Recommendations
D
The etiology of the pain must be evaluated, describing its location, duration,
intensity and circumstances when it becomes worse or is relieved. The use of
scales from 0 to 10 is recommended to determine the degree of pain.
B
The use of amitriptyline as a first-line drug is recommended, always bearing
in mind the side effects associated with its use and establishing the risk/benefit
balance in each case.
B
Anticonvulsant drugs (lamotrigine) can also be considered as an alternative to
antidepressants (amitriptyline), although the possible appearance of side effects
must be taken into account.
!
It is advisable to refer patients with uncontrolled central post stroke pain in
Primary Care to specialised pain management care.
8.3.1.5. Dysphagia
Between 27 and 69% of the patients with acute stroke present dysphagia202. Almost half either die
or recover within the following 14 days, and the rest are left with a certain degree of alteration in
swallowing203. The complications associated with dysphagia include aspiration pneumonia, malnutrition or dehydration due to a reduction in food and fluid intake. In another setting, it can also
affect the patient’s social life189.
The symptoms and signs that might lead to the suspicion of a patient Expert’s opinion 4
presenting dysphagia are described in table 14243.
Table 14. Signs and symptoms of dysphagia243
General
• Difficulty managing oral secretions or
drooling
• Absence or weakness of a voluntary cough
or swallow
• Changes in voice quality / tone
(hoarseness/moist sounding)
• Decreased mouth and tongue movements
• Frequent throat clearing
• Poor oral hygiene
• Changes in eating patterns
• Raised temperature
• Weight loss and/or dehydration
• Frequent chest infections
• Tongue thrust / primitive oral reflexes
When eating or drinking
• Slow to initiate a swallow and/or delay in
swallow (over five seconds)
• Pocketing of food in the cheeks
• Uncoordinated chewing or swallowing
• Oral or nasal regurgitation of food /
liquids
• Multiple swallows for each mouthful
• Extended time to eat / drink
• Coughing or sneezing during/following
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Following the consumption of food or drink
• A wet or hoarse sounding voice
• Changes in respiratory pattern
• Fatigue
There are some simple, non-instrumental, methods that can be used to evaluate dysphagia after a
stroke. The most commonly studies are variations of the glass of water test, consisting in giving
the patient different amounts of water to drink (between 30 and 90 ml) and observing if symptoms
such as choking, coughing or voice changes appear. Some of these tests combined the “glass of
water test” with monitoring oxygen saturation, considering desaturation a positive sign of dysphagia. The majority also include a preliminary examination together with a questionnaire about the
patient’s clinical data. These tests are usually applied as screening tests during hospital admission
on all patients who have suffered a stroke202.
The guidelines consulted agree about the need to rule out the presence of CPG (experts’
dysphagia in patients with acute stroke as soon as possible and in any case opinion) 4
before starting oral intake. When difficulties are detected in swallowing,
these will assessed by the relative specialist, checking, too, if there are associated nutritional problems, so, in principle, all patients should have been
evaluated before being discharged from hospital78,186,189,244.
The RCP also recommends that those patients who continue to have CPG (experts’
problems in swallowing either solids or liquids or their carers, be trained in opinion) 4
identifying and managing swallowing problems189.
Feeding by oral route
Although there is no exclusive diet for dysphagic patients, it is common to CPG (experts’
include modifications in the texture and viscosity of liquids and solids. These opinion) 4
modifications may reduce the nutritional content of the diet and the food may
not look so appetising, thus causing a reduction in the oral intake. Therefore,
it is advisable to enrich the food so that the patients’ nutritional requirements
are met, presenting it in an appetising and varied manner. The patients’ food
must be monitored and if necessary, refer to a nutritionist244.
Some of the food and modifications of the textures recommended are
given below245:
- Food in the form of purée, not leaving it too liquid or with lumps.
- Minced or ground food, referring to soft food with which a homogeneous and easy to chew bolus can be formed.
- Thickened liquids.
- Avoid foods containing mixed textures, such as a combination of solid
and liquid, food that can cause gastro-oesophageal reflux, bread and buns,
liquids and food in small dry pieces (rice, cereals, corn, peanuts).
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CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF STROKE PATIENTS IN PRIMARY HEALTH CARE