Early Dysphagia Screening in Stroke Patients

Literature Review on Early Dysphagia Screening in Stroke Patients
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Literature Review on Early Dysphagia Screening in Stroke Patients
To establish what is already known about dysphagia screening in stroke patients and identify an information gap, if any, an electronic search was conducted. Cochrane Library, PubMed Central, and Google Scholar databases were used to search for articles that were no older than five years. The search terms ‘dysphagia in stroke patients,’ ‘dysphagia screening in stroke patients,’’ dysphagia and stroke-associated pneumonia,’ and ‘aspiration pneumonia in stroke patients’ were used. About thirty articles on the topic of dysphagia and pneumonia in stroke patients were yielded and are the focus of this literature review. The goal is to understand what is known about the topic in terms of what counts as early dysphagia screening, dysphagia incidence, predictors of dysphagia and dysphagia screening, as well as the effects of dysphagia screening on stroke patients.
Main Findings from the Literature Review
What Counts as Early Dysphagia Screening
In their article on delays in dysphagia screening after acute stroke, Bray et al. (2017) stipulate that there is a lack of robust evidence on how quickly dysphagia screening should be done to yield the required results. To fill this gap in information, they conducted a study on 63,650 patients with acute stroke. They established that in the first 24 hours, the risk of stroke-associated pneumonia increased by 3% and after 24 hours, the risk increased by an additional 4% (Bray et al., 2017). Indeed, the risk of developing stroke-associated pneumonia increases as the patient delays in receiving dysphagia screening. Grossmann et al. (2021) support this finding that the first few hours of admission are crucial for the detection of dysphagia and the prevention of stroke-associated pneumonia. Also, Eltringham et al. (2018) indicate that it is recommended for dysphagia screening to be done within 4-24 hours after hospital admission. It is unclear from the literature why dysphagia screening needs to wait for at least those 4 hours before it can be initiated. However, it is clear that dysphagia screening should occur within the first 24 hours after hospital admission. Any screening that occurs after 24 hours should not be considered an early intervention for stroke-associated pneumonia because the risks of developing pneumonia increase significantly after the first 24 hours.
Incidence of Dysphagia in Stroke Patients
Dysphagia is a common complication experienced by stroke patients and contributes to the risk of stroke-associated pneumonia. In a prospective clinical trial at a university hospital in Belgium, De Cock et al. (2020) established that the incidence of dysphagia among 151 stroke patients with first ischemic stroke was 23%. However, this incidence was lower than what has been reported previously in other clinical trials. It is unclear why the incidence was lower in this particular study. De Cock et al. (2020) claim that the incidence rate in their study was significantly lower can be substantiated by findings from other studies. For instance, Rofes et al. (2018) conducted an observational cohort study that established that the incidence of oropharyngeal dysphagia was 45%. Kim et al. (2020) indicate that the incidence of dysphagia varies from 50% to 80%. However, it is unclear whether this prevalence rate is at a local, national, or global level. In a systematic review, Pacheco-Castilho et al., (2019) found that the incidence rate of dysphagia in Brazil was 59% to 76%. Oliveira et al. (2019) also reveal that the incidence varies from 8% to 80% depending on the methodology, assessment, and the time that has passed between admission and assessment. Jones et al. (2020) add that the varying incidence rates of dysphagia are a result of varying definitions of dysphagia which can be defined in terms of diet modifications or the scores after a dysphagia screening, among others. What this does is confirm that dysphagia among stroke patients is significantly high and requires interventions that facilitate early detection.
Predictors of Dysphagia and Dysphagia Screening
After examining dysphagia screening among stroke patients in China, Liang et al. (2022) found that the main predictors of dysphagia and dysphagia screening were admission to stroke units and the lack of past stroke history. Patients admitted in non-stroke units, those with a history of stroke, and those with a high National Institute of Health Stroke Scale (NIHSS) score were less likely to be screened for dysphagia. Liang et al. (2022) attributed the lack of screening to the probability that in severe stroke, dysphagia might not be a care priority. Yet, Joundi et al. (2017) found that the main predictor of dysphagia and dysphagia screening was the severity of stroke. They established that compared to patients with severe strokes, patients with mild strokes were less likely to be screened for dysphagia. This differs from Liang et al. (2022) who found that patients with high NIHSS scores (severe stroke) were less likely to be screened for dysphagia. Rofes et al. (2018) further reveal that in addition to past stroke history and high NIHSS scores, other predictors of dysphagia necessitating dysphagia screening were old age and high stroke lesion volume. The location of the lesion also predicts and influences the development of dysphagia in stroke patients (Fernandez-Pombo, et al., 2019).
Other predictors include male gender (Henke et al., 2017), speech deficit, and admission to an intensive care unit (ICU), step-down unit, or a stroke unit (Joundi et al., 2017). The findings of Joundi et al. (2017) differ from those of Liang et al. (2022) because Joundi et al. (2017) found that admission to other non-stroke units also warrants a dysphagia screening. However, Jones et al. (2020) reveal that there are quite a number of predictors of dysphagia and the less commonly mentioned ones in the literature include higher Glasgow Coma Scale on admission, facial palsy, hemorrhagic vs. ischemic stroke, malnutrition/low BMI at admission, brainstem involvement, and presence of dysarthria, among others. This reveals that dysphagia screening is driven by many factors which can vary from patient to patient.
Dysphagia and Stroke-Associated Pneumonia
The risk of developing stroke-associated pneumonia is highly associated with dysphagia (Eltringham et al., 2020). According to a systematic review by Pacheco-Castilho et al. (2019), the prevalence of developing stroke-associated pneumonia when a patient has dysphagia is 22% while the prevalence when a patent has no dysphagia is 2%. Further, in a study by Feng et al. (2019) where stroke patients were classified into dysphagia and non-dysphagia groups; the results revealed that when compared to the non-dysphagia group, patients in the dysphagia group were approximately 4 times more likely to develop stroke-associated pneumonia. This was within a period of one year. Also, the rate of mortality was higher in the dysphagia group. Chang et al. (2022), through a systematic review, also found that the incidence of stroke-associated pneumonia was higher in the dysphagia group when compared to the non-dysphagia group. However, unlike Feng et al. (2019), Chang et al. (2022) found no significant difference in the rate of mortality between the dysphagia and non-dysphagia groups.
However, Phan et al. (2019) and Liang et al. (2022) reveal that stroke-associated pneumonia is caused by more than just dysphagia; it is also caused by the severity of the stroke, older age, and comorbidity, which are also predictors of dysphagia. In addition, whether a patient receives dysphagia screening or not determines whether they will develop stroke-associated pneumonia (Liang et al., 2022). Patients who receive dysphagia screening early are less likely to develop pneumonia. Verma (2019) adds that one of the significant risk factors for stroke-associated pneumonia is dysphagia and related aspiration. As such, one of the interventions that can help reduce this risk is early detection of dysphagia, which can be achieved through early screening. The literature reveals that there is a strong relationship between dysphagia and aspiration pneumonia and that early screening can be beneficial to stroke patients.
Effects of Early Dysphagia Screening
Early dysphagia screening is recommended, especially before any medication or food is given orally because it is associated with a reduction in the rate of pneumonia (Sivertsen et al., 2017). As Schrock et al. (2017) reveal in their study, the rate of hospital-acquired pneumonia among stroke patients was reduced by approximately 6% after dysphagia screening in the emergency department (ED) was implemented. This decline shows that when dysphagia screening is done as soon as stroke patients get to the ED and before they are admitted to various units, their chances of developing stroke-associated pneumonia are significantly lowered. Melgaard et al. (2020) conducted a study to establish the feasibility as well as outcomes of dysphagia screening in the ED and found that such a protocol is feasible and can help in the early detection of pneumonia. Similarly, Yang et al. (2021), Perry et al. (2019), and Sherman et al. (2021) found that dysphagia screening significantly reduces the prevalence of stroke-associated pneumonia. In a systematic review, Boaden et al. (2021) also found weak evidence indicating that dysphagia screening using screening tools with high sensitivity can help in the detection of aspiration risk in patients with acute stroke. Further, Okuni and Ebihara (2022) indicate that the use of screening tools such as the Water Swallowing Test and Gugging Swallowing Test can not only help predict whether a patient will develop stroke-associated pneumonia but can also facilitate prevention based on the results of the screening tests.
However, Teuchl et al. (2018) indicate that approximately 14% of patients ...