EATING PROBLEMS AND NUTRITIONAL STATUS
AFTER STROKE.
AKADEMISK AVHANDLING
som med vederbörligt tillstånd av Rektorsäm betet vid Umeå
U niversitet för avläggande av doktorsexamen i m edicinsk
vetenskap kommer att offentligen försvaras i
aulan, Vårdskolan, Gluntens väg 10 B,
fredagen den 10 juni 1988 kl 9.00
av
K arin
Axelsson
Umeå 1988
UMEÅ UNIVERSITY MEDICAL DISSERTATIONS
New series No 218 - ISSN 0346-6612 ISBN 91-7174-360-X
EATING PROBLEMS AND NUTRITIONAL STATUS
AFTER STROKE.
Karin Axelsson, Departments of Advanced Nursing and M edicine,
University of Umeå, S-901 85 Umeå, Sweden.
ABSTRACT
E ating problem s and n utritional status were studied in a
consecutive series of 104 stroke patients adm itted to emergency
hospital care. During their stay in hospital eating problems were
observed in 46 patients. Certain common types of eating problems
were identified: aberrant eating behaviour as regards chew ing,
lokalization or swallowing, eating small amounts, hoarding of food
in the mouth, leakage of food from the mouth and unawareness of
eating problems. Poor nutritional status occurred in 16 % of the
patients on admission and in 22 % on discharge from the stroke
unit.
A subgroup of 32 patients hospitalized for 21 days or longer was
studied for three weeks. On at least one occasion during these three
weeks a poor nutritional status was observed in 18 patients, of
whom 17 had eating problems.
All subjects who had eating problems during their hospital stay,
plus those patients without eating problems but with neurological
deficits and those living in a nursing home one year after the stroke
(n=36) were selected for a longitudinal study 18 months after the
onset of stroke. Eating problems were identified in 23 of these
patients during their hospital stay while 21 had such problem s
when they were followed up.
Two patients who could not eat due to severe dysphagia (after a
stroke) for three years and 18 m onths resp e c tiv e ly , were
successfully trained to eat normally. One patient exhibited impaired
oral and hypopharyngeal function and the other im paired hypopharyngeal function and a spastic crico-pharyngeal muscle. In both
patients training in swallowing was the main rem edical measure
and one of them also had a myotomy of the spastic muscle.
Key words: eating problems, stroke, training in eating, nutritional
status, undernutrition, dysphagia, oral apraxia, oral agnosia, nursing
diagnosis, prognosis.
UMEÅ UNIVERSITY MEDICAL DISSERTATIONS
New series No 218 - ISSN 0346-6612
From the Departments of
Advanced Nursing and Medicine,
University of Umeå
Sweden
EATING PROBLEMS AND NUTRITIONAL STATUS
AFTER STROKE
by
Karin
Axelsson
Umeå 1988
Copyright © by Karin Axelsson
ISBN 91-7174-360-X
Printed in Sweden by
umpac ab
Umeå 1988.
Sören, Mikael, Robert and Maria.
CONTENTS
ABBREVIATIONS
4
ABSTRACT
5
ORIGINAL PAPERS
6
INTRODUCTION AND REVIEW OF THE LITERATURE
Eating
Stroke and
strokecare
Studies on
eatingandstroke
Nutritional
status
Nursing diagnoses
AIMS OF THE STUDY
SUBJECTS
Descriptive
Case studies
7
7
8
11
13
15
study
16
19
METHODS USED IN DESCRIPTIVE STUDY
Eating
Nutritional
status
Self-care performance
Inspections of the mouth
Analysis of data concerning eating
Statistics
19
20
21
21
22
23
METHODS USED IN CASE STUDIES
Single subject design
Tests of oral and hypopharyngeal functions
Other assessments
Relationship aspect of nursing therapeutics
Training and treatment
2
23
23
23
24
25
RESULTS
Eating problems in hospital (I)
Eating problems 18 months after the stroke (II)
Nutritional status on admission, on discharge
and 18months afterthe stroke (II, III)
Relations between eating problems and
nutritional status (II, III, IV)
Effects of trainingthe swallowing function (V, VI)
26
27
30
30
30
DISCUSSION
Patientselection
Methods used in descriptive study
Methods used in case studies
Results
31
31
32
33
GENERAL DISCUSSION
35
CONCLUSIONS
37
ACKNOWLEDGEMENTS
38
REFERENCES
40
Paper
I
49
Paper
II
59
Paper
III
77
Paper
IV
95
Paper
V
113
Paper
VI
123
3
ABBREVIATIONS
ADL
= Activities of daily living
AMC
= Arm muscle circumference
Cl
= Confidence Interval (95%)
cr
= Computerized tomography
Q 1.Q 3
= First and third quartile
NANDA = North American Nurses Diagnosis Association
TIA
= Transient ischemic attack
TSF
= Triceps skinfold thickness
4
EATING PROBLEMS AND NUTRITIONAL STATUS
AFTER STROKE.
Karin Axelsson, Departments of Advanced Nursing and Medicine,
University of Umeå, S-901 85 Umeå, Sweden.
ABSTRACT
Eating problems and nutritional status were studied in a
consecutive series of 104 stroke patients admitted to emergency
hospital care. During their stay in hospital eating problems were
observed in 46 patients. Certain common types of eating problems
were identified: aberrant eating behaviour as regards chewing,
lokalization or swallowing, eating small amounts, hoarding of food
in the mouth, leakage of food from the mouth and unawareness of
eating problems. Poor nutritional status occurred in 16 % of the
patients on admission and in 22 % on discharge from the stroke
unit.
A subgroup of 32 patients hospitalized for 21 days or longer was
studied for three weeks. On at least one occasion during these three
weeks a poor nutritional status was observed in 18 patients, of
whom 17 had eating problems.
All subjects who had eating problems during their hospital stay,
plus those patients without eating problems but with neurological
deficits and those living in a nursing home one year after the stroke
(n=36) were selected' for a longitudinal study 18 months after the
onset of stroke. Eating problems were identified in 23 of these
patients during their hospital stay while 21 had such problems
when they were followed up.
Two patients who could not eat due to severe dysphagia (after a
stroke) for three years and 18 months respectively, were
successfully trained to eat normally. One patient exhibited impaired
oral and hypopharyngeal function and the other impaired hypopharyngeal function and a spastic crico-pharyngeal muscle. In both
patients training in swallowing was the main remedical measure
and one of them also had a myotomy of the spastic muscle.
Key words: eating problems, stroke, training in eating, nutritional
status, undernutrition, dysphagia, oral apraxia, oral agnosia, nursing
diagnosis, prognosis.
5
ORIGINAL PAPERS
This thesis is based on the following papers, which will be referred
to in the text by their Roman numerals:
I:
Axelsson K, Norberg A, Asplund K. Eating after a stroke towards an integrated view. International Journal of
Nursing Studies 1984;21:93-9.
II:
Axelsson K. Longitudinal study of eating problems in
stroke patients. Submitted for publication.
III.
Axelsson K, Asplund K, Norberg A, Alafuzoff I. Nutritional
status in patients with acute stroke. Accepted for
publication in Acta Medica Scandinavica.
IV:
Axelsson K, Asplund K, Norberg A, Eriksson S. Eating
problems and nutritional status in patients with severe
stroke. Submitted for publication.
V:
Axelsson K, Norberg A, Asplund K. Relearning to eat late
after a stroke by systematic nursing intervention: a case
report. Journal of Advanced Nursing 1986;11:553-9.
VI:
Axelsson K, Norberg A, Asplund K, Söderberg O, Wenngren
BI. Training of eating after a stroke in a patient with
dysphagia of pharyngeal type. Scandinavian Journal of
Caring Sciences, in press.
The papers are reprinted with kind permission of the respective
journals.
INTRODUCTION AND REVIEW OF THE LITERATURE
E ating
Eating is a complex form of behaviour. Normal eating presupposes
that different factors interact successfully. The cerebral regulation
of hunger and satiation, food palatability, food habits and the
ability to perform those motor actions necessary for eating are
examples of such factors (1, 2).
Eating problems are to be expected in stroke patients for several
reasons. Firstly they are often elderly and there are some problems
related to age. The elderly have e.g. been reported to have an
increased threshold for both taste and smell (3). Secondly the
stroke can lead to impairments that may affect eating for example
appetite, perception of food and motor performance.
This thesis will focus on disturbances in eating behaviour
supposed to be primarily related to the stroke (cf. 4), and mainly,
within this perspective, on the transportation of food from the plate
to the mouth, handling it in the mouth and swallowing it.
Stroke and stroke care
The definition of stroke as formulated by the W orld Health
Organization is: "rapidly developed clinical signs of focal (or global)
disturbance of cerebral function, lasting more than 24 hours or
leading to death, with no apparent causes other than those of
vascular origin" (5).
Impairments after stroke include mobility, sensing, cerebral
integration and intrapsychological deficits (6). A disturbed function
in one arm, in chewing, in facial and swallowing muscles, an altered
sensing of food in the mouth, apraxia in one arm and in the mouth,
an altered ability to communicate and mental depression can all
cause eating problems.
In a study in Söderhamn the incidence of stroke was found to be
2.9/1000 population and year (7). In the Department of Medicine,
Umeå University Hospital the proportion of beds used for stroke
patients increased from seven to 15 per cent from 1971 to 1981
(8).
7
In January 1978 a six-bed non-intensive stroke unit was
established in one of the five wards at the Department of Medicine.
Patients are
admitted directly from the emergency room. The
admission criteria are presence of focal neurological dysfunction
(without trauma to the head) with a duration not exceeding one
week or a history of transient ischemic attack (TIA) during the last
week. Patients with subarachnoid hemorrhage are admitted or
transferred to the Department of Neurosurgery (9). When a bed in
the unit is available the first patient to fulfil the admission criteria
will come to the stroke unit.
During a 16 month period from 1979 to 1981 the unit received
38 per cent of the stroke patients who attended hospital in the
Umeå U niversity H ospital catchm ent area. There were no
differences in characteristics and symptoms on admission between
the patients in the stroke unit
and those treated in the general
medical wards (10).
The patients in the Umeå stroke unit seem to be comparable to
patients reported in other Swedish investigations. In 409 patients
with a well-defined stroke diagnosis who were investigated and
treated in the Umeå stroke unit from 1978 to 1982, the
male/female ratio was 1.25/1 and the mean age was 72 years.
Patients with
embolic infarction were the oldest while those with
TIA were the youngest (11).
In another study of 325 patients in Söderhamn with a first
stroke or TIA the proportions of intracerebral hemorrhage and TIA
were similar while a quite large group was not classified (7). The
distribution among the diagnostic groups in a study of 264 stroke
patients in Stockholm showed a similar distribution to that in the
Umeå study (Table 1). The mean age in the group was 73 years
( 12).
Studies on eating and stroke
Some stroke patients have described their experience of the disease
and the experience of eating as a great discomfort (13, 14). There
are a number of reports about eating problems in stroke patients
that could be characterized as summaries of the practical
knowledge of nurses (e.g. 15-19). In some reports dysphagia is the
8
T able 1. The distribution among different diagnostic groups in
three reported studies from various parts of Sweden (11, 7, 12).
C erebrovascular
diagnoses
Intracerebral
hemorrhage
Umeå
(n=409)
%
11
Söderham n3 Stockholm
(n=264)
(n=325)
%
%
15
Non-embolic brain infarction 51
8
59
41b
Embolic brain infarction
25
25
TIA
13
13
8
Subarachnoid hemorrhage
0
5
0
Unclassified
0
26
0
a First stroke or TIA
b In the study presented as : cerebral infarction.
only eating problem described (e.g. 20, 21). No systematic over-all
investigation of eating problems in stroke patients has been found
in the literature.
Dysphagia is the only eating problem which is fairly well
docum ented. Some studies concerned disabilities (22). In a
community sample of 976 stroke patients an investigation of
swallowing during the first week after the stroke was made in 545
patients. Seventeen per cent could not be tested due to decreased
consciousness, 12 per cent choked, 5 per cent had abnormal
swallowing patterns and 19 per cent were very slow when
swallowing was tested by the drinking of water (23).
Other studies connected disabilities to localization of brain
damage. In a study of 39 patients with well-defined Wallenberg's
9
syndrome 29 had dysphagia during the acute phase (24). Another
study of 35 patients with W allenberg’s syndrom e showed
dysphagia in 74 per cent of the patients in the acute phase (25). A
study of 91 consecutive stroke patients showed a 45 per cent
incidence of dysphagia on admission to a stroke unit (26). The
dysphagic patients were older and had more severe stroke
symptoms than those without dysphagia. The dysphagic patients
also showed a higher frequency of abnormality in cranial nerve
tests. Of the patients who had dysphagia and were alive six weeks
after the stroke 71 per cent had had their dysphagia for eight days
or less (26).
Further studies concerned both disabilities and impairments in
relation to localization of the brain damage. A group of 38 stroke
patients with dysphagia consecutively referred for examination by
videofluorography was studied (27). Seventeen had brain damage
in the left hemisphere, 11 in the right hemisphere and 10 in the
brainstem. The most common swallowing problem was delayed
reflex (82 per cent) followed by reduced pharyngeal peristalsis (58
per cent), reduced lingual control (50 per cent), reduced laryngeal
adduction and cricopharyngeal dysfunction (five per cent each).
More than one type of swallowing problems occurred in 76 per cent
of the patients investigated (27).
Vague descriptions of patient selection criteria and methods of
investigation make it difficult to draw any precise conclusion about
the true prevalence and types of dysphagia.
Assessment instruments such as the Katz’ Index of Independence
in Activities of Daily Living (28) and the Activity Index developed
by Hamrin andWohlin (29) include eating. Using these indexes and
other ADL scales (30) it is possible to register the patients' ability to
eat independently.
General assessments of stroke patients' requisites for eating have
been presented (31) as well as more specific assessments of oral
function (32, 33). Investigations of oral apraxia have been
performed in patients with aphasia and an oral apraxia test has
been developed (34). Tests of oral perception in healthy subjects
showed that they could identify rather complicated forms in the
mouth (35).
10
More general guidelines for measures to help the patient with
eating difficulties (36-38) as well as techniques for the support,
stimulation and training of oral muscles and tongue control (39-41)
have also been presented. A programme based on the training of
oral muscles and instructions to the patient about the basic process
of swallowing followed by training in swallowing water and then
smooth food has been successfully used in 15 patients with
dysphagia of various origins (42). Training in swallowing based on
attempts to stim ulate salivation with a lem on/glycerin swab,
depression of the tongue, elevation of the larynx by manual
pressure simultaneously with instructions in how to swallow has
been shown be of benefit in patients with dysphagia (43, 44).
A method for relearning the initiating of swallowing by training
the patients suck and then to elevate the larynx and finally to suck
on ice chips and swallow, has been applied in seven cases with
dysphagia after a stroke (45). Application of an intra-oral palatal
training appliance is a method used to stimulate the involuntary
swallowing mechanism. This wire loop has been successfully used
in 164 stroke patients with dysphagia (46). Myotomy has been
used in dysphagic patients with spasm in the cricopharyngeal
muscle (47).
The various techniques for training patients with eating
problems that have been presented seem to work. Unfortunately,
the patients' functional deficits were not always clearly described
In patients with dysphagia the hypopharyngeal function was for
instance investigated but not the oral or the oesophageal function.
N utritional status
One consequence of eating problems could be a reduced intake of
food resulting in undernutrition. Undernutrition in hospitalized
patients is caused, in addition to decreased intake, by increased
expenditure of energy and nutrients (48). Some patients are
already undernourished on admission to hospital while others reach
this state during their stay.
In a study of 75 patients admitted as emergencies to a medical
ward, 22 per cent were undernourished (49). A study of 179 men
visiting an outpatient clinic in the USA, showed undernutrition in
11
29 per cent of patients younger than 65 years and in 38 per cent of
patients 65 years or more (50). When nutritional status and dietary
intake were studied in three Nordic hospitals (Gothenburg, Helsinki
and Oslo) 29 per cent of the 56 patients exam ined were
undernourished on admission and during their hospital stay their
nutrient intake was reduced by between 25 to 35 per cent of the
normal intake at home (51).
In a study of 112 surgical patients, undernutrition was found in
29 per cent (52). Nutritional status in 10 oncological patients
treated with radiotherapy showed that four patients had two or
more nutritional param eters (four param eters were assessed)
below the reference limit before and four patients after the therapy
(53).
Assessment of nutritional status in 91 patients in psychogeriatric
wards showed undernutrition in 30 per cent (54). In a study of 16
p atien ts in a p sych o g eriatric ward 50 per cent were
undernourished. The mean dietary intake was significantly higher
than their calculated needs and the median intake was somewhat
higher in the undernourished group than in the well-nourished
group (55).
U ndernutrition in itself may further reduce the intake and
expenditure of energy and nutrients (56). Patients with under­
nutrition are prone to lesions in the oral mucosa (57), bed sores
(58) and infections (59) due to an impaired cell-mediated immune
defense (60). Decreased physical activity caused by undernutrition
(61) may be detrimental to the early physical rehabilitation of
stroke patients. Nutritional deficiencies have been associated with a
reduced cognitive function in elderly people (62). Nutritional status
has been shown to be an important determinant of the clinical
course in different clinical contexts, such as surgery (63) and
oncology (64).
Thus, undernutrition occurs in hospitalized patients as well as in
patients visiting outpatient clinics but no study of nutritional status
in stroke patients was found in the literature. Several interacting
factors such as the distribution of meals throughout the day, the
composition of food and the interest of the staff influence the
nutritional status (65, 66). The role of eating problems as one of the
12
interacting factors in the development of undernutrition was the
object of this study.
Nursing diagnoses
Any system atic developm ent of methods for treating eating
problems must be based on a thorough diagnosis of those problems.
Intensive work aimed at developing methods for diagnosing
nursing problems is being carried out mainly in the USA (67, 68).
Using a deductive approach the North American Nursing Diagnosis
Association (NANDA) has presented a list of nursing diagnoses (69).
In that list "altered nutrition: less than body requirement" is a
diagnostic label and eating problems are specified under it. "Altered
nutrition (potential for less than body needs) related to: difficulty
chewing and swallowing" (69, p. 109) is an example of a nursing
diagnosis concerning eating problems. "Self-care deficit: feeding" is
another diagnostic label in the NANDA-list (69, p. 499). "Impaired
swallowing" is also included under the heading (69, p. 499). A
complete nursing diagnosis concerning eating could be "alteration in
nutrition: less than body requirem ents related to im paired
swallowing and chewing defect, related to hemiplegia and related to
homonymous hemianopsia" (70).
In another list the nursing diagnoses concerning eating are:
"nutrition, alterations in: less than body requirement related to"
either "chewing" or "swallowing difficulties" or "anorexia" (71, p.
287) or "self-care deficit related to inability to feed self" (71, p.
374). In a third list the main category concerning eating problems
is "self-care deficits in food/fluid intake" (72, p. 164). Examples of
labeled nursing diagnoses under that category are: "incapacity or
partial incapacity to feed/hydrate self" (72, p. 165) and "partial
incapacity to chew/swallow food or fluids" (72, p. 167).
The diagnostic categories presented above all seem to be too
vague and general to serve as starting points for the development
of specific nursing therapeutics for eating problems. The focus is
mainly on nutrition and problems in eating performance are
subordinated to it. There are, however, eating problems that are not
necessarily related to problems of nutrition.
13
An inductive approach to diagnosing patients' problems has also
been presented (73). The nursing diagnosis, according to this
method, is seen as a conclusion often based on more than one
patient problem. The formulation of the diagnosis may include the
interaction between the problems and their causes (74). No list of
nursing diagnoses developed by this method has been presented.
The author and co-workers (68) developed a model for a more
specific nursing diagnosis of eating problems primarily related to
the disease (68). The model is connected to both the WHO
classification of impairments, disabilities and handicaps (75) and to
the International Classification of Disease (76).
According to this model nursing diagnoses should be formulated
in two steps. A general nursing diagnosis is based on observations
and interviews and is placed on the level of disabilities. A specific
nursing diagnosis is based on specific tests and investigations and is
connected with impairments (symptom diagnoses) (Figure 1).
DISABILITIES
WHO*
ICD°
(PR O B LEM
/N E E D )
in e a tin g
D ysphagia
GENERAL
NURSING
D IA G N O S I S
A trial
fibrillation-«'
c a rd ia c
embolus
WÊÊSSËIËÉIBBICAU F0 CU a
v
PR O BLEM
B rain
in fa rc tio n
O ral a p r a x ia
N U R SIN G F o c u s
CAUSE
TYPE
SYM PTOM
R ig h t-sid e d
hem iparesis
P roblem s
E .G .
D ISEA SE
IMPAIRMENTS
O B SERV ED
BEHAVIOUR
\Ö lA O N O « IS
SPECFIC
NURSING
D IA G N O S I S
FATO-
srm o o iO A L
a n a t o m ic a l
d ia o n o « «
d ia g n o s i s
N
F ig ure 1. The connection between nursing diagnosis, medical
diagnosis and the classifications of im pairm ents, disabilities,
handicaps, and diseases. E.G. denotes an example.
* Levels in the classification of impairments, disabilities and
handicaps (74). The level of handicaps is not described in the
model.
° Levels according to the International Classification of Diseases
(76).
This figure is adopted from Vård i Norden 1986;6:309 (ref 68).
14
When this model for the diagnosing of eating problems is
compared with the models mentioned above it seems reasonable to
suggest that their formulations of diagnoses should be regarded as
general diagnoses, and that no specific diagnoses have been
presented.
M alnutrition could be regarded as a consequence of eating
problems (77) but it could also be seen as part of a cause. Therefore
assessments of nutritional status are an essential element in the
care of the patient with eating problems. The logical connection
between eating problems and nutritional problems has to be
elaborated.
AIMS OF THE STUDY
The aims of the present study were:
• to identify and describe eating problems and nutritional status in
stroke patients in the acute phase of the disease and at a long-term
follow-up.
• to explore the interrelations between
nutritional status in stroke patients.
eating
problems
and
• to summarize how patients with cerebrovascular disease describe
their eating problems some time after the stroke.
• to implement and develop further methods for diagnosing and
training severe dysphagia after stroke.
• to suggest general nursing diagnoses.
15
SUBJECTS
D escriptive study
From March 1982 to June 1983 all patients admitted to the stroke
unit were asked to participate in a study about eating problems and
nutritional status (phase 1). One patient did not want to participate.
The study included 104 patients (65 males, 39 females). The
patients stayed in hospital for 23 days (mean, range 0-117). Paper
I includes all patients
and Paper III those with a nutritional
assessment on admission (n=100, 64 males, 36 females) and on
discharge (n=78, 49 males, 29 females). Patients with a hospital
stay of 21 days or more (n=32, 22 males, 10 females) were selected
for a longitudinal study of eating problems and nutritional status
during hospitalization (IV).
Patients identified as having eating problems during their
hospital stay were selected for a follow-up 3 months after the
stroke (phase 2). Out of the 46 patients who had eating problems in
hospital 11 were dead at the time of the study and one declined to
participate. Hence 34 persons (23 males, 11 females) were visited
in their home or at the institution where they were living. The
results have been presented elsewhere (78).
All subjects with eating problems during their hospital stay were
selected for a follow up 18 months after the stroke. The same
applied to subjects with neurological deficits and those living in a
nursing home one year after the stroke, regardless of whether or
not eating problems had been present during hospitalization (phase
3). Six patients who had suffered a recurrent stroke before the visit
were excluded. The group fulfilling the selection criteria consisted
of 36 patients (25 males, 11 females). Their mean age (on
admission to hospital) was 72 years. The individuals were visited in
their homes or in the place where they lived. Paper II presents the
results from this group.
Figure 2 is a description of the distribution of patients among the
different substudies and Table 2 describes the patients in Papers IIV.
16
P atients v i t h i 2
n u tritio n a l
assessm ents
n= 78
Patients
v ith no
n u tritio n a l
assessm ent
n= 4
P atients v i t h one
n u tritio n a l
assessm ent
n= 22
P aper III
P atients v i t h a
v a rd stay 1 21 days
n= 32 *
P aper I
P atients visited
a fte r 18 m onths
n= 36 *
Figure 2. Distribution of patients between the different substudies.
* There was an overlap of 15 patients between the two groups.
Times of
phase
phase
phase
data collection periods were:
1: March 1, 1982 - June 10, 1983
2: June 1982 - September 1983
3: September 1983 - December 1984
17
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Gase studies
,
Papers V and VI are single subject studies. The patients presented
were the first two with severe dysphagia who asked for help at the
clinic. One patient was 78 years : old when training started. Three
years previously he had had a stroke, presum ably in the
vertebrobasilar vascular territory. After the stroke he was fed by
nasogastric tube. The other patient was 65 years old. He had had a
stroke of the Wallenberg type one and a half year previously. He
was at first fed by nasogastric tube (Clinifeed®) but six months
after the stroke he got a Witzel fistula.
METHODS USED IN DESCRIPTIVE STUDIES
E ating
On adm ission a sem istructured interview was performed. It
concerned the patient's eating problems at home, gastrointestinal
symptoms (including history of peptic
ulcer) and feelings of
sickness, vomiting and loss of appetite during the week before
adm ission.
Patients with persisting stroke symptoms were studied by direct
structured and unstructured observations during regular meals. A
total of 495 observations were made on 82 patients. The
observation form was designed for this study. It included 70
variables covering different aspects of eating, e.g. body position
during the meal, cutlery used, handling of food in the mouth and
swallowing. The observations were repeated during the hospital
stay, as a rule more than once a week. There were two observers: a
trained enrolled nurse and aresearch nurse (the author). No notes
were taken during
the observation itself,
the structured
observation form was filled in afterwards.
Before the study the two observers practiced observations
together and discussed every variable on the observation form in
detail until consensus was reached concerning interpretations and
registrations. During the data collection period criteria for the
variables on the observation form were discussed repeatedly so as
to keep the same criteria as in the beginning. Observations of 32
19
meals were made simultaneously by the two observers during the
latter part of the study. The inter-observer exact agreement was 88
per cent and no systematic bias was noted.
The research nurse wrote field notes after each contact with a
patient and his/her relatives. The field notes focused on eating
problems. After the observation of eating the notes mainly focused
on factors not included on the observation form. Discussions with
the personnel about the patients’ eating problems and measures to
help the patients were summarized in the field notes. It was not
possible to register all measures systematically. Therefore they are
not reported.
At the visit 18 months after the stroke one meal per patient was
observed using the same methods as in hospital. Twenty persons
were given a standardized meal consisting of potatoes, brawn,
pickled beetroot, crispbread and some fluids. Ten ate parts of this
and six ate regular food served in the nursing homes. A focused
tape-recorded interview concerning eating problems was conducted
for 32 of the patients.
Ten patients with eating problems were video-recorded during
eating in hospital, six patients once, one twice, two on three and one
on six occasions. At the follow-up 18 months after the stroke four
of these subjects were video-recorded.
N utritional status
The nutritional status was assessed by percentage of reference
w eight, triceps skinfold thickness (TSF), upper arm muscle
circum ference (AMC), plasma albumin, serum transferrin and
plasma prealbumin. In hospital the assessments were performed on
admission and then weekly during the hospital stay. In four
patients, who all died within two days, the nutritional status was
not assessed. Twenty-two patients were discharged within one
week. In these patients only one assessment was performed.
Nutritional status also was assessed in patients visited after 18
months.
The body weights were compared with age adjusted reference
weights (79) and relative body weight was calculated (III).
20
In hospital the TSF and AMC assessments were performed by
two persons. TSF was measured by a Harpenden caliper (80, 81) on
both arms. The mid-upper arm circumference was measured on
both arms. The mean value of three measurements of TSF and mid­
upper arm circumference was used and AMC was calculated (81,
III). Reference data for the anthropometic variables were obtained
from age-adjusted reference data on healthy populations in Sweden
and the 10th percentile was chosen for the lower limit (82).
Intra-rater exact agreem ent was 98 per cent and exact
agreem ent between raters was 87 per cent for the TSF
measurements. The corresponding figures for AMC were 92 and 88
per cent.
The TSF and AMC measurements from the right arm were used
in the analysis of the data from admission. In the analysis of data
on discharge and after 18 months the measurements taken on the
left arm were chosen when the right arm was paralyzed during the
hospital stay (III).
Plasma albumin and serum transferrin were determined by
Technicon Auto A nalyzer and the prealbum in by immunoelectrophoresis (83). Reference data were obtained from a
representative sample of elderly people in the Umeå area (84). Poor
nutritional status was defined when two or more of the six
nutritional variables fell below the lower reference limit.
Self-care performance
Self-care performance was assessed by data about the patients'
behaviour the first week in hospital and notes in their medical
records. After 18 months an interview with the subject, relatives or
personnel about self-care performance in the preceding week
served as the basis for classification. The Katz' Index of
Independence in Activities of Daily Living (28) was used.
Inspections of the mouth
During the first phase of the study a dentist was associated with the
research team for consultations. During hospitalization the patients
with persistent symptoms of stroke were subject to regular
inspections of the mouth. Lesions of the oral mucosa were
registered as was the presence of their own teeth or presence and
21
use of dentures. After 18 months a new inspection of the mouth
was made.
Analyses of data concerning eating
Data subject to analysis were the structured observation form, field
notes, video-records and notations from the inspections of the
mouth. When an eating problem was identified in the observations
of eating and in discussions with the patient during the stay in
hospital, the patient was classified as having eating problems, if the
problem lasted for more than one day and measures to treat it
were tried. As different types of eating problems andtheir cues
were identified, each problem was labeled and treated as a concept.
Every patient was classified as having or not having eating
problems during their stay in the ward.
After the first phase of data collection ended a new analysis was
performed. It resulted in identification of the eating problems for
each patient. When there were video-recordings comparisons with
observations were made. A last analysis was performed after the
visit to the patients 18 months after their stroke.
The term "assistance with food" denoted the fact that the patient
got help in preparing food on the plate. The term "assisted feeding"
meant that the patient got help in putting food in to the mouth.
Recordings about assistance with food and assisted feeding were
only performed during the observations.
After 18 months the criteria for each eating problem, in addition
to those described above, were the patient's descriptions of eating
problems expressed in the focused interview. The term "eating
small amounts" was used when the subject reported in the
interview that they ate much less than before the stroke.
A change in terminology was made during the last analysis. The
term "sores in the mouth" was seen as an eating problem in the
earlier analyses while in the last one it was regarded as a cause of
eating problems. "Inability to perceive part of the tray" was
changed to "aberrant eating behaviour as regards localization".
Labels for other eating problems were adjusted to describe the
forms of behaviour observed.
22
S ta tis tic s
Paired Student’s t-test was used for comparison of parametric data
and the chi-square test and the Fisher test for exact probability
were used when testing differences betw een proportions.
Confidence intervals (Cl) were used for some frequencies (95 per
cent). The effect of eating disturbances and other variables on
nutritional status was estimated in a general linear hypothesis
programme. The statistical calculations were performed with SPSS
package (85) and SYSTAT (86).
METHODS USED IN CASE STUDIES
Single subject design
In the two case studies (V, VI) a single subject design was used (87,
88). The baselines were, determined by the patients’ history,
examinations, tests and test meals. Video-recordings were made
once a day.
Tests of oral and hypopharyngeal functions
Oral praxiä was tested by a modification of the test developed by
DeRenzi and co-workers (34). Small glass fibre objects of different
shapes (cube, pyramid, cylinder and sphere) were used to test oral
perception. The objects were held by a dental ribbon and placed in
the patient’s mouth. The patient was asked to identify each object.
For help the patient was presented with a sheet of paper which
showed both the tested objects and three distractors as drawn
figures and names. This test was developed from ideas by Landt
(35). The ability to recognize smell and taste was tested by routine
tests. Cineradiography and manometry wereused to examine the
hypopharyngeal and the oesophageal structures and functions.
Other assessm ents
The ability to swallow was tested by requests to swallow saliva,
teaspoonfulls of water, teaspoonfulls of youghurt and a piece of
crisp bread. The ability was evaluated by observations of the
swallowing movements and by observations of whether the mouth
was emptied. The patient’s own reports about whether his mouth
23
was emptied were also registered. The amount the patient spat out
was measured. Eating, self-care performance, nutritional status, and
inspections of the mouth were assessed by the same methods as in
the descriptive study.
Test meals, training sessions and regular meals were video­
recorded and/or field notes were taken. Interviews about the
patients' experiences of not being able to eat, their views on eating
and swallowing as well as their experiences of training were taperecorded.
Relationship aspect of nursing therapeutics
Nursing therapeutics can be seen as a com munication. This
communication consists of a relationship aspect and a content
aspect (89). The programmes for training were seen as a content
aspect. The relationship between the patient and his trainer was
interpreted according to the Erikson theory of 'eight stages of man’
(90). Erikson describes eight crises that follow man throughout life:
trust - mistrust (hope); autonomy - shame/doubt (will); initiative guilt (purpose); industry - inferiority (competence); identity identity confusion (fidelity); intimacy - isolation (love); generativity
- stagnation (care); integrity - despair (wisdom). At each stage of
developm ent there is an actual version of all crises. The
development of a therapeutic relationship between the patient and
his trainer started with dialogues during which the latter tried to
understand within which of the eight crises the patient’s primary
concerns were. The trainer then approached him according to what
she thought the actual crisis required. As the therapeutic
relationship developed the patient trusted the trainer, followed the
instructions and talked about his concerns. During the final stage of
training the trainer gradually took a more passive role and
encouraged the patient to become more active and autonomous.
24
Training and treatment
A training programme developed by Heimlich (45, 91) was initially
used in the first patient (V). It prescribes training of sucking before
training of swallowing as the ability to suck is a prerequisite for
swallowing (91). Training in a specific oral movement was given
based on the results of the oral apraxia test. Taste and oral tactile
gnosia were also trained. Dentures were adjusted in one case (VI).
When the patient was able to initiate and perform swallowing
movements he practiced swallowing the kind of food that he could
best swallow as indicated by the swallowing test. Furthermore, the
patient was trained to swallow instead of clearing his throat when
he sensed fluids in it. During the training sessions instructions were
sometimes given as commands. More often the patient was given
instructions about how to train and then he trained by himself
without being disturbed. The training sessions lasted for 20 to 80
minutes (V, VI).
In one of the patients a myotomy of the cricopharyngeal muscle
(47) was performed (VI).
When the patient was able to eat, he first got food which was
easy to chew. When his ability improved he was given normal food.
If the patient needed extra concentration to be able to eat he
received instructions about strategies for communication during
meals.
Both of the patients trained were cognitively alert and from the
beginning highly motivated to train. Each step of the training was
carefully explained to the patients who were also given information
about the results of tests and investigations.
25
RESULTS
Eating problem s in hospital (I)
Different eating problems were observed in 46 of the 104 patients
in hospital. In addition six terminally ill patients were not able to
eat at all during their hospital stay. The occurrence of eating
problems and the localization of the cerebral lesion for the 46
patients are presented in Table 3.
Patients with eating problems stayed longer in the stroke unit
than patients without (mean=36 vs 14 days). Only one patient
without eating problems was discharged to a long-term clinic while
33 per cent of the patients with eating problems were. None of the
patients without eating problems died in the stroke unit while five
(11 per cent) of the patients with problems did.
Table 3. The localization of the vascular lesion documented by CTscan or autopsy in 46 stroke patients with eating problems during
hospital stay.
Eating problem
Number
of patients
Aberrant eating behaviour
as regards
chewing
localization
swallowing
Eating small amounts
Hoarding of food in the mouth
Leakage of food from the mouth
Vascular territory affected*
V erteb ro ­
Right
Left
carotid carotid basilar
31
9
31
23
33
31
11
4
9
5
15
13
12
2
13
9
12
12
Unawareness of eating problems 30
12
11
2
Any eating problem
15
17
6
46
.
5
1
4
4
2
2
* In 10 patients no lesion was found in the CT-scan. In one patient
no CT-scan was performed. Three patients had lesions on both
sides.
26
Eating problem s 18 m onths afte r the stroke (II)
Out of the 36 subjects who fulfilled the selection criteria for the
follow up study, 23 had eating problems during their hospital stay
and 21 had eating problems after 18 months. Four subjects with
eating problems in hospital had no eating problem at the follow-up
while two subjects without eating problems in hospital had eating
problems at 18 months. In the 32 focused interviews, 18 subjects
described one or more of their present eating problems.
Tw enty-nine eating problems were observed and 31 were
described by the subjects in the focused interview (Table 4). One
subject who hoarded food in the mouth and one with leakage of
food from the mouth described the problem in the interview
although they did not deal with it during the meal. One subject with
observed aberrant behaviour as regards swallowing denied having
swallowing problems.
Table 4. Eating problems in 36 subjects 18 months after a stroke.
Eating problem
Observed Described U naw are
Aberrant eating behaviour as regards
chewing (n=12)
8
localization (n=2)
1
swallowing (n=11)
7
Eating small amounts (n=l)
0
Hoarding of food in the mouth (n=12) 6
Leakage of food from the mouth (n=7) 7
10
1
7
1
9
Total
31
29
3
,
0
1
1
0
T " '
..3 .,.
6
Assistance during meals was given to 20 (56 per cent) of the
subjects during their hospital stay while 11 (31 per cent) got such
help after 18 month. In hospital two subjects (6 per cent) got help
with assisted feeding as did one (3 per cent) after 18 months.
The observed behaviour and the subjects' descriptions of eating
problems can serve as a basis for the development of criteria for
general nursing diagnoses (Table 5).
27
Table 5. Descriptions and the subjects' expressions for each of the
eating problems in hospital and at 18 months after the stroke.
A b e rra n t
eating
behaviour as
reg ard s
chewing
O b se r v a t io n • No, few, small, extremely big, predominantly
vertical, extremely fast, or extremely slow chewing
movements. Dentures loosened when chewing.
INTERVIEW
A b e rra n t
• Described the pain he had when chewing, badly
fitting dentures, avoidance of food because of
difficulties in chewing.
eating
behav io u r as
reg ard s
localization
O b s e r v a t io n • Food left on the plate, ate when the plate was turned
around or did not mention or point out the food left
when requested to do so. Asked for food which was
there. Put the spoon or fork to the side of his mouth.
Made some seeking movements with his fork or spoon
around his plate or beside it to put food on it. Placed
his glass on the edge of his plate or tray, or on the
cutlery.
I n t e r v ie w
A b e rra n t
• Described how he tried to find the food, felt insecure
because he might not find everything on the table or
because he might drop or put things down because he
had not noticed them.
eating
b eh av io u r
as
re g a rd s
swallow ing
O b s e r v a t io n • Coughed immediately after swallowing. Interrupted
oral movements before swallowing. Swallowed many
times before the mouth was empty. Food in the mouth
for a long time without swallowing which resulted in
reminder to swallow.
I n t e r v ie w
• Described how he had to concentrate on swallowing
when eating, how he coughed after swallowing,
swallowed repeatedly, avoided drinking certain things
because of difficulties in swallowing.
28
Table 5 cont.
Eating small amounts
O b s e r v a t io n • Ate extremely small amounts (less than half a
serving) for more than three days (after 18 months less than before the stroke).
I n t e r v ie w
• Described how, as a result of poor appetite, he ate
smaller amounts than before the stroke.
Hoarding of food in the mouth
OBSERVATION • Put in food although his mouth was already full.
Food protruded from his mouth. Seldom emptied his
mouth during the meal. Hoarded food in one or both of
his cheeks during the meal. Food left in one or both
cheeks after the meal.
INTERVIEW
• Described how he rinsed his mouth regularly after
meals because there was often food left in it.
Leakage of food from the mouth
O b s e r v a t io n • Food (liquids and/or solid food) dribbled out of his
mouth when chewing or when swallowing, when
opening his mouth for another fork or spoon with food
and/or when talking.
INTERVIEW
• Described how he frequently wiped his mouth, how
his relatives looked at the leakage from his mouth and
how they signalled non-verbally reminding him to
wipe it.
Unawareness
of
eating
problems
O b se r v a t io n • Did not pay any attention to the problem while
eating. Did not spontaneously mention his eating
problem .
INTERVIEW
• Denied the problem.
This table is also presented in Paper II (Table 2).
29
N utritional status on adm ission, on discharge and 18
months after the stroke (II, III)
The mean values for the circulating proteins were above the lower
reference limits for males and females on admission, on discharge
and after 18 months. Subnormal values were most common in
plasma albumin. On admission, 16 per cent of the patients had a
poor nutritional status. The corresponding figures on discharge and
after 18 months were 23 and 11 per cent, respectively.
Undernutrition on admission was associated with the female sex,
high age and a history of atrial fibrillation. On discharge poor
nutritional status was related to infections, the male sex, the intake
of cardiovascular drugs and high age. The nine patients who
developed poor nutritional status during their hospital stay were all
males.
Relations between eating problems and nutritional status
(II, III, IV)
Of the 18 patients who had a poor nutritional status on discharge
15 had eating problems. The corresponding proportion of those who
developed undernutrition in hospital was seven out of nine (III). In
the group with a hospital stay of 21 days or more (n=32) 18 had a
poor nutritional status at some time during the hospital stay. Of
those 17 had eating problems. In a linear hypothesis programme
the factors associated with undernutrition were low self-care per­
formance, poor nutritional status on admission and male sex; factors
of less importance were energy-containing intravenous infusions,
high age, paresis in the right arm and eating problems (IV).
The four subjects with poor nutritional status after 18 months all
had eating problems (II).
Effects of training the swallowing function (V, VI)
Training was initiated and carried out in hospital. Between the
training periods the patients trained at home. The total time for the
patients’ hospital stays was 27 and 29 days, respectively. Both
subjects have been eating normal food for 3 and 4.5 years after
having started to eat normally again, one without any problems and
the other still needing more time than usual for eating and with a
habit of clearing his throat during eating.
30
DISCUSSION
Patient selection
The distribution of the patients amongst the various diagnostic
groups was comparable with other studies from Umeå (11),
Söderhamn (7), and Stockholm (12). The patients in the present
study were the youngest (by 1-2 years). The male/female ratio was
similar to that in the Umeå study. With regard to distribution of
diagnoses, sex and age, the studied group was similar to the other
population-based groups. Thus the studied group could be regarded
as representative of Swedish stroke patients with exception of
patients with subarachnoid hemorrhage. The subgroups (II, III, IV)
were selected from a representative sample and therefore with the
same selection criteria, the results could be applicable to other
stroke groups.
Methods used in descriptive study
An inductive methodology was applied. No concepts of specific
eating problems were formulated at the start of the study. The
instruments for observing eating have not been used before. As
data on eating problems were collected distinct concepts emerged
and were labeled. This type of data analysis was repeated for each
phase of the
study to make sure that as many phenomena as
possible were included in the concepts. The concepts were
relabelled but the new labels did not change the classification of the
patients into the different problem-groups made previously. Sores
in the mouthwas never the only problem a patient had. Therefore
the fact that
this phenomenon was regarded as an eating problem
in Paper I and as a cause of eating problems in Paper II did not
affect the estimation of the prevalence of eating problems.
Reduced independent eating was not a focus for observations to
such an extent that it was possible to make descriptions and
formulate a concept. Only 'assistance during meals' and 'assisted
feeding' were recorded.
Nutritional
assessments aredependent on the validity and the
precision of the indicators used. There is no universally accepted
single variable that reflects the overall nutritional situation in a
31
patient. Moreover, reference intervals must be reliably defined as
to sex, age and probably also ethnical background. In some
previous investigations of nutritional status in patient samples, the
delineation of 'normal' has relied on arbitrarily chosen limits, such
as 80-120 per cent of population mean, set at 100 per cent (81). In
this study, statistically defined limits for variables were used
where such information was available. The anthropometric data as
well as the laboratory reference data obtained in normal ageing
Swedish populations and published in the last few years (82, 84)
have facilitated the definitions of 'normal' with regard to sex, age
and ethnic background. In view of the intricacies involved in each
of the nutritional variables at least two of the six indicators should
point in the same direction for a patient to be assigned to the group
with poor nutritional status. Using this interpretation, it is possible
that more subtle forms of undernutrition have not been recognized.
Taking all these considerations in mind, it is evident that the
nutritional categorization of an individual patient at agiven point of
time should be taken as a crude estimate.
Methods used in case studies
The oral apraxia test developed by DeRenzi and co-workers (34)
was modified and has been used to assess the oral phase of
swallowing (V, 92). It served this purpose very well. The test, of
course, has to be evaluated in a larger sample of subjects.
The oral agnosia test for forms was developed in the research
group (V) together with the dentist who was associated with the
group. This test has not yet been validated.
The training was based on the results from the tests and the
investigations. Papers V and VI are descriptions of only two
patients and a training programme for use in clinical practice
would, of course, have to be based on more cases. A more exact
description of the circumstances under which different treatments
can be used is necessary.
The relationship aspect of nursing therapeutics was interpreted
according to the Erikson theory (90). These interpretations seemed
to fit in the cases studied. More studies are needed in order to
elucidate the possibilities and limits of the interpretations.
32
R esu lts
It was evident that eating problems were common during the acute
phase of the disease. After 18 months most of the patients were
aware of their eating difficulties and experienced them as
problems. Three months after the stroke the investigation of
patients with eating problems in hospital showed that 46 per cent
of the problems remained. The corresponding figure was 43 per
cent 18 months after the stroke (II). Thus the rate of recovery
seemed to be greatest in the first few months after the onset of the
disease.
When an eating problem was identified by the research nurse
the patient was classified as having eating problems, if the problem
lasted for more than one day and measures to treat it were taken.
The measures were not reported. However, as measures were
probably taken more intensively during the study than in ordinary
clinical care this may have influenced the presented recovery from
eating problems.
According to the model of diagnosing eating problems in stroke
patients (Figure 1), the concepts of eating problems presented
(Table 5) could be regarded as general nursing diagnoses. In the
single subject studies (V, VI) it was possible to formulate specific
nursing diagnoses based on tests and investigations of impairments.
The disabilities, impairments and types of diseases presented in
Figure 3 have to be combined in order to form testable hypotheses.
Aberrant eating behaviour as regards swallowing could for example
be caused by impairment of pharyngeal muscular function, by
impairment of sensory function - tactile sensibility (oral agnosia),
by impairment of cerebral integration (e.g. oral apraxia) or by a
combination of the above-mentioned impairments. Eating small
amounts could be caused by impairment of sensory function such
as reduced taste and smell or by im pairm ent of m ental
performance including depression. Studies should be carried out to
test these hypotheses. The specific nursing diagnosis connects and
partly overlaps the medical symptom diagnosis.
Today validated tests and investigations of impairments after
stroke are often lacking but badly needed in clinical practice (93).
33
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The proportion of patients with undernutrition on admission was
somewhat lower than in com parable studies (III, 49,
51).
Undernutrition on discharge was also lower than that presented in
studies of patients in a surgical ward (52) and in psychogeriatric
wards (54, 55). In the patient group studied for three weeks the
number of patients with undernutrition increased from admission
to the end of the three weeks. Patients at risk of developing
undernutrition during hospitalization were identified. Routine
nutritional treatment in the ward together with the measures to
treat eating problems carried out during this study were thus
insufficient to entirely prevent the development of undernutrition.
The study showed that factors other than eating problems were
im portant for developing undernutrition (IV). The measures
performed to alleviate eating problems may have reduced the
possibilities to discover a relationship between eating problems and
undernutrition. But for ethical and human reasons it was neither
reasonable nor possible to perform the study without attempting to
help the patients with eating problems.
GENERAL DISCUSSION
Every second stroke patient suffers from eating problems which in
many cases will persist 18 months after the stroke (I, II).
Different types of eating problems were identified and described
(I, II). The descriptions were developed throughout the study and
eventually came to be regarded as general diagnoses concerning
eating. This is seen as the first step towards nursing diagnoses that
can be used as the basis for the developm ent of specific
therapeutics for eating problems.
The general diagnosis gives a detailed description of the eating
disability but does not connect it to impairments and/or brain
dam age.
In the two case studies the diagnoses were developed further to
include assessments of impairments and also in one case (VI)
localization of the brain damage. These specific diagnoses made it
35
possible to choose specific treatm ents such as training the
performance of a certain oral movement.
The case studies also lead to the development of a method for
interpreting the patient’s existential situation according to the
Erikson theory of the 'eight stages of man' (90). This diagnostic
procedure seems to be important for the implementation of the
treatm ent planned. It is in agreement with the notation by
Carnevali (73) that nursing diagnoses should connect the patient’s
daily living with his pathology and its treatment as well as his agerelated biological status and developmental tasks.
Therefore it is not possible to draw a definitive conclusion about
the connection between eating problems and nutrition per se.
However, the studies did show that every fifth patient was
undernourished. This problem, of course, has to be considered
seriously and measures taken to reduce it.
Knowledge of the prognoses for specific eating problems is
essential in the planning of treatment (73). The longitudinal study
of the course of eating problems treated only by unsystematic
measures showed that most problems persisted after 18 months.
Both the single subject studies showed that the prognosis for
treatment of dysphagia was very good although the patients had
had their problems for 1 1/2 and 3 years respectively. This
suggestion is in agreement with the results from other treatment
evaluations (45).
It is essential that further research is conducted to develop
specific diagnoses and elucidate the prognosis for different eating
problems related to specific impairments. The localization of the
brain damage might also turn out to be an important prognostic
factor.
The evaluation of nutritional status in stroke patients (II, IV)
suggested that the effects of eating problems on nutrition were
modest during the acute phase. This could be influenced by the fact
that nutritional supply was provided during the ward stay.
As it may become evident that not all types of eating problems
can be successfully treated research should also be aimed at
prevention of consequences/handicap (other than undernutrition)
caused by eating problems.
36
CONCLUSIONS
The main findings in the studies presented were:
• eating problems occur in half of randomly sampled stroke
patients during the acute phase of the disease.
• eating problems remain and are still prevalent long after the
cerebrovascular accident.
• identified eating problems are:
aberrant eating behaviour as regards chewing
aberrant eating behaviour as regards localization
aberrant eating behaviour as regards swallowing
eating small amounts
hoarding food in the mouth
leakage of food from the mouth
• among patients with eating problems, a majority are unaware of
their eating problems during the acute phase but there is a timedependent improvement in awareness.
• undernutrition is common among stroke patients on admission to
hospital and the prevalence appears to increase during the
hospital stay.
• eating problems do not seem to be a major contributor to short­
term changes in the nutritional status during the acute phase of
stroke.
• it is possible to train severe dysphagia late after a stroke
37
ACKNOWLEDGEMENTS
This study was carried out at the Department of Advanced Nursing
and Medicine. I wish to thank everyone who in any way has
contributed in this study and those who in one way or another have
given me valuable help.
I wish to express my sincere gratitude to Professor Astrid Norberg
for introducing me to the world of nursing research, for her
enthusiasm and encouraging support and for her constructive
criticism during these years.
I also wish to express my sincere thanks to Associate Professor Kjell
Asplund for scientific advice, encouragem ent and stim ulating
criticism.
Special thanks go to:
Professor P. O. Wester for encouragement and support.
Mrs. Eva Lindmark for skilful data collecting.
Irina Alafuzoff, Dr Med Sci, for her analyses of the plasma
prealbum in.
Associate Professor Emeritus Doris Carnevali, Seattle, for advice and
support in the work with nursing diagnoses.
Professor Thorild Ericsson for stimulating discussions.
Sture Eriksson, Dr Med Sci, for statistical advice.
Mrs. Birgitta Hammarström for never ending patience in computer
work.
Ingegerd Johansson, DDS, for computer assistance in the estimation
of nutritional intake.
Mrs. Ann-Sofie Kärreby, for assessment of nutritional intake.
Mats Ryberg, DDS, for fruitful discussions and advice in oral
investigations.
Mrs. Åsa Sundh, Mrs. Patricia Shrimpton and Fil lie Robert Elston for
excellent linguistic revisions.
38
Ove Söderberg, Dr Med Sci, and Dr. Britt-Inger Wenngren for co­
operation and support.
The stroke nurses Kristina Östman, Margareta Engde and Margot
Helgesson and Head nurse Barbro Lindgren for their interest,
support and co-operation.
To the entire staff of the stroke unit for their support and co­
operation.
The Nursing Research Group in Umeå for critical discussions and
support.
And last but not least to my family, Sören, Mikael, Robert and Maria
for their constant support and for helping me to keep the balance
between work and other parts of life.
This project was supported by grants from Umeå University, grant
No. 7342 from the Swedish Medical Research Council to Karin
Axelsson, and grant No. to 6260 to Astrid Norberg, grant No. 81/99
from the Delegation for Social Research, Ministry of Health and
Social A ffairs, grant No. 82/65 from the Bank of Sweden
Tercentenary Foundation, King Gustav V’s and Queen Victoria's
Foundation, the Joint Committee of the Northern Health Region of
Sweden, Västerbotten County Council, Roussel Nordiska AB, Swedish
Nutrition Foundation and the Foundation of 'Gamla Tjänarinnor’.
39
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