Dysphagia and Obstructive Sleep Apnea in Acute, First-Ever, Ischemic Stroke

Noninstrumental Dysphagia Assessment and Screening: A Proposed Checklist

PURPOSE

In the field of dysphagia research, there is a need to establish a framework for the critical appraisal of methodological reporting. A working group was formed to develop a tool to aid in such critical appraisal across various domains of dysphagia research (called the FRONTIERS [Framework for RigOr aNd Transparency In REseaRch on Swallowing] Framework). The goal of the current paper is to present and describe one domain of this tool: noninstrumental assessment and screening tools.

METHOD

Methods describing the development of the FRONTIERS Framework and the associated tool are detailed in the prologue of this series.

RESULTS

A set of questions specific to the critical appraisal of transparency and rigor of research involving noninstrumental screening and assessment tools was developed. This included 13 "yes/no" questions, each of which is presented with a rationale for its inclusion and an example of its implementation.

CONCLUSIONS

The use of this framework will serve researchers and those appraising the quality of research that uses noninstrumental dysphagia assessment and screening tools. More broadly, the FRONTIERS Framework will facilitate improved rigor and transparency across dysphagia research. Special considerations and future goals are discussed.

Strengthening oropharyngeal muscles as an approach to treat post-stroke obstructive sleep apnea: A feasibility randomised controlled trial

This study aimed to determine the feasibility of a randomised controlled trial (RCT) evaluating oropharyngeal exercise (OPE) intervention as an alternative therapy for obstructive sleep apnea (OSA) in patients with stroke or transient ischaemic attack (TIA). Despite the high prevalence of OSA in this population, the standard therapy, continuous positive airway pressure (CPAP), is often poorly tolerated. Thirty stroke/TIA patients with OSA unable to tolerate CPAP were randomly assigned to an oropharyngeal exercise or sham exercise protocol. They performed exercises for 6 weeks, 5 days per week, 30 minutes twice per day. Feasibility was ascertained by the proportion of enrolled patients who completed more than 80% of the OPE regimen. Isometric tongue pressures, apnea-hypopnea index (AHI), oxygen desaturation index (ODI), daytime sleepiness, and quality of life (QOL) outcomes were collected at baseline, post-training (6-week follow-up), and retention (10-week follow-up) to document preliminary efficacy. Adherence to study exercises was excellent, with 83% of participants completing more than 80% of the exercises. The isometric tongue pressures were observed to improve in the oropharyngeal exercise group (compared with the sham group), along with a decrease in OSA severity (measured by the AHI and ODI), reduced daytime sleepiness, and enhanced quality of life outcomes following the exercise programme. Only the effects on posterior isometric tongue pressure and daytime sleepiness remained significantly different between groups at the retention session. In conclusion, an RCT evaluating the efficacy of oropharyngeal exercises on post-stroke/TIA OSA is feasible and our preliminary results suggest a clinically meaningful effect.

Prevalence, risk factors, and outcomes of dysphagia after stroke: a systematic review and meta-analysis

Background

Dysphagia is a common complication after stroke, which not only brings adverse outcomes but also greatly affects the quality of life of patients. At present, there is no systematic review or meta-analysis to comprehensively evaluate the epidemiological characteristics of post-stroke dysphagia (PSD). A systematic review of the prevalence, risk factors, and prognosis of PSD is essential.

Methods

Through 31 December 2022, a comprehensive literature search was performed for observational studies related to PSD. Five databases were retrieved. Random-effects models were used to estimate the pooled prevalence, odds ratio (OR), and 95% CIs.

Results

A total of 34 studies were included, and the results showed that the overall prevalence of PSD was 46.6% (95% CI, 0.405-0.528). The prevalence of dysphagia in ischemic stroke and hemorrhagic stroke was 43.6% (95% CI 0.370-0.501) and 58.8% (95% CI 0.519-0.654), respectively. The prevalence of PSD in Africa was 49.4% (95% CI, 0.196-0.792), in Asia was 40.1% (95% CI, 0.348-0.454), in Europe was 45.8% (95% CI, 0.327-0.590), in North America was 44.3% (95% CI, 0.370-0.517), in South America was 57.5% (95% CI, 0.441-0.708), and in Oceania was 64.1% (95%CI, 0.558, 0.724). In risk factor analysis, hypertension, previous stroke, and atrial fibrillation were significantly associated with the occurrence of PSD, pooled OR = 1.179 [(95% CI, 1.002-1.386), p < 0.05], pooled OR = 1.514 [(95% CI, 1.204-1.905), p < 0.001], and pooled OR = 1.980 [(95% CI, 1.580-2.481), p < 0.001]. In outcome studies, the prevalence of aphasia and dysarthria in PSD was 35.6% (95% CI, 0.213-0.499) and 54.5% (95% CI, 0.293-0.798), respectively. The prevalence of respiratory tract infection was 27.1% (95%CI, -0.038-0.579), and the prevalence of pneumonitis was 32.1% (95% CI, 0.224-0.418). Persistence of dysphagia at discharge and at 1 month was 74.5% (95% CI, 0.621-0.869) and 50.9% (95% CI, 0.142-0.876), respectively. Mortality rates for PSD patients during admission and discharge at 1 month, 3 months, and 1 year were 11.8% (95% CI, 0.083-0.152), 26.5% (95% CI, 0.170-0.359), 25.7% (95% CI, 0.19-0.324), and 31.3% (95% CI, 0.256-0.369), respectively.

Conclusion

This study found that the overall prevalence of PSD was 46.6%. Prevalence is most influenced by the diagnosis method. Hypertension, history of stroke, atrial fibrillation, patient age, and stroke severity were risk factors significantly associated with PSD. The prevalence of aphasia, dysarthria, respiratory tract infection, and pneumonitis in PSD patients is 2-4 times that of patients without PSD.Systematic review registration: www.crd.york.ac.uk/PROSPERO, PROSPERO, CRD42021252967.

Association between dysphagia and symptoms of depression and anxiety after ischemic stroke

BACKGROUND AND PURPOSE

Dysphagia is associated with poor outcome, higher mortality, reduced quality of life, and social isolation. We investigate the relationship between swallowing impairment and symptoms of anxiety and depression after ischemic stroke.

METHODS

Consecutive patients with ischemic stroke participating in the prospective STROKE-CARD Registry study from 2020 to 2022 were assessed for dysphagia on hospital admission (clinical swallowing assessment) and for persistence until discharge and 3-month follow-up (SINGER Independency Index). Anxiety and depression symptoms were recorded using Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS) at 3-month follow-up.

RESULTS

Of 648 patients, 19.3% had dysphagia on admission, persisting in 14.8% at discharge and 6.8% at 3-month follow-up. With the presence or duration of dysphagia (no dysphagia, dysphagia at baseline, at discharge, at 3 months), score (mean ± SD) increased on the BDI (7.9 ± 6.7, 12.5 ± 8.7, 13.5 ± 9.0, 16.5 ± 10.2), HADS-D (4.4 ± 3.7, 7.1 ± 4.2, 7.7 ± 4.4, 9.8 ± 4.3), and HADS-A (4.4 ± 3.5, 5.4 ± 3.6, 6.0 ± 3.6, 7.0 ± 3.6). In linear regression analysis adjusting for age, sex, diabetes, dementia, and either functional disability or stroke severity, BDI and HADS-D scores were significantly higher in patients with dysphagia across all points in time (admission, discharge, 3-month follow-up). An independent association with HADS-A scores was only evident in patients with persisting dysphagia after 3 months. Patients with dysphagia were more likely to receive antidepressants, antipsychotics, or benzodiazepines at discharge and 3-month follow-up.

CONCLUSIONS

Dysphagia after stroke is common and severely affects psychosocial functioning of individuals. Our results highlight swallowing impairment as an independent predictor for poststroke depressive and, to a lesser extent, anxiety symptoms.

Association of Obstructive Sleep Apnea and Atrial Fibrillation in Acute Ischemic Stroke: A Cross-Sectional Study

Background: There is a growing body of evidence suggesting a link between obstructive sleep apnea (OSA) and atrial fibrillation (AF). The primary objective of this study is to evaluate the association between OSA and AF in acute ischemic stroke. The secondary objective is to describe the clinical features of patients with acute ischemic stroke and concomitant OSA. Methods: We enrolled consecutive patients with acute ischemic stroke. All patients underwent full-night cardiorespiratory polygraphy. To determine if there is an association between AF and OSA, we compared the observed frequency of this association with the expected frequency from a random co-occurrence of the two conditions. Subsequently, patients with and without OSA were compared. Results: A total of 174 patients were enrolled (mean age 67.3 ± 11.6 years; 95 males). OSA and AF were present in 89 and 55 patients, respectively. The association OSA + AF was observed in 33/174 cases, which was not statistically different compared to the expected co-occurrence of the two conditions. Patients with OSA showed a higher neck circumference and body mass index, a higher prevalence of hypertension and dysphagia, and a higher number of central apneas/hypoapneas. In the multivariate analysis, dysphagia and hypertension were independent predictors of OSA. A positive correlation was observed between OSA severity, BMI, and neck circumference. The number of central apneas/hypoapneas was positively correlated with stroke severity. Conclusions: Our data suggest that OSA and AF are highly prevalent but not associated in acute stroke. Our findings support the hypothesis that OSA acts as an independent risk factor for stroke.

A systematic review on the association of sleep-disordered breathing with cardiovascular pathology in adults

Sleep-disordered breathing (SDB) is characterized by repeated breathing pauses during sleep. The prevalence of SDB varies widely between studies. Some longitudinal studies have found an association of SDB with incident or recurrent cardiovascular events. We sought to systematically describe the current data on the correlation between SDB and cardiovascular pathology. Studies were included if they were original observational population-based studies in adults with clearly diagnosed SDB. The primary outcomes include all types of cardiovascular pathology. We carried out pooled analyses using a random effects model. Our systematic review was performed according to the PRISMA and MOOSE guidelines for systematic reviews and was registered with PROSPERO. In total, 2652 articles were detected in the databases, of which 76 articles were chosen for full-text review. Fourteen studies were focused on samples of an unselected population, and 8 studies were focused on a group of persons at risk for SDB. In 5 studies, the incidence of cardiovascular pathology in the population with SDB was examined. In total, 49 studies described SDB in patients with cardiovascular pathology. We found an association between SDB and prevalent /incident cardiovascular disease (pooled OR 1.76; 95% CI 1.38–2.26), and pooled HR (95% CI 1.78; 95% CI 1.34–2.45). Notably, in patients with existing SDB, the risk of new adverse cardiovascular events was high. However, the relationship between cardiovascular disease and SDB is likely to be bidirectional. Thus, more large-scale studies are needed to better understand this association and to decide whether screening for possible SDB in cardiovascular patients is reasonable and clinically significant.

Sleep and Stroke: Opening Our Eyes to Current Knowledge of a Key Relationship

PURPOSE OF REVIEW

To elucidate the interconnection between sleep and stroke.

RECENT FINDINGS

Growing data support a bidirectional relationship between stroke and sleep. In particular, there is strong evidence that sleep-disordered breathing plays a pivotal role as risk factor and concur to worsening functional outcome. Conversely, for others sleep disorders (e.g., insomnia, restless legs syndrome, periodic limb movements of sleep, REM sleep behavior disorder), the evidence is weak. Moreover, sleep disturbances are highly prevalent also in chronic stroke and concur to worsening quality of life of patients. Promising novel technologies will probably allow, in a near future, to guarantee a screening of commonest sleep disturbances in a larger proportion of patients with stroke. Sleep assessment and management should enter in the routinary evaluation of stroke patients, of both acute and chronic phase. Future research should focus on the efficacy of specific sleep intervention as a therapeutic option for stroke patients.

Neurological manifestations in COVID-19 and its possible mechanism

In December 2019, the first cases of the acute respiratory illness now known as Corona Virus Disease 2019 (COVID-19) occurred in Wuhan, Hubei Province, China. The main clinical manifestations of COVID-19 are a fever, dry cough and general weakness, although in some patients, a headache, tight chest, diarrhea, etc. are the first clinical manifestations. Neurological practice is involved in all aspects of medicine, from primary care for patients with migraines to consultations with patients in the intensive care unit. Few disorders spare the nervous system, and newly emerging infections are no exception. As neurologists, we are concerned about the effects of SARS-CoV-2 infections on the nervous system. Multiple neuropathy, rhabdomyolysis, cerebrovascular disease, central nervous system infections and other common neurological diseases require attention during this outbreak.

Sleep-disordered breathing in patients with stroke-induced dysphagia

This study examined the nature and characteristics of sleep-disordered breathing, including obstructive sleep apnea and central sleep apnea, in patients with post-stroke dysphagia, to determine the demographic, anthropometric and clinical variables that were associated with sleep-disordered breathing. Thirty-nine patients diagnosed with acute stroke (28 males and 11 females with a mean age of 72.3 ± 10.0 years) underwent overnight polysomnography (within 3.9 ± 1.6 days after admission). Sleep-disordered breathing was described by the apnea-hypopnea index and its obstructive and central components by the obstructive apnea-hypopnea index and central apnea-hypopnea index, respectively. Severity of dysphagia was assessed using the Mann Assessment of Swallowing Ability score. Severity of stroke and functional dependence were assessed by the National Institute of Health Stroke Scale and the modified Barthel index, respectively. Most of the cohort (87%) had moderate-to-severe dysphagia (Mann Assessment of Swallowing Ability of 143.2 ± 19.9). Sleep-disordered breathing (apnea-hypopnea index ≥ 5 events/hr) was present in 38 participants (97%) with a mean apnea-hypopnea index of 37.5 ± 24.4 events/hr. Sleep-disordered breathing was predominantly obstructive in nature, with a mean obstructive apnea-hypopnea index and central apnea-hypopnea index of 19.6 ± 15.7 and 11.4 ± 17.6 events/hr, respectively. Multivariate linear regression analyses showed that the apnea-hypopnea index was associated with sex (p = .0001), body mass index (p = .029) and the modified Barthel index (p = .006); the obstructive apnea-hypopnea index was associated with the Mann Assessment of Swallowing Ability (p = .006), sex (p = .004) and body mass index (p = .015) and had a nonlinear relationship with the modified Barthel index (p = .019); and the central apnea-hypopnea index was associated with sex (p = .027) and the modified Barthel index (p = .019). The present study showed that dysphagia severity was associated with obstructive sleep apnea severity and this association was independent of sex, modified Barthel index and body mass index. However, stroke-induced dysphagia was not associated with central sleep apnea or overall sleep-disordered breathing.