This study investigated the association between the severity of oropharyngeal dysphagia in elderly individuals in the late stage of stroke and their quality of life.
The results demonstrated that most individuals, in the clinical evaluation, were classified as presenting mild oropharyngeal dysphagia for all food textures analyzed. Studies analyzing the incidence of dysphagia in elderly individuals in both acute (3,4) and late (7) stages of stroke observed that more than 50% of this population presents oropharyngeal dysphagia, which may range from mild, usually in the late stage, moderate or severe in the acute stage, according to the clinical evaluation of swallowing. It should be considered that, in the late stage of stroke, there may be a reduction in feeding difficulties, since these individuals find different manners to adapt their feeding, yet the quality of intake and type of foods may be impaired (24).
The results of clinical evaluation overestimated the instrumental evaluation, similar to the report of Leder(10), since the classification of dysphagia based on the DOSS scale was considered grade 6 for more than half of individuals (64.71%), i.e. with functional limitations. Conversely, several authors observed that the number of patients after the late stage of stroke with dysphagia increases after instrumental evaluation (9,25), identifying those without signs on clinical evaluation. Several factors may contribute to the divergent results found in the present study and in the literature, such as the different age range (6,11), stage of stroke (10-11) and motor and cognitive impairment (13,14), as well as different evaluation procedures, such as the use of videofluoroscopy (9,10,25)..
Evaluation of the quality of life related to swallowing using the SWAL-QOL protocol demonstrated that most individuals presented maximum score close or equal to 100 points, and few had scores close to the expected minimum, both concerning the scores of each domain and the global score. No studies were found in the literature applying the SWAL-QOL protocol in individuals affected by stroke in the late stage, yet in laryngectomized individuals (13) it was observed that the lowest means and medians were within the domains “duration of feeding”, “communication” and “fear to feed”, similar to the present study. Conversely, for individuals with Parkinson disease (14), there is a reduction in scoring in the protocol with the disease, evolution, especially in the domains “burden”, “duration of feeding”, “communication”, “social function”, “sleep” and “fatigue”.
Most individuals in the present study were classified as presenting mild oropharyngeal dysphagia oropharyngeal swallowing with functional limitations; however, it is believed that the quality of life is an important factor to be investigated, regardless of the degree of oropharyngeal dysphagia, since the different standpoints of each individual should be considered (26).
The scores of the SWAL-QOL protocol were correlated with the degree of oropharyngeal dysphagia classified both by clinical and instrumental evaluation, and it was possible to observe statistically significant correlation in both. Thus, the worse the degree of dysphagia, the greater the impact on the quality of life of these individuals.
The present results agree with the literature even when studies were conducted using other quality of life protocols, such as the BDI protocol (Beck depression inventor)(27), SF 36(26) and the SS-QOL scale (Stroke Specific Quality of Life Scale)(27), and according to all authors, in the case of oropharyngeal dysphagia, quality of life is an important aspect to be investigated, since it is altered regardless of the degree of dysphagia.
It was o possible to observe correlation between some specific domains of the SWAL-QOL protocol both by clinical and instrumental evaluation, such as the domains: burden, duration of feeding, wish to feed, frequency of symptoms and mental state. All these domains were related with at least one texture, yet more frequently with solid food. Greater damages to feeding with solid texture may be explained by the need to better prepare the food bolus, which demands a good oral stage of swallowing.
Aging may evolve with tooth loss and utilization of dentures, which are not always well adapted, leading to greater masticatory and swallowing difficulties. Thus, the degree of dysphagia and the oral ingestion level are influenced by the oral health condition (28).
Based on the present results, it may be observed that oropharyngeal dysphagia, even mild, influenced the quality of life related to swallowing in elderly individuals after the late stage of stroke in the global score and specific domains such as burden, duration of feeding, wish to feed, frequency of symptoms and mental state. Thus, the greater the swallowing disorder, the greater was the burden, an overall indicator of daily difficulties experienced by patients with swallowing disorder. Also, the greater was the lack of wish to feed, there were more symptoms of oropharyngeal alterations and more disorders in mental stage, identified as self-image problems and psychological suffering (29) in elderly individuals affected by the late stage of stroke in this study.
Even though videofluoroscopy is considered the most effective gold standard method to evaluate and diagnose the oropharyngeal dysphagia, in the present study the accomplishment of nasoendoscopy also allowed application of a validated classification scale (22). Other study limitation to be considered concerns the fact that the Brazilian Portuguese version of the SWAL-QOL protocol was applied to oncological patients in the process of translation and transcultural adaptation (13), while this study evaluated neurological patients, which may have impaired the analysis or even the manner through which the patients responded to the protocol.
The lack of information on the type of stroke and affected areas represent a limitation of the study, since the stroke may affect several areas of the central nervous system besides the brainstem, and the severity of dysphagia is related to the neurological characteristics of patients (6,7, 14,15).
The lack of studies correlating the SWAL-QOL protocol with swallowing dysfunction in individuals affected by the late stage of stroke impairs the comparison with the literature. Thus, further studies are necessary to investigate the quality of life related to swallowing in the different stages of stroke.
Also, it is important to longitudinally follow these individuals concerning the feeding aspects.