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Inicio Revista Científica de la Sociedad Española de Enfermería Neurológica (Englis... Effect of stroke on nutritional status and its relationship with dysphagia
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Original article
DOI: 10.1016/j.sedeng.2019.04.003
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Available online 22 September 2019
Effect of stroke on nutritional status and its relationship with dysphagia
Influencia del ictus en el estado nutricional y su relación con la disfagia
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M. Ángeles Ortega Barrio
Corresponding author
aortegab@saludcastillayleon.es

Corresponding author.
, Florita Valiñas Sieiro, M. Teresa Almarza Fernández, Sara Bravo Santamaría, Rafael Moreno Maestro
Enfermería, Servicio de Neurología, Hospital Universitario, Burgos, Spain
Received 25 July 2018. Accepted 01 April 2019
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Tables (2)
Table 1. Sociodemographic, clinical characteristics and those relating to the functional capacity of the patients included in the study on admission, at discharge and at 3 months.
Table 2. Descriptive analysis of the demographic variables and stroke type compared with the rest of the variables collected on admission.
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Abstract
Aim

To study the relationship between malnutrition and dysphagia in stroke patients.

Method

An observational, descriptive, longitudinal and prospective study that included 183 patients admitted to the neurological department of the University Hospital of Burgos with a diagnosis of stroke. Sociodemographic and clinical variables were collected using body mass index (BMI), CONUT index, Mini Nutritional Assessment (MNA), Barthel's index, Rankin scale, volume-viscosity clinical examination method, on admission, on discharge, and at 3 months.

Results

On admission to hospital, 64.3% (92) of the patients had some degree of malnutrition according to the CONUT index, and 13.4% (22) were at risk of malnutrition according to the MNA. The median (interquartile range) of dependency was 100 (90;100). The median disability was 1 (0;2). Forty point four percent (67) of the patients had dysphagia.

At 3 months, using the abovementioned scales, 58.2% of the patients had some degree of malnutrition, and 17.1% (28) were at risk of malnutrition. The median dependency was 95 (80;100). The median disability was 1 (1;3). Twelve percent (20) had dysphagia. There was a statistically significant relationship between dysphagia and level of malnutrition according to the CONUT index on admission (p=.021) and at 3 months (p=.045), and according to the MNA at 3 months (p=.009).

Conclusion

In stroke patients, there is an association between dysphagia and malnutrition, both on admission to hospital and at three months. After initial worsening, an improvement was observed at 3 months with regard to the degree of dependency and disability but pre-stroke levels were not achieved.

Keywords:
Cerebrovascular accident
Swallowing disorders
Malnutrition
Disability assessment
Dependency
Resumen
Objetivo

Estudiar la relación entre desnutrición y disfagia en pacientes con ictus.

Método

Estudio observacional, descriptivo, longitudinal y prospectivo que incluyó 183 pacientes ingresados en Neurología del Hospital Universitario de Burgos, diagnosticados de ictus. Se recogieron variables sociodemográficas y clínicas utilizando el índice de masa corporal (IMC), el índice CONUT, el Mini Nutritional Assessment (MNA), el índice de Barthel, la escala de Rankin y el método de exploración clínica volumen-viscosidad al ingreso, al alta hospitalaria y a los 3 meses.

Resultados

Al ingreso el 64,3% (92) de los pacientes presentaban algún grado de desnutrición según CONUT y el 13,4% (22) tenían riesgo de malnutrición según el MNA. La mediana (rango intercuartílico) de la dependencia fue 100 (90;100). La mediana de la discapacidad fue 1 (0;2). El 40,4% (67) de los pacientes presentaban disfagia.

A los 3 meses, utilizando las escalas anteriores, el 58,2% (83) de los pacientes presentaban algún grado de desnutrición y el 17,1% (28) tenían riesgo de malnutrición. La mediana de la dependencia fue 95 (80;100). La mediana de la discapacidad fue 1(1;3). El 12% (20) tenían disfagia. Existe una relación estadísticamente significativa entre disfagia y grado de desnutrición según CONUT al ingreso (p=0,021) y a los 3meses (p=0,045), y según el MNA a los 3meses (p=0,009).

Conclusión

En los pacientes con ictus existe una asociación entre disfagia y desnutrición tanto al ingreso como a los 3 meses. Tras el empeoramiento inicial, se objetiva mejoría a los 3meses en relación con el grado de dependencia y discapacidad, sin llegar a alcanzar los valores previos al ictus.

Palabras clave:
Accidente cerebrovascular
Trastornos de la deglución
Desnutrición
Evaluación de la discapacidad
Dependencia
Full Text
Introduction

A sudden disruption of cerebral blood flow that temporarily or permanently alters the function of a particular region of the brain is termed stroke.1 Stroke is a major cause of disability; in fact, it is the leading cause of permanent disability in adulthood.2 The cumulative incidence rates of cerebrovascular disease (CVD) were 218 (95% CI: 214–221) in males and 127 (95% CI: 125–128) in females.3

In the particular case of Spain, the cumulative incidence rate of CVD per 100,000 inhabitants has risen in the population >24 years of age to 218 new cases in males and 127 in females.4 Even with appropriate treatment, more than 30% of patients who survive a stroke have significant sequelae, which limit their activities of daily living, often require care from relatives and other people, and result in important health expenditure.5

Dysphagia is one of the most important clinical manifestations of stroke, defined as difficulty in passing the food bolus efficiently and safely.3 Studies performed in patients with dysphagia after a stroke have shown that it is often transitory, which could explain the wide variation in its prevalence, between 28% and 73%.3,6,7

Complications associated with dysphagia significantly increase mortality in these patients and contribute to poor prognosis in terms of morbidity and functional recovery. These include dehydration, malnutrition or respiratory infection of bronchoaspiratory origin.8

In acute processes of CVD, correct nutritional management is associated with better outcomes, from a functional perspective and in the prevention of complications.9 At the time of their stroke up to 20% of patients are already malnourished, probably due to advanced age and some previous disability, which is associated with a poorer prognosis. After a stroke, nutritional status deteriorates, generally due to dysphagia and neurological deficits that make autonomous feeding difficult.3

We sought to undertake a study to describe the clinical-nutritional status of stroke patients in the province of Burgos, its relationship with dysphagia and its progression over time.

The general objective of this study is to examine the relationship between malnutrition and dysphagia in stroke patients. The specific aims were to analyse the nutritional status, presence of dysphagia, degree of disability, and the functional dependence of patients hospitalised after a stroke on admission and at 3 months.

Methodology

This is an observational, descriptive, prospective and longitudinal study in which a first assessment was made on admission, then at discharge and at 3 months after discharge from hospital.

Participants

The study included 183 patients admitted to the neurology department of the University Hospital of Burgos (HUBU) from 1 November 2015 to 30 June 2016 with a diagnosis of stroke. The exclusion criteria were: residence abroad, in-hospital death, carrying an enteral tube or having been diagnosed with dysphagia prior to admission. All the patients agreed to participate voluntarily and gave their written consent, with due data protection in accordance with current legislation (Law 15/1999, of 13 December, on Personal Data Protection), and HUBU's Clinical Research Ethics Committee approved the study.

Instruments for the collection of data

The following questionnaires, indices, scales and examination methods were used:

  • Semi-structure questionnaire. The following sociodemographic and clinical variables were collected: age, sex, type of stroke (ischaemic or haemorrhagic), social assessment (living alone/accompanied/institutionalised), antidepressant treatment (yes/no), diagnosis of cognitive impairment according to medical criteria (yes/no), active oncological processes recorded in the clinical history (yes/no), height, weight (with scales adapted to bed) and analytical values (cholesterol, albumin and lymphocytes).The socio-family assessment is based on the social assessment scale used in HUBU by protocol.Regarding the assessment of anxiety and depression, we show the patients under treatment with antidepressants or anxiolytic drugs. It is down to the physician to prescribe treatment in the cases they deem necessary.

  • Assessment of nutritional status

  • 1.

    Body mass index (BMI). This assesses the weight and height ratio. It is divided into the following categories: <18.5: underweight; 18.5–24.9: healthy; 25.0–29.9: overweight; 30.0–39.9: obese; >40: extreme or high-risk obesity.10

  • 2.

    CONUT Index. This is a filter system that uses the analytical parameters of serum albumin, total cholesterol and total lymphocyte count to screen for malnutrition. The scores according to plasma levels and severity levels of malnutrition risk are no risk of malnutrition (0–1), mild risk of malnutrition (2–4), moderate risk of malnutrition (5–8) and severe risk of malnutrition (>8).11

  • 3.

    Mini Nutritional Assessment (MNA). This is a simple, reliable and inexpensive tool for detecting the presence or risk of malnutrition in the ambulatory geriatric population, hospital inpatients or people in geriatric institutions. It includes two questionnaires. The first, the MNA-SF, examines 6 sections and helps rule out the risk of malnutrition; a result ≥11 points implies normal nutrition, ≤10 points possible malnutrition, making it necessary to continue with the second questionnaire, which examines 12 sections and enables a precise assessment of nutritional status; an overall score of 17–23.5 implies risk of malnutrition, and less than 17 points malnutrition.10

  • Assessment of state of dependency and disability

  • 4.

    Barthel index. A scale designed by Mahoney and Barthel (1965) that assesses an individual's functional capacity and level of autonomy to carry out the basic activities of daily living. Degree of dependency: 0–20: total dependency; 21–60: severe dependency; 61–90: moderate dependency; 91–99: mild dependency; 100: independent.12,13The patients’ dependency was measured on three occasions during the study: before the stroke, at the time of discharge and at 3 months.

  • 5.

    Modified Rankin Scale. This assesses global disability, not specific activities. Its score ranges from 0 (no symptoms) to 6 (death).14

  • Assessment of dysphagia

  • 6.

    Volume-viscosity swallow test (V-VST)). A screening method that enables the detection of patients with dysphagia, the existence of clinical or silent aspiration, to select the safest and most efficient volume (5, 10 and 20ml) and viscosity (syrup, liquid and pudding) of the bolus for fluid intake and appropriately programme instrumental examination.3We highlight that at the time of admission none of the patients had a diagnosis of dysphagia and the V-VST was performed during admission at 3 months.

Procedure

All the patients were assessed for the study on three occasions: initially on admission, on discharge from hospital and at the 3-month follow-up. The patients or those responsible included in the study were contacted by telephone, and those who wanted to continue participating were given an appointment in the Neurology department. The data was collected by all the investigators.

Statistical analysis

The data were processed using IBM SPSS 19® with a 95% confidence interval (CI). Microsoft Office Excel 2010 was used beforehand for the collection and processing of the data. The level of statistical significance is .05.

A descriptive analysis of the sample was carried out, providing means±standard deviation or medians (interquartile range) for the quantitative variables, depending on whether or not they complied with normality (Kolmogorov–Smirnof test), and absolute frequencies (relative frequencies) for the qualitative variables.

Possible differences between the different variables were evaluated by the χ2-test (Fisher's) test for qualitative variables and the Student's t-test for independent samples/ANOVA (provided that conditions of use were verified; otherwise, the corresponding non-parametric tests: Mann–Whitney U/Kruskall–Wallis) if one of the variables was quantitative.

The following tests were used for related samples: McNemar's test (two qualitative), Student's t-test for related samples (two quantitative, or their nonparametric Wilcoxon test), Friedman test (more than two quantitative) and Cochran Q test (more than two dichotomous variables).

Results

Of an initial sample of 183 subjects, 17 were excluded for different reasons (voluntary withdrawal, death and refusal to undergo check-up). Of the 166 patients who were eventually included, the median (interquartile range) age was 78 (66;84), with a range of 34–94 years; 93 were male(56%) and 73 (44%) female (Table 1).

Table 1.

Sociodemographic, clinical characteristics and those relating to the functional capacity of the patients included in the study on admission, at discharge and at 3 months.

  n  Admission  Discharge  At 3 months  p* 
Sex, n (%)
Male  166  93 (56.0)       
Female    73 (44.0)       
Age, median (interq. range)  166  78 (66;84)       
Type of stroke, n (%)
TIA  166  15 (9.0)       
Haemorrhagic stroke    17 (10.2)       
Ischaemic stroke    134 (80.7)       
Height (m), mean±standard dev.  156  1.6±.1       
Weight (kg), mean±standard dev.  156  72.3±15.8    71.3±14.2  .021a 
BMI, mean±standard dev.  156  27.3±3.9    27.0±3.8  .022a 
Sociofamiliar situation, n (%)
Accompanied  166  133 (80.1)  121 (73.3)  128 (77.1)  <.001b 
Institutionalised    8 (4.8)  26 (15.8)  20 (12.0)   
Living alone    25 (15.1)  18 (10.9)  18 (10.8)   
Antidepressant treatment, n (%)
Yes  165  29 (17.6)  34 (20.6)  40 (24.2)  .019c 
Cognitive impairment, n (%)
Yes  165  17 (10.3)  37 (22.4)  34 (20.6)  <.001c 
Cognitive impairment, n (%)
Yes  165  2 (1.2)  2 (1.2)  4 (2.4)  .368c 
Cholesterol, mean±standard dev.  157  165.8±32.7    151.4±33.8  <.001a 
Albumin, median (interq. range)  144  3.6 (3.4;3.9)    4.2 (3.7;4.4)  <.001d 
Lymphocytes, median (interq. range)  158  1700 (1300;2300)    1950 (1500;2500)  <.001d 
Barthel Index, median (interq. range)  165  100 (90;100)  90 (60:100)  95 (80;100)  <.001e 
Ranking Scale, median (interq. range)  165  1 (0;2)  2 (1;3)  1 (1;3)  <.001e 
Mini nutritional
Normal nutrition  164  141 (86.0%)    134 (81.7%)  .478b 
Risk of malnutrition    22 (13.4%)    28 (17.1%)   
Malnutrition    1 (.6%)    2 (1.2%)   
CONUT index
Without malnutrition  143  51 (35.7%)    60 (42.0%)  .472b 
Mild malnutrition    72 (50.3%)    69 (48.3%)   
Moderate malnutrition    20 (14.0%)    14 (9.8%)   
Dysphagia
Yes  166  67 (40.4%)    20 (12.0%)  <.001 
*

Significant value for p<.05.

a

Repeated measures t-test.

b

McNemar's test.

c

Cochran Q test.

d

Wilcoxon test.

e

Repeated measures Friedman test.

The stroke types were distributed as: haemorrhagic (10.2%), ischaemic (80.7%) and TIA (9%) (Table 1).

The mean (±standard deviation) BMI on admission was 27.3±3.9 (Table 1). Grouped together, they were classified as: normal weight (26.1%), overweight (52.8%), obese (20.5%) and underweight (.6%). Regarding BMI, statistically significant differences were observed in the mean at admission and at 3 months, and although the patients had lost weight at 3 months, the mean of the sample was in the overweight category (p=.021) (Fig. 1).

Figure 1.

Comparison between body mass index (BMI) on admission and at 3 months.

(0.11MB).

A total of 4.8% of the patients were institutionalised in social health centres before their stroke; this rose to 15.8% on discharge from hospital, although this increase does not imply any statistically significant differences (Table 1).

At the time prior to admission, 17.6% of the patients were under antidepressant treatment, this percentage rose to 20.6% on discharge and to 24.2% at 3 months. Therefore, statistically significant differences were observed in the percentage of patients on antidepressant treatment pre- and post- stroke (p=.019) (Table 1).

Prior to admission, 10.3% of the patients had been diagnosed with cognitive impairment, this rose to 22.4% on discharge and reduced to 20.6% at 3 months. Therefore, statistically significant differences were observed in relation to cognitive impairment (p<.001) (Table 1).

In relation to plasma values, there was a reduction in cholesterol levels at 3 months and an increase in albumin with respect to on admission (Table 1).

With regard to the nutritional assessment, 64.3% of the patients had malnutrition at the time of admission according to the CONUT index, while 13.4% had a risk of malnutrition according to the MNA and only.6% had established malnutrition.

At 3 months, the percentage of malnourished patients according to the CONUT index had dropped to 58.2%, and to 17.1% according to the MNA. Thus, there were differences in relation to the nutritional assessment according to the CONUT index and to the MNA, although these were not statistically significant: p=.472 and p=−.478, respectively (Table 1).

Regarding functional capacity variables (Barthel index), on admission the patients had a median of 100 (90;100) and 1(0;2) on the Modified Rankin Scale. This degree of dependency and disability increased on discharge and had reduced at 3 months, without reaching pre-admission levels (p<.001) (Table 1).

The percentage of patients with dysphagia during admission was 40.4%, whereas this percentage had reduced to 12% at 3 months (Table 1).

A descriptive analysis of the sample was performed comparing the variables collected on admission with the demographic variables and stroke type to describe their distribution (Table 2).

Table 2.

Descriptive analysis of the demographic variables and stroke type compared with the rest of the variables collected on admission.

  Variables on admission  n  Male (n=93)  SexAge  TIA (n=15)  Type of stroke
        Female (n=73)  p*    ≤65 (n=40)  >65 and ≤80 (n=59)  >80 (n=67)  p*      Haemorrhagic stroke (n=17)  Ischaemic stroke (n=134)  p* 
Sex, n (%)Male  166        35 (87.5)  30 (50.8)  28 (41.8)  <.001  7 (46.7)  9 (52.9)  77 (57.5)  .701
Female          5 (12.5)  29 (49.2)  39 (58.2)      8 (53.3)  8 (47.1)  57 (42.5) 
Age, median (interq. range)≤65  16635 (37.6)  5 (6.8)  <.0011          5 (33.3)  3 (17.6)  32 (23.9)  .749
>65 and ≤80  30 (32.3)  29 (39.7)            4 (26.7)  8 (47.1)  47 (35.1) 
>80  28 (30.1)  39 (53.4)                6 (40.0)  6 (35.3)  55 (41.0) 
Stroke type, n (%)TIA  1667 (7.5)  8 (11.0)  .70115 (12.5)  4 (6.8)  6 (9.0)  .749         
Haemorrhagic stroke  9 (9.7)  8 (11.0)  3 (7.5)  8 (13.6)  6 (9.0)             
Ischaemic stroke  77 (82.8)  57 (78.0)  32 (80.0)  47 (79.7)  55 (82.1)             
Mean BMI±standard dev.    156  27.7±3.5  26.8±4.5  .146  28.7±4.1  26.6±2.8  27.1±4.6  .033  27.8±2.8  26.4±3.6  27.3±4.1  .627a 
Sociofamiliar situation, n (%)Accompanied  16682 (88.2)  51 (69.9)  .012134 (85.0)  51 (86.4)  48 (71.7)      12 (80.0)  15 (88.2)  106 (79.1)   
Institutionalised  2 (2.2)  6 (8.2)  0 (.0)  1 (1.7)  7 (10.4)      0 (.0)  1 (5.9)  7 (5.2)   
Living alone  9 (9.7)  16 (21.9)  6 (15.0)  7 (11.9)  12 (17.9)      3 (20.0)  1 (5.9)  21 (15.7)   
Median Barthel Index (interq. range)    165  100 (95;100)  95 (82;100)  .001  100 (100;100)  100 (95;100)  87 (64;100)  <.001  100 (90;100)  95 (85;100)  100 (90;100)  .384b 
Median RANKIN Scale (interq. range)    165  0 (0;2)  1 (0;2)  .073  0 (0;0)  0 (0;1)  2 (1;3)  <.001  0 (0;2)  1 (0;3)  1 (0;2)  .211b 
Mini NutritionalNutrición normal  16483 (90.2%)  58 (80.6%)      36 (90.0%)  53 (91.4%)  48 (71.7%)      15 (100%)  16 (94.1%)  110 (83.3%)   
Malnutrition risk  9 (9.8%)  13 (18.1%)      4 (10.0%)  4 (6.9%)  14 (21.2%)      0 (.0%)  1 (5.9%)  21 (15.9%)   
Malnutrition  0 (.0%)  1 (1.4%)      0 (.0%)  1 (1.7%)  0 (.0%)      0 (.0%)  0 (.0%)  1 (.8%)   
CONUT indexWithout malnutrition  14329 (37.2%)  22 (33.8%)  .371118 (54.5%)  20 (37.0%)  13 (23.2%)  .0287 (58.3%)  3 (21.4%)  41 (35.0%)   
Mild malnutrition  41 (52.6%)  31 (47.7%)  13 (39.4%)  28 (51.9%)  31 (55.4%)    50 (41.7%)  11 (78.6%)  56 (47.9%)   
Moderate malnutrition  8 (10.3%)  12 (18.5%)  2 (6.1%)  6 (11.1%)  12 (21.4%)    0 (.0%)  0 (.0%)  20 (17.1%)   
Dysphagia  Yes  166  37 (39.8%)  30 (41.1%)  .864  10 (25.0%)  17 (28.8%)  40 (59.7%)  <.001  1 (6.7%)  13 (76.5%)  53 (39.6%)  <.001c 
*

Significant value for p<.05.

a

Student's t-test/ANOVA.

b

Mann–Whitney U/Friedman.

c

χ2.

Of the 67 patients with dysphagia on discharge, only 19 lasted until the 3 months. Curiously, at 3 months, dysphagia was detected in a patient who did not have it at time of discharge (Fig. 2).

Figure 2.

Incidence of dysphagia of the patients included in the study on admission and at 3 months.

(0.06MB).

There was a statistically significant association between the degree of malnutrition and the presence of dysphagia, both on admission (only with the CONUT index) and at 3 months (according to the CONUT index and the MNA) (Fig. 3).

Figure 3.

Relationship between dysphagia and malnutrition on admission and at 3 months.

(0.21MB).

On admission and on discharge there was a relationship between having and not having dysphagia and degree of dependency and disability, according to the Barthel Index and the Rankin scale, respectively. Thus, the median Barthel score of patients with dysphagia during admission was lower than that of those who did not have dysphagia. Therefore, the patients with dysphagia were more dependent. The same thing occurred with the Rankin scale, where the patients with dysphagia had a higher median and therefore greater disability.

On evaluating the same parameters at 3 months, the same results were obtained with medians that reflect greater dependency and disability (Fig. 4).

Figure 4.

Relationship between dysphagia and functional capacity on admission and at 3 months.

(0.13MB).
Discussion

This paper studies the relationship between malnutrition and dysphagia in stroke patients admitted to an acute unit and their progress at 3 months in HUBU.

Regarding sociodemographic data, a slightly higher incidence of stroke was found in males, similar to other studies.13,15 By contrast, several studies have found higher stroke incidence rates in males. According to the 2006 meta-analysis in the Spanish population, the prevalence was significantly lower in women, with an odds ratio of (OR) or .79, similar to other European studies. In another Catalan population study (2002), the cumulative stroke incidence rates were almost twice as high in males as in females (218 vs 127).5

In terms of type of stroke, 89.7% were ischaemic and 10.2% haemorrhagic in origin, as in other studies.15

Regarding BMI, the mean at admission was 27.3, and 27 at 3 months (both data are classified as overweight); similar data are observed in other studies.15

Most of the patients (80.1%) lived accompanied in the family home before the stroke, as reported in other studies.13,15 This percentage reduces to 77.1% at 3 months.

According to the data from our study, the sociofamiliar situation influences nutritional status, and therefore the institutionalised patients obtained higher scores in the CONUT index. Similar results have been found in other studies, although they used the MNA questionnaire as a measurement tool.15

On admission, 17.6% were on treatment with antidepressants, which suggests the presence of baseline clinical depression. This data is similar to that obtained in other studies, which estimate the prevalence of depression in the older population at between 16% and 34.5%.16

Given that the presence of depression was inferred from the prescription of antidepressants, it is possible that this data has been very much under-estimated. In fact, several studies highlight the poor detection by health professionals of depression in the elderly following a stroke.17

Of the stroke patients, 10.3% had been diagnosed with some degree of cognitive impairment prior to admission. This figure is lower than the prevalence detected in Spain, which estimates it at 18.5%. As with symptoms of depression, it is possible that cognitive impairment is being under-diagnosed if health professions do not systematically use screening tools. We now know that depression is the most common neuropsychiatric complication after a stroke.18 The brain damage it causes results in increased cognitive impairment.

With regard to the assessment of dependency, our results show that after the initial worsening due to stroke there was an improvement at 3 months [mild dependency with a median of 95 (80;100) and mild disability with a median of 1 (1;3)], although the levels prior to the stroke were not achieved. Similar data can be found in another study, although it analysed the degree of dependency at 6 months following a stroke.19

According to the analytical levels of cholesterol, albumin and lymphocytes (collected to analyse the CONUT index), a reduction in cholesterol levels at 3 months and an increase in albumin levels compared to on admission are noteworthy; this could be explained by the patients following the diet recommended on discharge from hospital.

According to the CONUT index, on admission 50.3% had a slight degree of malnutrition, and 14% moderate. This data is consistent with the PREDYCES® study, performed on 1597 patients from 31 hospitals throughout the country. In this study, performed under conditions of routine clinical practice, a risk of malnutrition was found in 37% of patients over the age of 70, and in 47% of those over 85, and this risk was increased in some conditions such as neoplasias, respiratory, cardiovascular, neurological disease, or diabetes or dysphagia.20 If we take our results from the MNA on admission into account, 13.4% had a risk of malnutrition, and only .6% had criteria of malnutrition. The disparity of these percentages compared to the CONUT index and the PREDYCES® study could be related to the clinical method of nutritional screening used. Both the results of the MNA and the CONUT index in our study are consistent with a systematic review of 8 studies performed in patients with acute stroke, which estimates a prevalence of malnutrition in the Spanish population of between 8.2% and 49%.21

In this regard, there were changes at 3 months that could be considered favourable, such as a significant reduction in BMI to values closer to normal weight, and a reduction in cholesterol levels, the latter being considered a risk factor for stroke.17

Of the patients, 40.4% had dysphagia secondary to stroke, consistent with another study in 2013 in which a prevalence of dysphagia was estimated at between 24.3% and 52.6% of patients following acute stroke.21 Another study shows an incidence of dysphagia in the acute phase between 29% and 65%, depending on the site of the lesion, decreasing to 12% at 3 months after the stroke; these data are similar to those obtained in our study.22,23

At 3 months there was a reduction in the percentage of patients with dysphagia (40.4% on admission vs 12% at 3 months), similar to other studies,22,24 which could have influenced improvement in the nutritional assessment. Nevertheless, we found no significant differences in the degree of malnutrition to indicate an improvement when we analysed the entire population as a whole.

Other studies indicate that patients with dysphagia had lower scores on the MNA and, therefore, poorer nutritional status than those who did not have dysphagia.15

In our study, an association was found between the presence of dysphagia and the degree of malnutrition during admission (only when the CONUT index was used but not with the MNA) and at 3 months (with both tools). It should be noted that on admission, when the degree of malnutrition did not depend on dysphagia a priori, this association was also shown with the CONUT index, although not with the MNA. This suggests that patients with poorer nutritional status may have a higher risk of developing dysphagia secondary to stroke. By contrast, at 3 months this association found with both tools could be inversely related, i.e., that the presence of dysphagia increases the risk of malnutrition.8 However, given that there are many factors that can influence the degree of malnutrition, it would be necessary to evaluate which risk factors could act as predicting factors by means of logistic regression analysis

We consider the large sample a strength of our study, having carried out a comprehensive assessment

As for the study's limitations, clinical depression was inferred from the prescription of antidepressant treatment, and not by using validated scales for this variable. Similarly, clinical cognitive impairment was extrapolated from the information in the clinical histories and detection tools were not used.

In addition, during the course of the study we found some shortage of resources in the transfer of subjects to the hospital for data collection in the second assessment, as well as difficulty in carrying out the control analysis at 3 months, which resulted in a reduction of the initial sample.

With regard to future perspectives, we consider it necessary to evaluate the variables that influence a state of malnutrition by means of statistical analysis of logistic regression.

On the other hand, it would be appropriate to carry out this study in other acute units in order to extrapolate the results and establish protocols aimed at improving the nutritional status of patients with dysphagia.

Conclusions

Dysphagia adversely affects nutritional status. In stroke patients there is an association between dysphagia and malnutrition, both on admission and at 3 months. After an initial worsening, an improvement in the degree of dependency and disability is seen at 3 months, without reaching pre-stroke levels.

Patients with a poorer nutritional level could be at greater risk of developing dysphagia secondary to stroke. By contrast, at 3 months this could be inversely related, i.e., that dysphagia increases the risk of malnutrition. Therefore we can conclude that there is a relationship between malnutrition and dysphagia.

In relation to the specific aims, it is worth noting that malnutrition related to increased disability and functional dependency. At 3 months favourable progress was observed in dysphagia, disability and functional dependence, but not in nutritional status.

This study suggests that the stroke patients were overweight which contrasts with a high percentage of mild malnutrition.

Funding

Collaboration from the University Hospital of Burgos.

Sedene Prize: special prize for the best neurological nursing research project 2015.

Conflict of interests

The authors have no conflict of interests to declare.

Acknowledgements

To the Neurological Department of the University of Burgos.

To the Research Department of the University of Burgos.

To the patients and family members who participated in this study.

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Please cite this article as: Ortega Barrio MÁ, Valiñas Sieiro F, Almarza Fernández MT, Bravo Santamaría S, Moreno Maestro R. Influencia del ictus en el estado nutricional y su relación con la disfagia. Rev Cient Soc Esp Enferm Neurol. 2019. https://doi.org/10.1016/j.sedene.2019.04.001

Copyright © 2019. Sociedad Española de Enfermería Neurológica
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