Practical guidance for diagnosis and nutritional management of dysphagia in acute stroke

Please find here practical guidance for the diagnosis and nutritional management of dysphagia in acute stroke. This guidance document is designed for use by stroke HCPs and other members of the multidisciplinary team on how to screen, assess and nutritionally manage dysphagia in acute stroke patients, with the aim of avoiding dysphagia-related complications and to facilitate recovery of swallow function.

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This guidance is for healthcare professionals only.

The guidance has been adapted from: Dziewas, et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. European Stroke Journal 2021; 6: LXXXIX-CXV.

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IMPACT OF POST-STROKE DYSPHAGIA ON STROKE OUTCOME1

Swallowing difficulty (dysphagia) is common after stroke:
icon_acute-stroke
icon_stroke-six-months

IMPACT OF POST-STROKE DYSPHAGIA ON STROKE OUTCOME1

Post-stroke dysphagia (PSD) increases risk (odds ratio) of:
Post-stroke dysphagia (PSD) increases risk (odds ratio) PSD also increases the risk of malnutrition and dehydration, affects psychological well-being and level of independence and is linked to low mood and depression

DYSPHAGIA AND NUTRITIONAL SCREENING1

Recommendations:
Conduct a formal dysphagia screening test to prevent post-stroke pneumonia and decrease risk of early mortality. Screen patients as fast as possible after admission. For screening, either water-swallow-tests or multiple-consistency tests may be used.
No administration of any food or liquid items (NPO), including oral medication, until dysphagia screening has been done and swallowing judged to be safe.
Expert opinion:
There is consensus among the guideline group that patients with acute stroke should be screened for nutritional risk within the first days after hospital admission using validated screening tools.

DYSPHAGIA ASSESSMENT1

Recommendations:
Dysphagia assessment is suggested in all stroke patients failing a dysphagia screen and/or showing other clinical predictors of PSD, in particular a severe facial palsy, severe dysarthria, severe aphasia or an overall severe neurological deficit (NIH-SS ≥ 10 points).
Dysphagia assessment should be done as soon as possible. In addition to the clinical swallow examination, VFSS or, preferentially, FEES should be available.
Swallowing of tablets is suggested to routinely be evaluated as part of dysphagia assessment in addition to assessing the swallowing of liquid and different food consistencies and quantities.
Examples of Practical Screening and Assessment Tools for PSD
SUITABLE HCP
DESCRIPTION
AIM
WATER SWALLOW TEST

Nurses in stroke units with limited time/resources to assess acute stroke patients

Simple bedside screening tools that involve functional assessment of the patient, including a water swallow challenge

Identify aspiration risk, the most appropriate feeding route, and possible need for additional specialist assessment

SUITABLE HCP
DESCRIPTION
AIM
MULTIPLE CONSISTENCY TEST

Nurses and/or swallow specialists in stroke units with moderate time/resources to assess acute stroke patients

Bedside screening tool that uses foods/liquids of varying consistency to help determine the severity of swallowing impairment

Identify aspiration risk, the most appropriate feeding route/consistency, and the possible need for additional specialist assessment

SUITABLE HCP
DESCRIPTION
AIM
FIBEROPTIC ENDOSCOPY

SLTs and/or specialist clinicians in stroke units with access to FEES medical imaging equipment and trained in its use

Specialized method for swallowing assessment after acute stroke that grades severity by visualising the swallowing process directly in response to foods/liquids of varying consistency

Provide direct visualisation of the oropharynx and advise the most appropriate feeding route/consistency to be used

CLICK FOR EXAMPLE
CLICK FOR EXAMPLE
CLICK FOR EXAMPLE
Example of Practical Screening Tool for Malnutrition
Click for example
Not part of clinical guidelines

TREATMENT OF POST-STROKE DYSPHAGIA1

Recommendations:
DIETARY INTERVENTIONS
Texture-modified diets and/or thickened liquids are suggested to be used to reduce the risk of pneumonia.
Texture-modified diets and/or thickened liquids should be prescribed only based on appropriate assessment of swallowing.
Monitor fluid balance and nutritional intake in stroke patients put on texture-modified diets and/or thickened liquids.
NUTRITIONAL INTERVENTIONS
In patients with PSD and insufficient oral intake, it is suggested to use early enteral nutrition via a nasogastric tube.
In stroke patients who present with a risk of malnutrition or with manifest malnutrition and can tolerate an oral diet, it is suggested to consider the use of oral nutritional supplementation.
Specialised nutrition solutions can address key nutritional challenges to support stroke patients along their recovery journey:
Hyper-acute
Acute
Early Subacute
Late Subacute
Chronic
Dysphagia
Malnutrition
Nutilis Range
Nutilis Range
Thickening agents and Pre-thickened ONS
Nutrison Range
Nutrison Range*
Enteral feeds
*In patients with PSD and insufficient oral intake, it is suggested to use early enteral nutrition via a nasogastric tube
Nutrison Range
Nutrison Range*
Enteral feeds
Fortimel Compact Protein
Fortimel Compact Protein
ONS
Nutilis Complete
Nutilis Complete
Pre-thickened ONS
Malnutrition
Nutrison Range
Nutrison Range*
Enteral feeds
Fortimel Compact Protein
Fortimel Compact Protein
ONS
Nutilis Complete
Nutilis Complete
Pre-thickened ONS
Muscle Loss in Sarcopenia
Pressure Injury
Fortimel Advanced
Fortimel Advanced
Muscle-targeted ONS
FortiFit
FortiFit
Muscle-targeted Powder
Cubitan
Cubitan
Wound-targeted ONS
Cubison
Cubison
Wound-targeted enteral feed
Not part of clinical guidelines
Nutricia products shown above are Foods for Special Medical Purposes (FSMP) and must be used under medical supervision.
Indications: Nutilis Clear & Nutilis Powder are for the dietary management of dysphagia; Nutilis Complete & Nutilis Aqua are for the dietary management of DRM with dysphagia; Nutrison products are for the dietary management of DRM (indication may vary, please refer to product technical sheet or ask a Nutricia representative); Fortimel Compact Protein is for the dietary management of DRM; Fortimel Advanced is for the dietary management of DRM with muscle loss; FortiFit is for the dietary management of diseases associated with protein malnutrition with a loss of muscle mass; Cubitan is for the dietary management of chronic wounds; Cubison is for the dietary management of DRM with chronic wounds.
DRM: disease-related malnutrition, NPO: nil per os, ONS: Oral nutritional supplement, PSD: Post-stroke dysphagia

Stroke & Dysphagia healthcare professional pages

The Healthcare professionals pages provide access to a range of articles and resources related to nutritional management in stroke & dysphagia, including clinical guidelines and detailed product information. The pages are for healthcare professionals only.

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Dysphagia and its impact on eating and drinking

Dysphagia (swallowing difficulty) can lead to increased anxiety at mealtimes. The risk of accidently inhaling drinks or food can lead to loss of enjoyment when eating or drinking. Some patients will reduce their fluid and food intake out of worry; the levels of malnutrition and dehydration in dysphagia patients are high and can negatively impact the recovery process[2,3]. An effective and widely used way of managing dysphagia is to change the consistency and texture of food and drinks.

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  1. Dziewas, et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. European Stroke Journal 2021; 6: LXXXIX-CXV
  2. Bouziana SD, et al. J Nutr Metab 2011
  3. Geeganage C, et al. Cochrane. Database Syst. Rev. 2012

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