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The premier source of information for the management of patients with Dysphagia

Dysphagia and Malnutrition in Stroke Patients

What is stroke?

A stroke or cerebrovascular accident (CVA) is defined as 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 (RCP, 2012).

There are two main causes of strokes:

  • Ischaemic: the blood supply/ flow is stopped due to a blood clot. The mechanism of ischaemic stroke is similar to that of a myocardial infarction (heart attack). Ischaemic stroke accounts for 85% of all cases.
  • Haemorrhagic: a weakened blood vessel supplying the brain bursts and causes brain damage. It includes primary intracerebral and subarachnoid haemorrhages and accounts for 15% of all cases (RCP, 2012).

Types of stroke

Prevalence of stroke

There are approximately 152,000 cases of stroke in the UK per year, more than one every 5 minutes. It is estimated that there are approximately 1.1 million stroke survivors living in the UK. Stroke incidence is approximately 25% higher in men than women. However, although stroke incidence is higher for men, there are more strokes in women since women generally live longer than men (Stroke Association Statistics, 2013)

Stroke remains the fourth most common cause of death in the UK, after cancer, heart and respiratory disease, accounting for more than 55,000 deaths in 2010 (Townsend et al, 2012), with implications on healthcare resources (RCP Audit, 2010). One in five strokes is fatal. Stroke causes about 7% of deaths in men and 10% in women.

In Ireland, there are approximately 10,000 strokes each year. Of these, five out of six strokes happen in people over the age of 60. Each year, approximately 2,000 Irish people die from stoke which accounts for more deaths than breast cancer, prostate cancer and bowel cancer combined. An estimated 30,000 people are living in the community with disabilities as a result of a stroke. This makes stroke the third biggest cause of death in Ireland and the biggest cause of acquired disability (Irish Heart Foundation, 2014).

Malnutrition is prevalent in stroke patients

The overall prevalence of malnutrition in stroke patients ranges from 6.1% to 62% (Foley et al. 2009a). A recent study carried out in UK hyper acute stroke units found that the prevalence of patients at high risk of malnutrition is 29% (Gomes et al. 2014). This value agrees with the proportion of stroke patients at risk of malnutrition previously reported by Stratton and colleagues of 30% for those in the acute and community setting (Stratton et al. 2003).

Dysphagia and dehydration

There are a number of clinical consequences of stroke, one of which is dysphagia (difficulty swallowing). Dysphagia is common following stroke and it is present in 40-50% of patients who survive the first few days (Stroke Association, 2012; Bogaardt et al. 2009). Dysphagia after stroke may involve difficulties with both the oral and pharyngeal phases of swallowing and increases the risk of respiratory complications and aspiration pneumonia (Sura et al. 2012) and mortality (Singh & Hamdy 2006).

It can add an average of 1.6 days to a typical hospital stay (Cichero & Altman, 2012) and prolong length of stay 13 days due to associated complications such as infections e.g. pneumonia, urinary tract infections (Ingeman et al.2011).

Dysphagia is also a strong predictor of malnutrition risk (Sura et al. 2012) and dysphagic stroke patients are 2.4 times more likely to be malnourished compared with those who have normal swallowing (p <0.008) (Foley et al. 2009b). The serious consequences of malnutrition and dysphagia in stroke mean that it is extremely important to identify those patients who are at risk.

Dysphagia has also been associated with dehydration; it is estimated that 62% of stroke patients suffer from dehydration at some point during their admission (Rowat et al. 2012). Patients often limit their drinking, probably due to concerns about choking and may need enteral or intravenous fluids to meet their requirements (Vivanti et al. 2009). Dehydration is a predictor of poor outcomes including discharge to long term-care (Lakshminarayan et al. 2010; Finlayson et al. 2011, Crary et al. 2013).

Dysphagia and Dehydration

Identifying Malnutrition and Dysphagia in Stroke

The NICE Clinical Guideline for Stroke (NICE CG68, 2008) and the Royal College of Physicians (RCP) National Clinical Guideline for Stroke (RCP, 2012) support the identification and management of malnutrition and dehydration in stroke patients. They recommend that:

  • All patients should be screened for malnutrition at the time of admission and weekly thereafter
  • Stroke patients should also have their hydration assessed on admission, reviewed regularly and managed so that normal hydration is maintained
  • People with dysphagia should be given food, fluids and medications modified in a form that can be swallowed without aspiration
  • People unable to take adequate nutrition and fluids orally should receive tube feeding with a nasogastric tube within 24 hours of admission and be referred for detailed nutritional assessment, individualised advice and monitoring
  • Nutrition support should be initiated for people with stroke who are at risk of malnutrition. This may include oral nutritional supplements (ONS), specialist dietary advice and/or enteral tube feeding (ETF).

Early assessment of nutritional risk, with appropriate nutritional management, may improve survival of stroke patients (Yoo et al. 2008). Delays in assessment, treatment and rehabilitation of stroke patients will increase the risk of secondary complications, hinder recovery, increased likelihood of malnutrition and dehydration, and lead to long-term disability or even death.

The Evidence for Nutrition Intervention

Diet Modification

Texture modification of food and fluids is widely used for the management of dysphagia (Stoke Association, 2012). Guidelines have been produced based on best available current evidence and a consensus of expert opinion, which support the use of thickeners to thicken fluid and foods (Dysphagia Diet Food Texture Descriptors, 2012; Irish Consistency Descriptors for Modified Fluids and Fluids Consensus Document 2009).

There is evidence to suggest that increasing the bolus viscosity improves swallowing function in neurological patients (including stroke survivors) which can lead to a significant reduction in aspiration (Clavé et al. 2006). Food and fluids need to be modified with a thickener to a consistency which provides patients with best control over the rate at which foods and fluids pass through the pharynx (Thomas and Bishop, 2007). If consistency recommendations are not followed, patients may consume food/fluids which they do not have sufficient control over and thus put them at risk of aspiration (Garcia et al. 2010).

Modified texture diets are often nutritionally deficient due to the need to add liquid to reduce the consistency of the meal for certain consistencies (Wright et al. 2005; Foley et al. 2006; Keller et al. 2012). If these diets, which are deficient in energy and protein, are administered for prolonged periods without appropriate nutrition support, they in themselves can lead to dehydration and malnutrition.

Nutrition Support

A randomised control trial by Ha et al. examined whether individualized nutrition support (including ONS in the acute stage of stroke) could prevent or minimize weight loss at 3 months in patients at risk of malnutrition. The nutritional intervention provided was energy- and protein fortified meals, or ONS (0.8-1.5 kcal/ml, 0.04-0.1 g/ml protein), or enteral tube feeding (1-4 kcal/ml) based on nutritional needs. The study showed that weight loss (≥5%) was significantly lower in patients receiving ONS during the first week in hospital (p = 0.013). Moreover, there is a trend towards decreased weight loss at 3 months with ONS however this was not statistically significant (Ha et al. 2010a). Energy and protein supplementation (via fortified diet, ONS or ETF) was also linked with a significant improvement in handgrip strength (Ha et al. 2010b).

Nutritional Management of Stroke Patients

When managing people with stroke, ONS, ETF, texture modified diets and thickened fluids should be considered as per NICE CG32 and RCP guidelines (NICE, 2006; RCP, 2012).

Nutritional management of stroke patients

There are a variety of products which may be suitable for patients following a stroke. These include enteral tube feeds for patients who are unable to meet their nutritional requirements through oral diet alone or have an unsafe swallow; powdered thickeners for patients who require texture modified food or fluids and/or pre thickened oral nutritional supplements for those that are at nutritional risk and oral nutritional supplements patients who can tolerate normal consistency fluids but require nutritional support.

The management of stroke patients by a multidisciplinary team, which includes a Speech and Language therapist and Dietitian, is key to successful outcomes for the stroke patient with dysphagia.


REFERENCES:

Bogaardt HCA et al. The use of biofeedback in the treatment of chronic dysphagia in stroke patients. Folia Phoniatr Logop, 2009; 61: 200-205.

Cichero JA, Altman KW. Definition, prevalence and burden of oropharyngeal dysphagia: a serious problem among older adults worldwide and the impact on prognosis and hospital resources. Nestle Nutr Inst Workshop Ser, 2012; 72; 1-11.

Clavé P et al. The effect of bolus viscosity on swallowing function in neurogenic dysphagia. , 2006; 24(9): 1385-1394.

Crary MA et al. (2013) Dysphagia, nutrition, and hydration in ischemic stroke patients at admission and discharge from acute care. Dysphagia, 2013; 28: 69-76.

Dysphagia Diet Food Texture Descriptors, 2012. http://www.bda.uk.com/publications/statements/NationalDescriptorsTextureModificationAdults.pdf

Finlayson O et al. Risk factors, inpatient care, and outcomes of pneumonia after ischemic stroke. Neurology, 2011; 77(14): 1338–1345.

Foley N et al. Energy and protein intakes of acute stroke patients. J Nutr Heath Aging, 2006; 10: 171-175.

Foley NC et al. Which reported estimate of the prevalence of malnutrition after stroke is valid? Stroke, 2009a; 40: e66-74.

Foley NC et al. A review of the relationship between dysphagia and malnutrition following stroke. J Rehabil Med, 2009b; 41: 707-713.

Garcia MJ et al. Quality of care Issues for dysphagia: modifications involving oral fluids. J Clin Nurs, 2010; 19: 1618-1624.

Gomes F et al. Risk Of Malnutrition On Admission Predicts Mortality, Length Of Hospital Stay And Hospitalisation Costs At 6 Months Post Stroke. Stroke, 2014; 45: A63.

Ha LT et al. Body composition in older acute stroke patients after treatment with individualized, nutritional supplementation while in hospital. BMC Geriatr, 2010a; 10: 75.

Ha LT 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, 2010b; 29(5): 567-573.

Ingeman A et al. In-hospital medical complications, length of stay, and mortality among stroke unit patients. Stroke, 2011; 42: 3214-3218.

Intercollegiate Stroke Working Party. National clinical guideline for stroke, 4th edition. London: Royal College of Physicians (RCP), 2012.

Irish consistency Descriptors for Modified Fluids and Fluids Consensus Document ,2009. http://www.iaslt.ie/docs/public/information/Irish%20consistency%20descriptors%20for%20modified%20fluids%20and%20food.pdf

Irish Heart Foundation, 2014. http://www.irishheart.ie/iopen24/facts-heart-disease-stroke-t-7_18.html

Keller H et al. Issues associated with the use of modified texture foods. J Nutr Health Aging, 2012; 16(3): 195–200.

Lakshminarayan K et al. Utility of dysphagia screening results in predicting post stroke pneumonia. Stroke, 2010; 41(12): 2849–2854.

NICE Diagnosis and initial management of acute stroke and transient ischaemic attack (Clinical Guideline 68), 2008.

NICE Nutrition Support in Adults: Oral Nutritional Support, enteral tube feeding, and parenteral nutrition (Clinical Guideline 32), 2006.

Royal College of Physicians National Sentinel Stroke Clinical Audit 2010. Round 7 Public report for England, Wales and Northern Ireland. Prepared on behalf of the Intercollegiate Stroke Working Party. P43, 2011.

Rowat et al. Dehydration in hospital-admitted stroke patients: detection, frequency, and association. Stroke, 2012; 43(3): 857-859.

Singh S, Hamdy S. Dysphagia in stroke patients. Postgrad Med J, 2006; 82(968): 383–391.

Stratton RJ et al. Disease-related malnutrition: an evidence-based approach to treatment. Cabi Publishing; 2003.

Sura L et al. Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging, 2012; 7: 287-298.

Stroke Association. Swallowing problems after stroke, 2012. http://www.stroke.org.uk/sites/default/files/Swallowing%20problems%20after%20stroke.pdf

Stroke Association. Statistics, 2013. www.stroke.org.uk/sites/default/files/Stroke%20statistics.pdf

Thomas B, Bishop J (Eds) Manual of Dietetic Practice. 4th ed. Oxford; Blackwell Publishing, 2007.

Townsend N et al. Coronary heart disease statistics, 2012 edition. British Heart Foundation: London. P20, 2012.

Vivanti AP et al. Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalised patients with dysphagia. J Hum Nutr Diet, 2009; 22(2):148-155.

Wright L et al. Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. J Hum Nutr Diet, 2005; 18: 213-219.

Yoo SH et al. Undernutrition as a predictor of poor clinical outcomes in acute ischemic stroke patients. Arch Neurol, 2008; 65: 39-43.

 


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