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