Post on 01-Dec-2019
Nutricia
Nutrition and Stroke
Objectives
1. To understand the definition of stroke
2. To understand the cost and prevalence of stroke in the UK
3. To be able to identify the risk factors of stroke
4. To be able to summarise the causes and consequences of
malnutrition in stroke
5. To understand the nutritional requirements of patients with
stroke
6. To be able to explain the nutritional risks for people with
stroke
7. To be able to describe the nutritional therapy in the
management of stroke
Outline
• Introduction to Stroke
• What is stroke
• Statistics
• Impact
• Malnutrition in Stroke
• Statistics
• Consequences
• Nutritional management of patients with Stroke
• Nutritional requirements
• Nutritional management of Stroke
• Evidence for nutritional support in Stroke
• Case study
Introduction
1
What is Stroke or Cerebrovascular Accident (CVA)?
• A loss of function caused by a disruption of the blood supply to a part of the brain. This can lead to brain damage and possibly death
• Ischaemic: the blood supply/ flow is stopped due to a blood clot
• Haemorrhagic: a weakened blood vessel supplying the brain bursts and causes brain damage
• Trans Ischaemic Attack (TIA): 'mini-stroke‘ the supply of blood to the brain is temporarily interrupted
85%
cases
15%
cases
Source: Intercollegiate Stroke Working Party. https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines [16.03.2016].
Non-modifiable risk
factors1,2:
Age
Ethnicity
Family history
Medical history
Modifiable risk factors1,2:
Excessive alcohol intake
High blood pressure
High cholesterol levels
Lack of exercise
Overweight & obesity
Smoking
Risk factors of stroke
1. Intercollegiate Stroke Working Party. https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines [16.03.2016]. 2. Stroke association. https://www.stroke.org.uk/sites/default/files/stroke_statistics_2015.pdf [16.03.2016].
Numbness
Mobility problems:
Weakness or paralysis Slurred speech
Blurred Vision Severe Headache
Signs and Symptoms of Stroke
Emotional Difficulties
Neuropathic
Pain
Difficulties
E&D
Confusion
Fatigue &
tiredness
Swallowing
difficulties
Source: NHS Choices. Stroke – Act F.A.S.T.
Consequences of Stroke
• Largest cause of complex disability
• Half of all stroke survivors have a disability
• Greater range of disabilities than any other condition
• Over a third of stroke survivors are dependant on
others
Source: Intercollegiate Stroke Working Party. https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines [16.03.2016].
Prevalence of Stroke
Source: Seshadri S, et al. Stroke. 2006;37:345-50.
Prevalence, Incidence and Cost in the UK
• ~152,000 cases per year
• One every 3 minutes 27 seconds
• Fourth single largest cause of death
• 1 in 8 are fatal within the first 30 days
• 1 in 4 are fatal within the first year
• 1.2 million survivors living in the UK
Source: Stroke association. https://www.stroke.org.uk/sites/default/files/stroke_statistics_2015.pdf[16.03.2016].
Impact of Stroke on the NHS
• Total prevalence has increased by 26% from 2005 to 20141
• Stroke patients occupy a large proportion of hospital beds
• 20% of all acute beds
• 25% of long-term beds2
• It is estimated that it costs the economy around £9 billion per year2
• 5% of total NHS spend3
1. Stroke association. https://www.stroke.org.uk/sites/default/files/stroke_statistics_2015.pdf [16.03.2016]. 2. Bourn J. https://www.nao.org.uk/wp-content/uploads/2005/11/0506452.pdf [cited 16.03.16]. 3. Saka O, et al. Age Ageing. 2009;38:27-32.
Malnutrition
in Stroke
2
Prevalence of Malnutrition in Stroke
• The overall prevalence of malnutrition in stroke
patients is up to 62%1
Causes of malnutrition in stroke1-5
Reduced intake
Dysphagia
Loss of appetite & interest in
food
Fatigue & physical disability
Restricted ability to self-feed
Depression & anxiety
Visual problems
Poor oral hygiene
Medication side effects
1. Foley NC, et al. Stroke. 2009;40:e66-74. 2. Bouziana SD, et al. Malnutrition in patients with acute stroke. J Nutr Metab, 2011;2011:167898. 3. Stratton RJ, et al. Disease-related malnutrition: an evidence-based approach to treatment. Cabi Publishing; 2003 4. Nip WFR, et al. J Hum Nutr Diet. 2011;24:460-9. 5. Gomes F, et al. J Stroke Cerebrovasc Dis. 2016 [Epub ahead of print]
Prevalence of Malnutrition in Stroke
Stroke Patients
29% are at high risk of
malnutrition1
62% suffer from
dehydration2
45-50% are dysphagic3,4
1. Gomes F, et al. J Stroke Cerebrovasc Dis. 2016 [Epub ahead of print]. 2. Rowat A, et al. Stroke. 2012;43:857-9. 3. Stroke association. https://www.stroke.org.uk/sites/default/files/stroke_statistics_2015.pdf[16.03.2016]. 4. Bogaardt HCA, et al. Folia Phoniatr Logop. 2009;61:200-5.
Consequences of Malnutrition in Stroke
• Malnutrition in stroke has serious consequences
including1-6:
Increased Decreased
Risk of falls Weight
Complications Muscle strength
Infections Mobility
Poor outcomes Functional recovery
Impact on rehabilitation Wound healing
Mortality Quality of life
Length of stay
Healthcare costs
1. Bouziana SD, et al. J Nutr Metab. 2011;2011:167898. 2. Stratton RJ, et al. Disease-related malnutrition: an evidence-based approach to treatment. Cabi Publishing; 2003. 3. Nip WFR, et al. J Hum Nutr Diet. 2011;24:460-9. 4. Gomes F, et al. J Stroke Cerebrovasc Dis. 2016 [Epub ahead of print] 5. Dennis M. Stroke. 2003;34:1450-5. 6. Yoo SH, et al. Arch Neurol. 2008;65:39-43.
Consequences of Malnutrition
High risk of malnutrition in stroke patients can have serious consequences
Cost Mortality Length of Stay
1.5 times more
costly than
those at low
risk (£8,718 vs
£4,918)
7 times higher
mortality rate
than those at
low risk
(41.7% vs
5.8%)
3 times longer
stay than
those at low
risk (48 days
vs 14 days)
Source: Gomes F, et al. J Stroke Cerebrovasc Dis. 2016 [Epub ahead of print]
Nutritional
Management
of Stroke
3
Nutritional requirements in Stroke
• A number of studies have been conducted to investigate if there
are increased metabolic demands post stroke; but all failed to
reach statistically significant results1-5
HOWEVER
• PENG recommends the following stress factors:
• Haemorrhagic stroke – 30%
• Ischaemic stroke – 5%
• Stroke is linked with low energy & protein intake6-8
• Comorbidities such as pressure areas and infections which are
common in stroke can raise energy and protein requirements8
1. Weekes E, et al. Clin Nutr. 1992;11:18-22. 2. Finestone HM, et al. Stroke. 2003;34:502-7. 3. Bardutzky J, et al. J.Neurosurg. 2004;100:266-71. 4. Esper DH, et al. JPEN J Parenter Enteral Nutr. 2006;30:71-5. 5. Frankenfield DC, et al. Nutrition. 2012;28:906-11. 6. Foley NC, et al. Stroke. 2009;40:e66-74. 7. Chalela JA, et al. Neurocrit Care. 2004;3:331-4. 8.Thomas B, et al.Manual of Dietetic Practice. 4th ed. Oxford; Blackwell Publishing, 2007.
NICE Clinical Guideline 68: Stroke
• On admission, people with acute stroke should have their
swallowing screened by an appropriately trained healthcare
professional before being given any oral food, fluid or medication
• People with acute stroke who are unable to take
adequate nutrition and fluids orally should:
• Receive tube feeding with a nasogastric tube within 24 hours of
admission
• Be considered for a nasal bridle tube or gastrostomy if they are
unable to tolerate a nasogastric tube
• Be referred to an appropriately trained healthcare professional
for detailed nutritional assessment, individualised
advice and monitoring
Source: NICE guideline (CG68).
Multidisciplinary Stroke Team1-3
Medical team
Nurses
Physiotherapy
Occupational Therapy
Dietetics
Pharmaceutical Care
Psychology
Social Work
SLTs
1. Intercollegiate Stroke Working Party. https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines [16.03.2016]. 2. NICE guideline (CG68). 3. Scottish Intercollegiate Guidelines Network. http://www.sign.ac.uk/pdf/sign118.pdf {16.03.16]
Management of Malnutrition
• Nutritional goals should be agreed for patients at risk of malnutrition
• Screening
• NICE CG68 and National Clinical Guideline for Stroke recommend screening and
managing malnutrition and dehydration following stroke1,2
• Early assessment of nutritional risk, with appropriate nutritional management, may improve
survival of stroke patients3
• Nutrition support strategies:
• Nutrition support should be initiated for people with stroke who are at risk of malnutrition.
This may include oral nutritional supplements, specialist dietary advice and/or tube feeding2
• Review:
• The following should be reviewed regularly:
‒ Oral intake
‒ Hydration status
‒ Weight
‒ Tolerance of ONS/enteral feeds
1. Intercollegiate Stroke Working Party. https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines [16.03.2016]. 2. NICE guideline (CG68). 3. Yoo SH, et al. Arch Neurol. 2008;65:39-43.
Nutritional Management Pathway for Stroke Patients
Nutritional Management of Stroke Patients
Nil By Mouth
Enteral tube feeding
High risk of malnutrition with
dysphagia
Texture modified diet
Thickeners
Pre-thickened ONS
enteral tube feeding
High risk of malnutrition without
dysphagia
Dietary advice
Oral nutritional supplements
Low/ medium risk of malnutrition
Dietary advice
Therapy assessment to optimise access to
food
Regular screening and monitoring
Evidence for
Nutrition Support
in Stroke
4
Diet Modification
• Texture modification of food and fluids is widely used for the management
of dysphagia which can occur as a result of stroke1
• Speech and language therapists assess patients to determine which
consistency provides patients with the best control over the rate at which
food and fluids pass through the pharynx2
• If the patient consumes food or fluids of the incorrect consistency they
are at risk of aspiration3
• The use of xanthan gum-based thickeners improves safety of swallow in
patients with dysphagia4
1. Clave P, et al. Ailment Pharmacol Ther. 2006;24:1385-94. 2. Thomas B, et al. Manual of Dietetic Practice. 4th ed. Oxford; Blackwell Publishing, 2007. 3. Garcia MJ, et al. J Clin Nurs. 2010;19:1618-24. 4. Rofes L, et al. Ailment Pharmacol Ther. 2014;39:1169-79.
Oral Nutrition Supplements (ONS)
• Use of ONS is linked with a significant improvement in:
• Attenuating weight loss1
• Energy and protein intake2
• Risk of pressure sores2
• Handgrip strength3
• QoL3
• Markers of cognitive recovery4
• Measures of motor function5
1. Ha LT et al. BMC Geriatr, 2010;10:75. 2. Geeganage CJ, et al. Cochrane Database Syst Rev. 2012;10:CD0003233. 3. Ha LT, et al. Clin Nutr. 2010;29:567-73. 4. Aquilani R, et al. Nutr Neurosci. 2008;11:235-40. 5. Rabadi MH, et al. Neurology. 2008;71:1856-61.
Enteral Tube Feeding (ETF)
• NICE CG681 and the National Clinical Guideline for Stroke2
recommend that people with stroke who are unable to take
adequate nutrition and fluids orally should:
• Receive tube feeding with a nasogastric (NG) tube within 24
hours of admission
• Be considered for a nasal bridle tube or gastrostomy if they are
unable to tolerate an NG tube.
1. NICE guideline (CG 68). 2. Intercollegiate Stroke Working Party. https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines [16.03.2016].
Enteral Tube Feeding (ETF) cont.
• The Post-Stroke Rehabilitation Outcomes Project1
• Patients who received EFT during their stay but were not
discharged with a feeding tube had:
‒ Increased total functional independence measure (FIM) gains
‒ Greater improvement in severity of illness by discharge
• Stable stroke patients on long term EFT appear to have reduced
energy requirements, as a result2,3:
• Lower energy feeds are often used with stroke patients with
very low activity levels
• Lower energy feeds may help prevent unwanted weight gain
1. James R, et al. Arch Phys Med Rehabil. 2005;86:S82-92. 2. Leone A, et al. Clin Nutr. 2010;29:370-2. 3. Hubbard G, et al. Proc Nutr Soc. 2011;70(OCE5):E313.
Case Study
5
Case Study
Mrs. Williams
• 80 year old female
• Presenting condition: CVA (stroke)
• Referred for nutrition support as on a texture modified
diet and poor oral intake
• MHx: Congestive heart failure
• Medications: furosemide TDS
• SHx: lives at home alone, supportive family
Case Study
Anthropometry
• Weight: 56kg / 9st 6lb
• Height: 165cm / 5ft 5in
• BMI: 20.6kg/m2 (within healthy weight range, reference range: 20-
25kg/m2)
• Wt Hx: 60kg two weeks ago on admission, therefore 4kg loss of
weight which equates to 7% loss of total body weight.
• Signs of mild muscle wasting and subcutaneous fat loss
Biochemistry
• Na+ 154 (↑), eGFR 60 (down from 90 on admission), Urea within
normal range but trending up
• Indicative of dehydration
Case Study
Clinical
• Dysphagia - Stage 2 fluids and puree diet
• Fluctuating drowsiness
• Reduced appetite past 1/52
• Left sided hemiplegia impacting ability to self feed
• Nil nausea, vomiting or diarrhoea
• Nil oedema or ascites
• MUST = 3
• 1800mL fluid restriction due to heart failure
Energy: 1421kcal1
Protein: 67-100.5g2
Fluid: 1800ml
Estimated
Requirements
1. Henry CJ. Public Health Nutr 2005;8:1133-1152. (Activity factor: 20%%, Stress factor: 5%)
2. Deutz NEP, et al. Clin Nutr 2014;33:929-936 (1.2-1.5g/kg/day )
Case Study
Diet:
Meal Food Consumed Energy
(kcal)
Protein
(g) Fluid (ml)
Breakfast 1/4 bowl porridge with milk
1 cup thickened orange juice
59
58
2.5
0.8
20
200
Lunch ½ puree chicken and vegetables
1 cup thickened orange juice
135
58
16.4
0.8
200
Dinner
¼ puree beef casserole and potato
½ serve custard
1 cup thickened tea with milk & 1 sugar
74
71
36
8.1
2.3
0.8
200
Snacks 1 cup thickened tea with milk & 1 sugar 36 0.8 200
Total 527 32.5 820
Case Study
Nutritional Diagnosis
Inadequate energy, protein and fluid intake
Related to:
• Dysphagia
• Drowsiness
• Reduced ability to self feed
As evidenced by:
• 7% weight loss in 2/52
• Current intake ~37% estimated energy requirement (894kcal
deficit), ~32-49% estimated protein requirement (34.5-68g deficit)
and ~46% fluid requirement (980ml deficit)
Case Study
Nutrition Intervention
1. Commence HEHP puree diet and liaise with patient re: diet preferences
2. Liaise with OT to see if there are any appropriate strategies or modified
cutlery that may help improve oral intake
3. Liaise with nursing staff to encourage oral intake, especially fluids, to
prevent dehydration
4. Liaise with nursing and HCA staff to assist patient with feeding
5. Liaise with medical team re: dehydration & possible need for slow IV
fluids
6. Commence TDS pre-thickened stage 2 ONS, such as Nutilis Complete
Stage 2 (918kcal, 36g protein)
7. Consider top up enteral feeds if oral intake remains poor and poor
consumption of ONS
8. Liaise with SLT to keep updated on any changes to texture of food &
fluids
9. Weekly weights
10. Review
Summary
• Stroke is a loss of function caused by a disruption of the blood
supply to a part of the brain. This can lead to brain damage and
possibly death
• 152,000 cases per year, that’s one every 3 minutes 27 seconds
• Estimated cost to the economy of £9 billion per year
• Malnutrition is prevalent in stroke patients and it’s causes are
multifactorial
• NICE guidelines state nutrition support should be initiated for
people with stroke who are at risk of malnutrition. This may
include oral nutritional supplements, specialist dietary advice
and/or tube feeding advice and monitoring
References
Aquilani R, Scocchi M, Boschi F, et al. Effect of calorie-protein supplementation on the cognitive recovery of patients with
subacute stroke. Nutr Neurosci. 2008;11:235-40.
Bardutzky J, Georgiadis D, Kollmar R, et al. Energy demand in patients with stroke who are sedated and receiving mechanical
ventilation. J Neurosurg. 2004:100;266-71.
Bogaardt HC, Grolman W, Fokkens WJ. The use of biofeedback in the treatment of chronic dysphagia in stroke patients. Folia
Phoniatr Logop. 2009;61:200-5.
Bourn J. Reducing Brain Damage: Faster access to better stroke care [Internet]. London: National Audit Office; November 10,
2005. Retrieved from: https://www.nao.org.uk/wp-content/uploads/2005/11/0506452.pdf [cited 16.03.16].
Bouziana SD, Tziomalos K. Malnutrition in patients with acute stroke. J Nutr Metab. 2011;167898.
Chalela JA, Haymore J, Schellinger PD, et al. Acute stroke patients are being underfed: a nitrogen balance study. Neurocrit
Care. 2004;3:331-4.
Clave P, de Kraa M, Arreola V, et al. The effect of bolus viscosity on swallowing function in neurogenic dysphagia. Ailment
Pharmacol Ther. 2006;24:1385-94.
Dennis M. Poor nutritional status on admission predicts poor outcomes after stroke Observational data from the FOOD trial.
Stroke. 2003;34:1450-5.
Deutz NEP, Bauer JM, Barazzoni R, et al. Protein intake and exercise for optimal muscle function with ageing:
Recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33:929-36.
Esper DH, Coplin WM, Carhuapoma JR. Energy expenditure in patients with nontraumatic intracranial hemorrhage. JPEN J
Parenter Enteral Nutr. 2006:30;71-5.
Finestone HM, Greene-Finestone LS, Foley NC, et al. Measuring longitudinally the metabolic demands of stroke patients:
resting energy expenditure is not elevated. Stroke. 2003:34;502-7.
Foley NC, Salter KL, Robertson J, et al. Which reported estimate of the prevalence of malnutrition after stroke is valid? Stroke.
2009;40:e66-74.
References
Frankenfield DC, Ashcraft CM. Description and prediction of resting metabolic rate after stroke and traumatic brain injury.
Nutrition. 2012:28;906-11.
Garcia JM, Chambers E 4th, Clark M, et al. Quality of care Issues for dysphagia: modifications involving oral fluids. J Clin Nurs.
2010;19:1618-24
Geeganage CJ, Beaven J, Ellender S, et al. Interventions for dysphagia and nutritional support in acute and subacute stroke.
Cochrane Database Sys Rev. 2012;10:CD0003233.
Gomes F, Emery PW, Weekes CE. Risk of malnutrition is an independent predictor of mortality, length of hospital stay, and
hospitalization costs in stroke patients. Journal of Stroke and Cerebrovascular Diseases. 2016 [epub ahead of print].
Ha LT, Hauge T, Iversen PO. Body composition in older acute stroke patients after treatment with individualized, nutritional
supplementation while in hospital. BMC Geriatr. 2010;10:75.
Ha LT, Hauge T, Spenning AB, et al. Individual, nutritional support prevents undernutrition, increases muscle strength and
improves QoL among elderly at nutritional risk hospitalized for acute stroke: a randomized, controlled trial. Clin Nutr. 2010;29:
567-73.
Henry CJ. Basal metabolic rate studies in humans: measurement and development of new equations. Public Health Nutr.
2005;8:1133-52.
Hubbard G, Finch H, White S, et al. A survey of enterally tube fed patients receiving low energy tube feeding regimens. Proc
Nutr Soc. 2011;70(OCE5):E313.
Intercollegiate Stroke Working Party. National clinical guideline for stroke, 4th edition. London: Royal College of Physicians
(RCP); 2012. Retrieved from: https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines [16.03.2016].
James R, Gines D, Menlove A, et al. Nutrition support (tube feeding) as a rehabilitation intervention. Arch Phys Med Rehabil.
2005;86:S82-S92.
Leone A, Pencharz PB. Resting energy expenditure in stroke patients who are dependent on tube feeding: a pilot study. Clin
Nutr. 2010;29:370-2.
National Institute for Health and Care Excellence (2008) Diagnosis and initial management of acute stroke and transient
ischaemic attack. NICE guideline (CG68).
References
NHS Choices. Stroke – Act F.A.S.T. Accessed via www.nhs.co.uk
Nip WF, Perry L, McLaren, et al. Dietary intake, nutritional status and rehabilitation outcomes of stroke patients in hospital. J
Hum Nutr Diet. 2011;24:460-9.
Rabadi MH, Coar PL, Lukin M, et al. Intensive nutritional supplements can improve outcomes in stroke rehabilitation.
Neurology. 2008;71:1856-61.
Rofes L, Arreola V, Mukherjee R, et al. The effects of a xanthan gum-based thickener on the swallowing function of patients
with dysphagia. Ailment Pharmacol Ther. 2014;39:1169-79.
Rowat A, Graham C, Dennis M. Dehydration in hospital-admitted stroke patients: detection, frequency, and association.
Stroke. 2012;43:857-9.
Saka O, McGuire A, Wolfe C. Cost of stroke in the United Kingdom. Age Ageing. 2009;38:27-32.
Scottish Intercollegiate Guidelines Network. Management of patients with stroke Rehabilitation, prevention and management
of complications, and discharge planning. Edinburgh: SIGN; June 2010. Retrieved from: http://www.sign.ac.uk/pdf/sign118.pdf
[16.03.16]
Seshadri S, Beiser A, Kelly-Hayes M, et al. The lifetime risk of stroke: estimates from the Framingham Study. Stroke.
2006;37:345-50.
Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Cabi Publishing; 2003
Stroke association. State of the Nation: Stroke statistics. London: Stroke Association; January 2016. Retrieved from:
https://www.stroke.org.uk/sites/default/files/stroke_statistics_2015.pdf [16.03.2016].
Thomas B, Bishop J (Eds) Manual of Dietetic Practice. 4th ed. Oxford; Blackwell Publishing, 2007.
Weekes E, Elia M. Resting energy expenditure and body composition following cerebro-vascular accident. Clin
Nutr.1992;11:18-22.
Yoo SH, Kim JS, Kwon SU, et al. Undernutrition as a predictor of poor clinical outcomes in acute ischemic stroke patients.
Arch Neurol. 2008;65:39-43.
Thank you