Clinical studyDysphagia in acute ischaemic stroke: severity, recovery and relationship to stroke subtype
Introduction
Dysphagia is a common occurrence in acute stroke with a reported incidence between 14–94%.[1], [2], [3], [4], [5], [6] It has been associated with complications such as pneumonia,[1], [7] nutritional compromise,[8], [9], [10] increased length of hospital stay[11], [12] and poorer outcomes.12
Dysphagia leading to aspiration of food, fluids or secretions is known to be a contributing factor in pneumonia and aspiration pneumonia.[3], [9], [13] In addition to dysphagia, other factors such as dental caries14 and tube-feeding15 can be significant predictors of aspiration pneumonia. Studies have found a high incidence of dysphagia in early stroke,[16], [17], [18] although it can be transient, with difficulties resolving in the acute phase.[1], [3], [4], [16], [18], [19] Chest infection has been reported to occur most commonly in the first month post-stroke.[3], [5]
The aim of this study was to identify clinical and demographic predictors of pneumonia in a cohort of acute ischaemic stroke patients within 30 days post-stroke. The study also sought to identify whether dysphagia is related to a particular stroke subtype, whether one particular subtype is more prone to severe dysphagia and whether there is a greater incidence of chest infection in a particular stroke subtype. Such information identifying high-risk patient groups would be useful to neurologists, medical officers, speech-language pathologists and other health professionals for resource allocation, discharge planning and infection control purposes. It also assists health professionals to better monitor and prevent malnutrition, dehydration and respiratory tract infections in the acute stroke period.
Section snippets
Methods
Patients admitted to the three tertiary hospitals in Perth, Western Australia, between August and October 2003 with a principal diagnosis of ischaemic stroke were eligible to participate in the study. Patients were identified through perusal of daily hospital admission lists. While subjects were approached for consent to participate in the study prospectively, data were obtained retrospectively on outcomes via careful perusal of medical records and from general practitioners. Diagnosis of
Demographics and mortality
Characteristics of the cohort of 88 patients are shown in Table 1. Fifty nine (67%) subjects had experienced a first stroke, 21 (24%) a second stroke. There was no gender difference with respect to prior stroke. During the follow-up period, there were eight deaths (9%) and the mortality rate was comparable to the literature.23 Among the deaths, six were diagnosed as TACI strokes and two were LACI strokes. All deceased patients were “nil by mouth” on admission to hospital and seven of these were
Dysphagia and risk of chest infection
Sixty-two percent of survivors were prescribed some form of modified diet or thickened fluids or were made “nil by mouth” 2 days after admission to hospital, which is comparable to the literature for subjects with first-ever stroke.[4], [18], [20], [25] The incidence of pneumonia or chest infection of 18% was also similar to that reported previously for subjects with first-ever stroke.[3], [18], [26] However, the current study did not exclude subjects who had a history of previous stroke.
Conclusion
In a cohort of 80 ischaemic stroke survivors the incidence of dysphagia decreased from 62.5% to 51.2% during the first week following admission to hospital. Dysphagia severity was strongly associated with stroke subtype, with TACI strokes incurring the most severe and persistent dysphagia. Survivors who were “nil by mouth” due to a profound swallowing impairment demonstrated a high incidence of respiratory infection, possibly due to aspiration of secretions colonised by bacteria.
Acknowledgement
This study was made possible by the cooperation and assistance of the Speech Pathology Departments at Fremantle, Royal Perth and Sir Charles Gairdner Hospitals in Western Australia. Their contributions are gratefully acknowledged.
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