Definición de la actitud

n(%) DIED n(%) INSTITUTIONAL L O S CARE (Geometric mean) n(%) (95% Confidence limits) DOC Safe 9/57(16)“ Unsafe 20/60(33) 3/50(6)" 10/47(21)“ 18/49(37) 14/31(45) 24.5 (18,33)' 44.8 (32,62) SLT Safe 12/69(17)' Unsafe 14/32(43) 7/58(12)" 11/51(22)“ 10/28(36) 9/18(50) 24.7 (19,33)" 68.4 (51-92) VF No ASP 12/74(16) ASP 7/20(35) 6/68(9) 4/18(22) 20/62(32) 4/14(29) 28.1 (4,180) 36.4 (6,147) a: p<0.05 b: p<0.001 c: p< 0.01 d: p =0.022

Numbers in each column vary due to deaths and withdrawals at different stages of the study.

DOC: Doctor SLT: Speech and Language Therapist VP: Videofluoroscopy LOS: Length of hospital stay

Table 1: OUTCOME FOLLOWING ACUTE STROKE

In an attempt to determine whether the association between aspiration or dysphagia with poor outcome (mortality, lower Barthel scores, Length of stay and occurrence of chest infection ) remained after other accepted indicators of poor prognosis were taken into account (weakness, neglect, hemianopia, incontinence, apraxia, age and gender). The presence of a reduced conscious level is a major and accepted prognostic marker of outcome following stroke, but in this study these patients were excluded from the analysis of outcome. The presence of dysphagia remained a significant predictor of mortality (DOC, x^(l)=6.4, p=0.01; SLT, x^(l)=4.4, p=0.04), and for chest infection (SLT x^(l)=9.6, p=0.002). The presence of aspiration as demonstrated on videofluoroscopy was not an independent predictor of mortality or for the presence of chest infection. Neither dysphagia or aspiration on videofluoroscopy were independent predictors of the length of stay or Barthel score.

DISCUSSION

Previous studies have linked clinical swallowing difficulties (dysphagia) to a poor outcome following stroke (Gordon et al., 1987; Wade and Hewer, 1987; Barer, 1989; Kidd et al., 1995), but only Kidd et al., (1995) included data from videofluoroscopy imaging. This study has examined the different and separate roles of the clinical assessment and the videofluoroscopy examination on outcome following stroke. The results have shown that dysphagia was significantly related to outcome.

The outcomes studied were mortality, development of chest infection, disability, length of stay and place of discharge.

Post mortem studies have suggested that aspiration pneumonia, following stroke is a significant cause of death within the first week (Brown and Glassenberg, 1973; Silver et al, 1984). Gordon et al. (1987) noted that when patients had dysphagia there was a two fold increase in the occurrence of chest infection. More recently Schmidt et al. (1994) noted a 7.6 fold increase in the risk of developing pneumonia following aspiration. Unfortunately the study was retrospective and only involved 52 patients. Holas et al., (1994) in a prospective study of 114 patients found an increased risk of pneumonia of between 7 and 8 fold in those patients aspirating on videofluoroscopy 4 weeks after their stroke. Martin et al. (1994) performed videofluoroscopy and clinical

assessments of the ability to swallow on patients with a diagnosis of aspiration pneumonia and non aspiration pneumonia, noting that those with aspiration pneumonia were more likely to have swallowing problems.

This study has confirmed that those with dysphagia are more likely to develop a chest infection. There is a possibility that this result was biased by the fact the person assessing for the presence of a chest infection was also assessing the patient’s ability to swallow, but this is finding is supported by the fact that those patients assessed as having an unsafe swallow by the SLT also had an increased risk of developing a chest infection. The SLT was not informed as to the presence or absence of a chest infection. This study has not found a significant association between the development of a chest infection in the first week following stroke and the presence of aspiration on videofluoroscopy which confirms the work by Kidd et al. (1995).

What is not clear is the relationship between swallowing difficulties, chest infection and stroke severity. Using logistic regression analysis, this study has shown that dysphagia is independently associated with the occurrence of a chest infection, but aspiration documented on videofluoroscopy was not.

Other workers have suggested that the mortality following acute stroke is increased if swallowing problems are present regardless of conscious level

(Wade and Hewer, 1987). This study confirmed that those patients with an unsafe swallow had an increase in mortality which was between three and six fold higher. The mortality in the unsafe groups whether assessed by the SLT or DOC was 36% and 37% respectively, the same order of magnitude as Wade and Langton Hewer (1987) in their study (42%). There was no relationship between aspiration on videofluoroscopy and mortality, though the number of deaths within these groups was small, which would confirm the work by both Schmidt et al. (1994) and Holas et al. (1994).

In the present cost conscious Health Service, LOS, functional outcome and place of discharge are important. Axelsson (1989) suggested that swallowing difficulties following stroke were associated with an increased LOS. Like others (Gordon et al., 1987; Barer, 1989) this study has shown an increase in LOS associated with the presence of dysphagia, but not with aspiration on videofluoroscopy.

It has also been suggested that the functional outcome of patients with swallowing difficulties is worse (Wade and Hewer, 1987; Barer, 1989). This study has confirmed that the presence of dysphagia is associated with a worse functional outcome, as assessed by the Barthel score.

Now that the access to institutionalised care is regulated by the local authority.

markers suggestive of eventual institutionalisation are being increasingly investigated. Those with dysphagia present at the time of admission were twice as likely to be admitted to institutionalised care which is in keeping with the findings of Kalra et al. (1993) where the presence of dysphagia at two weeks was predictive of admission to a nursing home.

In conclusion these results confirm that dysphagia, as detected at the bedside is an independent predictor of the development of chest infection and mortality (survival). The presence of aspiration on videofluoroscopy does not appear to add greatly to this risk assessment.

CHAPTER 14

DISCUSSION and CONCLUSIONS