Clinical Profile of Dysphagia Post-Acute Stroke J Ind Fed NR
Page | 3
Mehul Desai et al. Journal IFNR Volume 1, Issue 1
INTRODUCTION
Stroke is a major cause of morbidity and mortality
all over the world. In the acute phase, it is
associated with the occurrence of medical
complications such as cardiac complications,
aspiration pneumonia, urinary tract infection, deep
vein thrombosis, pulmonary thromboembolism,
incontinence, depression, anxiety, pressure ulcers,
shoulder pain and dysphagia which further adds to
the miseries of patients and their families and
impairs clinical recovery(1–3). Dysphagia
following acute stroke is a common but often
under-diagnosed and under-recognized entity. The
incidence of dysphagia ranges from 19-81%(4-6)
and this wide range is possibly attributed to the
differences in the study design and the parameters
used for evaluation of dysphagia (4). In acute
stroke patients with dysphagia, there may be rapid
recovery during the first few days or it may remain
persistent at the time of discharge and up to 6
Profile of dysphagia in acute stroke: a prospecve observaonal study
from a terary care centre in Mumbai, India.
Mehul Desai
1
, Nirmal Surya
2
and Hitav Someshwar
3
1. DM resident, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India, 2. Hon. Consultant Neurologist,
Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India. 3. Assistant Professor, Physiotherapy School & Center,
Topiwala Naonal Medical College and BYL Nair Ch. Hospital, Mumbai, Maharashtra, India.
ABSTRACT
Background and Objectives: Acute stroke is a leading cause of morbidity and mortality all around the world. Post-
stroke dysphagia is an important yet under-recognised complication occurring in the post-stroke period that may
result in undernutrition, dehydration, aspiration pneumonitis, and retard the recovery of the patient. Despite the
many path-breaking research in the management of stroke in the present era, post-stroke dysphagia remains a
neglected area of research. Materials and methods: In the current study, consecutive patients of acute stroke who
fulfilled inclusion criteria during hospitalization were evaluated for swallowing functions using a validated scale
with varying consistencies of food at the time of admission and discharge. We analysed different parameters to
evaluate swallowing functions following an acute stroke; incidence of post-stroke dysphagia, association between
stroke severity and dysphagia and lastly impact of the dysphagia on duration of hospital stay and healthcare
expenditure. Results: In our study, the incidence of dysphagia was 35% amongst all categories of acute stroke and
stroke severity at admission was a strong predictor for risk of post-stroke dysphagia. Patients with dysphagia had
higher average NIHSS scores as compared to patients without dysphagia. Despite the high incidence of dysphagia,
most of the patients recovered significantly at the time of discharge. Post-stroke dysphagia was associated with
extended duration of hospital stay and increased cost of healthcare as compared to patients without dysphagia.
Conclusion: Dysphagia is a common complication occurring in patients with acute stroke and is seen in patients
with increasing severity of stroke. Adequate screening of dysphagia and its management can help reduce
complications, reduce hospital stay and the economic burden to the patient.
KEYWORDS- Stroke, Dysphagia, Swallowing, Bed-side swallowing assessment.
CORRESPONDING AUTHOR
Dr. Nirmal Surya,
Hon. Consultant Neurologist,
Bombay Hospital and Medical Research Centre,
Mumbai, Maharashtra, India.
Email- nirmal_surya@gmail.com.
Received on- 1
st
March 2024
Published on- 13
th
July 2024
Clinical Profile of Dysphagia Post-Acute Stroke J Ind Fed NR
Page | 4
Mehul Desai et al. Journal IFNR Volume 1, Issue 1
months (7). If the normal swallowing does not
return by day-10 then significant recovery in
swallowing is unlikely to occur till 2-3 months (8).
Dysphagia following stroke predisposes the
patients to the risk of aspiration pneumonia,
malnutrition and adds significantly to morbidity,
mortality and increases the duration of hospital
stay, hence increasing overall healthcare
expenditure (9–11). While a significant proportion
of patients typically have obvious features of
aspiration such as coughing, choking while
swallowing etc; many times, patients may not have
any overt signs of aspiration – ‘silent
aspiration’(12). Management of acute stroke has
seen many advances and research in the last 2
decades including thrombolysis, mechanical
thrombectomy etc, however management of
dysphagia following stroke is a neglected area of
research. Dysphagia following stroke is a major
cause of pneumonia in this subgroup of patients and
dysphagia is associated with a 3-fold increase and
aspiration is associated with an 11-fold increase in
the risk of pneumonia (4).
Normal swallowing, a very smooth and
coordinated process, requires reflex and voluntary
control that involves smooth orchestration between
the nerves and muscles (13). Sound concept of the
normal physiology of swallowing is a pre-requisite
for understanding complex disorders related to
dysfunctional swallowing ‘dysphagia’! Normal
swallowing is divided into 3 phases: oral,
pharyngeal and oesophageal phase. The oral phase
is further subdivided into oral preparatory and
propulsive phases. During the oral-preparatory
phase, the bolus is processed into smaller pieces by
the process of chewing till it is optimal for
swallowing. During the next stage, processed food
bolus is propelled by the tongue to the oro-pharynx,
completing the first phase of swallowing. The
pharyngeal phase comprises rapid sequential
movement of food bolus from oro-pharynx to
oesophagus. Smooth sequential contraction of
pharyngeal muscles propels safe entry of bolus to
the oesophagus. This phase is integral in airway
protection by preventing entry of food bolus into
larynx. Interplay of several airway protective
mechanisms come into picture like closure of
glottis, elevation of hyoid and larynx as well as
backward tilt of epiglottis to seal laryngeal
vestibule. During the final phase of swallowing
food bolus enters stomach via peristaltic wave of
oesophageal muscles to complete the cycle of
swallowing (13–15). Swallowing is also intricately
linked to respiration such that breathing transiently
ceases while swallowing by two-fold mechanisms
of closure of airway by soft palate and neural
suppression of respiration.
Both hemispheric and brainstem strokes can affect
one or multiple aspects of normal physiology of
swallowing. (16–18)
1) Cerebral lesions cause impairment of neural
control of swallowing.
2) Lesion in primary motor cortex leads to
paresis of contralateral facial, lingual and buccal
musculature.
3) Lesions that affect and cause impairment of
attention and consciousness.
4) Impaired sensations from oral cavity in case
of brain-stem strokes, leading to disruption of
normal smooth process of swallowing.
5) Lower cranial nerve nuclear or fascicular
dysfunction
6) Oro-bucco-lingual apraxia.
Once the primary assessment and management of
acute stroke are taken care of, evaluation for
swallowing functions should be a priority and
preferably be done within first 24 hours. Early
detection of dysphagia and prompt intervention by
speech language pathologists can reduce incidence
of aspiration and pneumonia in patients with acute
stroke(19). Evaluation of dysphagia following
stroke can be done by either bedside swallowing
assessment (BSA) method or with instrumentation
supported procedures like videofluoroscopy (VFS)
and function endoscopic evaluation of swallowing
(FEES). In developing nations like India, where
cost and availability of such procedures preclude its
widespread utility, most centres rely on bedside
assessment for swallowing evaluation for
screening. Various studies have used different
screening tools ranging from simple patient-
oriented questionnaires to more refined scales like
Gugging swallowing screen (GUSS)(20–22). In
view of paucity of data from India, current study
was undertaken to identify profile of dysphagia, its
incidence, association between stroke severity,
Clinical Profile of Dysphagia Post-Acute Stroke J Ind Fed NR
Page | 5
Mehul Desai et al. Journal IFNR Volume 1, Issue 1
vascular territory and presence of dysphagia,
burden of dysphagia on healthcare expenses and
long-term morbidity and mortality.
METHODOLOGY
Study design- Prospective observational study.
The current study was conducted from 1st January
2019 to 31st December 2020 at a tertiary care
centre in Mumbai.
Inclusion criteria- We enrolled 100 consecutive
patients with acute stroke admitted at our centre
over a study period of 2 years. Those fulfilling
exclusion criteria were excluded from the study.
Exclusion criteria included patients with
mechanical dysphagia due to other causes. Patients
with residual dysphagia from previous strokes.
Patients with persistently obtunded state.
All the eligible patients were assessed for
swallowing functions using Nair Hospital Bed-side
Swallowing Assessment (NHBSA) and Nair
Hospital Swallowing Ability Scale (NHSAS)
within 24 hours of admission (23). Patients were re-
assessed once they were shifted out of ICU and at
the time of discharge. Those patients who
continued to have dysphagia on day-7 of
hospitalization were referred to the speech and
swallow clinic and FEES was performed.
TECHNIQUE
All the patients were initially tested in sitting
position with dry swallow testing, which once
found safe, were evaluated using varying
consistencies of food including thin liquids, thick
liquids and soft-solids.(Table 1) Once patients were
assessed with bedside evaluation, their dysphagia
was graded as per Nair hospital swallowing
assessment scale (NHSAS)(23) which is a 7-point
ordinal scale ranging from no dysphagia to slight,
mild, moderate, moderately severe, severe and
complete dysphagia.(23) Informed consent was
taken for everyone who participated in the study
and institutional ethics committee approval was
available.
RESULTS
Out of 100 patients in our study, 58 were males and
42 females. The average age of the patients during
our study was 62.3 years with an age range from
18-94 years. Out of 100 stroke patients, 86 had
ischemic stroke and 14 had haemorrhagic stroke.
(Figure 1) In the category of ischemic stroke, 78
patients had hemispheric strokes and 8
Table 1- Food trials for swallowing assessment
patients had brainstem strokes. Out of 78 patients
with hemispheric ischemic strokes 29 had
dysphagia during initial evaluation. (29/78 =
37.2%). (Figure 2) Out of 8 patients with brainstem
ischemic strokes 5 had dysphagia during early
evaluation. (5/8 = 62.5%). (Figure 3) During follow
up at the time of discharge, 12/78 patients with
acute ischemic hemispheric stroke had persistent
dysphagia while, 3/8 patients with brainstem acute
ischemic stroke had persistent dysphagia. To
summarise, 41% (12/29) of hemispheric and 60%
(3/5) of brainstem stroke patients with dysphagia at
the onset of stroke had persistent dysphagia at the
time of discharge. (Figure 4) Average duration of
hospitalization for patients with dysphagia was
8.53 +/- 2.93 days as compared to 4.52 +/- 0.87
days for patients with no dysphagia. (p<0.0001).
(Figure 5) Duration of hospital stay for patients
who had persistent dysphagia at time of discharge
was 11.25 +/- 2.17 days. (p < 0.002) Patients with
dysphagia had average NIHSS score of 12 +/- 3.77
as compared to patients without dysphagia who had
average NIHSS score of 4.75 +/- 1.81, p < 0.00001.
(Figure 6) Presence of dysphagia was associated
with average total healthcare cost of 96 thousand
INR as compared to those without dysphagia, in
whom average total healthcare expense was 67
thousand INR.
DISCUSSION
Dysphagia, ‘difficulty with swallowing’ is a
commonly encountered condition in patients with
acute stroke of various aetiologies and vascular
territories. Although data about prevalence and
Food trials for
swallowing
assessment
Thin liquid 5 ml water via spoon
Thick liquid 5 ml milk-biscuit mixture
via spoon
Soft solids Small pieces of biscuits
dipped in milk