ESPEN Congress Lisbon 2015 NUTRITIONAL SUPPORT OF STROKE ... Congress Lisbon 2015 Nutrition support in acute stroke - when and how R. Wirth (DE) NUTRITIONAL SUPPORT OF STROKE PATIENTS

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  • ESPEN Congress Lisbon 2015

    Nutrition support in acute stroke - when and howR. Wirth (DE)

    NUTRITIONAL SUPPORT OF STROKE PATIENTS

  • Nutritionsupportinacutestroke when and how

    RainerWirthSt.MarienHospitalBorken,GermanyWorkinggroup Nutritionand metabolism,GermanGeriatric Society(DGG)Chair for Geriatric Medicine,UniversityErlangenNrnberg,GermanyInstitutefor Biomedicine of Aging,UniversityErlangenNrnberg,Germany

  • Disclosure of speakers interest

    No conflict of interest

    Incidental speakers honoraria fromNutricia,B.Braun,Freseniuskabi,Nestle,Shire,CocaCola,BayerHealthCare,BundesverbandMedizintechnik,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)willrisefrom 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

    OutcomeMortality,Mobility,Functionality,

    Complications,Length of hospital stay

    Neuropsychiological deficitsSomnolence,Anxiety,Depression,Delirium,Neglect,Apraxia,Anopsia

    Dysphagia

    MalnutritionDehydration

    Paralysis

    AspirationImmobility

  • Which reported estimate of the prevalence ofmalnutrition 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 prevalenceof malnutrition afterstroke is valid?

    Foleyetal.Stroke 2009

    10% within the first days

    25% after2weeks

    45% inrehabilitation period

  • Areview of the relationsship betweendysphagia and malnutrition following stroke

    Foleyetal.JRehabil Med 2009

    Malnutritiononadmission:8 26% Dysphagia onadmission:24 53%

    Dysphagia accounts for 2,5foldrisk ofmalnutrition inthe weeks afterstroke(OR2,45;95%CI1,01 5,93;p

  • 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 onshorttermfunctional 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

    0

    5

    10

    15

    20

    25

    30

    35

    40

    30 40 50 60 70 80 90

    Musclemass(kg)

    Age(y)

    1 % / aSarcopenia threshold

  • Sarcopeniaand catabolic crises

    0

    5

    10

    15

    20

    25

    30

    35

    40

    30 40 50 60 70 80 90

    Musclemass(kg)

    Age(y)

    1 % / aSarcopenia threshold

  • Sarcopeniaand catabolic crises

    0

    5

    10

    15

    20

    25

    30

    35

    40

    30 40 50 60 70 80 90

    Musclemass(kg)

    Age(y)

    1 % / aSarcopenia threshold

    young

    old

  • Changeinmuscle mass,fat mass,and bonemineral 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 (%) dysphagia

    Mortality (%)+dyphagia

    RR

    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 afterstrokeMartinoR.etal.Stroke 2005

    screening techniques:37% 45% clinical testing:51% 55% instrumentaltesting:64%to 78%

  • Fiberoptic endoscopicevaluation of swallowing (FEES)

  • Video of Prof. Dr. med. Rainer Dziewas, University Mnster, Germany

  • Fiberoptic Endoscopic Dysphagia Severity Scalepredicts outcome afteracute stroke

    Warneckeetal.Cerebrovasc Dis2009

    FEDSSProtocol Mainfindings Score Clinicalimplication

    Saliva Penetration/aspiration 6 No oralfood,tube feeding,consider intubation

    Purree Penetration/aspiration withoutor insufficient cough (reflex)

    5 No oralfood,tube feeding

    Purree Penetration/aspiration withsufficient cough (refelx)

    4 Tubefeeding,purree onlyduring swallowing therapy

    Liquid Penetration/aspiration withoutor insufficient cough (reflex)

    4 Tubefeeding,purree onlyduring swallowing therapy

    Liquid Penetration/aspiration withsufficient cough (reflex)

    3 Oral purreed foodand fluids i.v.

    Softsolidfood Penetration/aspiration ormassiveresidues

    2 Oralpurreed foodand oralfluids

    Softsolidfood No penetration/aspirationMildto moderateresidues

    1 Oralsoftsolidfoodand oralfluids

  • Dysphagia Bedside Screeningfor AcuteStrokePatients TheGugging Swallowing Screen

    Trapl Metal.Stroke 2007

  • Dysphagia Bedside Screeningfor AcuteStrokePatients 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 outcomesthrough 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 oneweek require early enteralnutrition viafeeding tube (at leastwithin 72hours)(C).

    If asufficient oralfood intake is notpossible during the acutephase of stroke,enteralnutrition shall be preferably given viaanasogastric tube (A).

    If enteralfeeding is likely for alonger period of time(>28days),aPEGshould be chosen and shall be placed inastable clinicalphase (after14 28days)(A).

  • Some recommendationsII Nasogastric tube feeding does notinterfere with swallowing

    training.Therefore,dysphagia therapy shall start as early aspossible alsointubefed patients (A).

    Themajority of conscious dysphagic stroke patients with tubefeeding should have additionaloralintake,according to the kindand severity of dysphagia (B).

    Stroke patients,who are able to eat and who have beenidentified to be at risk of malnutrition,who are malnourishedor who are at risk for pressure sores should receive oralnutritionalsupplements (B).

    Afterassessment of the swallowing act (e.g.careful evaluationby the speechlanguage pathologists and/or video fluoroscopicor endoscopic examination)atexture modified diet andthickened fluids of asafe texture should be given to patients(CCP).

  • DysphagiaAspirationrisk

    Oralfood

    Oralfood+ONS

    Texturemodified

    diet(safe texture)

    Texturemodifieddiet +ONS+fluids i.v.

    Tubefeeding

    No(FEDSS1;GUSS20)

    Mild(FEDSS2;

    GUSS1519)

    Moderate(FEDSS3;

    GUSS1014)

    Severe(FEDSS46;GUSS09)

    Preexistingnutritionalrisk(NRS,MNA,SGA)

    Intensiveswallowing training

  • Thank you for your attention!