Dysphagia and daily oral fluids among cerebrovascular stroke patients: an theory-based nursing intervention protocol

Dysphagia is one of the more serious medical complications among people who have recently experienced a cerebrovascular stroke (CVS), in that it leads to aspirated pneumonia, dehydration, malnutrition, and weight loss. Although stroke is a clinical focal disorder of cerebral function and can lead to death, survivors of a stroke may die from the complications emerging from the presence of dysphagia.^1,2 The World Health Organization (WHO) estimated that approximately 1 in 6 people will suffer a stroke in their lifetime.³ In acute stroke, the prevalence of dysphagia has been reported as between 28% and 65%; globally, 15 million people suffer from stroke annually and up to 65% have problems associated with swallowing, of whom half will be symptomatic.⁴

Dysphagia screening should be performed in all ischemic and hemorrhagic stroke patients before being given anything by mouth, including food, fluids, and oral medications.^5,6 Therefore, the patient must remain on nothing per mouth (NPO) until a dysphagia screening has been completed.⁷ An initial screening of dysphagia is critical to prevent future health complications and should have a high priority in health care practices.⁸ One of the most dangerous and common complications of dysphagia is dehydration; however, contrary to superficial appearances, it may be associated not merely with the decreased amount of oral fluids attributable to dysphagia but might also emerge owing to the fact that the patients experience aspiration every time they drink fluids, and so they become reluctant to drink more fluids.^9,10

Dehydration increases hemoconcentration and blood viscosity, and decreases blood pressure. Consequently, the result is more brain damage and more severe symptoms, which may worsen the effects of brain ischemia that cause more deterioration in vital and functional prognosis.¹¹ Dehydration is also related to a higher risk of complications, such as venous thrombosis. Furthermore, increasing urine osmolality could be significantly associated with an increase in stroke severity and independence outcome after an acute ischemic stroke.¹²

Nurses’ role is critical in supporting the management of people with swallowing problems. Yet, there is no structured routine nursing practice of stroke management in the hours after a patient develops a stroke. If nurses are to screen dysphagia within 24 h of admission, then newly admitted stroke patients will not spend time without nutrition and hydration,¹³ and this practice will increase good clinical outcomes for stroke patients. Nurses are the primary health care providers for stroke patients with dysphagia; so, the provision of suitable training for nurses that enables them to assess and recognize dysphagia may enhance stroke patients’ safety.¹⁴ Previous studies have recognized this need, and accordingly recommended providing training to registered nurses as one of the effective means for ensuring care for stroke patients with dysphagia.^15,16

Previous studies have indicated that some exercises improved the swallowing function for individuals with dysphagia.¹⁷ For example, recent research using simultaneous pharyngeal manometry and intramuscular electromyography confirms that the tongue-hold maneuver significantly increases the activation of the superior pharyngeal constrictor.¹⁸ Additionally, the literature mentions that the MRI data reveal that the effortful pitch glide elicits greater muscle activation than swallowing and subsequent data collected using dynamic MRI revealed that the effortful pitch glide had an equivalent motor output to swallowing.¹⁹

Swallowing exercises cause specificity and intensity (or overload) to the muscles, which are the 2 basic principles of swallowing improvement training. Specificity is considered an important part of the activity in terms of improving the strength of certain muscles. Intensity refers to overloading the target muscles, which in turn causes muscle fatigue and triggers neuronal adaptations, including muscle strengthening.¹⁶ The Shaker exercise is one of the useful swallowing exercises that was used in many studies and has been designed to improve swallowing by strengthening the suprahyoid muscles. Another swallowing exercise, Effortful Swallowing, is approved as a compensatory maneuver to improve pharyngeal propulsion or clearance and pharyngeal strength.²⁰

1.2.

Theoretical framework

Dysphagia management needs patients to adhere cooperatively to a daily exercise program, which in turn needs changing behavior patterns to achieve the best level of efficacy of the management.²¹ Previous studies recommend using health behavior theory in the research and management of dysphagia, which may increase patient adherence to dysphagia management recommendations since patient adherence is viewed as an aspect of health behavior. Dysphagia intervention based on health behavior theory is consistent with the current emphasis on using evidence-based interventions in behavioral medicine.²²

Patients who have swallowing impairment often require complex and specific interventions requiring altered daily patterns of behavior. Patients with dysphagia who do not follow recommendations or prescribed exercises may not receive the maximum benefit of an intervention. Poor adherence also makes it more difficult to evaluate the efficacy of treatment in both clinical and experimental settings.²³ Behavior Perspective Model (BPM) (Figure 1) suggests that there are 2 types of consequences of consumer behavior, namely utilitarian and informational. Utilitarian consumption can be defined as an increase or decrease in operant behavior. The informational consequences of the same include reinforcement or punishment, and may be classified into positive and negative.²⁴

Figure 1.

Regarding influencing behavior, BPM supports using the principles of effective learning to influence behavior, such as identifying antecedent stimuli, elicited behavior, and consequences. Antecedents, or preceding events, are divided into internal and external; thoughts can be mentioned as a primary constituent of the internal ones whereas environmental circumstances that elicit a behavior largely constitute the external ones. Consequences are largely the same as those expected, namely rewards or punishments that also influence behavior. It focuses on the importance of positive and negative reinforcement as a mechanism for influencing behavior.²⁵

Application of the BPM in dysphagia management will help staff nurses to adhere to swallowing recommendations and exercises. Previous research revealed that antecedent stimuli, including staff training visual materials and availability of pre-thickened drinks, improved caregiver adherence to dysphagia management measures. In addition, a patient’s subjective perception of the negative consequences associated with non-adherence to dysphagia management protocol could be a strong motivation for the patient’s adherence.²³

The demographic characteristics of both groups (study and control) are mostly similar; there were no significant statistical differences in the characteristics between the groups (Table 1). Males in the study group were 76.6% and in the control group were 70%. In total, 70% of the study group participants were working whereas only 53.3% of the control group were working; further, 86.6% of the control group were married whereas only 73.3% of the study group were married. Regarding smoking, 76.6% of the study group were smoking and 70% of the control group were smoking; further, 73.3% of the control group had a recurrent stroke whereas 60% of the study group had a recurrent stroke.

Results revealed that the severity of dysphagia markedly decreased among study group patients after nursing intervention (Table 2). A chi-square test of independence revealed that there was a statistically significant relationship among the study group between the pre- and post-nursing intervention (P = 0.05).

Also, there was a highly statistically significant difference in the severity of dysphagia between the study and control group patients after the nursing intervention (Table 3). There was a marked decrease in the severity of dysphagia among the study group participants more than in the control group (P = 0.05).

There was a statistically significant relationship among the study group between the pre- and post-nursing intervention regarding the amounts of daily oral fluids (Table 4). Among the study group, post-nursing intervention was characterized by the receipt of greater amounts of fluids orally, in contrast with pre-nursing intervention (P < 0.05). On the other hand, there was no statistically significant difference between pre- and post-nursing intervention among the control group regarding the daily amounts of daily oral fluids served (Table 5; P = 0.84). With regard to post-nursing intervention, there was no statistically significant association between the study and control groups regarding the amounts of daily oral fluids served (Table 6; P = 0.070).

Regarding the relation between demographic characteristics and severity of dysphagia (Table 7), there was a high, positive statistically significant difference observed in terms of the relation of smoking and recurrent stroke with the severity of dysphagia (P < 0.01). A slight, positive statistically significant relationship of age and female gender with the severity of dysphagia was also observed, P < 0.05.

Nurses play a critical role in supporting the management of people with swallowing problems. Nurses are the primary health care providers for stroke patients with dysphagia. Many recent studies approved the improvement of dysphagia among stroke patients by utilizing swallowing exercises, which will be illustrated in this discussion. First, regarding the demographic characteristics of the present study, it was found that the majority of the studied patients were males. Many studies have shown that the prevalence rate of stroke is higher in men than in women and this is related to the fact that heavy smoking among men is more common than among women. Markidan et al.²⁷ focused their study on young men, and their results analyzed smoking history in the ages of 18–20 years; the study’s results demonstrated that smoking history was a predictor of ischemic stroke before the age of 45 years.

This finding is in line with the findings of a Swedish study of young men that analyzed smoking history in the military.²⁹ Smoking history prediction of ischemic stroke does not match with the results of the present study. This could be due to the presence of risk factors leading to stroke in addition to smoking in Egyptian society. Smoking as a predictor of stroke needs further research focusing on the relation between smoking history and the incidence of stroke.

The findings of this study revealed that a majority of the stroke patients in this study achieved an improvement in the severity of dysphagia after the nursing intervention protocol based on the BPM and comprising early dysphagia assessment and daily swallowing exercises. Many studies’ results agree with this finding.^31,32 A study conducted by Bhuvaneshwari and Somiya¹² on swallowing ability among patients who had undergone a cerebrovascular accident showed similar results. This study used dysphagia exercises, which are designed to enhance muscles and coordinate the nerves and muscles involved in swallowing.

Using BPM in designing the dysphagia management nursing protocol helped in ensuring staff nurses’ adherence to the protocol, such that nurses gained adequate skill through training, with the result that they became familiarized and expertized enough to perform dysphagia assessment and swallowing exercises in an easy manner. At the same time, the motivation delivered to patients represented an improvement in swallowing and obtaining sufficient nutrition through the oral route instead of parenteral nutrition or Ryle feeding, in addition to negative reinforcement delivered to patients, which represented the worse outcomes of malnutrition or aspirated pneumonia if they did not adhere to management protocol; these positive and negative reinforcements delivered to patients pushed them to adhere to the dysphagia management nursing protocol.

Previous research has supported this finding; a systematic review conducted by Krekeler et al.²² mentioned that reported barriers to adherence to dysphagia management were difficulty in exercising; fatigue; internal factors, such as motivation, social support, and psychological well-being; and external factors, such as environment, having written instructions about exercises, and eating alone, which are strategies used through applying the BPM model.²²

The study revealed that dysphagia practices were an effective, inexpensive, and simple measure for improving swallowing. Another recent study examined the effectiveness and safety of an exercise-based swallowing therapy (McNeill Dysphagia Therapy) and documented a greater reduction in dysphagia severity, an improved oral intake, and an earlier return to a pre-stroke diet.¹⁴ In contrast to these studies, a study by Molfenter et al.³³ was conducted to compare pharyngeal swallowing measures in healthy seniors between regular effort and effortful conditions, and revealed that the effortful swallowing condition was associated with less or worse pharyngeal shortening compared with the regular swallowing condition.³⁴

Molfenter et al.’s study³³ mainly targeted seniors; contrastingly, most of the patients in the present study were under 40 years old, and that might be the reason for the different results. Seniors may not have a good ability to practice effortful swallowing. On the other hand, the present study did not support the effectiveness of dysphagia exercises in increasing the amounts of daily oral fluids consumed. The same result has been achieved by Murray et al.,³⁰ when they investigated the relationship between dysphagia and the amount of oral fluids taken in among recent CVS patients: their study revealed that dysphagia was not a significant predictor of poor oral fluid intake.

The present study revealed that there was a highly significant positive relationship between smoking and the severity of dysphagia. This finding is in contrast to the findings of a study conducted by Kumaresan et al.,¹⁵ which focused on determinates of dysphagia following stroke and revealed that risk factors of stroke, including smoking, did not influence the severity of dysphagia. There was another positive strong relation between recurrent stroke and the severity of dysphagia. This result was also in conformity with those of Mourão et al.³⁴ and Powers et al.,³⁵ which revealed an association of a previous history of stroke with the presence of dysphagia.

Additionally, the present study revealed that there was a slightly significant relation between age and gender and the severity of dysphagia. These findings were supported by Baroni et al.,⁴ who studied risk factors for swallowing dysfunction in stroke patients and reported that swallowing dysfunction more frequently occurs in older individuals, particularly in men older than 60 years.

The study is promising for a nursing intervention protocol composed of early dysphagia assessment and daily swallowing exercises, for it shows improved dysphagia and increased amounts of daily oral fluid servings. Although there is no difference between the study and control groups regarding the amount of daily oral fluid servings, the nursing intervention increased the amount of daily oral fluid servings for the study group. This could be attributable to the fact that most stroke patients who have dysphagia are reluctant to drink fluids by mouth, due to 1 or more previous experiences of hard aspiration. One possible explanation for this is a patient’s reluctance to drink after having the frightening experience of choking/aspiration. Once a patient has gained some confidence and obtained strength training through swallowing exercises, they might be more likely to take in more fluids by mouth.

Dysphagia is a very serious complication after CVS. It can lead to many fatal other complications such as aspiration pneumonia, malnutrition, and dehydration, which in turn worsen CVS by increasing the chance of further stroke development. In addition, the hard experience of aspiration with oral fluid supplements causes a situation wherein people who recently experienced a CVS are reluctant to repeat the trial of taking in oral fluids. A nursing intervention protocol composed of early dysphagia assessment and daily swallowing exercises, such as Shaker exercise and Effortful Swallowing, resulted in decreases in the severity of dysphagia. The nursing intervention also increased the amount of daily oral fluids servings, although it did not achieve statistical significance.