2.

1 Incidence of dysphagia in stroke patients

Dysphagia, that is difficulty in swallowing, is a common, serious consequence of stroke and
results from damage to the upper motor neurone of the lower cranial nerves. In an unselected
hospitalized group of stroke patients, 45% had difficulty in swallowing when admitted to
hospital, 7% had dysphagia for nine or more days, but only 3% were dysphagic after 40 days,
with a 6 week mortality rate of initially dysphagic patients of 46%.
The health related quality of life of dysphagic stroke survivors will vary with functional status
following stroke. Dysphagia is associated with severe stroke. Although most dysphagic patients
either recover their swallowing ability or die in the first few weeks following the stroke, some
patients regain the ability to eat at a later stage. Patients with dysphagia are at a high risk of
aspirating their food and consequently of aspiration pneumonia. Enteral feeding does not
remove this risk but does contribute to an improved nutritional status.
Carole Cummins, Tom Marshall & Amanda Burls. 2000. Percutaneous Endoscopic Gastrostomy
(PEG) Feeding In The Enteral Nutrition Of Dysphagic Stroke Patients Indications For Enteral
Nutrition. A West Midlands Development and Evaluation Service Report. Birmingham:
Department of Public Health & Epidemiology University of Birmingham.
Optimal hydration and nutrition is required to meet the bodys daily nutritional requirements.
Patients with dysphagia may be unable to attain these minimum nutritional requirements with
oral intake and require enteral nutrition [2-9]. These patients include those who are unable to
swallow due to neurological damage or degeneration [4, 10-15]. Dysphagia with resulting
malnutrition and/or dehydration is common in patients who have had a CVA.
There are different enteral nutrition routes, and the route chosen is determined according to
the length of time and the type of enteral support needed for a specific patient. The different
types of enteral nutrition include nasogastric tubes (NGTs) and nasojejenal tubes (NJTs);
surgically placed gastrostomy tubes (GTs) and jejenostomy tubes (JTs); and non-surgical
placement methods include percutaneous endoscopic gastrostomy (PEG) or percutaneous
endoscopic jejenostomy (PEJ).
mortality in patients with CVAs usually occurs in the acute stage when a
patient is still in the hospital [65]. Dysphagia is common following a CVA [65] and many CVA
patients will regain their ability to swallow within two weeks post infarct [66]. During the acute
stages post CVA, an NGT is recommended for the provision
of hydration and nutrition [13].
Cairan dan nutrisi yang optimal diperlukan untuk memenuhi kebutuhan gizi harian tubuh. Pasien
dengan disfagia mungkin tidak dapat mencapai kebutuhan gizi minimum tersebut dengan asupan
oral dan membutuhkan nutrisi enteral (Bankhead et al, 2009). Pasien-pasien ini termasuk orangorang yang tidak mampu menelan akibat kerusakan saraf atau degenerasi (Vivanti et al, 2009).
Disfagia dengan gizi buruk dan/atau dehidrasi dihasilkan umum pada pasien yang memiliki
CVA. Ada yang berbeda-rute nutrisi enteral, dan rute yang dipilih ditentukan menurut lamanya
waktu dan jenis dukungan enteral dibutuhkan untuk pasien tertentu. Berbeda jenis nutrisi enteral
meliputi tabung nasogastric (ngts) dan tabung nasojejenal (NJTs); pembedahan ditempatkan
tabung gastrostomy (GTS) dan tabung jejenostomy (JTS); dan non-bedah metode penempatan
termasuk perkutan gastrostomi endoskopi (PEG) atau percutaneous jejenostomy endoskopi
(PEJ). Mortalitas pada pasien dengan CVA biasanya terjadi pada tahap akut ketika pasien masih

di rumah sakit. Disfagia umum mengikuti dan banyak CVA pasien akan mendapatkan kembali
kemampuan mereka untuk menelan dalam waktu dua minggu pasca infark. Selama tahap akut
posting CVA, sebuah NGT dianjurkan untuk penyediaan cairan dan nutrisi (Kenny dan Shajila,
2015).
Bankhead, R., Boullata, J., Brantley, S., Corkins, M., Guenter, P., Krenitsky, J., Lyman, B.,
Metheny, N.A., Mueller, C., Robbins, S., & Wessel, J. 2009. A.S.P.E.N. Enteral Nutrition
Practice Recommendations. Journal of Parenteral and Enteral Nutrition, 33,122.
Vivanti, A. P., Campbell, K. L., Suter, M. S., Hannan-Jones, M., & Hulcombe, J. A. 2009.
Contribution Of Thickened Drinks, Food And Enteral And Parenteral Fluids To Fluid Intake In
Hospitalised Patients With Dysphagia. Journal of Human Nutrition and Dietetics: The Official
Journal of the British Dietetic Association, 22(2), 148-155.
Kenny, N. dan Shajila A. S. 2015. Decision Making for Enteral Nutrition in Adult Patients with
Dysphagia A Guide for Health Care Professionals. Seminars in Dysphagia. South Africa: Chris
Hani Baragwanath Academic Hospital, Speech Therapy and Audiology Department,
Johannesburg, South Africa, University of Cape Town, Department of Communication
Disorders, Cape Town, South Africa. http://dx.doi.org/10.5772/60987 [28 Juni 2016].
Dysphagia, a difficulty in swallowing, can be caused by many pathologies including stroke. In
patients with stroke, it is characterised by difficulty in safely moving food or liquids from the
mouth to the stomach without aspiration. It may also involve difficulty in oral preparation for the
swallow, such as chewing and tongue movement.
Dysphagia is a frequent and potentially serious complication of stroke and in some cases may be
the sole or overriding symptom. Reports of incidence vary according to the definition of
dysphagia and the timing and method of assessment. Videofluoroscopic evidence indicates the
presence of dysphagia in 64-90% of conscious stroke patients in the acute phase, with aspiration
confirmed in 22-42% of cases. Dysphagia is associated with excess morbidity and increased
mortality rates. It gives rise to a risk of aspiration and associated bronchopulmonary infections,
fluid depletion and undernutrition. Whilst it is recognised that the development of undernutrition
is multifactorial, nutritional problems may be exacerbated by decreased swallow function
following stroke. Patients with acute stroke who are undernourished may take significantly
longer to recover and have a higher mortality than those who are well nourished. Most dysphagia
resolves within the first few weeks, but in some cases it may persist with resulting long term
consequences for nutrition management and psychosocial adjustment. Implementation of a
systematic programme of diagnosis and management of dysphagia within an acute stroke
management plan can reduce the occurrence of pneumonia. Despite this evidence, the detection
and management of swallowing problems in acute stroke is inadequate in many hospitals. The
aim of this guideline is to assist practitioners in reducing the morbidity associated with dysphagia
by early detection of swallowing disorders in stroke patients and application of appropriate
methods to support food and fluid intake.

NHS Quality Improvement Scotland (NHS QIS). 2010. Management Of Patients With Stroke:
Identification And Management Of Dysphagia A National Clinical Guideline. Scottish
Intercollegiate Guidelines Network. www.sign.ac.uk [29 Juni 2016].
Pasien stroke mungkin sangat rentan terhadap kekurangan gizi protein-energi akibat berbagai
faktor yang mempengaruhi kesediaan atau kemampuan mereka untuk diri pakan, seperti
kehilangan nafsu makan terkait dengan depresi, defisit kognitif, disfagia (kesulitan menelan),
mengabaikan visual, atas ekstremitas paresis, dan apraxia (ketidakmampuan untuk menggunakan
benda-benda dengan benar) (Finestone et al. 2003). Namun, beberapa studi ada yang
menggambarkan energi dan protein intake pasien stroke di rumah sakit. Gariballa et al.
melaporkan bahwa asupan energi dua minggu rata-rata pasien stroke yang tidak memiliki
menelan kesulitan mengikuti stroke dan yang mengkonsumsi diet rumah sakit biasa adalah 1.338
kilokalori (KKal) mewakili 74 persen dari kebutuhan mereka diprediksi (Gariballa 2001).
Tingkat kecukupan tidak berbeda secara signifikan dari 42 pasien nonstroke usia dan jenis
kelamin-cocok yang mengkonsumsi 1.317 KKal, atau 73 persen dari kebutuhan, menunjukkan
bahwa asupan pasien stroke yang mirip dengan pasien dirawat di rumah sakit lain. Satu-satunya
studi lainnya yang meneliti protein dan energi intake setelah stroke melaporkan bahwa rata-rata,
terlepas dari jenis diet (lisan atau non-oral) dan tekstur (diet biasa atau tekstur-dimodifikasi
karena gangguan menelan), pasien dirawat di rumah sakit dikonsumsi rata-rata 85 persen dari
kebutuhan energi mereka, dan 86 persen dari kebutuhan protein, selama 21 hari pertama setelah
stroke (Foley et al. 2006).
Finestone, H. M., Greene-Finestone, L. S., Foley, N. C., & Woodbury, M. G. 2003. Measuring
Longitudinally The Metabolic Demands Of Stroke Patients: Resting Energy Expenditure Is Not
Elevated. Stroke, 34(2), 502-507.
Gariballa, S. E. 2001. Malnutrition In Hospitalized Elderly Patients: When Does It Matter?.
Clinical Nutrition, 20(6), 487-491.
Foley, N., Finestone, H., Woodbury, M. G., Teasell, R., & Greene, F. L. 2006. Energy And
Protein Intakes Of Acute Stroke Patients. J.Nutr.Health Aging, 10(3), 171-175.
The relationship between stroke severity and malnutrition was examined in three studies (Davis
et al. 2004; Dennis et al. 2005a; Yoo et al. 2008). Increasing stroke severity was associated with
baseline malnutrition in one of these trials (Yoo et al. 2008). In all of these studies severity was
assessed using the National Institutes of Health Stroke Scale (NIHSS) and was examined during
the first several days following acute stroke. Only one study examined the relationship between
stroke type and malnutrition (Choi-Kwon et al. 1998). The prevalence of malnutrition reported in
this study was much higher among patients suffering from intracerebral hemorrhagic versus
ischemic stroke; however, the authors suggested that the result was likely attributable to
differences in pre-existing malnutrition between groups.

Davis, J. P., Wong, A. A., Schluter, P. J., Henderson, R. D., O'Sullivan, J. D., & Read, S. J. 2004.
Impact Of Premorbid Undernutrition On Outcome In Stroke Patients. Stroke, 35(8), 1930-1934.
Dennis, M. S., Lewis, S. C., & Warlow, C. 2005. Effect Of Timing And Method Of Enteral Tube
Feeding For Dysphagic Stroke Patients (FOOD): A Multicentre Randomised Controlled Trial.
Lancet, 365(9461), 764-772.
Yoo, S. H., Kim, J. S., Kwon, S. U., Yun, S. C., Koh, J. Y., & Kang, D. W. 2008. Undernutrition
As A Predictor Of Poor Clinical Outcomes In Acute Ischemic Stroke Patients. Arch.Neurol.,
65(1), 39-43.
Enteral feeding may represent a sole or supplemental source of feeding. Generally, enteral
nutrition as the sole source of nutrient intake is reserved for dysphagic patients for whom oral
feeding is considered unsafe. However, failure to thrive non-dysphagic stroke patients may
also be candidates for enteral feeding in the presence of prolonged and inadequate oral intake.
The use of feeding tubes in these stroke patients has been shown to reverse malnutrition.
Therefore, the use of feeding tubes can prevent or reverse the effects of malnutrition in patients
who are unable to safely eat and those who may be unwilling to eat. Data from the Post-Stroke
Rehabilitation Outcomes Project (James et al. 2005), which retrospectively studied the outcomes
of 919 patients from six inpatient rehabilitation sites, provides evidence that tube feeding is an
effective intervention. Patients with both moderate and severe stroke who had received tube
feeding during hospital stay but who were not discharged with a feeding tube in place achieved
greater increases in total FIM gains and experienced greater improvement in severity of illness
by discharge.
James, R., Gines, D., Menlove, A., Horn, S. D., Gassaway, J., & Smout, R. J. 2005. Nutrition
Support (Tube Feeding) As A Rehabilitation Intervention. Arch.Phys.Med.Rehabil., 86(12 Suppl
2), S82-S92.