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