Eating difficulties in elderly, focusing on patients with stroke

Abstract: The aim of this thesis was to describe eating difficulties and interventions to improve eating among elderly patients, especially those with stroke, to make comparisons between patients with dysphagia and those without (Papers I & II), those with and without assisted eating (Paper IV), and to analyse the relation between eating difficulties, nutritional status (Papers II-V), pressure ulcers (Paper IV), length of hospital stay and levels of independent living when discharged (Paper V). Eating difficulties were mainly assessed using structured observations. Katz’s ADL index was used to assess activities of daily living, and Subjective Global Assessment form (SGA) for nutritional status. The frequency of dysphagia in acute stroke patients was found to be 27% or 40% if those who were unconscious, terminally ill or had a previous history of dysphagia were included. Overall stroke severity indicated dysphagia. Three groups were identified: those who were unable to complete a meal because of reduced alertness and impaired swallowing; those who could complete a meal despite reduced alertness and dysphagia; and those who could complete meals with minor difficulties (Paper I). The level of alertness seemed important for the ability to eat and swallow, the development of complications over time, and the types of interventions that could be implemented (Paper II). Among patients (n=520) in various rehabilitation care settings 82% had one or more eating difficulties, 36% assisted eating and 46% malnutrition. Difficulties with ingestion, deglutition and low energy were associated with assisted eating, and low energy with malnutrition (Paper III). Eating difficulties were found, through principal component analysis, to include ingestion, i.e. preparation and transportation of food to the mouth; deglutition, i.e. the oral and pharyngeal ability to handle food; energy, i.e. alertness, speed and amount of food eaten (Paper III). Eating difficulties were found in 80% of patients in stroke rehabilitation and 52.5% were unable to eat without assistance. The most common eating difficulties were: eating 3/4 or less of served food (60%), difficulties in manipulating food on the plate (56%), and transportation of food to the mouth (46%). Thirty-two percent were malnourished, which was more common among patients with assisted eating (49%) than those without assistance (13%, p <.0005). Among patients who were dependent in one or more functions in Katz’s ADL index 15% had pressure ulcers. Alertness, swallowing difficulties, eating 3/4 or less of served food, and aberrant eating speed predicted malnutrition. Malnutrition predicted pressure ulcers (Paper IV). Especially ingestion difficulties decreased during the rehabilitation period. Patients with longer LOS and those discharged to institutional care had more eating difficulties on admission and were more dependent in ADL than patients with shorter LOS and those who returned home. Patients discharged to institutional care were older, more often lived alone before admission, and stayed longer. LOS was mainly explained by ingestion difficulties on admission. Discharge to institutional care was explained by living alone before admission, ingestion difficulties at discharge, male gender and high age (Paper V). It is of great importance to assess and take systematic measures for each of the three categories of eating difficulties, i.e. ingestion, deglutition and energy to improve eating abilities. Measures should be taken in order to prevent development of complications that can decrease the patients’ ability to take active part in rehabilitation, and it needs to be a continuous process.