Risk factors independently associated with the maintenance of severe restriction of oral intake and alternative feeding method indication at hospital outcome in patients after acute ischemic stroke

Leite, Karoline Kussik de Almeida; Sassi, Fernanda Chiarion; Perissinotti, Iago Navas; Comerlatti, Luiz Roberto; Andrade, Claudia Regina Furquim de

doi:10.1016/j.clinsp.2023.100275

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Original articles • Clinics 78 • 2023 • https://doi.org/10.1016/j.clinsp.2023.100275 linkcopy

Risk factors independently associated with the maintenance of severe restriction of oral intake and alternative feeding method indication at hospital outcome in patients after acute ischemic stroke

Authorship SCIMAGO INSTITUTIONS RANKINGS

Background and aims From a clinical point of view, post-stroke patients present difficulties in swallowing management. The purpose of this research was to identify risk factors that were independently related to the maintenance of a severe restriction of oral intake in patients affected by acute ischemic stroke.

Methods The authors conducted a prospective observational cohort study of patients with dysphagia post-acute ischemic stroke who were admitted to an Emergency Room (ER). Demographic and clinical data were collected at ER admission. Swallowing data was based on The Functional Oral Intake Scale (FOIS) and was collected at two distinct moments: initial swallowing assessment and at the patient outcome. Patients were divided into two groups according to their FOIS level assigned on the last swallowing assessment (at hospital outcome): G1 with severe restriction of oral intake and indication of feeding tube - patients with FOIS levels 1 to 4; G2 without restriction of food consistencies in oral intake - patients with FOIS levels 5 to 7.

Results One hundred and six patients were included in our study. Results of the multivariate logistic regression model for the prediction of maintenance of a severe restriction of oral intake at hospital outcome in patients post-acute ischemic stroke indicated that increasing age (p = 0.006), and dysarthria (p = 0.003) were associated with higher chances of presenting severe restriction of oral intake at hospital outcome.

Conclusions Patients with acute ischemic stroke in an Emergency Room may experience non-resolved severe dysphagia, indicating the need to prepare for the care/rehabilitation of these patients.

Keywords
Dysphagia; Deglutition disorders; Stroke; Dysarthria; Gastrostomy

Dysphagia has a high incidence in post-stroke patients.
Alternative long-term feeding method indication in post-stroke patients.
Dysartrhia associated dysphagia in post-stroke patients.

	G1 (n = 72)	G2 (n = 34)	Total (106)	p-value
Age (mean ± SD)	72.9 (12.93)	65.38(12.87)	70.49 (12.91)	0.004 a
Female sex, n (%)	34 (45.84%)	16 (47.2%)	49(46.23%)	0.987b
*Previous neurological injury,* n (%)**	43 (59.7%)	9 (26.5%)	55(51.88%)	0.001 b
Lateralization, n (%)				0.269c
Left	39(54.17%)	19(55.88%)	58(54.72%)
Rigth	30(41.67%)	15(44.12%)	45(42.45%)
Bilateral	3(4.16%)	0	3 (2.83%)
Circulation, n (%)				0.541c
Carotid Territory	61 (84.72%)	31(91.18%)	92(86.79%)
Vertebral basilar territory	11(15.28%)	3 (8.82%)	14(13.20%)
NIHSS, n (%)
0 to 5	8(11.11%)	2(5.89%)	10(9.44%)	0.513b
6 to 13	18(25%)	14(41.17%)	32(30.18%)	0.151a
> 14	46(63.89%)	18(52.94%)	64(60.38%)	0.077 a
Acute opercular injury, n (%)	32 (50%)	17 (40.5%)	49(46.22%)	0.121b
Thrombectomy on admission, n (%)	1 (1.38%)	1 (2.94%)	2 (1.88%)	0.541c
Thrombolysis on admission, n (%)	20 (27.78%)	17 (50%)	37(34.90%)	0.025 b
Hemorrhagic transformation, n (%)	10 (13.88%)	6 (17.64%)	16(15.09%)	0.772c

	G1 (n = 72)	G2 (n = 34)	Total (106)	p-value
Number of days from swallowing assessment to oral feeding return (mean ± SD)	3.33 (3.61)	2.88 (4.05)	3.11 (3.81)	0.435d
Use of alternative feeding tube before swallowing assessment, n (%)	27 (37.5%)	10 (29.41%)	37 (34.90%)	0.415b
Pre-swallowing assessment fasting, n (%)	42 (58.33%)	23 (67.64%)	65 (61.32%)	0.358b
Exclusive alternative feeding tube indication after swallowing assessment, n (%)	52 (72.22%)	12 (35.29%)	64 (60.38%)	<0.001 b
Alternative feeding method associated a oral feeding indicated after swallowing assessment, n (%)	20 (22.78%)	22 (64.71%)	42 (39.62%)	<0.001 b
Number of days from swallowing assessment to recommendation to remove the alternative feeding indication (mean±SD)	9 (5.43)	6.29 (5.55)	6.64 (5.38)	0.751d
In-hospital gastrostomy, n (%)	17 (23.61%)	1 (2.94%)	18 (16.98%)	0.011 c
FOIS at swallowing assessment (mean ± SD)	2 (0.95)	2.94 (0.86)	2.3 (1.02)	<0.001 d
FOIS at hospital outcome (mean ± SD)	2.22 (1.09)	5.97 (0.87)	3.42 (2.03)	<0.001 d
Indication to remove alternative feeding method at hospital outcome, n (%)	0	34 (100%)	34 (32.07%)	<0.001 c

Hospital outcome	G1 (n = 72)	G2 (n = 34)	Total (106)	p-value
Hospital discharge, n (%)	42 (58.33%)	32 (94.12%)	74 (69.81%)	<0.001a
Suspended swallowing therapy due clinical worsening, n (%)	8 (11.11%)	0	8 (7.54%)	0.052a
Hospital transfer, n (%)	7 (9.72%)	2 (5.88%)	9 (8.49%)	0.715a
In-hospital death, n (%)	15 (20.83%)	0	15 (14.15%)	0.002a
Death < 2 months post-outcome, n (%)	13 (22.81%)	1 (2.94%)	14 (15.38%)	0.014a

	G1 (n = 72)	G2 (n = 34)	Total (106)	p-value
Dysphonia, n (%)	48 (66.66%)	12 (35.29%)	60 (56.60%)	0.002a
Altered gag reflex, n (%)	48 (66.66%)	16 (47.05%)	64 (60.37%)	0.054a
Weak/ineffective cough, n (%)	50 (69.44%)	13 (38.23%)	63 (59.43%)	0.002a
Vocal alteration in water test, n (%)	44 (61.11%)	11 (32.35%)	55 (51.88%)	0.006a
Cough in water test, n (%)	62 (86.11%)	18 (52.94%)	80 (75.47%)	<0.001a
Dysarthria, n (%)	66 (91.66%)	23 (67.64%)	89 (83.96%)	0.002a
Aphasia, n (%)	44 (61.11%)	15 (44.11%)	59 (55.66%)	0.100a
Facial palsy, n (%)	63 (87.5%)	33 (97.05%)	96 (90.56%)	0.116a
Lowered level of consciousness, n (%)	28 (38.88%)	6 (17.64%)	34 (32.07%)	0.029a

	Odds Ratio	95% IC		p-value
		Inferior	Superior
Age	1.04	1.00	1.09	0.046 a
Previous Neurological Injury	2.31	0.78	6.87	0.131
Thrombolysis on admission	0.40	0.14	1.17	0.096
Dysphonia	1.64	0.35	7.63	0.527
Altered gag reflex	1.10	0.26	4.65	0.893
Weak/ineffective cough	0.99	0.19	5.28	0.994
Vocal alteration after swallowing	0.80	0.14	4.64	0.809
Cough in water test	3.11	0.97	10.01	0.056
Dysarthria	5.29	1.19	23.46	0.028 a
Lowered level of consciousness	1.07	0.25	4.57	0.924

	Odds Ratio	95% CI		p-value
		Lower	Upper
Age	1.05	1.02	11.09	0.006 a
Dysarthria	6.01	1.87	19.33	0.003 a

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[1] DP, Standard Deviation; n, number of participants; %, Percentage of participants; G1, With severe restriction of oral intake; G2, Without severe restriction of oral intake; NIHSS, National Institute of Health Stroke Scale; IQR, Interquartile Amplitude.

[TFN1] ^a
Significant difference (p < 0.05) in the t-test.

[TFN2] ^b
Significant difference (p < 0.05) in Pearson's Chi-square test.

[TFN3] ^c
Significant difference (p < 0.05) in Fisher's exact test.

FOIS 1	Nothing by mouth
FOIS 2	Tube dependent with minimal attempts of food or liquid
FOIS 3	Tube dependent with consisitent oral intake of food or liquid
FOIS 4	Total oral diet of a single consistency
FOIS 5	Total oral diet with multiple consistencies, but requiring special preparation or compensations
FOIS 6	Total oral diet with multiple consistencies without special preparation, but with specific food limitation
FOIS 7	Toral oral diet with no restrictions