You are what you eat Nutrition in Stroke

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You are what you eatNutrition in Stroke

• Helen Mann
• Stroke CNS
• April 2009

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Current issues in Nutrition

• How are we doing? The evidence
• NG Feeding
• Maximising food and fluid intake

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Need for Screening and Nutritional Careplanning

• NICE Feb 2006 Nutrition Support for Adults Oral
  Nutrition Support, Enteral Tube Feeding and
  Parenteral Nutrition. Methods, Evidence,
  Guidance
• BAPEN Nutritional Screening Survey, 2007
• 2008 RCP / NICE Guidelines

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Consequences of malnutrition

• ? Muscular weakness
• ? Functional disability less ability to
  participate in rehab
• Impaired immune function
• Impaired wound healing
• ? Morbidity and mortality
• ? LOS
• (Hoffer 1999, Jeejeebhoy Sole 2001, Scrimshaw
  2003, Johansen et al 2004)

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Prevalence of Underdetection

• Kelly et al (2000)
  13 admissions malnourished, 75 not diagnosed
• Corrish et al (2000)
  11 malnourished on admission.
  63 of those assessed on
  discharge had further weight loss

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BAPEN Key Points

• MUST screening tool
• UK wide, 9336 adult pts
• Within 72hrs of admission, admitted 27th -29th
  September.
• 28 malnourished, throughout all types of
  hospitals, wards, diagnostic categories, care
  homes, ages
• 22 high risk 6 medium risk

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BAPEN Key Points

• Malnutrition more common in
• Over 65 yrs
• GI conditions
• Neurological conditions
• 89 hospitals have screening policy
• Less than half pts were weighed
• RCP Stroke Audit 2006 57 weighed

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MUST 5 step Screening Tool

• Weight, height and BMI
• unplanned weight loss
• Acute disease effect
• Score malnutrition risk
• Develop careplan
• Inclusive tables, scoring charts

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RCP 2008 Guidelines re
nutritional screening tool

• Assess body mass index (BMI)
• Measure unintentional weight loss
• Consider time over which nutrient intake has been
  unintentionally reduced
• Consider likelihood of future impaired intake.

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RCP Audit Key indicators
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2008 Stroke Guidelines for those unable to
swallow (enough)

• NG feeding within 24 hours of admission
• Considered nasal bridle tube or gastrostomy if
  unable to tolerate NG
• Detailed nutritional assessment
• Individualised advice
• Weekly monitoring and nutrition support as
  indicated

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Issues re NG Feeding

• Checking correct position
• Repeated removal ? inadequate nutrition

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Restraint
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Nasal Bridle

• Use of a Nasal Bridle reduces incidence of
  accidental NG removal (Gunn, Early, Zenati, et al
  JPEN 2009)
• Introduced bridle after 3 incidents of tube being
  pulled out
• 36 removal in (ICU) group using tape, 10
  removal in group using bridle
• Needs similar consent to NG insertion

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SGH nasal bridle policy (Adults) contraindications

• Extremely confused patients who may continue to
  pull at the NG tube and cause trauma to the nasal
  septum.
• Patients with basal skull fractures
• Patients with a deviated or perforated nasal
  septum
• Patients with any structural deformity of the
  nose or nasopharynx

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Issues re NG Feeding

• Contraindications
• Complications

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Contraindications for NG

• Laryngectomy, max-fax problems
• Oropharyngeal tumours, upper gastro-intestinal
  disorders
• Some GI disorders
• Sometimes Post GI surgery

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Reducing aspiration
and chest infection risk

• Pts with ? level of consciousness
• Pts with ? swallow reflex
• Persistently high Residual Volumes
• (North American Summit on Aspiration Consensus
  Statement, McClave et al 2002)

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NG Feeding Position

• 30-45

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Reducing aspiration
and chest infection risk

• Small bore Tubes
• Continuous Feeding
• 30 minimum elevation of bedhead
• Prokinetics - metoclopramide, erythromycin
• Mouthcare ? pathogenic colonisation
• MDT Input

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Increasing oral intake

• NG tubes dont reduce swallowing function (Wang
  et al 2006, Dziewas et al 2008)
• Time constrictions at mealtimes
• Impact of ageing on nutrition
• Volunteer Mealtime Assistants
• How many calories?

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Impact of ageing on nutrition

• Smaller appetite
• Altered GI function - ?digestion, absorption
• ?salivation
• ?oesophageal motility
• Taste changes
• Impaired dentition, chewing
• Side effects of medications

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Volunteer Mealtime Assistants

• Volunteers commit to
• 3 hour teaching period
• 3 x 1½ hour competency training sessions
• A minimum x 1 weekly attendance for 3 months

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Volunteer Mealtime Assistants

• Competencies are supervised and assessed by a
  trained nurse
• Written protocol clarifies volunteers
  responsibilities
• Positive evaluation from nurses
• Increased awareness of correct mealtime
  positioning

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How many calories do patients need ?

• Harris Benedict Equation, Schofield Equation -
  increased energy demands with different stressors
  
• Stroke size, location and severity have no effect
  on resting energy expenditure. (Finestone HM. et
  al 2003)
• Persistent fever increases metabolic rate by
  10-25
• 1300-2000 kcal

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Hospital puree meal 300-350 kcals
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High energy/protein supplements

• 200cal per (125g) pot
• 12g protein per pot
• 300cal per 200ml
• 12g protein per bottle

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Comparative Food Values

• Toast and Jam
• 250kcal
• Yoghurt 80/100kcal
• Milk (glass) 100 kcal
• Soup 110 kcal

• Cheese sandwich 400kcal
• Forticreme pudding 200kcal
• Build-Up Shake - 270kcal
• Build-Up Soup - 215kcal

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Refeeding syndrome

• Occurs within 4 days of starting to feed
  malnourished pts
• Sudden shift from fat to carbohydrate metabolism
• Sudden increase in insulin levels
• High carbohydrate loads ? phosphate, magnesium
  and potassium
• Pts develop fluid electrolyte disorders
• Shift of electrolytes fluid balance ? cardiac
  workload heart rate acute heart failure.

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Refeeding syndrome

• Potentially fatal if not recognized and treated
  properly.
• Correct low potassium, phosphate or magnesium
• Prescribe thiamine, vitamin B complex (strong)
  and a multivitamin and mineral
• Monitor biochemistry regularly until stable.

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References and websites

• Dennis, M. Lewis, S. Warlow, C. Effect of timing
  and method of enteral tube feeding for dysphagic
  stroke patients (FOOD) a multicentre randomised
  controlled trial. Lancet. 2005. 26 Feb.
  365(9461). p764-72.
• Donaldson, E., Early, T., Sheilds, P (2007) The
  Nasal Bridle Its place within an integrated
  nutrition service a prospective audit of one
  years data. Gut (56) Suppl 56 A137
• Metheny NA (2004) Preventing Aspiration in older
  adults with Dysphagia. Try This Best Practices
  in Nursing Care to Older Adults, vol./is.
  /20(0-1),

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References and websites

• http//www.bapen.org.uk
• http//www.nice.org.uk
• Finestone HM. Greene-Finestone LS. Foley NC.
  Woodbury MG. Measuring longitudinally the
  metabolic demands of stroke patients resting
  energy expenditure is not elevated. Stroke.
  34(2)502-7, 2003 Feb.
• Holmes S (2008) Nutrition and eating difficulties
  in hospitalised older adults. Nursing Standard.
• 22, 26, 47-57.