ESPEN Congress Lisbon 2015

NUTRITIONAL SUPPORT OF STROKE PATIENTS

Nutrition support in acute stroke - when and how

R. Wirth (DE)
Nutritionsupportinacutestroke
when and how
RainerWirth
St.MarienHospitalBorken,Germany
Workinggroup Nutritionand metabolism,GermanGeriatric Society(DGG)
Chair for Geriatric Medicine,UniversityErlangenNrnberg,Germany
Institutefor Biomedicine of Aging,UniversityErlangenNrnberg,Germany
 Disclosure of speakers interest

No conflict of interest

Incidental speakers honoraria from

Nutricia,B.Braun,Freseniuskabi,Nestle,Shire,
CocaCola,BayerHealthCare,Bundesverband
Medizintechnik,AOKBundesverband
Outline Nutritionsupport afterstroke
Relevance
Pathophysiology
How stroke impairs nutrition
Why malnutrition impairs recovery
Diagnosis
Diagnosisof malnutrition
Diagnosisof dysphagia
Therapy
When and how
Outline Nutritionsupport afterstroke
Relevance
Pathophysiology
How stroke impairs nutrition
Why malnutrition impairs recovery
Diagnosis
Diagnosisof malnutrition
Diagnosisof dysphagia
Therapy
When and how
 Stroke epidemiology
Worldwide,15million people suffer astroke each year;onethird dieand
onethird are left permanently disabled.
TheWorldHealth Organization (WHO)predicts that disabilityadjusted life
years (DALYs)lostto stroke (ameasure of the burden of disease)willrise
from 38million in1990to 61million in2020.

The Atlas of heart disease and stroke, WHO 2004.

http://www.who.int/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf
Outline Nutritionsupport afterstroke
Relevance
Pathophysiology
How stroke impairs nutrition
Why malnutrition impairs recovery
Diagnosis
Diagnosisof malnutrition
Diagnosisof dysphagia
Therapy
When and how
 Stroke
Paralysis Neuropsychiological deficits Dysphagia
Somnolence,Anxiety,Depression,
Delirium,Neglect,Apraxia,Anopsia

Malnutrition
Immobility Aspiration
Dehydration

Outcome
Mortality,Mobility,Functionality,
Complications,Length of hospital stay
 Which reported estimate of the prevalence of
malnutrition afterstroke is valid?
Foleyetal.Stroke 2009

18Studies
Varying timeafterstroke
17differentassessment methods
4Studieswith validated tools (SGA,MNA,NRS)
Prevalence 1 73%
Which reported estimate of the prevalence
of malnutrition afterstroke is valid?
Foleyetal.Stroke 2009

10% within the first days

25% after2weeks

45% inrehabilitation period

 Areview of the relationsship between
dysphagia and malnutrition following stroke
Foleyetal.JRehabil Med 2009

Malnutritiononadmission:8 26%
Dysphagia onadmission:24 53%

Dysphagia accounts for 2,5foldrisk of

malnutrition inthe weeks afterstroke
(OR2,45;95%CI1,01 5,93;p<0,048)
Outline Nutritionsupport afterstroke
Relevance
Pathophysiology
How stroke impairs nutrition
Why malnutrition impairs recovery
Diagnosis
Diagnosisof malnutrition
Diagnosisof dysphagia
Therapy
When and how
Prognostic impact of weight change onshortterm
functional outcome inacute ischemic stroke
KimYetal.Int JStroke 2015

Prospective observational study

654 patients with ischemic stroke
Length of stay = 9 days
Modified ranking scale after 3 months
 Sarcopeniaand aging
40
35
30
Muscle mass (kg)

25
1%/a
20 Sarcopenia threshold
15
10
5
0
30 40 50 60 70 80 90
Age(y)
 Sarcopeniaand catabolic crises
40
35
30
Muscle mass (kg)

25
1%/a
20 Sarcopenia threshold
15
10
5
0
30 40 50 60 70 80 90
Age(y)
 Sarcopeniaand catabolic crises
40
young
35
30
Muscle mass (kg)

25
1%/a
20 Sarcopenia threshold

15 old
10
5
0
30 40 50 60 70 80 90
Age(y)
Changeinmuscle mass,fat mass,and bone
mineral content inthe legs afterstroke
JrgensenLetal.Bone 2001
Outline Nutritionsupport afterstroke
Relevance
Pathophysiology
How stroke impairs nutrition
Why malnutrition impairs recovery
Diagnosis
Diagnosisof malnutrition
Diagnosisof dysphagia
Therapy
When and how
Outline Nutritionsupport afterstroke
Relevance
Pathophysiology
How stroke impairs nutrition
Why malnutrition impairs recovery
Diagnosis
Diagnosisof malnutrition
Diagnosisof dysphagia
Therapy
When and how
 Dysphagia afterstroke and mortality

N Mortality (%) Mortality (%) Mortality (%) RR

dysphagia +dyphagia
Gordon1987 91 33 22 46 2.1
Smithard 1996 121 21 6 37 6
Mann1999 128 4 0 8
Broadley 2003 149 17 1.3 32 24.1
489 18 6 30 5.0

Stroke with dysphagia = 5-fold increased mortality!

 (in)voluntary
56muscles
1swallow/minute
750mlsaliva/day
Prevalence of dysphagia afterstroke
MartinoR.etal.Stroke 2005

screening techniques:37% 45%

clinical testing:51% 55%
instrumentaltesting:64%to 78%
 Fiberoptic endoscopic
evaluation of swallowing (FEES)
Video of Prof. Dr. med. Rainer Dziewas, University Mnster, Germany
Fiberoptic Endoscopic Dysphagia Severity Scale
predicts outcome afteracute stroke
Warneckeetal.Cerebrovasc Dis2009
FEDSSProtocol Mainfindings
Saliva Penetration/aspiration
Purree Penetration/aspiration without
or insufficient cough (reflex)
Purree Penetration/aspiration with
sufficient cough (refelx)
Liquid Penetration/aspiration without
or insufficient cough (reflex)
Liquid Penetration/aspiration with
sufficient cough (reflex)
Softsolidfood Penetration/aspiration or
massiveresidues
Softsolidfood No penetration/aspiration
Mildto moderateresidues
Score Clinicalimplication
6 No oralfood,tube feeding,
consider intubation
5 No oralfood,tube feeding
4 Tubefeeding,purree only
during swallowing therapy
4 Tubefeeding,purree only
during swallowing therapy
3 Oral purreed food
and fluids i.v.
2 Oralpurreed food
and oralfluids
1 Oralsoftsolidfood
and oralfluids
Dysphagia Bedside Screeningfor AcuteStroke
Patients TheGugging Swallowing Screen
Trapl Metal.Stroke 2007
Dysphagia Bedside Screeningfor AcuteStroke
Patients TheGugging Swallowing Screen
Trapl Metal.Stroke 2007
Outline Nutritionsupport afterstroke
Relevance
Pathophysiology
How stroke impairs nutrition
Why malnutrition impairs recovery
Diagnosis
Diagnosisof malnutrition
Diagnosisof dysphagia
Therapy
When and how
 Improving poststroke dysphagia outcomes
through astandardized multidisciplinary protocol
Gandolfi Metal.Dysphagia 2014
 Some recommendationsI
Aformalised screening for dysphagia should be performed inall
stroke patients (B).
Allstroke patients should be screened for nutritionalrisk within
the first days afterhospital admission (CCP).
Severe swallowing difficulties that donotallow sufficient oral
food intake and are anticipated to persist for more than one
week require early enteralnutrition viafeeding tube (at least
within 72hours)(C).
If asufficient oralfood intake is notpossible during the acute
phase of stroke,enteralnutrition shall be preferably given viaa
nasogastric tube (A).
If enteralfeeding is likely for alonger period of time(>28days),
aPEGshould be chosen and shall be placed inastable clinical
phase (after14 28days)(A).
 Some recommendationsII
Nasogastric tube feeding does notinterfere with swallowing
training.Therefore,dysphagia therapy shall start as early as
possible alsointubefed patients (A).
Themajority of conscious dysphagic stroke patients with tube
feeding should have additionaloralintake,according to the kind
and severity of dysphagia (B).
Stroke patients,who are able to eat and who have been
identified to be at risk of malnutrition,who are malnourished
or who are at risk for pressure sores should receive oral
nutritionalsupplements (B).
Afterassessment of the swallowing act (e.g.careful evaluation
by the speechlanguage pathologists and/or video fluoroscopic
or endoscopic examination)atexture modified diet and
thickened fluids of asafe texture should be given to patients
(CCP).
 Dysphagia
Aspirationrisk

No Mild Moderate Severe

(FEDSS1; (FEDSS2; (FEDSS3; (FEDSS46;
GUSS20) GUSS1519) GUSS1014) GUSS09)

Preexisting
nutritionalrisk
(NRS,MNA,SGA)

Texture Texture
Oral Oralfood modified modified Tube
food +ONS diet diet +ONS feeding
(safe texture) +fluids i.v.

Intensiveswallowing training
Thank you for your attention!