Stroke is the third largest cause of death in England.1 It accounts for 11% of all deaths in England and Wales and is the single largest cause of adult disability.2,3 20-30% of people who have a stroke die within one month. The risk of recurrent stroke is 26% within five years of first stroke and 39% by 10 years.4  In addition, stroke costs the NHS and the economy about £7 billion a year.1

Defining stroke

The World Health Organization (WHO) definition of stroke is a clinical syndrome, of presumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral functions lasting more than 24 hours or leading to death.5

Stroke is a "brain attack" caused by a disturbance to the blood supply to the brain. There are two main types of stroke:

•     Ischaemic: the most common form of stroke, caused by a clot narrowing or blocking bloods vessels so that the blood cannot reach the brain, which leads to the death of brain cells due to a lack of oxygen

•     Haemorrhagic: caused by  bursting of  a blood vessel producing bleeding into the brain, which causes damage.1

In terms of pathology 85% are caused by cerebral infarction, 10% by primary haemorrhage and 5% by subarachnoid haemorrhage.3 Transient ischaemic attacks (TIA), also known as minor strokes, occur when stroke symptoms resolve themselves within 24 hours.1

Malnutrition and stroke

Dysphagia (swallowing difficulty associated with foods, liquids and saliva) is common, reported incidences varying in different studies depending on definition, but are commonly quoted at around 40%.2  Dysphagia can result in avoidable complications, such as malnutrition, dehydration, weight loss, reduced stamina, poor physical and psychological recovery, pressure ulcers, reduced wound healing, infections and increased mortality.6

Malnutrition is common in hospital inpatients and 25-34% of all patients admitted to hospital are at risk of malnutrition.7 Multiple factors may contribute to a high risk of malnutrition after stroke including physical, social and psychological issues, all of which will impact on quality of life, these include:

•     Swallowing problems (dysphagia)

•     Restricted arm function, ability to self feed/drink

•     Communication problems

•     Cognition problems (memory, attention, perception)

•     Visual problems

•     Absence of teeth and dentures

•     Poor mouth hygiene

•     Depression

•     Anxiety

•     Unfamiliar foods/environment

•     Fatigue.3

Nip et al undertook a study in 2011 assessing dietary intake, nutritional status and rehabilitation of stroke patients in hospital. The study demonstrated that dietary intake predicted rehabilitation outcomes, flagging the importance of a timely and accurate assessment of nutritional status, nutritional requirements and dietary intake, and of individually targeted nutritional management as part of stroke therapy.8

The FOOD trial collaboration identified that malnutrition is associated with an increased risk of death and dependency
after stroke.9

Guidance for Nutritional Management of Acute Stroke Patients from the Royal College of Physicians and NICE states that:2,3

•     All patients should be screened for malnutrition and the risk of malnutrition, at the time of admission and at least weekly thereafter. Screening should be undertaken by trained staff using a structured assessment such as the Malnutrition Universal Screening Tool (MUST)

•     Nutrition support should be initiated for people who are at risk of malnutrition, which may include oral nutritional supplements, specialist dietary advice and/or tube feeding

•     Stroke patients should be assessed within a maximum of four hours of admission for their ability to swallow, using a validated swallow screening test administered by an appropriately trained person.

Until a safe swallowing method has been established, all patients with identified swallowing difficulties should:

•     Be considered for alternative fluids with immediate effect

•     Have a comprehensive assessment of their swallowing function, undertaken by a specialist in dysphagia

•     Be considered for nasogastric feeding within 24 hours

•     Be referred for specialist nutritional assessment, advice and monitoring

•     Receive adequate hydration, nutrition and medication by alternative means

•     Be considered for the additional use of a nasal bridle if the nasogastric tube needs frequent replacement, using locally agreed protocols.

Patients with suspected aspiration on specialist assessment, or who require tube feeding or dietary modification for three days should be:

•     Reassessed and considered for instrumental examination (such as videofluroscopy or fibre optic endoscopic evaluation of swallowing)

•     Referred for specialist nutritional assessment.

Local guidance - East Sussex Healthcare Trust

All patients presenting to East Sussex Healthcare Trust with suspected stroke symptoms (FAST positive) are admitted directly from Accident and Emergency (A&E) onto the acute stroke specialist unit. On admission to the specialist unit, patients will be commenced on the acute stroke pathway and have specialist assessment by the acute stroke team. The acute stroke pathway documentation has been developed by lead members of the multidisciplinary team (MDT) including the consultant lead stroke physician, stroke specialist nurses, stroke ward matrons, senior physiotherapists, occupational therapists, speech and language therapists and dietitians, in accordance with National Guidelines for Stroke Services.10

Nutritional treatment of stroke patients

The National Patient Safety Agency in collaboration with the Royal College of Speech Language Therapists, the British Dietetic Association, the National Association of Care Catering, the National Nurses Nutrition Group and the Hospital Caterers Association, updated the dysphagia diet food texture descriptors in 2012 for all professionals and food providers to use as guidance.11 Descriptors include:

B     Thin Puree Dysphagia Diet

C     Thick Puree Dysphagia Diet

D    Pre-mashed Dysphagia Diet

E     Fork Mashable Dysphagia Diet.

 

Oral nutritional support

All stroke patients with a MUST score greater than or equal to 2 will be referred to the stroke specialist dietitian. Patients in ESHT Stroke Specialist Units requiring a texture modified diet for three days or more will be referred to the stroke specialist dietitian who will undertake a detailed nutritional assessment. The dietitian will consider the patients current oral intake versus individually calculated nutritional requirements and may use nutritional support advice, as agreed with patient/family wishes and taste preferences, to ensure that patients are meeting their requirements. Nutritional support advice may include high calorie/protein snacks/drinks, food fortification, oral nutritional support supplements (including pre thickened drinks). 

 

Enteral feeding: nasogastric tube

Patients who are nil by mouth and appropriate for artificial feeding should have a nasogastric (NG) tube passed within 24 hours to commence enteral feeding.10 For stroke patients who lack capacity (in accordance with the Mental Capacity Act 200512), to consent to insertion of NG tube (and/or bridle/mittens/gastrostomy tube) the acute stroke team will discuss with the patient's next of kin the decision to feed artificially, in the patient's best interest and a consent form will be completed by a stroke doctor. 

Ward experience and the FOOD trial9 have shown that patients frequently pull out NG tubes resulting in interruption of nutrition, hydration and/or medication.  ESHT Acute Stroke Specialist Units have a stock of NG bridles and hand mittens, which may be used for patients requiring artificial feeding via NG tube who lack capacity and who frequently remove NG tubes.

 

Enteral feeding: gastrostomy tube

Stroke patients being NG fed will be reviewed regularly by a dietitian and SALT. Patients who require artificial feeding for more than two weeks, or who cannot tolerate short term (<2 weeks) NG feeding (ie. frequent tube displacement) will be considered for gastrostomy insertion. The stroke team, dietitian and SALT will lead discussions with the patient and/or family/carers, explaining gastrostomy tube indication, insertion procedure and long-term care.

The stroke team will refer patients to a gastroenterologist and the patient will be assessed on a weekly Nutrition Support Team ward round, led by the gastroenterologist and including the lead nutrition support dietitian, IV specialist nurse
and pharmacist.

Following agreement of all professionals that gastrostomy placement is appropriate; the patient will be booked in for the endoscopy procedure. ESHT endoscopy departments have 1-2 dedicated percutaneous endoscopic gastrostomy (PEG) insertion slots each week.  On discharge from the Acute Stroke Specialist Unit all patients requiring ongoing dietetic input will
be referred to the Community Stroke Rehab Team (CSRT) dietitians for long-term follow up. 

Enteral feeding formulas are generally well tolerated within the stroke patient population. Elemental or semi elemental formulas are rarely used. Use of parenteral nutrition (PN) in the stroke population is rare, but prolonged inability to gain enteral access in the setting of inadequate nutritional intake can necessitate PN.13

Role of the multidisciplinary team

ESHT stroke services prioritise MDT working to ensure high quality patient care and to comply with the National Best Practice Guidelines.1,2,3  All MDT members recognise the crucial role of the dietitian within the stroke team and the importance of patients having adequate nutrition in order to aid rehabilitation potential.  Stroke specialist dietitians provide education sessions for all MDTs, to continue to raise the profile of nutritional management of stroke patients, including topics such as MUST, oral nutrition support, enteral feeding and the ethics of feeding.

ESHT Stroke Services are able to function successfully using strong communication links on the acute stroke specialist units and with the community stroke rehab team. This includes daily board rounds that are attended by acute therapists, an acute staff nurse, an acute social worker and a community therapist. They brief the patient on any updates and discuss discharge plans. The weekly MDT meeting are attended by all acute MDT members,
such as one community therapist, specialist discharge nurse and ward matron for community rehab unit. This is chaired by the lead stroke consultant and they discuss detailed patient care plans and discharge arrangements.

Long-term nutritional considerations

Long-term nutritional considerations for stroke patients should include lifestyle and dietary advice, to reduce the risk of recurrent strokes. NICE guidance recommends a cardioprotective diet for primary and secondary prevention of cardiovascular disease.14 The Stroke Association have produced a detailed patient information leaflet, which is available on their website for patients and professionals.15  

Conclusions/recommendations

The nutritional management of stroke patients is fundamental in aiding rehabilitation outcomes. Stroke services require dedicated dietetic support within a stroke specialist MDT, to achieve
best patient care and meet national guidance.

 

Conflict of interest: none declared

References

1.   Department of Health (2007). National Stroke Strategy.  Assessed online: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_081059.pdf

2.   National Institute for Health and Clinical Excellence (2008). Stroke (CG68) Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA).  Assessed online: http://publications.nice.org.uk/stroke-cg68

3.   Royal College of Physicians (2012). National clinical guideline for stroke.  Assessed online: http://www.rcplondon.ac.uk/resources/stroke-guidelines

4.   Mohan et al (2011). Risk and Cumulative Risk of Stroke Recurrence: A Systematic Review and Meta-Analysis. Stroke Journal of the American Heart Association 2011; 42: 1489-94

5.   WHO MONICA Project Investigators (1998). World Health Organisation MONICA project (Monitoring trends and determinants in cardiovascular disease). Journal of Clinical Epidemiology  1998; 41: 105-114

6.   Smithard DG, O'Neill PA, England RE, et al. Complications and outcome after acute stroke: does dysphagia matter? Stroke 1996; 27: 7: 1200-1204

7.   British Association Parenterl and Enteral Nutrition (BAPEN) assessed online: http://www.bapen.org.uk/about-malnutrition/introduction-to-malnutrition?showall=&start=4

8.   Nip WFR, et al (2001). Dietary intake, nutritional status and rehabilitation outcomes of stroke patients in hospital. Journal of Human Nutrition and Dietetics 2001; 24: 460-69

9.   FOOD Trial Collaboration. Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial. Stroke  2003; 34, 6: 1450-56

10. Rahmani MJR, et al. Acute Stroke Pathway, Integrated Care Pathway Document. East Sussex Healthcare Trust, 2012

11  Royal College of Physicians et al (2011). Dysphagia Diet and Food Texture Descriptors. Assessed online:http://www.bda.uk.com/publications/statements/

12. Mental Capacity Act 2005. Assessed online: http://www.justice.gov.uk/downloads/protecting-the-vulnerable/mca/mca-code-practice-0509.pdf

13. Corrigan M, et al. Nutrition in the Stroke Patient. Nutrition in Clinical Practice 2012; 26, 3: 242-52

14. National Institute for Health and Clinical Excellence (2008). Lipid Modification (CG67): Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Assessed online: http://guidance.nice.org.uk/CG67/Guidance/pdf/English

15. Stroke Association (2010). Assessed online: http://www.stroke.org.uk/factsheet/healthy-eating-and-stroke