Author: Joanne Murray
Murray, Joanne, 2016 Fluid intake, hydration and health status of inpatients with and without dysphagia following stroke, Flinders University, School of Health Sciences
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Dysphagia, a common consequence of stroke, compromises an individual’s ability to drink fluids and prescription of thickened fluids, a common strategy for reducing aspiration risk, may further exacerbate the risk of dehydration. To date few studies have investigated the impact of fluid intake on the outcomes of hydration and fluid–related health outcomes of individuals with dysphagia. This thesis uniquely describes the fluid intake, hydration and health status of hospital inpatients with dysphagia post-stroke who are reliant on thickened fluids. A randomised control trial (RCT) was conducted to determine whether water protocols improve these outcomes compared with thickened fluids alone. Simultaneously, a cohort study was conducted with individuals without dysphagia to determine whether stroke related comorbidities or institutional factors have an impact on fluid intake, hydration status and health outcomes. Three background studies were conducted to provide additional context; i) incidence of stroke and comorbidities in South Australian hospitals; ii) a retrospective medical record audit of consumption of thickened fluids by patients with dysphagia post-stroke in South Australian hospitals; and iii) a survey of Australian health professionals about their practices for providing thickened fluids and measuring consumption and hydration of patients with dysphagia. Unexpectedly, participants with dysphagia randomised to the water protocol group in the RCT did not drink any more than those on thickened fluids only, both groups consuming on average 1103ml per day. They typically drank 300ml of water per day but off-set this by consuming less of the thickened fluids offered. Those on the water protocol had an improving trajectory of hydration, faster resolution of their dysphagia for thin fluids and fewer adverse health outcomes than those on thickened fluids only, although none of these differences between groups were significant. No participants in either group developed pneumonia. The findings suggest that patients with dysphagia, with similar demographic and stroke characteristics as the present sample, could be safely trialled on a water protocol as a potential avenue for improving hydration. Combined findings from the RCT and cohort study indicated that individuals with dysphagia in inpatient rehabilitation drank significantly less on average per day (1103ml, representing 46% of their calculated fluid requirement) than those without dysphagia (1504ml, representing 67% of their calculated requirement). Collectively, 71% of the participants with dysphagia in the RCT had urea/creatinine results which classified them as dehydrated compared with 40% of those without dysphagia in the cohort study. They also had a significantly greater number of adverse health outcomes of dehydration, urinary tract infection and constipation (43%) compared with those without dysphagia (16%). The findings confirm that dysphagia is a major risk factor for dehydration. However, even individuals without dysphagia had suboptimal fluid intake and hydration compared with healthy adults living in the community and factors such as greater dependency, restricted mobility and older age had a significant impact on their fluid intake and hydration. In light of the findings, wide-ranging strategies for improving hydration are discussed which focus on patients with dysphagia but could be applicable to all patients hospitalised post-stroke. Recommendations for clinical practice and development of clinical guidelines are highlighted along with specific areas where further high quality research is needed.
Keywords: Dysphagia; stroke; fluid intake; thickened fluids; drinking; water; hydration; dehydration; water protocols; rehabilitation
Subject: Speech Pathology thesis
Thesis type: Doctor of Philosophy
School: School of Health Sciences
Supervisor: Dr Ingrid Scholten