Malnutrition in stroke patients on the rehabilitation service and at follow-up: Prevalence and predictors

doi:10.1016/S0003-9993(95)80655-5

Archives of Physical Medicine and Rehabilitation

Volume 76, Issue 4, April 1995, Pages 310-316

https://doi.org/10.1016/S0003-9993(95)80655-5 Get rights and content

Abstract

This prospective study presents the prevalence and risk factors of malnutrition in 49 consecutive stroke patients on the rehabilitation (Rehab) service and at 2- to 4-month follow-up. Malnutrition was diagnosed using biochemical and anthropometric data. Stroke patients, on admission to Rehab, have a very high prevalence of malnutrition. Malnutrition, 49% on admission, declined to 34%, 22%, and 19% at 1 month, 2 months, and follow-up, respectively. Dysphagia, 47% on admission, was associated with malnutrition (p = .032) and significantly declined over time. Using logistic regression, predictors of malnutrition on admission involved acute service tube feedings (p = .002) and histories of diabetes (p = .027) and prior stroke (p = .013). Tube feedings, associated with malnutrition on admission (p = .043), were more prevalent in brain stem lesion patients. Patients tube fed ≥ 1 month during rehabilitation or at home were not malnourished. Malnutrition was associated with advanced (>70 years) age at 1 month (p = .002) and weight loss (p = .011) and lack of community care (p = .006) at follow-up. Early and ongoing detection and treatment of malnutrition are recommended during rehabilitation of stroke patients both on the service and at follow-up.

References (32)

WeinsierRL et al.
Hospital malnutrition, a prospective evaluation of general medical patients during the course of hospitalization
Am J Clin Nutr
(1979)
BuzbyGP et al.
Prognostic nutritional index in gastrointestinal surgery
Am J Surg
(1980)
ViartP
Hemodynamic findings during treatment of protein-calorie malnutrition
Am J Clin Nutr
(1978)
AptakerRL et al.
Serum albumin level as a predictor of geriatric stroke rehabilitation outcome
Arch Phys Med Rehabil
(1994)
AxelssonK et al.
Eating problems and nutritional status during hospital stay of patients with severe stroke
J Am Diet Assoc
(1989)
GrantJ et al.
Current techniques in nutritional assessment
Surg Clin North Am
(1981)
DonnerMW
Swallowing mechanism and neuromuscular disorders
Semin Roentgenol
(1974)
AxelssonK et al.
Eating after a stroke-towards an integrated view
Int J Nurs Stud
(1984)
MullinTJ et al.
The effect of nutritional support on immune competency in patients suffering from trauma, sepsis or malignant disease
Surgery
(1981)
AshkenaziJ et al.
Nutrition and the respiratory system
Crit Care Med
(1982)

MullhollandJH et al.

Protein-metabolism and bedsores

Ann Surg

(1943)

MacFadyenBV et al.

Management of gastrointestinal fistulas with parenteral hyperalimentation

Surgery

(1972)

GlennMB et al.

Serum albumin as a predictor of course and outcome on a rehabilitation service

Arch Phys Med Rehabil

(1985)

GroherME et al.

The prevalence of swallowing disorders in two teaching hospitals

Dysphagia

(1986)

GordonC et al.

Dysphagia in acute stroke

Br Med J

(1987)

TeasellR et al.

Dysphagia and nutrition following stroke

Cited by (224)

Risk factors for dysphagia in patients with acute and chronic ischemic stroke: A retrospective cohort study
2024, Heliyon
Dysphagia is a common and clinically significant complication of ischemic stroke. The prevalence and risk factors for dysphagia may vary at different stages following an ischemic stroke.
This study included patients with acute and chronic ischemic stroke who were treated at the Department of Rehabilitation, First Affiliated Hospital, Zhejiang University School of Medicine from 2019 to 2022. Various demographic, clinical, and laboratory parameters were collected, and statistical analyses were performed to investigate their association with dysphagia.
Among the 399 ischemic stroke patients included in the study, 165 (41.4 %) experienced dysphagia, with 72 (38.7 %) in the acute phase and 93 (43.7 %) in the chronic phase. Univariate analysis revealed significant associations (p < 0.05) between dysphagia and factors such as pulmonary infection, aphasia, NIHSS score, ADL score, NLR score, lower extremity Brunnstrom's stages, and sit-to-stand balance. Multiple logistic regression analysis, after adjusting for confounding factors, identified the ADL score as an independent predictor of dysphagia. These findings were consistent across three time-windows: the acute phase, the chronic phase, and 180 days after stroke onset. Additionally, the lymphocyte count and pulmonary infection were identified as potential independent indicators.
This study investigated the prevalence and risk factors for dysphagia in ischemic stroke patients at different time-windows. A low ADL score (<40) may serve as a valuable and reliable predictor for poststroke dysphagia in clinical settings.
Prevalence of Malnutrition Diagnosed with GLIM Criteria and Association with Activities of Daily Living in Patients with Acute Stroke
2021, Journal of Stroke and Cerebrovascular Diseases
Malnutrition is associated with a poor functional outcome in patients with stroke. However, the prevalence of malnutrition diagnosed with the Global Leadership Initiative on Malnutrition (GLIM) criteria or its association with activity of daily living (ADL) in patients with acute stroke have not been reported.
To investigate the prevalence of the malnutrition diagnosed with the GLIM criteria and its association with ADL or discharge destination in patients with acute stroke.
In this cross-sectional study, we diagnosed malnutrition with the GLIM criteria and the European Society for Clinical Nutrition and Metabolism (ESPEN) criteria and assessed ADL by functional independence measure motor domain (FIM-M) score in patients with acute stroke. Multivariate regression analysis was used to investigate the relationship between FIM-M score or home discharge and malnutrition defined with GLIM or ESPEN criteria.
A total of 115 acute stroke patients (39 females; median age: 72 years) were enrolled in this study. The prevalence of malnutrition according to GLIM-criteria and ESPEN-criteria was 28.7% and 16.5%, respectively. Multivariate analyses for FIM-M score after adjusting for potential confounders showed that GLIM criteria and ESPEN criteria were independently associated with FIM-M score (β = -0.238, p < 0.001; β = -0118, p = 0.040, respectively). A multivariate analysis for discharge destination found that only malnutrition from the GLIM criteria was significantly associated with home discharge (OR = 0.08, 95% confidential interval = 0.01-0.69, p = 0.02).
Malnutrition with the GLIM criteria is negatively associated with ADL and is also associated with discharge destination in patients with acute stroke.
Reliable predicting factors for post-stroke dysphagia – Our experience
2020, Neurology Psychiatry and Brain Research
Dysphagia affects more than 50 % of stroke survivors. The most common consequences of post-stroke dysphagia are malnutrition, dehydration, aspiration pneumonia, choking, limited quality of life, increased mortality and morbidity rate. Patients with post-stroke dysphagia should be identified as soon as possible so that special measures can be taken to avoid these consequences. The objectives of our study were to evaluate the prevalence of post-stroke dysphagia in a tertiary care hospital, to analyse the reliability of predicting risk factors for dysphagia and to determine the stroke locations and brain regions respectively connected with post-stroke dysphagia. We included 207 patients who presented with acute stroke and were admitted to Department of Neurology – Stroke Unit from September 2016 to September 2017. Forty-three percent of patients had post-stroke dysphagia. We investigated patient's age, gender, arterial hypertension, diabetes mellitus, atrial fibrillation, previous statin therapy, severity of stroke and localisation of stroke as possible predicting factors for post-stroke dysphagia.
Our results showed that the only reliable predicting factor for post-stroke dysphagia was the location of the brain lesion, which according to our study were Brodmann areas 4, 8, 24, 30 and pons lesions.
The Gugging Swallowing Screen in dysphagia screening for patients with stroke: A systematic review
2020, International Journal of Nursing Studies
Dysphagia in patients with stroke can cause serious complications, such as aspiration and pneumonia, that often lead to increase in mortality and length of hospitalization. Several screening tests for dysphagia have been developed and are used in clinical practice to prevent dysphagia complications. The Gugging Swallowing Screen is 1 such screening test. It is suggested for use in the assessment of the ability of patients to swallow fluid and non-fluid foods separately. It also promotes effective communication between healthcare providers.
We aimed to investigate the validity and benefit of the Gugging Swallowing Screen.
This was a systematic review.
We sourced data from electronic databases including Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, KoreaMed, Research Information Sharing Service, and Korean studies Information Service System.
We conducted a systematic review of electronic databases. We included studies published in English and Korean up to November 2018 that pertained to the Gugging Swallowing Screen. We designed strategies that included Medical Subject Headings and keywords, such as “dysphagia,” “swallowing,” “assessment,” “screening,” and “GUSS,” used alone or in combination.
Of the 297 studies that appeared in the search result, 219 articles were reviewed by 2 independent reviewers after duplicate studies were eliminated. Finally, 8 articles were included in this study. With regard to validity, the Gugging Swallowing Screen had a pooled sensitivity of 0.97 (95% confidence interval: 0.93–0.99), a pooled specificity of 0.67 (95% confidence interval: 0.59–0.74), and an area under the receiver operating characteristic curve of 0.9381. With regard to benefit, early systematic dysphagia screening using Gugging Swallowing Screen performed by nurses reduced both screening time and pneumonia rate compared to the control group (p = 0.004). The incidence of X-ray-verified pneumonia was significantly lower in the Gugging Swallowing Screen group than in the clinical screening group (p ˂ 0.01), but no significant difference was observed in the incidence of pneumonia compared to the value predicted using the 10 mL water swallowing test.
The Gugging Swallowing Screen is a reliable and sensitive tool for screening dysphagia. Early and systematic assessment can prevent aspiration and pneumonia. However, further studies are needed to confirm the effectiveness of this tool.
Association Between Malnutrition and Outcomes in Patients With Severe Ischemic Stroke Undergoing Rehabilitation
2020, Archives of Physical Medicine and Rehabilitation
To investigate the incremental prognostic significance of malnutrition in patients with severe poststroke disability.
Retrospective cohort study. The patients were recruited from 3 specialized inpatient rehabilitation facilities. Nutritional status was assessed using the Prognostic Nutritional Index (PNI), which is calculated from serum albumin and total lymphocyte count. Scores >38 points reflect normal nutrition status, scores of 35-38 indicate moderate malnutrition, and scores <35 indicate severe malnutrition. The association of PNI categories with outcomes was assessed using multivariable regression analyses.
Inpatient rehabilitation facility.
Patients (N=668) with ischemic stroke admitted to inpatient rehabilitation within 90 days from stroke occurrence and classified as Case-Mix Groups 0108, 0109, and 0110 of the current Medicare case-mix classification system.
Not applicable.
Three outcomes were examined: (1) the combined outcome of transfer to acute care and death within 90 days from admission to rehabilitation; (2) 2-year mortality; and (3) FIM motor effectiveness, calculated as (FIM motor change/maximum FIM motor−admission FIM motor score)×100.
Overall, the median time to rehabilitation admission was 18 days (range, 12-26 days). The prevalence of moderate and severe malnutrition was 12.7% and 11.5%, respectively. Ninety-one patients (13.6%) experienced the combined outcome. After adjusting for independent predictors including sex, atrial fibrillation, dysphagia, FIM cognitive score, and hemoglobin levels, neither moderate (P=.280) nor severe malnutrition (P=.482) were associated with the combined outcome. Similar results were observed when looking at 2-year mortality. Overall, FIM motor effectiveness was 30%±24%. After adjusting for independent predictors, severe malnutrition (β coefficient −0.458±0.216; P=.034) was associated with FIM motor effectiveness.
Approximately 1 in every 9 patients presented severe malnutrition. On top of the independent predictors, severe malnutrition did not provide additional prognostic information concerning risk of the combined outcome or 2-year mortality. Conversely, severe malnutrition was associated with poorer functional outcome as expressed by FIM motor effectiveness.
Nutritional situation of enterally fed patients in neurological early rehabilitation and impact of nutritional status on functional outcome
2020, Clinical Nutrition
Studies focusing on the nutritional status of neurological and neurosurgical early rehabilitation (NNER) patients are limited. The aim of the current study was to determine the nutritional status of NNER patients upon admission, to observe weight changes and to investigate the influence of nutritional status on complications and outcome.
109 enterally fed NNER patients were included in this prospective observational study. Weight changes, complications, neurological outcome scores (Early Rehabilitation Index [ERI], Barthel-Index [BI]) and the length of stay (LOS) were recorded. In addition, daily energy requirement was calculated and compared with daily intake to identify under-/optimally- and oversupplied patients.
A general weight loss was observed in the study group. Weight changes during rehabilitation differed between men and women as well as between under- and oversupplied patients. Nutritional supply during rehabilitation had no influence on the LOS and the change of neurological outcome scores, but significant differences in the frequency of nosocomial infections was observed between under-/optimally- and oversupplied patients. The nutritional status (weight group on admission) had a crucial impact on neurological outcome scores, indicated by lower BI at discharge in normal-compared to underweight patients. In addition, underweight + undersupplied patients showed a significantly lower improvement of the BI than underweight + oversupplied patients. To the contrary, underweight + oversupplied patients had a higher BI improvement than underweight + optimally supplied patients.
The nutritional status upon admission in combination with the nutritional supply during rehabilitation appears to have an impact on changes of neurological outcome scores.

View all citing articles on Scopus

: This research was supported by a grant from the Department of Physical Medicine and Rehabilitation, University of Western Ontario, Canada.

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

View full text

ArticleMalnutrition in stroke patients on the rehabilitation service and at follow-up: Prevalence and predictors

Abstract

Am J Clin Nutr

Am J Surg

Am J Clin Nutr

Arch Phys Med Rehabil

J Am Diet Assoc

Surg Clin North Am

Semin Roentgenol

Int J Nurs Stud

The effect of nutritional support on immune competency in patients suffering from trauma, sepsis or malignant disease

Surgery

Nutrition and the respiratory system

Crit Care Med

Protein-metabolism and bedsores

Ann Surg

Management of gastrointestinal fistulas with parenteral hyperalimentation

Surgery

Serum albumin as a predictor of course and outcome on a rehabilitation service

Arch Phys Med Rehabil

The prevalence of swallowing disorders in two teaching hospitals

Dysphagia

Dysphagia in acute stroke

Br Med J

Dysphagia and nutrition following stroke

Article
Malnutrition in stroke patients on the rehabilitation service and at follow-up: Prevalence and predictors