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Assessment and Management of Dysphagia and Malnutrition Following Stroke

2016 UPDATE
February 2016

The Canadian Stroke Best Practice Recommendations for Stroke Rehabilitation, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Assessment and Management of Dysphagia and Malnutrition following Stroke, and all other sections of the Stroke Rehabilitation recommendations, please click on this URL which will take you to the recommendations online in the IJS: http://journals.sagepub.com/doi/pdf/10.1177/1747493016643553

For the French version of these recommendations, open the appendix at this link :  http://wso.sagepub.com/content/suppl/2016/04/18/1747493016643553.DC1/Stroke_Rehabilitation_2015_IJS_Manuscript_FINAL_FRENCH.pdf

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through www.strokebestpractices.ca, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.

ERRATA June 2016
Kindly note the following update to Dysphagia recommendations 7.1 (i) and 7.1 (ii).  Text in red denotes changes from version published in IJS in April 2016.

7.1 Dysphagia

  1. Patients should be screened for swallowing deficits as soon as they are alert and ready for trialing oral intake (e.g. medications, food, liquid) using a valid screening tool by an appropriately trained professional  [Evidence Level B]. Refer to Appendix Table 3: Canadian Stroke Best Practices Swallow Screening and Assessment Tools for more information.
  2. Abnormal results from the initial or ongoing swallowing screens should prompt a referral to an expert in dysphagia, ideally a speech-language pathologist, for more detailed bedside swallowing assessment and management of swallowing [Evidence Level B].
    1. If a speech-language pathologist is not available, then referral should be made to an occupational therapist, dietitian or other trained dysphagia clinician [Evidence Level C].
    2. An individualized management plan should be developed to address therapy for dysphagia, dietary needs, and specialized nutrition plans [Evidence Level B].
Rationale

The published estimates of the incidence of stroke-related dysphagia vary widely from 19% to 65% in the acute stage of stroke, depending on the lesion location, timing and selection of assessment methods. The presence of dysphagia is important clinically because it has been associated with increased mortality and medical complications, including pneumonia. The risk of pneumonia has been shown to be 3 times higher when patients are dysphagic. Stroke-related pneumonia is fairly common with estimates that range from 5% to 26%, depending on diagnostic criteria. Patients with dysphagia often do not receive sufficient caloric intake, which may result in poorer outcomes as a result of malnutrition.

System Implications

In order to manage dysphagia and malnutrition post stroke organizations should:

  • develop and deliver educational programs to train appropriate staff to perform an initial swallowing screen for stroke patients. This may include staff across the continuum, such as in emergency departments, acute inpatient units, rehabilitation facilities, and community and long-term care settings;
  • ensure access to appropriately trained healthcare professionals such as speech–language pathologists, occupational therapists, and/or dietitians who can conduct in-depth assessments and recommend appropriate management to prevent malnutrition and aspiration.
Performance Measures
  1. Proportion of stroke patients with documentation that an initial dysphagia screening assessment was performed in the emergency department or during hospital admission (core).
  2. Proportion of stroke patients who fail an initial dysphagia screening who then receive a comprehensive assessment by a speech–language pathologist, occupational therapist, dietitian, or other appropriately trained healthcare professional.
  3. Median time in minutes from patient arrival in the emergency department to initial swallowing screening by a trained clinician.
  4. Incidence of malnutrition among patients admitted to inpatient care for stroke which is leads to delays in discharge.

Measurement Notes:

  • In chart audits, dysphagia screening has been poorly documented. Clinical providers should be educated and made aware of the importance of documenting dysphagia screening for valid and reliable measurement and monitoring.
  • Measure 1 is a mandatory reporting indicator for the Accreditation Canada Stroke Distinction Program
Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information

Patient Information

Summary of the Evidence

Evidence Table 7: Assessment and Management of Dysphagia and Malnutrition following Stroke

Evidence suggests a standardized program for screening, diagnosis and treatment of dysphagia following acute stroke results in reductions in the incidence of pneumonia, feeding tube dependency and length of hospital stay (Hinchey et al. 2005, Lakshminarayan et al. 2010). Bedside screening may include components related to a patient’s level of consciousness, an evaluation of the patient’s oral motor function and oral sensation, as well as the presence of a cough. It may also include trials of fluid. Coughing during and up to one minute following test completion, and/or “wet” or hoarse voice are suggestive of an abnormal swallow. Silent aspiration may occur in patients who do not cough or complain of any problems with swallowing or have no wet-sounding voice. If there is silent aspiration, the patient may not display any signs or symptoms on the trial swallows. It is possible for them to not demonstrate obvious problems during the initial screen and still be aspirating. Therefore, all stroke patients, regardless of their screening result, should be informally monitored during their hospital stay for symptoms of swallowing problems.

The effectiveness of a variety of treatments for dysphagia management was recently the subject of a Cochrane review (Geeganage et al. 2012). The results from 33 RCTs examining acupuncture, behavioural interventions, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation (thermal, tactile), transcranial direct current stimulation, and transcranial magnetic stimulation, were included. Pooling of results was not possible due to the small number of studies available evaluating similar interventions/outcomes. Death or dependency at end of trial was the primary outcome, although only two RCTs were included in the pooled result. The results were not significant (OR=1.05, 95% CI 0.63 to 1.75, p=0.86). Acupuncture and behavioural modifications were associated with a reduction in the incidence of dysphagia at the end of treatment. No significant treatment effect was associated with subgroup analysis by therapy type (behavioural interventions, drug therapy, and electrical stimulation) for the outcome of chest infections. These findings appear to be inconsistent with those from an earlier systematic review by Speyer et al. (2010), who concluded that a variety of treatments available for the management of dysphagia are generally effective. However, given the inclusion of patients with non-stroke etiologies of dysphagia and relatively small number of RCTs, these findings should not be compared directly with those reported by Geeganage et al. (2012).

Dietary modifications, including altered textured solids and fluids and the use of restorative swallowing therapy, and compensatory techniques, are the most commonly used treatments for the management of dysphagia in patients who are still safe to continue oral intake. Unfortunately, there is little direct evidence of their benefit. The effectiveness of behavioural modifications and dysphagia therapy has been examined in two RCTs. Carnaby et al. (2006) randomized 306 patients with dysphagia admitted to hospital within 7 days of acute stroke, to receive usual care, standard low-intensity intervention (composed of environmental modifications, safe swallowing advice and appropriate dietary modifications), or standard high-intensity intervention and dietary prescription (daily direct swallowing exercises, dietary modification), for up to one month. When the results from the high-intensity and low-intensity groups were combined and compared with the usual care group, patients in the active therapy group regained functional swallow sooner and had a lower risk of chest infections at 6 months. There were no differences between groups for the risk of death, death or dependency, death or institutionalization, or return to normal diet within 6 months. De Pippo et al. (1994) did not report a reduction in the incidence of pneumonia, dehydration, recurrent upper-airway obstruction or death associated with daily sessions with a speech language therapist during hospitalization on a stroke rehabilitation unit.

Enteral feeding is used when patients’ swallowing impairment precludes safe oral feeding. In the early days following stroke, treatment decisions usually centre on the type of feeding type to use (i.e., nasogastric or enteric feeding tubes). The evidence relating to the superiority of one type is lacking. In one arm of the FOOD trial (2005), patients were randomized to receive either a percutaneous endoscopic gastrostomy (PEG) or nasogastric (NG) feeding tube within 3 days of enrolment into the study. PEG feeding was associated with an absolute increase in risk of death of 1.0% (–10.0 to 11.9, p=0.9) and an increased risk of death or poor outcome of 7.8% (0.0 to 15.5, p=0.05). In a later systematic review by Foley et al. (2008), the authors (on the basis of 3 RCTs including the FOOD trial) concluded that NG feeding tube is not associated with a higher risk of death compared with PEG feeding. However, they suggested that PEG feeding is associated with fewer tube failures and fewer declines in nutritional status.

Treatment with neuromuscular electrical stimulation may be effective in the rehabilitation of dysphagia, although it is a treatment option not commonly used in clinical practice in Canada. Carnaby-Mann & Crary et al. (2007) conducted a systematic review and meta-analysis, which included the results from 7 studies of patients with oropharyngeal dysphagia secondary to stroke, cancer or other disease. A moderate treatment effect was reported for the outcome of change in swallowing score assessed using the Mann Assessment of Swallowing Ability score or the Functional Oral Intake Scale (SMD=0.66, 95% CI 0.47 to 0.85, p<0.001). Evidence of improvement in swallowing ability associated with NMES treatment has also been reported in RCTs which included only patients recovering from stroke (Kim et al. 2009, Xia et al. 2011, and Park et al. 2013).

Oral supplementation can be used for patients who are not able to consume sufficient energy and protein to maintain body weight, or for those with premorbid malnutrition. The FOOD trial (2005) aimed to establish whether routine oral nutritional supplementation in patients who could safely swallow and were prescribed a regular hospital diet, was associated with improved outcome after stroke. A total of 4,023 patients were randomized to receive or not receive an oral nutritional supplement (540 Kcals) in addition to a regular hospital diet, provided for the duration of their entire hospital stay. At 6 month follow-up, there were no significant differences between groups on the primary outcome of death or poor outcome (OR=1.03, 95% CI 0.91 to 1.17, p>0.05). The absolute risk of death or poor outcome was 0.7%, 95% CI -2.3 to 3.8. Only 314 (8%) patients were judged to be undernourished at baseline. The anticipated 4% absolute benefit for death or poor outcome from routine oral nutritional supplements was not evident. The FOOD trial results would be compatible with a 1% to 2% absolute benefit or harm from oral supplements. Results from RCTs examining nutrition-related outcomes suggest that oral supplements can increase the amount of energy and protein patients consume, and prevent unintentional weight loss (Gariballa et al. 1998, Ha et al. 2010).

It is also suggested that lifestyle modifications help improve an individual’s nutritional and physiological status. A recent RCT by Kono et al. (2013) demonstrated that 35 patients with stroke randomized to receive lifestyle modifications, in the form of education, counselling, and regular exercise, showed significantly lower salt intake (p=0.018), blood pressure (p<0.001), and HDL-C levels (p=0.022) compared to those receiving advice only (n=35). Lifestyle modifications are an important part of the rehabilitation process post stroke; all health care professions should advocate for appropriate lifestyle modifications that are individualized and appropriate for their patients.