Malnutrition in Stroke Patients

Sharanya Kumar

Objectives
Why is it important? NICE Guidelines Advice Risk Factors for Malnutrition Assessing Malnutrition

Malnutrition Universal Screening Tool Indicators of Malnutrition

Management

Objectives
Why is it important? NICE Guidelines Advice Risk Factors for Malnutrition Assessing Malnutrition

Malnutrition Universal Screening Tool Indicators of Malnutrition

Management

Malnutrition
Condition that results from a diet that does not provide enough nutrients, such as calories, protein and vitamins
Associated

with worse outcomes in stroke

patients:
Complications during hospital admission
Higher rates: Pressure Sores, UTIs, Respiratory Infections

Poor functional outcome Increased length of stay Mortality

Important

PREVENTABLE complication of stroke

Increased

metabolic demands during recovery

Objectives
Why is it important? NICE Guidelines Advice Risk Factors for Malnutrition Assessing Malnutrition

Malnutrition Universal Screening Tool Indicators of Malnutrition

Management

NICE Guidelines

Malnutrition should be screened for on admission Should continue to screen once weekly during admission

Use the Malnutrition Universal Screening Tool

Objectives
Why is it important? NICE Guidelines Advice Risk Factors for Malnutrition Assessing Malnutrition

Malnutrition Universal Screening Tool Indicators of Malnutrition

Management

Risk Factors
Dysphagia is the major risk factor Also: Reduced Level of Consciousness Poor Oral Hygiene Depression Reduced Mobility Arm / Facial Weakness Interestingly, the characteristics of the stroke (location, type, affected dominant arm) are not associated with malnutrition.

Risk Factors
Others include: Presence of chronic diseases Polypharmacy, Eating difficulties Functional disability Diabetes mellitus History of stroke

Objectives
Why is it important? NICE Guidelines Advice Risk Factors for Malnutrition Assessing Malnutrition

Malnutrition Universal Screening Tool Indicators of Malnutrition

Management

MUST
Malnutrition Universal Screening Tool 5 Step Screening Tool Identifies patients who are:

Malnourished At risk of under nutrition Obese

Provides a management plan

Objectives
Why is it important? NICE Guidelines Advice Risk Factors for Malnutrition Assessing Malnutrition

Malnutrition Universal Screening Tool Indicators of Malnutrition

Management

Assessing Malnutrition
1.

Detailed History
Food Intake Recent weight history

2.

Indicators of Malnutrition
Serum Albumin Serum Prealbumin Serum Transferrin Total Lymphocyte Count BMI Triceps skin fold thickness Mid upper arm circumference

Difficulties

Bodys physiological response to the damage caused by stroke is inflammation

Inflammation affects albumin, transferrin and lymphocyte count

BMI
Proportion of fat to lean tissue varies between ethnicities Can be misleading if fluid retention present in severe malnutrition due to hypoalbuminaemia

Triceps skin fold thickness & Midarm Muscle circumference

Low sensitivity Subjective

Objectives
Why is it important? NICE Guidelines Advice Risk Factors for Malnutrition Assessing Malnutrition

Malnutrition Universal Screening Tool Indicators of Malnutrition

Management

Management
1.

Dietary Intake Chart

To record and monitor daily intake

2.

Weight
Should be measured weekly Important as, obesity can affect patients calorific requirements

3.

Identify:
Level of Consciousness Presence of Depression? Visual Disturbances Arm Strength

All can affect ability to maintain adequate oral intake, and must be managed appropriately.

Nutritional Support
In patients requiring support with nutrition, two routes are available:
1. 2.

Enteral Feeding Parenteral Feeding

Enteral Nutrition
The process of feeding with the use of a tube.

It requires a normal functioning GI tract.

SHORT TERM Nasogastric Tube Nasoduodenal Tube Nasojejunal Tube LONG TERM Gastrostomy Jejunostomy

From: Bouziana SD, Tziomalos K. Malnutrition in Patients with Acute Stroke. [Review Article]. J Nutr Metab 2011; 2011: 167898. Published online: 2011 Dec 07

Gastrostomy
An artificial opening is created in the abdominal wall so that a tube can be placed directly into the stomach. This is useful if: Gut is inaccessible due to oesophageal carcinoma Long term feeding is required. There are 3 approaches that can be used to site a gastrostomy:
1. 2. 3.

Endoscopy [PEG] Interventional Radiology [RIG] Surgical

PEG Feeding

PEG Feeding
Percutaneous Endoscopic Gastrostomy

Does not require GA (only mild sedation)

Can be extended to small intestine using a jejunal extension tube through the PEG and pylorus (PEG J Tube)
Indicated when:
normal feeding / nasogastric tube is impossible A longer term solution is required

PEG Feeding
Sited using: Push (Ponsky) Method Pull (Sachs Vine) Method Introducer (Russell) Method

PEG Risks
Can be classified as:
Immediate Early Late

N.B. Inappropriate patient selection is closely related to risk of serious complications

Immediate
Complications resulting from procedure itself.

Respiratory
Aspiration Drug induced respiratory depression
From Sedation

Airway Obstruction
If underlying tumour

Bleeding
Minor oesophageal bleeding Due to perforation of abdominal structure

Peritonitis

Early
Complications occurring within 4 weeks of procedure

Infection

Early Displacement
Aspiration Pneumonia
Patients can still aspirate oral secretions Feeds can reflux from stomach (gastrooesophago-tracheal aspiration)

Late
Complications occurring more than 4 weeks following procedure, once fistula has matured.

Skin irritation
Chemical burns from leakage.

Hypergranulation (around stoma)

Can bleed

Tube dysfunction
Blocked / split Buried Bumper

Colo cutaneous fistula

RIG Feeding
Radiologically Inserted Gastrostomy

Parenteral Nutrition
The process of feeding intravenously, thereby bypassing the GI Tract

Required in patients with non functional GI tracts, either due to blockage / leakage.

Either:
Peripheral Parenteral Nutrition (PPN) Total Parenteral Nutrition (TPN)

Risks
Infection Thrombosis Electrolyte Disturbances

N. B. Refeeding syndrome

Hepatic dysfunction
Fatty Liver Liver Failure

Gallstones Hyperglycaemia

Food Supplements
There are many products on the market to help patients unable to meet their energy requirements.

There are 3 main types:

1.

Elemental

2.
3.

Semi Elemental
Polymeric

Elemental
These formulas are made up of the individual building blocks of different food groups:

Individual amino acids Glucose polymers

Therefore they are low in fat.

Semi Elemental
These formulas contain bigger molecules: Peptides of varying chain lengths Simple sugars Starch Medium chain triglycerides

Polymeric
These formula contain: Whole intact proteins Complex carbohydrates Long chain triglycerides

Food Supplements
These products can be used in patients still able to swallow OR As an energy enhancer in tube and sip feeds. They can: Provide adequate electrolytes Act as an energy enhancer Act as thickeners to aid swallowing difficulties

Summary
When deciding which method of artificial nutrition to use, you must ask the following questions:
1. 2.

Do they have a functional gut? Is their gut accessible?

E.g. Oesophageal / Head & Neck Malignancies?

3.

How long is feeding required?

4.

Patient Factors:
(Prognosis, Risks vs Benefits)

NICE Guidelines
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

FOOD Trials
Three multicentre RCTs looking at nutritional support in stroke patients. Non dysphagic stroke patients were enrolled into:
1.

Hospital Diet vs Hospital Diet plus Oral Nutritional Supplementation Trial

Dysphagic Acute Stroke patients were enrolled into:

1. 2.

Early vs Avoid Trial

PEG vs Nasogastric Trial

Primary Outcome was: Death or Poor outcome at 6 months

1. Hospital Diet vs. Diet with Oral Nutritional Supplementation

Q. Do routine oral nutritional supplements improve outcomes after stroke?
Results:

No significant effect was found

No significant difference in survival No significant differences in complications (pneumonia / UTI etc) No difference in Quality of Life between groups

2. Early vs Avoid
Q. Does starting enteral feeding early improve outcomes? Patients enrolled within 7 days of admission and randomly allocated to:

Early enteral tube feeding

OR

No tube feeding for at least 7 days

Results

Survival did not differ significantly between the treatment groups Non significant reduction in absolute risk of death favouring early allocation Higher rate of GI Haemorrhage in Early group No significant difference in frequency of:
Recurrent stroke Worsening neurological symptoms Complications such as: Pneumonia / UTI / Venous Thrombo embolic events

3. PEG vs NGT
Q. Does PEG feeding provide better outcomes than NGT?
Patients were randomly allocated to enteral feeding via PEG or NGT within 3 days of enrolment.

Results

PEG Group:
Non significant increase in absolute risk of death of 1.0% Borderline significant increase in absolute risk of death / poor outcome of 7.8%

NGT Group:
Higher rate of GI haemorrhage

No significant difference in frequency of:

Recurrent stroke Worsening neurological symptoms Complications such as: Pneumonia / UTI / Venous Thrombo embolic events

References
1. 2. 3. 4.

5.

6.

7.

NICE. Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack (TIA). Clinical Guidelines, CG68. Issued: July 2008 Bouziana SD, Tziomalos K. Malnutrition in patients with acute stroke. J Nutr Metab. Dec 2011; 2011: 167898 [Epub] Hankey GJ. Nutrition and the risk of stroke [review]. Lancet Neurol. Jan 2012; 11 (1): 66 81 Bouziana SD, Tziomalos K. Malnutrition in Patients with Acute Stroke. [Review Article]. J Nutr Metab 2011; 2011: 167898. Published online: 2011 Dec 07 OToole P. Complications associated with the placement of percutaneous endoscopy gastrostomy. BSG Endoscopy Guidelines 2006. Dennis MS, Lewis SC, Warlow C. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet 2005; 365 (9461): 764-72 Dennis MS, Lewis SC, Warlow C. Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial. Lancet 2005; 365 (9461): 755 - 63