1030
Clinical Predictors of Dysphagia and Aspiration Risk: Outcome
Measures in Acute Stroke Patients
Stephanie K. Daniels, MS, Lindsay A. Ballo, MA, Mary-Claudia Mahoney, MCD, Anne L. Foundas, MD
ABSTRACT. Daniels SK, Ballo LA, Mahoney M-C, Foundas
AL. Clinical predictors of dysphagia and aspiration risk:
outcome measures in acute stroke patients. Arch Phys Med
Rehabil 2000;81:1030-3.
Objective: To use an established dysphagia clinical screen-
ing system to evaluate outcomes in acute stroke patients.
Design: Case-control study.
Setting: Tertiary care center.
Participants: Acute stroke patients (n 56) consecutively
referred to a speech pathology service.
Main Outcome Measures: Outcomes (ie, pneumonia, di-
etary status at discharge) in patients who were referred for a
videofluoroscopic swallow study (VSS) based on results of a
previously validated clinical screening system were compared
with outcomes in patients who were not referred for VSS based
on the clinical evaluation.
Results: Thirty-eight of 56 patients (68%) presented with 2
or more clinical predictors of moderate to severe dysphagia and
were further evaluated with VSS, whereas 18 patients (32%)
had fewer than 2 clinical features and were not evaluated
radiographically. Based on patient outcomes and VSS results,
identification of at least 2 clinical predictors significantly
distinguished patients with moderate to severe dysphagia from
patients with mild dysphagia or normal swallowing. None of
the patients in either group developed pneumonia while follow-
ing recommendations of the clinical or dynamic swallowing
evaluation, and 93% of the patients returned to a regular diet.
Conclusions: These data demonstrate that clinical use of this
screening system can objectively identify acute stroke patients
who warrant further diagnostic studies and can safely determine
which patients need no further deglutitive evaluation.
Key Words: Deglutition; Deglutition disorders; Stroke;
Screening; Fluoroscopy; Rehabilitation.
r 2000 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
D YSPHAGIA OCCURS in approximately 55% of acute
stroke patients,1,2 with aspiration, as identified by a video-
fluoroscopic swallow study (VSS), occurring in 40% of these
patients.1,3 Silent aspiration can occur in 40% to 70% of
From the Speech Pathology Section (Daniels, Ballo, Mahoney), and the Neurology
Section (Foundas), Department of Veterans Affairs Medical Center; and the Depart-
ment of Psychiatry and Neurology, Tulane University School of Medicine (Daniels,
Foundas), New Orleans, LA.
Submitted June 15, 1999. Accepted in revised form November 10, 1999.
Supported, in part, by NIH-NIDCD grant K08 DC00135 (ALF), and Department of
Veterans Affairs VISN16 MIRECC.
Presented in part at the Seventh Annual Dysphagia Research Society Meeting, New
Orleans, LA, October 15, 1998.
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.
Reprint requests to Stephanie K. Daniels, Speech Pathology, Department of
Veterans Affairs Medical Center, 1601 Perdido Street, New Orleans, LA 70112-1262.
0003-9993/00/8108-5678$3.00/0
doi:10.1053/apmr.2000.6301
Arch Phys Med Rehabil Vol 81, August 2000
dysphagic patients who aspirate,1,4 which can increase the risk
of developing aspiration pneumonia and increase length of
hospitalization. Based on clinical examinations, dysphagia was
noted in 7% of stroke patients at 6 months after stroke,5 and
19% of stroke patients with dysphagia were discharged with a
gastrostomy tube.6 These data indicate that dysphagia is a
common occurrence in poststroke patients, that it increases
morbidity, and that it can persist in some patients. Thus, a
comprehensive and validated clinical examination is warranted
in all acute stroke patients to evaluate swallowing and aspira-
tion risks and to identify patients who warrant diagnostic
deglutitive examination.
In a recent study of consecutive acute stroke patients in
which swallowing was evaluated clinically and radiographi-
cally, 6 clinical indicators were identified that significantly
predicted risk of aspiration on VSS.1 These clinical indicators
included abnormal volitional cough, abnormal gag reflex,
dysphonia, dysarthria, cough after swallow, and voice change
after swallow. The presence of any 2 of these 6 clinical
predictors was found to significantly distinguish patients with
moderate to severe dysphagia from patients with mild dysphagia/
normal swallowing with 92.3% sensitivity and 66.7% specific-
ity (table 1).7 Sensitivity was defined as the probability that 2 or
more clinical features would be present if aspiration was
present on VSS, and specificity was defined as the probability
that 2 or more clinical predictors would not be present if
aspiration was not identified on VSS. Although sensitivity and
specificity are frequently used to determine the effectiveness of
screening examinations, other measures of reliability and
validity are important in determining the value of clinical
evaluations. Similar results, with the exception of the signifi-
cance of abnormal gag reflex, were reported by another group
of investigators.8 Taken together, these findings suggest that the
presence of any 2 of the stated 6 clinical features can accurately
identify patients at risk for prandial aspiration and determine
which patients warrant VSS, but patient outcomes have not
been studied using these clinical predictors. Thus, it is unclear
whether stroke patients who did not receive VSS but have mild
features of dysphagia are apt to develop pneumonia because of
silent aspiration. Although recent research has revealed that the
causes of pneumonia are multiple,9 it is important to document
outcomes in patients who do not receive VSS. It is also unclear
whether recommendations made with this validated screening
system improve outcome or whether this clinical tool underesti-
mates patients at risk of prandial aspiration. The aim of this
retrospective study was to use a clinical pathway approach to
evaluate outcomes in consecutive acute stroke patients. All
acute stroke patients were administered a bedside clinical
examination, and patients who presented with two or more
clinical features underwent VSS. Diagnostic deglutitive exami-
nation was not recommended for those patients with fewer than
two clinical predictors. The outcome measures included identi-
fying the occurrence of medical complications (ie, pneumonia)
and discharge dietary status in all of the acute stroke patients
who were evaluated using this clinical pathway.
 DYSPHAGIA OUTCOMES IN ACUTE STROKE, Daniels
Table 1: Dysphagia Severity Scores
Score Characteristics
0 Normal swallowing. Overall normal functioning of
the oropharyngeal swallowing mechanism with
no resultant supraglottic penetration or aspira-
tion.
1 Mild dysphagia. Oral or pharyngeal dysfunction
resulting in no more than intermittent evidence
of trace supraglottic penetration with immediate
clearing.
2 Moderate dysphagia. Oral or pharyngeal dysfunc-
tion resulting in consistent supraglottic penetra-
tion with laryngeal vestibule stasis or two or less
instances of aspiration of a single viscosity.
3 Moderate-severe dysphagia. Oral or pharyngeal
dysfunction resulting in consistent aspiration of
a single viscosity.
4 Severe dysphagia. Oral or pharyngeal dysfunction
resulting in aspiration of more than one consis-
tency.
METHODS
Subjects
Fifty-six acute stroke patients who were consecutively re-
ferred within a 19-month period to the Speech Pathology
Service at the Veterans Affairs Medical Center in New Orleans
were studied. Nonhemorrhagic ischemic stroke was confirmed
by documentation of acute infarct by either computed tomogra-
phy or magnetic resonance imaging scans in the patients
studied. Lesion site was not a criterion for inclusion in the
study. Patients who could not be clinically tested within 5 days
of admission because of obtunded levels of alertness or
significant agitation were excluded from the study, as were
those with a prior history of oropharyngeal dysphagia, oropha-
ryngeal structural damage, or a neurologic disease other than
stroke that could produce dysphagia. Mean patient age was 64
years (SD 10.58), and all patients were men. These patients
had not been previously enrolled in prior dysphagia studies.
A clinical swallowing screening was completed on all
patients within 5 days of admission. Based on the results of the
clinical screening, two patient groups were identified: group 1
(n 38) consisted of patients who presented with 2 or more
clinical indicators, and group 2 (n 18) consisted of patients
with 1 or no clinical indicator. Group 1 was further evaluated
with VSS. Group 2 was not evaluated with VSS. Therapeutic
swallowing intervention was initiated in patients as needed
based on the VSS results.
Procedures
The clinical swallowing screening consisted of assessment of
dysphonia, dysarthria, abnormal volitional cough, abnormal
gag reflex, cough after swallow, and voice change after
swallow, which were scored on a binary present/absent basis
(table 2). Clinical swallowing integrity was assessed with
calibrated volumes of water. Assessment of each of these
parameters has previously been described in detail.1,7 Patients
in group 1 were further evaluated with VSS, which was
completed within an average of 5 days from the clinical
screening. The VSS was completed with the standard tech-
niques previously described,1,7 and dysphagia severity was
rated on a scale of 0 (normal) to 4 (severe dysphagia). Table 1
summarizes dysphagia severity scores. Dysphagia severity was
1031
classified according to frequency of supraglottic penetration
and aspiration as well as supraglottic stasis and invading
viscosity. Although penetration and aspiration are symptoms of
physiologic or anatomic abnormalities of deglutition, they are
perhaps the most significant disturbances identified during
diagnostic testing. Although not as detailed as the Penetration-
Aspiration Scale,10 which classifies airway invasion into eight
levels and notes depth of penetrated material as well as reaction
and ability to expel material from the airway, our scale does
identify frequency and number of viscosities penetrated or
aspirated. Severity was determined before therapeutic interven-
tion was initiated. Based on the results of the VSS, subjects in
group 1 were further divided into two categories: those with
normal swallowing/mild dysphagia (scores 0 to 1) and moder-
ate to severe dysphagia (scores 2 to 4). Outcome measures were
obtained from the patients medical charts and consisted of the
dietary status at discharge (eg, regular diet, pureed, thickened
liquids, tube feedings) and medical complications during hospi-
talization related to aspiration pneumonia. Specifically, the
criterion for diagnosis of aspiration pneumonia was new
infiltrate on chest x-ray or a cluster of symptoms including
sustained temperature of 100.5F, elevated white blood cell
count, positive sputum culture for respiratory pathogen, and/or
the presence of ronchi and rales.
RESULTS
Of the total stroke sample, 38 of 56 (68%) patients presented
with 2 or more clinical indicators (group 1), and 18 of 56 (32%)
patients presented with 1 or no clinical predictor (group 2).
Within the group referred for VSS (group 1), 14 of 38 (37%)
patients presented with normal swallowing/mild dysphagia
(dysphagia severity score 0 or 1), and 24 of 38 (63%) patients
presented with moderate to severe dysphagia (dysphagia sever-
ity score 2 to 4). Based on patient outcomes and the results of
the VSS, identification of 2 or more clinical predictors signifi-
cantly distinguished patients with normal swallowing/mild
dysphagia from patients with moderate to severe dysphagia
(2 19.895, p .00001). Calculation of a phi coefficient
equaled .596, which is associated with a large effect size.11
Chart review showed that no patient in either group developed
complications during hospitalization. Two patients died during
Table 2: Operational Definitions of the Six Clinical Predictors of
Risk of Aspiration
Dysphonia A voice disturbance in the parameters of
vocal quality, pitch, or intensity.
Dysarthria A speech disorder resulting from distur-
bances in muscular control affecting
the areas of respiration, articulation,
phonation, resonance, or prosody.
Abnormal gag reflex Either absent or weakened velar or pha-
ryngeal wall contraction, unilaterally
or bilaterally, in response to tactile
stimulation of the posterior pharyn-
geal wall.
Abnormal volitional A weak response, verbalized response,
cough or no response on given the command
to cough.
Cough after swallow Cough immediate or within 1 minute of
ingestion of calibrated volumes of
water (5, 10, and 20mL presented in
duplicate).
Voice change after Alteration in vocal quality following
swallow ingestion of calibrated volumes of
water.
Arch Phys Med Rehabil Vol 81, August 2000
1032 DYSPHAGIA OUTCOMES IN ACUTE STROKE, Daniels
hospitalization, with the cause of death unrelated to aspiration
pneumonia. Chart review of the 54 surviving patients showed
that at the time of discharge, 52 had returned to a regular diet
(92.8%), 1 continued to require diet alteration (chopped food),
and 1 patient continued to require tube feeding. The two
patients requiring a nonregular diet at discharge were in group
1, and their average length of hospitalization, including rehabili-
tation, was 45 days.
DISCUSSION
Early prevention of aspiration pneumonia in the acute stroke
patient is crucial to decrease length of hospitalization and to
expedite rehabilitative efforts. Lower respiratory tract infection
has been shown to be prominent during the first 2 weeks of
admission in aspirating stroke patients,12 so it is imperative that
acute stroke patients be evaluated for risk of prandial aspiration
within the first few days of hospitalization. Although clinical
features of dysphagia and aspiration have been noted in the
stroke population, studies have frequently evaluated chronic
rather than acute stroke patients,4,13 have not studied consecu-
tive patients,4,6 and have often not confirmed swallowing results
with VSS.2,6 Daniels and colleagues,1,7 along with McCullough
and colleagues,8 have demonstrated that identification of any 2
of the 6 specified clinical features can accurately identify stroke
patients with moderate to severe dysphagia and objectively
determine the need for VSS. These clinical features, which
include abnormal volitional cough, abnormal gag reflex, dyspho-
nia, dysarthria, cough after swallow, and voice change after
swallow, are readily observed on a bedside clinical examination
and require no more than 10 minutes to evaluate. Daniels and
colleagues7 found that acute stroke patients presenting with 1 or
none of these clinical features had either normal swallowing or
mild dysphagia, whereas patients with 2 or more of these
clinical features had moderate to severe dysphagia and in-
creased risk of aspiration. This retrospective study has further
advanced the notion that the use of this clinical pathway can
consistently distinguish acute stroke patients with normal
swallowing/mild dysphagia from those with moderate to severe
dysphagia without increasing morbidity or mortality. Further-
more, outcomes were not compromised for those patients who
presented with fewer than 2 clinical features and did not
undergo VSS, as none developed pulmonary complications.
Although one-fourth of the sample may not have warranted
VSS, these patients were included based on the stringent
parameters and the goal of reducing false-negative results. Each
VSS was completed within 5 days of the clinical evaluation,
and results were similar for both groups: 3.71 days for patients
with mild dysphagia/normal swallowing and 5.29 days for
patients with moderate to severe dysphagia. As previous
research has indicated, expanding the criteria for VSS to 3
clinical features reduced the false-positive count marginally
while increasing the false-negative count,7 and we opted to be
conservative and to err on the side of more false-positive rather
than false-negative occurrences. Future studies may further
discriminate patients who may not warrant VSS by using
additional factors such as lesion location14 and the presence of
other medical conditions or social history.
Therapeutic and diet recommendations based on results from
the VSS were justified because no patient in this group
developed medical complications, and all but 2 patients had
advanced to a regular diet by the time of discharge. Diet
recommendations determined from the VSS were based on a
patients masticatory ability and tolerance of varying volumes
of thinned and thickened liquids and semi-solid viscosities. Diet
Arch Phys Med Rehabil Vol 81, August 2000
recommendations for patients who did not undergo a VSS were
determined from results of the clinical examination. These
patients also advanced to a regular diet and had no complica-
tions. These findings suggest that early clinical screening and
intervention helps to decrease the risk of complications in all
stroke patients. Unlike Odderson et al,6 who reported a 19%
incidence of nonoral feeding at discharge, only 1 of our 54
patients (2%) was discharged with a gastrostomy tube. In-
creases in chest infection and mortality have been associated
with dysphagia on clinical examination but not with aspiration
identified with VSS.15 The negative outcome results of these
studies6,15 that use clinical examination may be due to the lack
of management based on the physiologic findings of the VSS.
Conversely, acute stroke patients with few clinical predictors of
aspiration risk can be treated without the use of VSS and are not
at increased risk of developing complications.
CONCLUSIONS
Identification of 2 or more of 6 clinical features consistently
distinguishes acute stroke patients at increased risk of aspiration
on VSS from patients at limited risk.1,7 These 6 clinical
indicators are abnormal volitional cough, abnormal gag reflex,
dysphonia, dysarthria, voice change after swallow, and cough
after swallow. Results of this study support previous research
that advocates the use of a clinical screening system to
objectively identify acute stroke patients who warrant further
diagnostic studies (ie, VSS) and to safely determine which
patients require no further deglutitive evaluation. Identification
of 2 or more clinical features distinguished patients at risk of
prandial aspiration from those patients at minimal risk. There
were no significant poststroke complications in any patients
studied, and most patients advanced to a regular diet. Use of this
simple and valid clinical deglutition screening tool can decrease
costs and limit diagnostic procedures while facilitating rehabili-
tative efforts. Early evaluation and treatment of stroke patients
with and without clinical predictors of aspiration yielded
favorable outcomes. Larger group studies are warranted to
replicate these findings and discern whether other factors, such
as other medical conditions or level of functioning with
self-care skills, may interact with these clinical criteria to put
patients at increased risk of developing aspiration pneumonia.
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