Swallowing Difficulties After Stroke: Impact On Nutrition

Stroke is the fourth leading cause of death in the United States and a major cause of disability. Nutritional status is an important factor in stroke recovery, with malnutrition being prevalent in stroke patients. Nutritional interventions are implemented to overcome the metabolic consequences of stroke.

Dysphagia is a common complication of stroke, affecting 30-50% of patients in the acute stage, and it leads to an increased risk of aspiration pneumonia and malnutrition.

Malnutrition before and after acute stroke is responsible for extended hospital stays, poorer functional outcomes, and increased mortality rates. Nutritional status and the type of stroke determine metabolic requirements and resting energy expenditures (REE).

The type of feeding depends on the swallowing status of the patient. If dysphagia is present, enteral nutrition (EN) through a nasogastric tube (NGT) or percutaneous endoscopic gastrostomy/jejunostomy (PEG/J) is preferred over oral feeding.

The metabolic profile in patients with intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) is not well-established. Some studies suggest that spontaneous ICH patients are not hypermetabolic, while others conclude that ICH and IVH patients are hypermetabolic and require monitoring to avoid undernutrition or over-nutrition.

Stroke patients with dysphagia are at risk of malnutrition and dehydration

Dysphagia is a common complication of stroke, affecting 30-50% of patients in the acute stage and around 10% of patients six months later. Dysphagia can lead to aspiration pneumonia, malnutrition, and dehydration, all of which can worsen the prognosis for stroke patients.

Malnutrition is prevalent in around 20% of stroke patients on admission, with studies reporting prevalences between 8% and 48%. Malnutrition is associated with extended hospital stays, poorer functional outcomes, and increased mortality rates.

Dysphagia screening should be performed on all stroke patients as part of the initial examination or upon arrival at the hospital, using methods such as the Water-Swallowing Test, Multiple-Consistency Test, or Swallowing-Provocation Test. Stroke patients with dysphagia should be given a more thorough assessment of their swallowing function.

Tube feeding is often necessary for stroke patients with severe dysphagia or a decreased level of consciousness. The timing and method of tube feeding are important considerations, as early tube feeding has been associated with reduced mortality in dysphagic stroke patients. The type of tube (e.g., nasogastric or percutaneous endoscopic gastrostomy) and method of feeding (e.g., continuous or bolus) depend on the patient's condition and risk factors.

Oral nutritional supplements may be beneficial for malnourished stroke patients or those at risk of malnutrition or pressure sores. However, there is limited evidence on the effectiveness of oral supplements in improving survival or functional outcomes in stroke patients.

Stroke patients with dysphagia may require a nasogastric, nasoduodenal, or percutaneous endoscopic gastrostomy tube to maintain hydration and nutrition

Dysphagia is a common problem after a stroke, affecting 30-76% of patients in the acute phase. It is caused by oral and pharyngeal disabilities due to abnormal lip closure, loss of oral motor function, and a delay or loss of the normal swallowing reflex. Dysphagia can lead to dehydration, malnutrition, and aspiration pneumonia, which have detrimental outcomes including prolonged hospital stay and increased mortality.

There are several methods of enteral feeding, including nasogastric (NG) tube feeding, gastrostomy, and oesophageal (OE) tube feeding. NG tube feeding is the most widely used method, but it can cause nasopharyngeal and esophageal inflammation and aspiration pneumonia due to continuous oropharyngeal stimulation and gastroesophageal reflux. OE tube feeding, on the other hand, is less invasive as the tube is only placed during feeding, and it enables the patient to maintain normal physiological and anatomical structures, which is beneficial for swallowing rehabilitation.

A study comparing OE tube feeding and NG tube feeding in stroke patients with dysphagia found that OE tube feeding was associated with a significant decrease in total acid reflux time, number of reflux episodes, and DeMeester composite score. These findings suggest that OE tube feeding may be more effective in reducing gastroesophageal reflux and could be a suitable alternative to NG tube feeding for stroke patients with dysphagia.

The American Society for Gastrointestinal Endoscopy (ASGE) guidelines recommend delaying percutaneous endoscopic gastrostomy (PEG) tube placement for two weeks after a stroke, as half of patients with dysphagia improve within this time. However, there is increasing demand for early PEG tube placement to meet requirements for timely discharge to rehabilitation facilities. A retrospective study found that early PEG tube placement (≤7 days post-stroke) did not result in higher mortality or complication rates and significantly decreased hospital length of stay. Given similar safety outcomes, early PEG tube placement should be considered to reduce length of stay and incurred costs.

Stroke patients with dysphagia may benefit from rehabilitation swallowing therapy

Dysphagia, or difficulty swallowing, is a common complication after a stroke. It is caused by damage to the parts of the brain that control the muscles involved in swallowing. This can lead to malnutrition, dehydration, aspiration pneumonia, and a significant decrease in quality of life.

Dysphagia is usually treated by a speech-language pathologist (SLP) and may include rehabilitative exercises, compensation techniques, and complementary treatments such as electrical stimulation and acupuncture, and swallowing maneuvers and/or biofeedback.

Rehabilitative exercises can help retrain the brain to control the muscles involved in swallowing. These exercises may not directly involve the act of swallowing but can help train the associated muscles and improve oral motor control.

Compensation techniques, such as eating soft foods, drinking thickened liquids, and sitting up straight while eating, can help minimize the risk of choking or aspiration pneumonia.

Complementary treatments, such as electrical stimulation and acupuncture, and swallowing maneuvers and/or biofeedback. can also be used in conjunction with rehabilitative exercises to improve swallowing function.

Stroke patients with dysphagia may benefit from neuromuscular electrical stimulation

NMES involves stimulating muscle contractions and activating sensory pathways by depolarizing the peripheral motor nerve, usually at the neuromuscular junction or motor end plate. It can be used to strengthen pharyngeal muscles and prevent atrophy, thereby reducing the risk of malnutrition and its associated complications.

Several studies have shown that NMES, when combined with conventional swallowing therapy, can significantly improve swallowing function in post-stroke dysphagic patients. However, the optimal timing and method of NMES therapy are still under investigation, and more research is needed to determine its effectiveness in chronic stroke patients.

Overall, NMES appears to be a promising treatment option for improving swallowing function in post-stroke dysphagic patients, but further research is needed to establish its efficacy and determine the optimal treatment regimen.

Stroke patients with dysphagia may benefit from a dysphagia diet, which consists of thickened liquids and foods with a smoothened texture

Dysphagia diets are designed to make swallowing easier and safer for people with swallowing difficulties. The International Dysphagia Diet Standardisation Initiative (IDDSI) framework describes different food consistencies and thickened liquids that can be used based on the severity of dysphagia. Here are some examples of dysphagia diet modifications:

• Level 4: Pureed food so that chewing is not necessary.
• Level 5: Minced and moist food that does not require biting.
• Level 6: Soft and bite-sized food that can be safely chewed and swallowed.
• Level 7: Regular food that can be eaten as usual.

Some tips for preparing softer foods include:

• Cooking vegetables in water to soften them instead of roasting or frying.
• Sieving or straining foods to remove pips, seeds, husks, or skins.
• Cooking meat until it is very tender.

It is important to note that dysphagia diets should be used under the guidance of a medical professional, as they may not be suitable for everyone. Additionally, dysphagia diets may need to be adjusted over time as the patient's swallowing function improves.

Frequently asked questions