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THE EFFECT OF DISPHAGIA TO NUTRITIONAL STATUS OF STROKE PATIENT IN WARD ROOM DR.

CIPTO MANGUNKUSUMO HOSPITAL JAKARTA Publication Script Presented in Partial Fulfilment of the Requirements for The Master Degree of Public Health

Proposed by: Ari Wijayanti NIM : 16775 / PS / IKM / 05 To: THE GRADUATE PROGRAM FACULTY OF MEDICINE GADJAH MADA UNIVERSITY YOGYAKARTA 2011

THE EFFECT OF DISPHAGIA TO NUTRITIONAL STATUS OF STROKE PATIENT IN WARD ROOM DR. CIPTO MANGUNKUSUMO HOSPITAL JAKARTA Ari Wijayanti1, Pernodjo Dahlan2, Herni Astuti3 ABSTRACT Background: Stroke can cause the decline of nutrition status. Undernourished nutrition is commonly found in stroke patients during early hospitalization at the prevalence of about 16%-22%. Undernourished nutrition status in stroke patients may bring some consequences such as increased urinary tract and respiratory infection, mortality after 3 months of stroke attack, prolonged hospitalization, and decreased functional status. Risk for undernourished nutrition status will increase in stroke patients that suffer from swallowing disorder or dysphagia. Dysphagia in stroke patients often causes less food intake, dehydration, and or complications such as pneumonia that requires enteral tube feeding. Objective: To identify the dysphagia influence to nutritional status of stroke patients at inpatient ward. Method: The study used prospective cohort design. Data were obtained from 65 samples of stroke patients at Dr. Cipto Mangunkusumo Hospital that included nutrition status, dysphagia food intake and method of feeding. Assessment of nutrition status used SGA whereas food intake used Comstock and Food Recall 24 hours. To get the influencing factor was used logistic regression analysis. Result : From this study is resulted that protein intake OR 1,03 (0,991,06), dysphagia of OR 0,55 (0,05-5,56), and the way of feeding OR 14,93 (1,44-154,46) influenced the nutritional status to stroke patients. While the analysis multivariate result stated that the way of feeding is the most influencing one to nutritional status of stroke patients. Conclusion: Dysphagia has 1.6 times of undernourished, energi and protein intake well-nourish prevent undernourish, and the way of feeding via naso gastric tube can cause undernourished 1.9 times. Keywords: dysphagia, method of feeding, nutritional status, stroke. 1. Dr. Cipto Mangunkusumo Hospital, Jakarta 2. Department of Neurology, Faculty of Medicine, Gadjah Mada University Nutriti

INTRODUCTION

The prevalence of stroke increases further with age. Stroke is the main cause of impairments in the elderly and of death of inpatients in all hospitals in Indonesia.1,2 In Dr. Cipto Mangunkusumo Hospital, in 2001, there were 862 cases of stroke.3 Stroke may cause a decrease in the individuals nutritional status,4 which may eventually cause increased urinary tract and respiratory infections, prolonged hospital stay, and Altered metabolism in stroke patiens decreased functional status.5,6,7

effects metabolism of nutrients. The prevalence of insufficient nutritional status of stroke patients on admission to a hospital is around 16 22%. The prevalence accelerates further during stay periods, which reaches 50%.7 The risk of insufficient nutritional status increases further in stroke patients suffering from swallowing disorder or dysphagia. Dysphagia in stroke patients often causes a decline in food intake, dehydration, and/or complications such as pneumonia, so that tube feeding is often required.6,8 The prevalence of dysphagia in stroke patients is found to be around 65%.9 The prevalence of insufficient nutritional status in stroke patients is around 16 49%.10 Paik11 reports that the prevalence of Research on

malnutrition in stroke patients with dysphagia is 65%.

relationships between nutritional status and dysphagia has not been conducted extentively and the existing research results show differences, Finestone et al.7 report that there is a relationship between dysphagia and nutritional status, but Davalos et al.6 report that there is no significant difference between stroke patients with dysphagia and those without dysphagia in upperarm circumstance, skinfold thickness, and serum albumin. Similarly, research conducted by Crary et al. does not find any relationship between nutritional status and dysphagia in stroke patients.12 Inadequate food intake in patients is one of the causes of insufficient nutritional status. In stroke patients, insufficient food intake

may be caused by dysphagic condition, decreased appetite and decreased awareness.13 Studies of patients residing in an infirmary conducted by Triyani14 and Suharyati15 find that there are relationships between food intake and nutritional status. It is hipothesized that methods of feeding (oral, parenteral) affect patients food intake, which eventually also affect nutritional status. Norton et al. find that there is a relationship between nutritional status and methods of feeding. 16 The objective of this study was to find out the effect of dysphagia on nutritional status in stroke patients on discharge from inpatient wards.

METHODS The research design employed in this study was a prospective cohort design. The study was conducted in Dr. Cipto Mangunkusumo Hospital from January 2008 to January 2009. The sample collection was conducted consecutively. The research subjects were all of the stroke patients residing in the Neurological Unit of Dr. Cipto Mangunkusumo Hospital, Jakarta, who satisfy the inclusion and exclusion criteria. The inclusion criteria included being diagnosed as having stroke and willing to participate in the research. The exclusion criteria included stroke patients with impaired renal functions, and hepatic functions and hematemesis melena. The sample size of this research was 65 subjects. The variables analyzed included nutritional status, dysphagia, nutritional intake (energy and protein), and methods of feeding. Nutritional status was assessed with SGA on hospital admission and discharge. Sufficient nutritional status was defined as 50% of the assesed elements graded A and insufficient nutritional status as 50% of the assesed elements graded B or C. The data of food intake was obtained by employing Comstock visual interpretation and 24 hour recall. Food intake was considered to be adequate if satifying 80% of enery and protein needs and was considered to be inadequate if satifying 80% of energy and protein needs. Methods of feeding were categorized as oral

and nasogastrict tube. Stastitical data analysis was performed by employing statistical data analysis software. Chi-Square Test was used to see the relationships between two variables, Multivariate analysis was aimed at finding out the main factor affecting the relationships between dysphagia and nutritional status. The variables included in the multivariate analysis were those which had p-value less than 0.25 in bivariate analysis. The convidence level used was 95%. Informed consent and research ethics were performed in this research.

RESULTS and DISCUSSIONThe characteristics of the research subjects are completely shown in table 1.

Characteristics Sex - Male - Female Age (years old) - < 50 - 50-59 - > 60 Early Nutritional status admission - Wellnourished - Undernourished Dysphagia - Yes - No Methods of Feeding - Oral - NGT

N (%)
37 (56,9) 28 (43,1) 18 (27,7) 25 (38,5) 22 (33,8) on 44 (67,7) 21 (32,2) 34 (52,3) 31 (47,7) 34 (52,3) 31 (47,7)

Means (SD)

Min - Max

55,7 (19,7)

25 - 78

The mode age in this reasearch was between 50 and 59 years old with the mean age of 55.7 years old, which agrees with the studies previously conducted by Rahayuningsih and Hariani, who state that stroke is more frequent at the age,17,18 while Crary12 finds that the mean age is

65.2 years old, This age difference is caused by better risk factor control, which can minimize and prevent stroke attacts. Stroke may occur at any age, but increases with age. Impairments most frequently occur at the age above 45.29 The prevalence of dysphagia in stroke patients in Dr. Cipto Mangunkusumo Hospital appears to increase from 45.9% in 1998 to 52.3% in this research. The prevalence of dysphagia in this research agrees with Smithards statement22 that after accute stroke, the prevalence of dysphagia is around 29 54%. Compared with the study conducted by Mann,23 which finds the prevalence of 65%, the prevalence in this research is lower. In this study, the prevalence of insufficient nutritional status in stroke patients with dysphagia is 44.1% (table 2). The prevalence value is lower than the prevalence found by Paik.14 Finestone et al. report that the prevalence of undernutrition in stroke patients from treatment to rehabilitation periods is 50%.7Table 3 shows that most of the subjects who get food by the oral method and those who get food by the NGT method, both, have sufficient energy intake (58% and 64.5%). Concerning protein intake, the proportion of the subjects who get sufficient intake and that of the subjects who get insufficient intake in the group of the subjects who get food by the oral method are the same while, in the group of the subjects who get food by the NGT method, the proportion of the subjects who get sufficient protein intake (87.1%) is bigger than that of the subjects who get insufficient protein intake (12.9%).

Table 2. The Characteristics of the Subjects Based on Dysphagia


Dysphagia (n[%]) P-value*

Sex - Male - Female Age - < 50 - 50-59 - > 60 Methods of feeding - Oral - NGT Energy intake (kcal) - Sufficient Insufficient Protein intake (g) - Sufficient - Insufficient Early nutritional status - Nourished - Undernourished

18 (58,1) 13(41,9) 8 (25,8) 14 (45,2) 9 (29,0) 29 (93,5) 2 (6,5) 19 (61,3) 12 (38,7) 19 (61,3) 12 (38,7) 25 (80,6) 6 (19,4)

19 (55,9) 15 (44,1) 10 (29,4) 11 (32,4) 13 (38,2) 5 (14,7) 29 (85,3) 21 (61,8) 13 (38,2) 25 (73,5) 9 (26,5) 19 (55,9) 15 (44,1)

0,86

0,56

0,00

0,96

0,29

0,03

The patients with dysphagia (52.3%) in this research have sufficient nutritional status. There is a significant relationship between dysphagia and the subjects nutritional status (p<0.05). This finding is not much different from the study conducted by Finestone et al. 7, which finds that there is a relationship between dysphagia and nutritional status. Different from the studies by Davalos6 and Crary12, Davalos does not find any significant difference between stroke patients with dysphagia and those without dysphagia in skinfold thickness and albumin serum, and, similarly, Crarys research does not find any relationship between nutritional status and dysphagia in stroke patients.

Table 3. The Propotion of the Subjects Based on Methods of Feeding and Intake Methods of feeding (n[%]) P-value

Energy intake (kkal) - Sufficient - Insufficient Protein intake (g) - Sufficient - Insufficient

20 (58,8) 14(41,2) 17 (50,0) 17 (50,0)

20 (64,5) 11 (35,5) 0,64*) 27 (87,1) 0,001**) 4(12,9)

*)Chi-square Test **) Fisher Exact In table 4, most of the subjects with dysphagia (52.9%) has sufficient nutritional status. This research finds that there is a significant relationship between dysphagia and the subjects nutritional status (p<0.05). The subjects with dysphagia have a 1.6 times higher risk of suffering from insufficient nutritional status .

Table 4. The Proportion of Subjects Based on Dysphagia and Nutritional Status Nutritional Satus (n[%])
Dysphagia No Yes

RR ( 95% IK)
1.6 (1.1 2.2)

P-value*
0,008

* Chi-square Test

26 (83,9) 18 (52,9)

5 (16,1) 16 (47,1)

Dysphagia is connected with an increased risk of aspiration, impaired functional capabilities, and decreased life quality. It also increases risks of malnutrition and low recovery rates. Teguh et al.25, in 2000, conducted research on nutritional status in stroke patients although, statistically, the results are not significant. However, the research, which was conducted 14 days long, shows an increase in albumin and protein, respectively 12% and 4.5%. Teguh explaines that the research on nutrition care was conducted on stroke with swallowing impairment, which included 36 patients. Besides, patients with impaired food intake because of

depression and decreased awareness were also included. The research shows symptoms of recovery because the main problem of stroke is impaired protein metabolism, so that the disintegration of neuropeptida, neurotransmitter, and neuroendrokin occurs. Whereas, protein is the

substance of the three factors, Giving drugs and balanced nutrients can accelerate the restoration of brain and organ systems, so that patients post-stroke life quality increses and recurrant attacts are minimalized.

Table 5. The Proportion of Subjects Based on Dysphagia and Posttreatment Nutritional Status
Nutritional Status (n[%]) Methods of feeding - Oral 30 (88,2) - NGT 14 (46,2) * Chi-square Test OR ( 95% IK) 9,1 (2,6 32,1) Pvalue 0,000

4 (11,8) 17 (54,8)

In this research, most of the subjects with sufficient protein intake have sufficient nutritional status. Similarly, most of the subjects who have insufficient protein intake have sufficient nutritional status. There is a significant relationship between protein intake and subjects nutritional status (p<0.05). The writers research agrees with the research of 77 stroke patients by Rahayuningsing et al.17, which find decreased albumin levels on the fifth day and increased urinary nitrogen levels on the third day, which shows that protein catabolism occur in stroke patients.In condition of stress, including stroke, the metabolism of nutrients, carbohydrates, protein, and fat. There is lack of reports on non-protein energy sources like carbohydrates and fat in stress condition. This is caused by lack of research which clearly shows the benefits of the two nutrients. Stroke patients swallowing function can revive, partly or totally, but special attention is required until recovery condition. Swallowing

impairments often cause undernutrition because of inadequate food

intake.

Dietary modification needs to be made individually, based on

types and levels of nervous system impairments and risk factors. This is seen from physical exam findings, blood pressure, and blood biochemistry.27 Dietary modification is a key on a general therapy program of dysphagia. Diets with soft food are recommended to patients with swallowing difficulty, who suffer from pocket food in the buccal recesses or who have pharyngeal retention of chewing solid food. Food consistency can be improved from soft food to semi-soft food with regular consistencies. It is recommended eating small portions and swallowing in the right positions.
11

Oral feeding can prevent malnutrition in stroke patients, but clinical research results need to be proved. In this research, the proportion of the subjects who get food by the oral method and have sufficient nutritional status (88.2%) is bigger than that of the subjects with insufficient nutritional status. The proportion of the subjects who get food by the NGT method and have sufficient nutritional status (45.2%) is smaller than that of the subjects with sufficient nutritional status. There is a significant relationship between methods of feeding and nutritional status (p<0.05). The subjects who get food by the NGT method have a risk of insufficient nutritional status 1.9 times higher than the subjects who get food by the oral method. The research finding agrees with Nortons research.15

Norton conducted cohort prospective research of 30 stroke patients with dysphagia to compare feeding by a gastronomy and that by a nasogastic tube. The research finds that there is a relationship between nutritional status and methods of feeding. It is concluded that gastrostomy feeding gives better outcome compared to a nasogastric tube. NGT is not 100% because of food consistency, so that it can cause the food consumed does not agree with recommended needs. Another factor is that blenderized food contains too much water, does not have any agreed standard, which is different from commercial formula food,

which is much more expensive. Blenderized food is more varied because it contains food with balanced nutrients.

Dysphagia, nutritional intake (energy and protein), and methods of feeding are variables. The result of the analysis shows that methods of feeding are the main variable affecting nutritional status of stroke patients with dysphagia.

Table 6. Multivariate analysis Dysphagia Methods of Feeding Protein intake 0,55 14,93 1,03 0,05 - 5,56 1,44 154,46 0,99 1,06 0,61 0,02 0,07

ConclusionThe conclusion of this research is that dysphagia affects stroke patients nutritional status. Subjects with dysphagia have 1.6 times higher risk of undernutrition and methods of feeding become the main factor affecting the effect of dysphagia on stroke patients nutritional status on disc

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