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Haider C, Zauner H, Gehringer-Manakamatas N, Kadar K, Wood G

Wallner K, Gassner A

Neurogenic dysphagia: Nutrition therapy improves


rehabilitation

Journal für Ernährungsmedizin 2008; 10 (3), 6-11

For personal use only.


Not to be reproduced without permission of Verlagshaus der Ärzte GmbH.
6 WISSENSCHAFTLICHE ARBEITEN

Neurogenic dysphagia: Nutrition


therapy improves rehabilitation
Augmented clinical nutrition optimizes the general rehabilitation outcome in patient s with
neurogenic dysphagia. A s tudy involving 127 s troke patient s undergoing pos tacute multi-
disciplinar y rehabilitation. u C H R I S T I N E H A I D E R a , H A R A L D Z A U N E R a , b , c , N A D J A G E R I N G E R -
MANAK ANATASa, K ARIN K ADARa, GUILHERME WOODb,c, KURT WALLNERa, ALFRED GASSNERa

❚ ABSTRACTS Z i e l s e t z u n g : Verbessert forcierte Ernährungstherapie


(Volkert et al. 2006, Williams 2006) den Rehabilitationser-
O b j e c t i v e s : To examine whether augmented nutrition folg bei Patienten mit neurogenen Schluckstörungen im
therapy (Volkert et al. 2006, Williams 2006) improves the Vergleich zu neurologischen Patienten ohne Dysphagie?
general rehabilitation outcome of patients with neuro- P a t i e n t e n / M e t h o d e n : Bei 127 Patienten nach akutem
genic dysphagia compared to neurologic patients with- Schlaganfall wurde ein Screening bezüglich neurogener
out dysphagia. Schluckstörungen und Unterernährung zu Beginn der multi-
S u b j e c t s / m e t h o d s : 127 stroke patients undergoing disziplinären Neurorehabilitation durchgeführt. Unter Ein-
postacute multidisciplinary neurorehabilitation approach satz verschiedener Maßnahmen wie Konsistenzadaption
were routinely screened for neurogenic dysphagia and von Nahrung und Flüssigkeit, Essbegleitung, Schluckthe-
undernutrition. An aspiration free daily input of 1300 to rapie, pharyngoskopischer Schluckuntersuchung, Sonden-
2500 kcal was assured by means of augmented clinical ernährung und parenteraler Ernährung wurde eine as-
nutrition including changes of food / fluid consistency, pirationsfreie tägliche Aufnahme von 1.300 bis 2.500 kcal
feeding assistance, mealtime supervision, therapeutic sichergestellt (Volkert et al. 2006, Williams 2006, ECRI 1999,
swallowing manoeuvres, endoscopic evaluation, tube Bath et al. 2002). Zur Beurteilung wurden neurofunktio-
feeding, and parenteral nutrition (Volkert et al. 2006, nale Scores bei Aufnahme und Entlassung der Patienten
Williams 2006, ECRI 1999, Bath et al. 2002). Outcome was verglichen. Der Ernährungsstatus wurde mittels Innsbruck
defined as difference of neurofunctional scores at ad- Nutrition Scale (Hackl 2004) und Nutritional Risk Screening
mission and discharge. Nutritional status was assessed (NRS 2002; Kondrup et al. 2003) bestimmt.
with Innsbruck Nutrition Scale (Hackl 2004) and Nutri- E r g e b n i s s e : 50 % (n = 64) der in der Untersuchung erfass-
tional Risk Screening (NRS 2002; Kondrup et al. 2003). ten Patienten benötigten Unterstützung bei der Nahrungs-
R e s u l t s : 50 % (n = 64) of all patients of the whole sam- aufnahme. Die starke Ausprägung kognitiver Einschrän-
ple needed nutritional support. A high amount of cogni- kungen bei Patienten mit Schluckstörungen (56 von 64)
tive impairment in these swallowing compromised pa- weist darauf hin, dass bei diesen Patienten Schluckstörun-
tients (56 out of 64) indicates that most of these patients gen vorlagen, die die präorale Schluckphase betreffen. Nur
suffered from neurogenic dysphagia affecting the pre- 31 von 63 Patienten ohne Schluckstörungen waren nicht
oral swallowing phase. Only 31 out of 63 of normal swal- von kognitiven Beeinträchtigungen betroffen. Patienten mit
lowing patients were cognitively normal. Swallowing Schluckstörungen konnten deutlich bessere Rehabilitations-
disordered patients exhibited a highly significant better erfolge erreichen als Patienten ohne Schluckstörungen.
outcome in rehabilitation compared to not swallowing S c h l u s s f o l g e r u n g e n : Der Einsatz verschiedener Metho-
disturbed patients. den für Screening und Klassifizierung von Schluckstörungen
C o n c l u s i o n s : Multiple approaches for screening and und Unterernährung bei Patienten nach akutem Schlag-
assessment of dysphagia and undernutrition after stroke anfall belegt ebenso wie die Ergebnisse unterstützender
and enforced nutrition scenario unmask the underes- Maßnahmen bei der Nahrungsaufnahme, dass das Rehabi-
timated rehabilitation potential of swallowing compro- litationspotenzial von Schlaganfallpatienten mit Schluck-
mised patients after stroke. störungen unterschätzt wird.
K e y w o r d s : Neurogenic dysphagia, clinical nutrition, S c h l ü s s e l w ö r t e r : Neurogene Schluckstörungen, Dys-
rehabilitation phagie, klinische Ernährung, Rehabilitation ❚

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T he incidence of neurogenic dysphagia in patients with


acute stroke ranges from 35 to 40 % respectively 50 %,
half of them not recovering in the first week living with dys-
Further patient characteristics for the whole sample are shown
in table 1. Table 2 shows the characteristics of patients with
(n = 64) versus without (n = 63) nutritional support.
phagia for months after stroke. Not only swallowing difficul- This research was completed in accordance with the guide-
ties but also altered consciousness and or sensory / percep- lines of the Helsinki Declaration (2004).
tual deficits may lead to dysphagia. Up to 20 % of stroke
survivors die during the first year from aspiration if stroke re- Rehabilitation setting
lated dysphagia is present, 37 % will develop pneumonia
(Adams et al. 2005, National guideline clearinghouse of the In our specialized department for inpatient neurorehabilita-
Heart and Stroke Foundation of Ontario (HSFO) 2005). tion therapy was individually adapted according to the prin-
Also for 60 % of patients with traumatic brain injury dyspha- ciples of Bobath (1993), Affolter (1997), proprioceptive neu-
gia is reported in the (post)acute phase (Mackay et al. 1999). romuscular facilitation (Wang 1994), cognitive therapeutic
Dysphagia increases the risk of developing poor nutritional exercises (Perfetti 1986), lactate adjusted treadmill training,
status, the risk of infections, impaired functional outcome, with / without partial body weight support (Hesse et al.
slower rate of recovery, poorer rehabilitation potential and 1995, Husemann et al. 2007), 24 hours rehabilitation nursing,
higher mortality (Williams 2006, Perry et al. 2003, Kondrup speech and swallowing diagnosis and therapy including
et al. 2003). fiberoptic endoscopic examination of swallowing (FEES) and
Fewer data are available for patients with complicated course functional dysphagia therapy (FDT; ECRI 1999, Bartholome
after surgery or sepsis and complex critical illness. Mertl- 1993, Bath et al. 2002), neuropsychological and psychologi-
Rötzer (2004) reports the high incidence of dysphagia in 80 % cal assessment, training and support (Prigatano et al. 1986,
of postacute patients after longterm ventilation, exact per- Finestone et al. 1995), caregiver involvement and training,
centages in former research are not available (Jarrett et al. social support, and recreational therapy. Individual rehabili-
1995, Isherwood et al. 2007). tation plans were established.
30 % of all geriatric patients in hospital are undernourished
(Volkert et al. 2006), a large part of them even at admission, Nutritional management
for the majority of them undernutrition develops further Screening for impaired nutritional and swallowing status was
while in hospital (Davalos et al. 1996). We suppose that this performed within three hours after admission before admin-
could be prevented if special attention would be paid to istering drugs, food or fluid (Kondrup et al. 2003, National
nutritional care. guideline clearinghouse of HSFO 2005).
This clinical study was conducted because in our rehabili- For screening for dysphagia a simple bedside observation
tation setting patients with neurogenic dysphagia seem to was conducted by trained nursing stuff and / or physician
exhibit quite remarkable improvement during neurorehabili- during initial examination including anamnestic data as recent
tation. Thus we investigated the hypothesis that augmented pneumonia, observation of consciousness, severe cognitive
nutritional strategy improves outcome and uncovers the deficits concerning attention, perception, quality of voice,
underestimated rehabilitation potential of stroke patients coughing, slow and effortful eating, globus syndrome, re-
with neurogenic dysphagia. duced deglutition rate. In case of any abnormalities bedside
swallowing assessment was conducted by speech and swal-
Methods/Subjects lowing therapists (SLP) within three hours after admission
including: anamnestic data as recent pneumonia, severe
128 consecutive inpatients undergoing postacute neuro- cognitive deficits see above, preoral swallowing phase, oro-
rehabilitation were enrolled, one patient dropped because facial motor and sensory abilities, pocketing, swallowing
of second stroke event during rehabilitation. Inclusion crite- water, voice quality before / after water according to National
ria were ischemic or hemorrhagic stroke (n = 89), traumatic Guideline Clearinghouse HSFO 2005 (Williams 2006).
brain injury (TBI), severe polyneuro- and myopathy after Bedside FEES was conducted, radiologic videofluoroscopic
complex critical illness (CID) as disabling disease (n = 38), examination of swallowing was conducted if swallowing
minimal duration of stay three weeks and no further stroke assessment remained unclear after FEES (ECRI 1999).
during rehabilitation. Energy and fluid intake was registered daily.
92 men and 35 women with median age of 65 years (SD 13.6)
were included and followed up. Median time since onset of Instrumental examination
signs and symptoms until start of neurorehabilitation was Fiberendoscopic evaluation of swallowing transnasal: inspec-
7.4 weeks, median length of stay was 29 days. 70 patients tion of mucosa, saliva, sialophagia, if possible one teaspoon
were obese (according to body mass index (BMI) > 25 kg /m2). water in different consistencies (food colouring), compensa-
Cognitive deficits (perceptual problems, hemispatial neglect, tory manoeuvres are tested in compliant patients. A speech
attention-, memory-deficits or problems in information pro- and swallowing therapist was always present, to administer
cessing / cognitive deceleration) were detected in 81 out of bolus and test compensatory manoeuvres in compliant
127 patients. patients (ECRI 1999).

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8 WISSENSCHAFTLICHE ARBEITEN

Augmented nutritional strategies including the complete u Barthel Index (BI), early rehabilitation version, was chosen
spectrum of therapeutic approaches: to avoid floor effects: substraction of 50 points each for
u Patients seated with an upright torso position whenever tracheotomy with frequent need for suctioning, need for
fed oral. intensive care and or mechanical ventilation, severe dys-
u Slow feeding rate. phagia, severe disorientation, aphasia from standard (range
u It was ensured that swallowing had taken place before any – 375 to + 100 points; Mahoney et al. 1965, Schönle 1995).
additional food or liquid was offered. For establishing the validity of neurorehabilitative improve-
u Changes of food or fluid consistency. ment we additionally calculated a Barthel Index without
u Oral nutrition supplements if indicated. swallowing associated items (BI-WS).
u Mealtime supervision by nursing stuff, feeding assistance. u Nottingham Basic activities of daily living (BADL, range 0
u Feeding assistance, mealtime supervision by speech and to 13 points; Whiting et al. 1980) and instrumental respec-
speech-language pathologist (SLP). tively extended activities of daily living (EADL, range 0
u Tube feeding (nasogastric or PEG), low threshold for intro- to 17 points; Lawton et al. 1969) covering basic personal
duction of transitory nasogastric tube. (such as grooming) and instrumental ADL such as using
u Parenteral nutrition, as soon as possible combination with the telephone, managing money, and leisure activities.
enteral feeding. u Rivermead motor assessment (RMA) measures motor func-
u In patients with frequent gastroesophageal reflux gastral tion after stroke, with three sections, gross function, leg
tube position was adjusted forwards jejunal. and trunk, arm (range 0 to 38 points; Collin et al. 1990).
u Adequate and safe (aspiration and reflux free) daily ener-
gy and fluid intake were ensured, approximately 1200 to Statistical Analysis
2500 kcal per day depending on metabolic demand (Volkert The statistical package for the social sciences (SPSS for Win-
et al. 2006, Wiliams 2006, ECRI 1999, National guideline dows, 13.0, 2004) was utilized for comparing means between
clearinghouse HSFO 2005, Kondrup et al. 2003). groups (chi-square test, t-test, Mann-Whitney-U-test).
64 of 127 consecutive patients routinely admitted for inpa-
Assessment Instruments tient neurorehabilitation needed nutritional support such
as mealtime supervision, feeding assistance, tube feeding or
For assessment of nutritional status the following parame- intravenous / central venous nutrition to reach safely and as-
ters included in Innsbruck Nutrition Score (INS; Hackl 2004) piration free obligatory daily energy input of approximately
were assessed: 1200 to 2500 kcal per day depending on metabolic rate (body
u Body mass index surface area, primary illness).
u Loss of weight Estimating undernutrition using the three variables BMI, per-
u Creatinin quotient (catabolic index) centage of recent weight loss and recent change in food in-
u Length (days) of oral food intake below 500 kcal /die take included in NRS 2002 in our sample we found 47 patients
Clinical nutrition is not indicated if score < 2, recommended exceeding the critical value of NRS 2002 score > / = 5, clearly
if score 3–4, indispensable if score > 5. INS is used mostly in indicating nutritional intervention, and 80 patients exhibit-
Austria and well established in large cohorts. Retrospectively ing NRS 2002 threshold score 3–4 for risk of undernourish-
we calculated Nutritional risk screening (NRS 2002; Kondrup ment. The latter with 17 patients out of this risk group with
et al. 2003) using the data available in patients’ medical his-
tory (post hoc data acquisition from nurses admission sur-
vey protocol) consisting of the following items: actual BMI Vari- Frequencies
kg /m2, unintentional loss of weight in last three months, able (n = 127)
decrease of food intake over last month, severity of illness.
Obesity (BMI > 25 kg /m2)
Monitoring and re-evaluation is indicated if score is 3–4 70
at admission
implying the threshold for risk of undernourishment. If scor-
Loss of weight > 3 kg 44
ing exceeds the critical value of NRS 2002 > / = 5 nutritional
Creatinin quotient > 25 21
intervention is clearly indicated. INS
Oral energy intake < 500 kcal /day 47
In our sample we found 47 patients with NRS 2002 score > 5,
Oral abstinence > 2 days 45
80 patients scored 3–4 in NRS 2002.
Sequelae known to be associated with neurogenic dysphagia NRS > / = 3 80
NRS > / = 5 47
and nutritional strategies were registered: sepsis, pneumo-
Nutritional support 64
nia, malnutrition, dehydration, tube feeding, vomiting, gas- NRS
Changes in food / fluid consistency 46
troesophageal reflux, osmotic diarrhoea (Volkert et al. 2006, 2002
Meal time supervision 45
Wiliams 2006, Finestone et al. 1995, Axelsson et al. 1988).
Tube feeding 29
Improvement in neurorehabilitation was calculated as the
Cognitive deficits 88
difference of rehabilitation assessment scores at admission
and discharge (Δ-value). Table 1: Patient characteristics for the whole sample

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Variable With nutritional support Without nutritional support P value (test)


(N=64) (N=63)
Age (mean years ± SD) 64.6 ± 12.9 60 ± 14.3 n.s.
Men / women 45 / 19 47 / 16 n.s.
Cognitively impaired (yes /no) 56 / 8 32 / 31 < 0.001 (chi square)
Weeks since onset, median (min.-max.) 6.3 (1.75–51.9) 8 (1.5–46) n.s.
NRS 2002, median (min.-max.) 6 (1–8) 2 (1–6) < 0.001 (U-test)
ΔBADL, median (min.-max.) 3 (0–12) 0 (0–13) 0.009 (U-test)
ΔEADL, median (min.-max.) 1 (0–16) 2 (0–14) n.s.
BI-Admission, median (min.-max.) –40 (–250–55) 40 (–135–100) < 0.001 (U-test)
BI-Discharge, median (min.-max) 25 (–150–100) 80 (0–100) < 0.001 (U-test)
ΔBI, median (min.-max.) 70 (0–250) 30 (0–165) < 0.001 (U-test)
ΔBI-WS, median (min-max.) 50 (0–240) 25 (0–155) 0.011 (U-test)
ΔRMA, median (min.-max.) 3 (0–32) 2 (0–22) n.s.
BMI-Admission, median (min.-max.) 24.8 (15.8–35.8) 25.5 (17–39) n.s.
BMI-Discharge, median (min.-max.) 26.1 (19.1–33.8) 26.3 (20.9–30.6) n.s.

Table 2: Characteristics of study sample splitted for nutritional support

borderline NRS 2002 scoring received nutritional strategies gastric or PEG), a higher percentage of patients (46 /127, 36 %)
according to clinical examination. needing consistency adaptation or mealtime supervision.
Neurogenic dysphagia was caused by problems in all phases The patients enrolled in FOOD trial were recruited within
of swallowing: preoral, oral, intradeglutitive, postdeglutitive the first two to three weeks after stroke for inpatient reha-
phase. A relatively high percentage (69 %) showed clinical rel- bilitation, for our cohort the median time since onset of
evant cognitive deficits such as perceptual problems, hemis- signs and symptoms until admission for neurorehabilitation
patial neglect, attention and/or memory deficits or problems was seven weeks.
in information processing / cognitive deceleration mostly af- In our study we used more sensitive and specific parameters
fecting preoral and oral phase. For these patients meal time to assess outcome in neurorehabilitation: highly significant
supervision and /or feeding assistance was essential. For the improvement could be documented for the ADL scales Basic
group with (n = 64) and the group without (n = 63) nutritional Activities of Daily Living and the Barthel Index, even when
support we found the same bimodal distribution for presence corrected for swallowing specific items. All swallowing com-
(2 / 3) or absence (1 / 3) of cognitive deficits. promised patients as compared to not swallowing disturbed
Using the INS item “daily oral energy intake < 500 kcal“ as nu- patients exhibited under augmented nutritional strategies a
tritional screening score (n = 47), blinded NRS 2002 analysis highly significant better outcome in rehabilitation also when
posthoc found the same group of patients with NRS 2002 scor- swallowing specific parameters were not considered in the
ing > 5 (n = 47). All these patients received nutritional support calculation of rehabilitation improvement.
including the complete spectrum of therapeutic approaches. In accordance with FOOD trial three patients with tube feed-
Characteristics and differences of the two subgroups see ing could not benefit in the same amount from augmented
table 2. Outcome of nutritional supported patients mea- nutrition as oral fed patients from mealtime supervision and
sured by BI, BI-WS and BADL showed highly significant differ- consistency adaptation.
ences in improvement compared to patients without need This confirms our clinical observation that the rehabilitation
for nutritional support. potential of these patients is strongly underestimated. There
is also an analogy between the cohort of FOOD trial 1 and
Discussion our sample: a very low percentage was remarkably under-
nourished. Nevertheless patients are able to swallow, meal-
Discrepancies between our data and the FOOD results (FOOD time supervision also for oral nutritional supplements in this
Trial Collaboration 2003a, 2003b, 2005) could be caused by patient cohort with cognitive deficits is essential.
the following different characteristics of samples: Not only dysphagia related problems showed significant
Most of our patients needed “conservative“ feeding assis- improvement but also mobility, ambulation, gross motor
tance, compared to FOOD trial a relatively small percentage function, cognitive deficits as indicated by the increment of
(29 /127, 23 %) of patients needed tube feeding (either naso- the outcome scales.

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10 WISSENSCHAFTLICHE ARBEITEN

Although there was a high prevalence of obesity with a mean 10. Dávalos A, Ricart W, Gonzalez-Huix F, Soler S, Marrugat J,
BMI at admission of 24.3 kg /m2 in patients receiving nutri- Molins A, et al. (1996): Effect of malnutrition after acute stroke
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11. ECRI (1999). Evidence Report/Technology Assessment Nr. 8.
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To reduce expenditure of time screening possibly could be model to predict stroke outcome in a large simple randomized
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