The Effect of Improved Dysphagia Care on Outcome in Patients with Acute Stroke: Trends from 8-Year Data of a Large Stroke Register

Abstract

Background: Early dysphagia screening and appropriate management are recommended by current guidelines to reduce complications and case fatality in acute stroke. However, data on the potential benefit of changes in dysphagia care on patient outcome are limited. Our objective was to assess the degree of implementation of dysphagia guidelines and determine the impact of modifications in dysphagia screening and treatment practices on disease complications and outcome in stroke patients over time. Methods: In this prospective register-based study (“Stroke Register of Northwestern Germany”), all adult stroke patients admitted to 157 participating hospitals between January, 2008 and December, 2015 were included (n = 674,423). Dysphagia incidence upon admission, the proportion of patients receiving a standardized swallowing screening, and the percentage of dysphagic patients being referred to a speech language therapist (SLT) for treatment were obtained per year. Pneumonia rate, modified Rankin Scale (mRS) at discharge, and in-hospital mortality were compared between groups of dysphagic vs. non-dysphagic patients over time. Results: Screening proportions continuously increased from 47.2% in 2008 to 86.6% in 2015. But the proportion diagnosed with dysphagia remained stable with about 19%. The number of dysphagic patients receiving SLT treatment grew from 81.6 up to 87.0%. Pneumonia incidence was higher in dysphagic stroke cases (adjusted OR 5.4 [5.2–5.5], p < 0.001), accompanied by a worse mRS at discharge (adjusted OR for mRS ≥3: 3.1 [3.0–3.1], p < 0.001) and higher mortality (adjusted OR 3.1 [3.0–3.2], p < 0.001). The order of magnitude of these end points did not change over time. Conclusion: Although advances have been made in dysphagia care, prevalent screening and treatment practices remain insufficient to reduce pneumonia rate, improve functional outcome, and decrease case fatality in dysphagic stroke patients. More research is urgently needed to develop more effective swallowing therapies.

Predicting Dysphagia with National Institute of Health Stroke Scale: Distinction between Infra- and Supratentorial Region is Essential

“…Comparison of patient groups, that is, with vs. without dysphagia, in our study confirms previously shown higher complication rate and worse outcome in dysphagic individuals [6] including higher need for artificial ventilation, incidence of pulmonary infection and longer LOS in affected patients, indicating once again the relevance of timely identification of dysphagia. Interestingly the overall mortality did not differ significantly.…”

“…It can lead to malnutrition and dehydration, and importantly, is associated with a worse long-term outcome including prolonged hospitalisation and extensive care dependency [1][2][3][4]. Especially the occurrence of aspiration pneumonia as typical and partly avoidable complication of swallowing disorders increases the overall mortality of stroke patients [5,6]. Pneumonia incidence has been shown to increase 1% per day of delay in dysphagia screening [7].…”

The role of the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke (GLOBE-3S) in the prevention of stroke-associated pneumonia (SAP)

“…In this clinical scenario, an accurate swallowing screening test may be crucial in lowering the incidence of SAP. Indeed, recent studies reported a higher SAP incidence in stroke patients who failed a high-sensitive screening for dysphagia compared to those who passed the screening [12,13]. In this view, measuring patients' pulse oximetry and laryngeal elevation could improve the accuracy of dysphagia bedside assessment [14][15][16][17][18], being important in detecting aspiration and consequently in reducing dysphagia-related pneumonia.…”

Effects of cognitive and motor dual-tasks on oropharyngeal swallowing assessed with FEES in healthy individuals

“…Oropharyngeal dysphagia frequently occurs in several neurological disorders such as stroke 1 , Parkinson's disease 2 , dementia 3,4 , multiple sclerosis 5 or neuromuscular disorders such as inflammatory myopathies or myasthenia gravis [6][7][8] , but also as age-related dysphagia in elderly otherwise healthy people 9 . Dysphagia not only affects patients' quality of life 10 , but is also prone to severe complications such as malnutrition, dehydration and aspiration pneumonia resulting in worse long-term outcome and increased mortality 1,8,[11][12][13][14][15][16][17][18][19][20] . In fact, pneumonia after aspiration is often a leading cause of death in these patient groups 1,8,18,[20][21][22][23] .…”