Laura Smith – Specialist Dietitian (stroke)
Fiona Brennan – Nutrition Nurse
Dehydration & malnutrition are common.
Associated with poor outcomes.
Malnutrition associated with increased mortality, complications, poorer functional and clinical outcomes.
Up to ¼ become more malnourished in the first weeks following stroke.
The risk of malnutrition increases with increasing hospital stay.
Poor nutritional intake, weight loss, and feeding and swallowing problems can persist for many months.
Multiple physical, social and psychological factors. swallowing problems reduced ability to self-feed cognitive impairment anxiety or depression unfamiliar foods fatigue delays in initiating feeding frequent dislodgement of NG tubes
Stroke and transient ischaemic attack in over 16s: diagnosis and initial management Clinical guideline [CG68]
Stroke rehabilitation in adults Clinical guideline [CG162]
Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition Clinical guideline [CG32]
RCP National clinical guideline for stroke fifth edition 2016
Hydration and Nutrition - Recommendations A. Patients with acute stroke should have their hydration assessed using
multiple methods within four hours of arrival at hospital, and should be reviewed regularly and managed so that normal hydration is maintained.
B. Patients with acute stroke should be screened for the risk of malnutrition on admission and at least weekly thereafter. Screening should be conducted by trained staff using a structured tool.
C. Patients with acute stroke who are adequately nourished on admission and are able to meet their nutritional needs orally should not routinely receive oral nutritional supplements.
D. Patients with acute stroke who are at risk of malnutrition or who require tube feeding or dietary modification should be referred to a dietitian for specialist nutritional assessment, advice and monitoring.
E. Patients with stroke who are at risk of malnutrition should be offered nutritional support. This may include oral nutritional supplements, specialist dietary advice and/or tube feeding in accordance with their expressed wishes or, if the patient lacks mental capacity, in their best interests.
F. Patients with stroke who are unable to maintain adequate nutrition and fluids orally should be:
◦ referred to a dietitian for specialist nutritional assessment, advice and monitoring;
◦ be considered for nasogastric tube feeding within 24 hours of admission;
◦ assessed for a nasal bridle if the nasogastric tube needs frequent replacement, using locally agreed protocols
◦ assessed for gastrostomy if they are unable to tolerate a nasogastric tube with nasal bridle.
G. People with stroke who require food or fluid of a modified consistency should:
◦ be referred to a dietitian for specialist nutritional assessment, advice and monitoring
◦ have the texture of modified food or fluids prescribed using nationally agreed descriptors.
H. People with stroke should be considered for gastrostomy feeding if they:
◦ need but are unable to tolerate nasogastric tube feeding;
◦ are unable to swallow adequate food and fluids orally by four weeks from the onset of stroke;
◦ are at high long-term risk of malnutrition.
I. People with difficulties self-feeding after stroke should be assessed and provided with the appropriate equipment and assistance (including physical help and verbal encouragement) to promote independent and safe feeding.
J. People with stroke discharged from specialist care services with continuing problems meeting their nutritional needs should have their dietary intake and nutritional status monitored regularly.
K. People with stroke receiving end-of-life (palliative) care should not have burdensome restrictions imposed on oral food and/or fluid intake if those restrictions would exacerbate suffering.
Oral Nutritional Supplementation
All hospital inpatients on admission should be screened for malnutrition and the risk of malnutrition. Screening should be repeated weekly for inpatients.
Screening should assess body mass index (BMI) and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this.
When screening for malnutrition and the risk of malnutrition, healthcare professionals should be aware that dysphagia, poor oral health and reduced ability to self-feed will affect nutrition in people with stroke.
Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training.
Routine nutritional supplementation is not recommended for people with acute stroke who are adequately nourished on admission.
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.
All people with acute stroke should have their hydration assessed on admission, reviewed regularly and managed so that normal hydration is maintained.
Avoidance of aspiration pneumonia
Aspiration pneumonia is a complication of stroke that is associated with increased mortality and poor outcomes.
In people with dysphagia, food and fluids should be given in a form that can be swallowed without aspiration, following specialist assessment of swallowing.
Dysphagia (swallowing difficulty associated with foods, fluids and saliva) is common after acute stroke with an incidence between 40 and 78%.
Higher risk of longer hospital stay, chest infection, disability and death.
Delays in the screening and assessment are associated with an increased risk of stroke-associated pneumonia.
The majority of people with dysphagia after stroke will recover.
A proportion will have persistent abnormal swallow and continued aspiration at 6 months
A small proportion will have chronic and severe swallowing difficulty.
People with persistent swallowing problems may avoid eating in social settings and thus lose the physical and social pleasures connected with food and drink.
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
People unable to swallow safely or take sufficient energy and nutrients orally should have an initial 2–4 week trial of nasogastric enteral tube feeding
Aphasia affects ~ 1/3 of people with stroke
Dysarthria is common in the early stages of stroke, and is often associated with dysphagia
A few people with stroke have apraxia
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.
If the admission screen indicates problems with swallowing, the person should have a specialist assessment of swallowing, preferably within 24 hours of admission and not more than 72 hours afterwards.
Relevant skills and training in the diagnosis, assessment and management of swallowing disorders/ dysphagia
Feedback re prognosis with swallowing
Speech therapists diagnose communication problem and explain the nature and implications to the person, their family/carers and the multidisciplinary team
Assistive technology and communication aids, interpreter services
Assess nutritional intake
Provide input to optimise nutritional intakes
Liaise with patient, family and MDT regarding tube feeding decisions
Provide appropriate feeding regimes
Discharge support for home enteral feeding
Provide medical update
Review medications
Assess capacity
Decisions regarding tube placement
Prognosis and end of life decisions
Mouth care, especially important if NBM also important to help reduce any risk of peristomal wound infection in PEG
Supporting patients who cannot self feed, red tray
MUST screening & Weights
Positioning, tolerance, and tube care
Preparing patients for PEG procedure
Food charts
Helping with meals – preparing to eat as well as assisting to eat
Support with texture modification
Able to give overview of how well patient eating and drinking
Regular weights
Counselling
Support around making difficult decisions
Assessing mood
Capacity
Kitchen assessments
Work on relevant skills around feeding
Adaptive cutlery other equipment
Feedback regarding home environment
Support decisions around discharge destination
Mobility/activity level will determine nutritional requirements
Feeding regimes need to fit in with rehab goals
Social worker – placement/ discharge planning
Pharmacist – advice on taking medications safely; including through tube
Diabetes specialist nurse – blood glucose control
Trust wide role
Assessment of PEG referrals from all clinical setting
Timely referrals – Suitability – Patient Choice
Looking at suitability & stability for procedure
Holistic approach to patient assessment
◦ PMH
◦ Previous surgery
◦ Co-morbidities
◦ Blood results
◦ Current medications
◦ Previous scans
◦ Psychological issues
◦ Any discussions regarding long-term feeding options
◦ Support of Nutritional Support MDT
Liaison between endoscopy and ward
Allocation of procedure date
Patient Preparation list ◦ Consent
◦ Cessation of medications
◦ Prophylactic antibiotics
◦ Bloods
◦ Fasting period
◦ Documentation
Patient follow up at 24 hours post procedure
Source of knowledge & advice for patients / family
Source of specialist knowledge & training for staff
Tube trouble shooting / Stoma care
Liason between patient / ward / endoscopy / Nutrition MDT
Development of related policies ◦ Continuity / Timely / Evidence based /
◦ Set standards / High Quality Care
Quality of life
Patient wishes regarding nutrition
Tube placement can be for feeding – for nutrition, hydration or medication
Continued risk of aspiration despite PEG
Psychological effect of long term NBM status and enteral feeding
Nasal insertion into stomach Advantages Bedside procedure Less invasive than PEG Easy to remove Disadvantages Short term feeding up to 4 weeks placement Requires regular risk assessment due to risk
risk of feeding into the lungs Less well tolerated
Pull through - the mouth into stomach out through abdominal wall
Advantages Longer term option Better tolerated Less Visible Disadvantages High risk endoscopic procedure Stoma heals quickly if displaced Stoma infection – common complication
Complex patients
Failed placements
Early decisions
Misconceptions/ expectations around tube feeding
http://pinnt.com/Therapies/Enteral-Nutrition.aspx
An introduction to PEG feeding
http://www.peng.org.uk/publications-resources/resources-for-patients-hcps.php
Enteral tube feeding your questions answered
Having an enteral feeding tube, further questions to ask
https://www.stroke.org.uk/resources/complete-guide-swallowing-problems-after-stroke
Complete guide to swallowing problems after stroke