6. Déglutition (dysphagie), alimentation et soins buccodentaires

La dysphagie est une complication fréquente observée après un AVC qui peut avoir des répercussions importantes sur la qualité de vie et l’apport nutritionnel d’une personne. Cette affection est due à une altération du contrôle des muscles de la gorge et de la bouche, entraînant ainsi des difficultés à avaler des aliments, des liquides ou des médicaments. Par conséquent, les personnes atteintes de dysphagie sont exposées à un risque accru de pneumonie d’aspiration, de malnutrition et de déshydratation. Les défis posés par la dysphagie peuvent également mener à un isolement social et à une détresse psychologique, l’heure des repas devenant souvent une expérience stressante. Les estimations publiées de l’incidence de la dysphagie associée à l’AVC fluctuent entre 19 % et 65 % dans la phase aiguë, en fonction du site de la lésion, du temps écoulé depuis l’AVC et du choix de la technique d’évaluation.¹⁶⁴

Les personnes ayant subi un AVC soulignent l’importance de l’éducation et de la formation des personnes ayant subi un AVC et de leurs aidantes et aidants en ce qui concerne les risques de dysphagie, comme l’aspiration, ainsi que l’importance d’obtenir des informations sur la prise en charge de la dysphagie. Elles soulignent aussi l’importance du dépistage et de l’évaluation de la dysphagie après un AVC et préconisent un dépistage de la dysphagie tout au long du continuum de soins de l’AVC. Les personnes ayant subi un AVC apprécient également les informations sur des sujets comme une alimentation saine et la santé buccodentaire, afin de favoriser leur rétablissement après l’AVC.

Pour prendre en charge la dysphagie et la malnutrition post-AVC, les organismes doivent optimiser les éléments suivants du système :

1. Les processus visant à garantir le dépistage des troubles de la déglutition avant toute prise orale, par un professionnel ayant reçu la formation appropriée.
2. L’élaboration et la mise en œuvre de programmes éducatifs pour former le personnel concerné au dépistage initial des problèmes de déglutition chez les personnes ayant subi un AVC. Il peut s’agir de membres du personnel de tous les secteurs du continuum, comme les services des urgences, les unités de soins de courte durée en milieu hospitalier, les établissements de réadaptation et les établissements de soins communautaires et de longue durée.
3. La mise en place de processus visant à garantir une communication claire entre les membres du personnel et les personnes ayant subi un AVC et leur famille, concernant l’état de déglutition des patientes et patients, afin que l’ensemble des membres de l’équipe soient au courant.
4. L’accès à des professionnels de la santé ayant reçu une formation appropriée, notamment des orthophonistes, des ergothérapeutes et des diététistes, qui peuvent effectuer des évaluations approfondies et recommander des mesures de prise en charge appropriées pour la prévention de la malnutrition et de l’aspiration.
5. L’élaboration et la mise en œuvre de programmes éducatifs visant à s’assurer que les prestataires de soins de santé ont reçu une formation adéquate sur les stratégies de prévention et de prise en charge de la santé buccodentaire après un AVC.
6. La mise en place de processus visant à garantir que l’éducation sur la dysphagie (p. ex. stratégies de préparation et de gestion des repas) pour la personne ayant subi un AVC, sa famille et ses aidantes et aidants est offerte en temps opportun.

Indicateurs du système

1. Présence d’un programme sur la dysphagie pour toutes les unités de réadaptation post-AVC en milieu hospitalier.
2. Accès à des programmes éducatifs sur la dysphagie pour le personnel, les personnes ayant subi un AVC et leur famille.
3. Proportion de personnes atteintes de dysphagie après un AVC en phase aiguë.

Indicateurs de processus

4. Proportion de personnes ayant subi un AVC en phase aiguë évaluées à l’aide d’un outil uniformisé de dépistage de la dysphagie le jour même de leur arrivée à l’hôpital (Agrément Canada).
5. Proportion de personnes ayant subi un AVC qui ont échoué au dépistage initial de la dysphagie et qui ont ensuite été évaluées par une ou un orthophoniste, ergothérapeute ou diététiste ou par un autre professionnel de la santé ayant reçu une formation appropriée.
6. Intervalle médian en minutes entre l’arrivée du patient au service des urgences et le dépistage initial de la dysphagie par une clinicienne ou un clinicien qui a reçu une formation à cet effet.
7. Proportion de personnes ayant subi un AVC dont l’état de la dysphagie est réévalué lors de la réadaptation post-AVC.

Indicateurs axés sur la personne

8. Incidence de la malnutrition sur les personnes ayant subi un AVC admises à l’hôpital en raison d’un AVC qui retarde la sortie de l’hôpital.
9. Proportion de personnes ayant subi un AVC en phase aiguë et atteintes de dysphagie qui présentent des complications post-AVC, comme une pneumonie.
10. Changements en ce qui a trait à la qualité de vie des personnes ayant subi un AVC et atteintes de dysphagie, mesurés à intervalles réguliers pendant le rétablissement et la participation, puis réévalués lorsque des changements dans l’état de santé ou d’autres événements de la vie surviennent (p. ex. 60, 90 et 180 jours après un AVC).

Les ressources et les outils ci-dessous, qui sont externes à Cœur + AVC et aux Recommandations, peuvent être utiles à la mise en œuvre des soins de l’AVC. Cependant, leur présence ne constitue pas une approbation réelle ou implicite par l’équipe des pratiques optimales de soins de l’AVC ni par Cœur + AVC. Nous vous encourageons à examiner ces ressources et ces outils d’un œil critique et à les mettre en œuvre dans votre pratique à votre discrétion.

Renseignements destinés aux prestataires de soins de santé

• Recommandations canadiennes pour les pratiques optimales de soins de l’AVC : Module Réadaptation, rétablissement et participation communautaire après un AVC – Première partie : Planification de la réadaptation post-AVC pour la prestation de soins optimaux; et Troisième partie : Optimisation de l’activité et de la participation communautaire après un AVC, mise à jour de 2025
• Cœur + AVC. Agir pour des soins de l’AVC optimaux communautaires et de longue durée : une ressource pour les prestataires de soins de santé
• Mini Nutritional Assessment (MNA) (évaluation de l’état nutritionnel)  
• BAPEN. Malnutrition Universal Screening Tool (MUST) (outil universel de dépistage de la malnutrition)  
• Le Groupe de travail canadien sur la malnutrition. Dépistage  
• Info AVC
• International Dysphagia Diet Standardization Initiative (en anglais seulement)  

Ressources destinées aux personnes ayant subi un AVC, à leur famille et à leurs aidantes et aidants 

• Cœur + AVC. Signes de l’AVC
• Cœur + AVC. Existe-t-il d’autres signes de l’AVC que VITE?
• Cœur + AVC. Votre cheminement après un AVC
• Cœur + AVC. Liste de vérification après un AVC
• Cœur + AVC. Infographie sur la réadaptation et le rétablissement
• Cœur + AVC. Infographie sur les transitions et la participation communautaire
• Cœur + AVC. Aide à l’autogestion après un AVC : liste de vérification pour les patients, les familles et les aidants
• Cœur + AVC. Aide-mémoire pour les soins de santé virtuels
• Cœur + AVC. Rétablissement et soutien
• Cœur + AVC. Soutien en ligne et soutien par les pairs
• Cœur + AVC. Répertoire des services et ressources
• Cœur + AVC. Difficultés à avaler
• CanStroke Essais post-AVC. Outils et ressources
• Info AVC

Evidence Table and Reference List 6a

Evidence Table and Reference List 6b

Dysphagia

The implementation of a standardized program for bedside screening is thought to decrease the incidence of dysphagia-related pneumonia. Components may include those related to a patient’s level of consciousness, an evaluation of oral motor function and oral sensation, as well as the presence of a cough. It may also include trials of small sips of water, whereby a “wet” or hoarse voice are suggestive of an abnormal swallow. While a variety of dysphagia screening tools are currently in use, it is unclear which one performs best. To further knowledge in this area, in a Cochrane review, Boaden et al. ¹⁶⁵ evaluated the test characteristics of 37 different screening tools of which 24 used only a water test, 6 used a combination of water and other liquid consistencies, and 7 used other methods. When compared against gold standards (which varied across studies), the best performing swallow screening tools were, the combined water swallow tests and Oxygen Saturation Test, Gugging Swallowing Screen (GUSS),¹⁶⁶ and Toronto Bedside Swallowing Screening Test (TOR-BSST). ¹⁶⁷ Screening tools that used a combination of water and other consistencies as testing materials were more accurate than screening tests that used only water. Nevertheless, the authors concluded that they were unable to identify a single screening tool with high, and precisely estimated sensitivity and specificity due to lack of high-quality studies.

Sherman et al. ¹⁶⁸ included the results from 30 studies, of which 6 were RCTs, including patients with swallowing problems following stroke. The outcomes of patients who received no screening vs. screening, were compared. Among the studies in which a previously validated screening tool was used, the Acute Screening of Swallow in Stroke/TIA ¹⁶⁹ was used most frequently (n=6), followed by the GUSS166 (n=4), and the Three-Step Swallowing Screen protocol ^170,171 and the MetroHealth Dysphagia Screen, ¹⁷² which were used in one study each. Overall, dysphagia screening was associated with reduced odds of pneumonia (OR=0.57, 95% CI, 0.45–0.72), mortality (OR=0.52, 95% CI 95% CI, 0.35–0.77), dependency (OR=0.54, 95% CI, 0.35-0.85) and reduced length of hospital length of stay (SMD= −0.62 days, 95% CI, −1.05 to −0.20).

While texture-modified diets, the use of restorative swallowing therapy, and compensatory techniques, are the most commonly used treatments for the management of dysphagia in patients who are still safe to continue oral intake, there is little direct evidence of their benefit. The effectiveness of a variety of treatments for dysphagia and nutritional management was evaluated in a Cochrane review. ¹⁷³ Dysphagia treatments examined in 41 RCTs included acupuncture, behavioural interventions, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation (thermal, tactile), transcranial direct current stimulation, and transcranial magnetic stimulation. Overall, there was no reduction in the odds of death or disability or case fatality at the end of the trial associated with dysphagia therapies. While swallowing therapy significantly reduced the proportion of participants with dysphagia at the end of the trial, reduced the risk of chest infections or pneumonia, and was associated with a mean reduction in hospital length of stay or almost 3 days, the authors cautioned that further high-quality trials are required before clinical decisions can be made about what treatments are effective. Another systematic review including the results of 22 RCTs of patients in acute or critical care settings with dysphagia. ¹⁷⁴ Interventions included non-invasive electrical brain stimulation (transcranial electrical stimulation or transcranial magnetic stimulation), pharyngeal electrical stimulation, neuromuscular electrical stimulation, acupuncture, behavioral therapy, chin tuck, respiratory muscle strength training, tongue palate resistance training, and effortful swallow training and traditional swallowing exercises. While swallowing therapy was not associated with a significantly decreased risk of aspiration (RR=0.79, 95% CI 0.44 to 1.45), it was associated with a decreased risk of pneumonia (RR=0.71, 95% CI 0.56 to 0.89).

Surface Neuromuscular electrical stimulation (NMES) using devices such as VitalStim has been used in the rehabilitation of swallowing function in patients with stroke-associated dysphagia.  While this treatment is popular in the United States and other countries, it is not widely used in Canada, and the evidence supporting its use is conflicting. Tarihci Cakmak et al. ¹⁷⁵ randomized 34 patients with dysphagia an average of 50 weeks post stroke to receive traditional dysphagia therapy + NMES with the VitalStim device (45 minutes/session x 5 days/week x 3 weeks) or dysphagia therapy only. The stimulation intensity level started at 2 mA, increased by 0.5 mA intervals, and stabilized when the patient felt vibration in the patient’s neck. From baseline to end of follow-up at three months, there were significant improvements within both groups in mean scores for all outcomes (Functional Oral Intake Scale [FOIS], Eating Assessment Tool (EAT-10), the Swallowing Quality of Life Questionnaire (SWAL-QOL), and voice-related quality of life questionnaire, with no between group differences. Carnaby et al.¹⁷⁶ recruited 57 patients with post-stroke dysphagia from a stroke rehabilitation unit. Patients were randomized to receive usual care, which included behavioral swallowing therapy for 1 hour/day for 3 weeks, or until hospital discharge, or McNeill Dysphagia Therapy (MDTP) swallowing therapy in addition to active NMES with the VitalStim device or MDTP + sham NMES. Post intervention, there was significantly greater improvement in mean Mann Assessment of Swallowing Ability (MASA) and (FOIS) scores in the MDTP group + sham stimulation compared with the other two groups. At 3 months, in adjusted analysis, compared with usual care, MDTP + sham NMES was associated with a significantly greater likelihood of return to normal diet (hazard ratio [HR]=4.32, 95% CI 1.08-17.2). Park et al. ¹⁷⁷ reported significantly greater improvement in swallowing ability following 6 weeks of active treatment with the VitalStim device among 61 stroke rehabilitation patients. At the end of treatment, patients who received active NMES had greater improvement in Videofluoroscopy Dysphagia Scale and Penetration–Aspiration Scale scores, compared with those who received sham treatment. A systematic review authored by Chen et al. ¹⁷⁸ included the results for 8 RCTs examining NMES and reported that active treatment was associated with significantly better swallowing function scores at the end of the treatment period (SMD=1.27 (95% CI 0.51-2.02).

For patients who cannot obtain their nutrient and fluid needs orally, enteral nutrition may be required. Results from the largest trial of its kind indicate that there is little difference in outcome between routes of enteral feeding. The Feed or Ordinary Diet (FOOD) trial ¹⁷⁹ also addressed the issues of timing of initiation of enteral feeding. The FOOD trial included 1,210 patients admitted within 7 days of stroke from 47 hospitals in 11 countries. In one arm of the trial, patients were randomized to receive either a percutaneous endoscopic gastrostomy (PEG) or nasogastric (NG) feeding tube within 3 days of enrolment into the study. PEG feeding was associated with a non-significant absolute increase in risk of death of 1.0% (–10.0 to 11.9, p=0.9) and a borderline increased risk of death or poor outcome of 7.8% (0.0 to 15.5, p=0.05) at 6 months. In the second part of the trial, patients were randomized to receive enteral feeds as early as possible or to avoid feeding for 7 days. Early tube feeding was associated with non-significant absolute reductions in the risk of death or poor outcome (1.2%, 95% CI -4.2 to 6.6, p=0.7) and death (15.8%, 95% CI -0.8 to 12.5, p=0.09) at 6 months. A Cochrane review ¹⁸⁰ comparing NG and PEG feeding tubes also reported few differences between feeding tube types. The review was composed of 11 RCTs including 735 adults with dysphagia, of whom 462 were recovering from stroke. PEG tubes were associated with significantly reduced odds of treatment failures (blocked tubes or disruptions in feeding schedule), but there was no significant difference between groups in mortality, aspiration-related pneumonia or adverse events.

Nutrition

Oral supplementation can be used for patients who are not able to consume sufficient energy and protein to maintain body weight, or for those with premorbid malnutrition. This topic has been explored more extensively in the geriatric population of individuals hospitalized for medical issues. In the Nutrition effect On Unplanned Readmissions and Survival in Hospitalized patients (NOURISH) trial, Deutz et al. ¹⁸¹ randomized 652 malnourished patients, recruited from 78 sites in the United States who were recently hospitalized to receive standard nutritional care + an oral supplement providing an 350 kcal, 20 g protein,  11 g fat, 44 g carbohydrate, and 1.5 g calcium-beta-hydroxy-methylbutyrate (HMB) twice daily or a placebo drink that contained 48 kcal, 12 g carbohydrate, and 10 mg vitamin C during their hospital stay and continuing up to 90 days following discharge. A significantly higher percentage of patients were classified as well-nourished at 90 days (category A, using Subjective Global Assessment) in the oral supplementation group (45.5% vs. 30.0%). For the primary outcome, a composite of death or nonelective readmission within 90 days post discharge, there was no significant difference between the groups (26.8% vs. 31.1%), nor was there a difference in the proportion of patients readmitted after 90 days (25.2% vs. 25.6%); however, mortality was lower in the oral supplementation group (4.8% vs. 9.7%, p=0.018). In a larger RCT, a similar finding was reported. The Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT), recruited 2,088 patients from 8 hospitals in Switzerland with a medical condition, a Nutrition Risk Score-2002 ≥3, who were able to consume food orally, and had an anticipated hospital stay of >4 days. ¹⁸² Patients were randomized to receive either individualized nutritional support (intervention group), or standard hospital food (control group). Patients in the intervention group received supplements and enteral feeding, as well as a prescription for oral nutritional supplements at discharge, as required. The primary (composite) outcome was all-cause mortality, admission to the intensive care unit from the medical ward, non-elective hospital readmission after discharge, major complications as a new occurrence or a decline in functional status of ≥ 10% from admission to day 30, measured by the Barthel Index. At 30 days, the risk of primary outcome was significantly lower in the intervention group (23% vs. 27%, adjusted odds ratio [OR]=0.79, 95% CI 0.64 to 0.97). Among the components of the primary outcome, mortality was significantly lower in the intervention group (7% vs. 10%, OR=0.65, 95% CI 0.47 to 0.91) as were the odds of functional decline (4% vs. 6%, OR=0.62, 95% CI 0.40 to 0.96).

The results of trials focused on stroke exclusively are less impressive. In the largest trial of its kind, the FOOD trial, reported that routine supplementation with an additional 540 Kcal/day for all patients, regardless of premorbid nutritional status, did not help to improve global outcomes. ¹⁸³ In this trial, 4,023 patients were randomized to receive or not receive an oral nutritional supplement in addition to a regular hospital diet, provided for the duration of their entire hospital stay. At 6-month follow-up, there was no significant difference between groups on the primary outcome, death or poor outcome (OR=1.03, 95% CI 0.91 to 1.17), which was comparable with a 1% to 2% absolute benefit or harm from oral supplements. However, in this trial, only 8% of patients were malnourished at baseline, which may have contributed to the null finding. In a recent Cochrane review, ¹⁸⁴ the focus was protein and energy supplementation. Although 52 RCTs were included, evaluating a broad range of interventions (protein and energy supplementation, enteral feeding, parenteral supplements, parenteral or enteral supplements, and oral and parenteral supplements) under the umbrella term of nutritional therapies, only data from one to two trials were available for the primary outcomes. Oral supplementation was not associated with a reduction in the odds of disability, defined as an mRS score of 0-2, at 6 months (OR=0.97, 95% CI 0.86 to 1.10; 1 trial [FOOD trial]: GRADE: low), or in the performance of activities of daily living, assessed using the Functional Independence Measure motor subscale, at 3.5 to 8 weeks follow-up (MD= 8.74, 95% CI 5.93 to 11.54, 2 studies; GRADE: very low).

Oral Care

Physical weakness following stroke may prevent patients from independently completing their ADLs, including oral care. Poor oral care, combined with potential side effects of medication (e.g., dry mouth, oral ulcers, stomatitis), may contribute to greater amounts of bacteria in the mouth, leading to an increased risk of pneumonia. Therefore, on admission to hospital, all patients should have an oral/dental assessment to examine mastication, tooth wear, oral disease, and use of appliances following stroke. However, few studies have examined interventions to improve oral hygiene in patients following stroke. A Cochrane review conducted by Campbell et al. ¹⁸⁵ included the results of 15 RCTs (n=1,546) that included patients receiving some form of assisted oral healthcare in a healthcare facility following stroke. Trials evaluated interventions designed to improve the cleanliness and health of the mouth, tongue and teeth (e.g., toothbrush, toothpaste, mouth gel, mouthwash, tongue cleaners, lip balm), care protocols led by healthcare staff or informal carers, combinations of education and training, selective decontamination of the digestive tract, and povidone-iodine rinses. Pooling of results was difficult due to the wide variation in treatment contrasts. Oral health care (OHC) interventions were associated with a significant reduction in denture plaque (MD=-1.31, 95% CI -1.96 to -0.66), and improvement in staff/patient OHC knowledge one month after the intervention was delivered (MD=0.70, 95% CI 0.06 to 1.35), when compared with usual care although the results from only a single small trial were included.

Sex & Gender Considerations

No literature was identified that discussed potential sex or gender differences on the topics of screening or treatment for dysphagia, nutrition or oral health, post stroke.