowing problems occur in different degrees of severity. It is difficult to say, however, which problems occur specifically with these conditions. There appears to be a large variability in the time between diagnosis and the occurrence of dysphagia. The incidence of dysphagia in patients with neurodegenerative diseases is estimated to be 40% (4, 5, 8).

    The treatment of swallowing problems in degenerative conditions consists predominantly of advice on posture while eating and drinking and learning compensatory strategies. Exercises to strengthen particular muscles or muscle groups is usually contraindicated for these patient groups (3, 8).

    Incidence and outcome of dysphagia in patients with head-and-neck cancer

    Head-and-neck cancer patients with dysphagia constitute a heterogeneous population strongly related to the extent of surgery and use of (chemo) radiation either in postoperative or primary setting (3, 4,16).

    The cause of dysphagia for patients undergoing surgical resection is evident. Tissue loss because of surgical excision, transection of muscles and nerves, and resulting scar and loss of sensation result in marked alteration in the functioning of tissues vital for normal swallowing. Swallowing rehabilitation is generally believed to be efficacious. Some studies suggest that postural techniques clearly result in decreased aspiration by 50% to 75% and that swallowing exercises may improve swallowing efficacy (17).

    Incidence and outcome of presbyphagia

    It has been recognized that 40%–60% of the institutionalized elderly have identifiable signs and symptoms of oropharyngeal dysphagia (2, 4). For these patients, widely accepted interventions such as meal texture modification, compensatory postures, food administration techniques, and direct therapeutic procedures are used (4,5). No outcome figures are available on interventions in this population.


    REFERENCES:

    2. Ekberg, O., Hamdy, S., Woisard, V., Wuttge-Hannig, A., Ortega, P. (2002). Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia 17, 139-146.

    3. Logemann, J. (1999). Evaluation and treatment of swallowing disorders. 2nd ed. Austin: Pro-Ed.

    4. Rofes, L., Arreola, V., Akmirali, J., Cabré, M., Camins L., García-Peris, P., Speyer, R., Clavé, P. (2011). Diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly. Gastroenterology Research and Practice Volume 2011, Article ID 818979, 13 pages.

    5. Schindler, A., Vincon, E., Grosso, E., Miletto, A.M., Rosa di, R., Schindler, O. (2008). Rehabilitative management of oroopharyngeal dysphagia in acute care settings: data from a large Italian teaching hospital. Dysphagia 23, 230–236.

    8. Easterling E.A. and Robbins, E. (2008). Dementia and dysphagia. Geriatric Nursing 29, 275-285.

    12. Dogget, D.L., Tappe, K.A., Mitchell, M.D., Chapell, R., Coates, V., Turkelson, C.M. (2001). Prevention of pneumonia in elderly stroke patients by systematic diagnosis and treatment of dysphagia: an evidence based comprehensive analysis of the literature. Dysphagia 16, 279-295.

    13. Becker, R., Nieczaj, R., Egge, K., Moll, A., Meinhardt, M., Schulz, R-J. (2010). Functional dysphagia therapy and PEG treatment in a clinical geriatric setting. Dysphagia, DOI 10.1007/s00455-009-9270-8.

    14. Elia, M., Stratton R.J., Holden, C., Meadows, N., Micklewright, A., Russel, C., Scott, D., Thomas, A., Shaffer, J., Wheatley, C., Woods, S.; Committee of the British Artificial Nutrition Survey (BANS). (2001). Home enteral tube feeding following cerebrovascular accident. Clinical Nutrition 20, 27-30.

    15. Prosiegel, M., Heintze, M., Wagner-Sonntag, E., Hannig, C., Wuttge-Hannig, A., Yassouridis, A. (2002). Schluckstörungen bei neurologischen Patienten. Eine porspektive Studie zu Diagnostik, Störungsmustern, Therapie und Outcome. Nervenarzt 73, 364-370.

    16. Nguyen, N.P., Frank, C., Moltz, C.C., Karlsson, U., Nguyen, P.D., Ward, H.W., Vos, P., Smith, H.J., Huang, S., Nguyen, L.M., Lemanski, C., Ludin, A., Sallah, S. (2009). Analysis of factors influencing dysphagia severity following treatment of head and neck cancer. Anticancer Research 29, 3299-3304.

    17. Langmore, S.E., Terpenning, M., Schork, A., Chen, Y., Murray, J., Lopatin, D., Loesche, W. (1988) Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia 13, 69-81.

     

    Feeding patients with dysphagia

    Positioning at Mealtimes

    • Sit upright in erect position
      1. Make sure the patient is sitting upright as possible – prop them up with plenty of pillow if they are unable to sit erect themselves.
    • Head tilted forward / chin down
      1. Ask the patient to tilt their head forward with their chin slightly forward – people often think that it’s best to get patients to tilt their head back to open the passage down to the oesophagus, but this actually makes it more difficult to swallow.
    • Support impaired side of body
      1. If a patient has one side weaker than the other make sure you support the impaired side.
    • Sit at or below patient’s eye level
      1. When feeding patients sit down so you are positioned at the same level, or slightly below the patients eye level, this will make it easier for him/her to maintain their head in the most appropriate position.
    • Place food in stronger side of mouth
      1. If your patient has any facial weakness make sure you sit on the strong and place food into the stronger side of the mouth to maximise careful feeding.
    • Sit on side which will maximise careful feeding
    • Take account of visual field deficits re-seating and food placement
      1. Finally take account of visual field deficits regarding seating and food placement – for example, if you are giving a patient a Forticreme Complete, make sure you put it well within arms reach, and the patient can see the pot.

    Watch our videos on how to feed a patient the right way and how to feed a patient the wrong way.


     


    Related Entries

    18 June 2011

    Dysphagia in different patient groups

    In general, patients with either acute or chronic dysphagia can be divided into three groups…

    more >>

    20 June 2011

    Stages of a Swallow

    Eating and drinking belong to the basic necessities of mankind. A healthy adult swallows between…

    more >>

    12 June 2011

    Feeding patients with dysphagia

    Positioning at Mealtimes Sit upright in erect position Make sure the patient is sitting upright…

    more >>