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

Published on Jan 1, 2018in Cerebrovascular Diseases2.681
· DOI :10.1159/000487811
Sonja Suntrup-Krueger7
Estimated H-index: 7
,
Jens Minnerup27
Estimated H-index: 27
+ 7 AuthorsRainer Dziewas34
Estimated H-index: 34
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.
  • References (36)
  • Citations (1)
References36
Newest
#1Sarah Hoffmann (Charité)H-Index: 9
#2Hendrik J. HarmsH-Index: 21
Last. Andreas Meisel (Charité)H-Index: 50
view all 17 authors...
Stroke-associated pneumonia is a frequent complication after stroke associated with poor outcome. Dysphagia is a known risk factor for stroke-associated pneumonia but accumulating evidence suggests that stroke induces an immunodepressive state increasing susceptibility for stroke-associated pneumonia. We aimed to confirm that stroke-induced immunodepression syndrome is associated with stroke-associated pneumonia independently from dysphagia by investigating the predictive properties of monocytic...
22 CitationsSource
#1Benjamin D. Bray (UCL: University College London)H-Index: 14
#2Craig J. Smith (MAHSC: Manchester Academic Health Science Centre)H-Index: 27
Last. Anthony Rudd ('KCL': King's College London)H-Index: 59
view all 9 authors...
Background There is no robust evidence that screening patients with acute stroke for dysphagia reduces the risk of stroke-associated pneumonia (SAP), or of how quickly it should be done after admission. We aimed to identify if delays in bedside dysphagia screening and comprehensive dysphagia assessments by a speech and language therapist (SALT) were associated with patients9 risk of SAP. Methods Nationwide, registry-based, prospective cohort study of patients admitted with acute stroke in Englan...
35 CitationsSource
#1Gaurav Gadodia (Emory University)H-Index: 1
#2Nibal Rizk (Lebanese American University)H-Index: 1
Last. Fadi Nahab (Emory University)H-Index: 12
view all 12 authors...
Objective There are limited data on which patients not treated with intravenous (IV) tissue-type plasminogen activator (tPA) due to mild and rapidly improving stroke symptoms (MaRISS) have unfavorable outcomes. Materials and Methods Acute ischemic stroke (AIS) patients not treated with IV tPA due to MaRISS from January 1, 2009 to December 31, 2013 were identified as part of the Georgia Coverdell Acute Stroke Registry. Multivariable regression analysis was used to identify factors associated with...
1 CitationsSource
#1Sonia HinesH-Index: 10
#2Kathryn KynochH-Index: 6
Last. Judy MundayH-Index: 6
view all 3 authors...
AbstractBackground: Dysphagia, or difficulty in swallowing, is a serious and life-threatening medical condition that affects a significant number of individuals with acute neurological impairment, largely from stroke. Dysphagia is not generally considered a major cause of mortality; however, the com
8 CitationsSource
#1Mohamed Al-KhaledH-Index: 10
#2Christine MatthisH-Index: 7
Last. Georg RoylH-Index: 17
view all 12 authors...
Background: Dysphagia is associated with poor outcome in stroke patients. Studies investigating the association of dysphagia and early dysphagia screening (EDS) w
17 CitationsSource
Aim Sarcopenia can cause varying physical function disorders, including dysphagia. Malnutrition, a potential result of dysphagia, can also cause sarcopenia. However, the association between sarcopenia and dysphagia is not fully understood, despite evidence suggesting correlations between deglutition disorders and degenerative loss of muscle mass. The present study investigated the prevalence of dysphagia among patients with sarcopenia, and the association between the two conditions. Methods We i...
73 CitationsSource
#1David L Cohen (Northwick Park Hospital)H-Index: 5
#2Christine Roffe (Keele University)H-Index: 27
Last. Philip M.W. Bath (University of Nottingham)H-Index: 67
view all 19 authors...
Post-stroke dysphagia (a difficulty in swallowing after a stroke) is a common and expensive complication of acute stroke and is associated with increased mortality, morbidity, and institutionalization due in part to aspiration, pneumonia, and malnutrition. Although most patients recover swallowing spontaneously, a significant minority still have dysphagia at six months. Although multiple advances have been made in the hyperacute treatment of stroke and secondary prevention, the management of dys...
47 CitationsSource
#1Marcel ArnoldH-Index: 53
#2Kai Timo LiesirovaH-Index: 3
Last. Hakan SarikayaH-Index: 20
view all 10 authors...
BACKGROUND Reported frequency of post-stroke dysphagia in the literature is highly variable. In view of progress in stroke management, we aimed to assess the current burden of dysphagia in acute ischemic stroke. METHODS We studied 570 consecutive patients treated in a tertiary stroke center. Dysphagia was evaluated by using the Gugging Swallowing Screen (GUSS). We investigated the relationship of dysphagia with pneumonia, length of hospital stay and discharge destination and compared rates of fa...
62 CitationsSource
#1Margitta T. Kampman (UNN: University Hospital of North Norway)H-Index: 21
#2Agnethe Eltoft (UNN: University Hospital of North Norway)H-Index: 2
Last. Stein Harald Johnsen (UNN: University Hospital of North Norway)H-Index: 23
view all 7 authors...
Background and Purpose:In patients with acute stroke, undernutrition and aspiration pneumonia are associated with increased mortality and length of hospital stay. Formal screening for nutritional risk and dysphagia helps to ensure optimal nutritional management in all patients with stroke and to reduce the risk of aspiration in patients with dysphagia. We developed a national guideline for nutritional and dysphagia screening in acute stroke, which was introduced in our stroke unit on June 1, 201...
2 CitationsSource
#1Darius G. NabaviH-Index: 34
#2Martin Ossenbrink (TÜV Rheinland)H-Index: 1
Last. Otto BusseH-Index: 20
view all 6 authors...
Zum 01.07.2015 werden die aktualisierten Zertifizierungskriterien fur regionale und uberregionale Stroke-Units (SU) in Deutschland wirksam. Aufgrund des vorbestehend hohen Qualitatsniveaus waren an vielen Stellen moderate Anpassungen und Konkretisierungen ausreichend. So wurde ein Grosteil der strukturellen Mindestmerkmale fortgeschrieben. Fur das arztliche Personal wurden erstmals Obergrenzen definiert, ab wann eine personelle Verstarkung notwendig wird. Die aktuellen Studienergebnisse zur endo...
17 CitationsSource
Cited By1
Newest
#1Miranda J. Cullins (UW: University of Wisconsin-Madison)H-Index: 2
#2Nadine P. Connor (UW: University of Wisconsin-Madison)H-Index: 2
Abstract Purpose Dysphagia is a common problem after stroke that is often associated with tongue weakness. However, the physiological mechanisms of post-stroke tongue muscle weakness and optimal treatments have not been established. To advance understanding of physiological mechanisms of post stroke dysphagia, we sought to validate the unilateral transient middle cerebral artery occlusion (MCAO) rat model of ischemic stroke as a translational model of post stroke dysphagia. Our goal was to estab...
1 CitationsSource
#1Bendix Labeit (MIT: Massachusetts Institute of Technology)
#2Paul MuhleH-Index: 7
Last. Rainer Dziewas (MIT: Massachusetts Institute of Technology)H-Index: 1
view all 4 authors...
Schluckstorungen haben bei nahezu allen neurologischen Erkrankungen eine hohe Pravalenz. Sie fuhren neben Mangelernahrung und Dehydration zu schwerwiegenden Komplikationen wie Aspirationspneumonie, die eine der haufigsten Todesursachen bei neurologischen Patienten darstellt. Ein fruhzeitiges Dysphagiemanagement verbessert deshalb nicht nur die Lebensqualitat der Patienten entscheidend, sondern senkt die Mortalitat. Dieser Artikel gibt eine Ubersicht diagnostischer und therapeutischer Verfahren d...
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