nutrition in acute stroke andreas h. leischker, m.d., m.a. head working group „neurology“,...
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Nutrition in Acute Stroke
Andreas H. Leischker, M.D., M.A.
Head Working Group „Neurology“, German Society for Nutritional Medicine
Working Group „Nutrition in Stroke“, ESPEN
Nutrition in Acute Stroke:
How it started
Baseline
No national and no international Guidelines on nutrition in acute stroke
Ten years ago…
First meeting of a interdisciplinary working group
„ Nutrition in patients with acute stroke“
August 2005Frankfurt/Germany
Working Group Members• Rainer Wirth (Geriatrician, DGEM and DGG)
• E.W. Busch (Neurologist, DGN)
• Beate Schlegel ( Nutritionist, DGEM)
• Kristian Hahn ( Geriatrician, DGG)
• Jens Kondrup ( Nutritionist , ESPEN)
• Andreas Leischker (Geriatrician, DGEM and DGG)
German Guideline- Societyes
German sociréty for Neurology(DGN)
German Society for Geriatrics (DGG)
German Society for Nutritional medicine (DGEM)
Two years later..First Milestone
„DGEM-Guideline Nutrition of patients with acute stroke“
• Review by the Medical Societyes DGEM, DGN und DGG
• Aktuell. Ernähr Med 2007;32:332-348
DGEM Guideline Clinical Nutrition„Neurology“
• Stroke
• Parkinsons Disease
• Huntingtons Disease
• Multiple Sclerosis
“Guideline Clinical Nutrition
in patients with stroke”Wirth R, Smoliner C, Jäger M, Warnecke T, Leischker AH, Dziewas R and
the DGEM Steering Committee,
Experimental & Translational Stroke Medicine 2013, 5:14
http://www.etsmjournal.com/content/5/1/14
Oral Nutritional Supplements(ONS)
FOOD Trial Part 1- ONS Dennis M, Lewis, S, Cranswick G Health Technology Assessment 2006
Randomisation within one month after admission
4023 without dysphagia
2007Normal nutrition
2016Normal nutrition
PLUSONS
FOOD Trial Part 1Dennis M, Lewis, S, Cranswick G:
Health Technology Assessment 2006
27,9 %
of patients did not tolerate ONS
Modified Rankin Scale after 6 month´s
0%
20%
40%
60%
80%
100%
Normal diet Normal diet plussupplements
Allocated treatment
Pe
rcen
tag
e o
f p
atie
nts Rankin 0
Rankin 1
Rankin 2
Rankin 3
Rankin 4
Rankin 5
Dead
FOOD Trial Part 1:Pressure sores during hospital stay
• No ONS: 1,3 %
• ONS: 0,7 %
P= 0,05
Recommendation ONS
ONS is not recommended in general
Who should recieve ONS
Patients with
• malnutrition
• risk for malnutrition
• Risk for pressure soresAWMF Leitlinie Ernährung des Schlaganfallpatienten 2007
Enteral Nutrition:When?
„Patients with prolonged dysphagia anticipated to last for more than 7 days
should receive tube feeding (within 72 hours)
(C)
Dysphagia Screening
• Water Swallowing Test ( WST)
• Multiple Consistency Test( Gugging Swallowing Screen,GUSS)
• Swallowing Provocation Test
Dysphagia Screening
• Screening for malnutrition should start as early as possible, on the latest within 48 hours after admission (C)
• When the patient is in a clinically stable condition, the screening is repeated in weekly intervals during the first month. When the clinical condition changes, screening should be repeated earlier (C).
AWMF Leitlinie 2007
Assessment
Stroke patients without pathological findings in the initial bedside testing (dysphagia screening) should be referred
to a further swallowing assessment if other known clinical predictors of dysphagia are present, such as
• a severe neurological deficit,• marked dysarthria or aphasia • a distinct facial palsy
Grade C Recommendation
Good news:Prevalence of dysphagia following
acute stroke• First day: about 50 %
• After six weeks:6,7 %
• After six months: 3,2 %
N.B.: About 10 % of patients get second stroke within the first week after admission !
Dysphagia follow up after discharge
At least once per month during the first 6 months
Randomization within 1 week
FOOD Trial 3 - PEG vs NG
321 pts with dysphagia
162PEG
159nasogastral
Food Trial 3 – Outcome at Follow-Up
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
NG PEG
Allocated treatment
Perc
enta
ge o
f pati
ents
18.9%MRS 0 to 3
33.3%MRS
4 to 5
47.8%Dead
48.8%
40.1%
11.1% BetterOutcome = 7.8% (p= 0.0504)
andreas.leischker @maria-hilf.de
How are patients fed 6 months later ?
Feeding 6 months after stroke
47.8% 48.8%
12.0%21.0%
38.4%29.0%
0%
20%
40%
60%
80%
100%
NG PEGAllocated treatment
Perc
enta
ge o
f pati
ents Normal
NG
PEG
Dead
If a sufficient oral food intake is not possible during the acute phase
of stroke, enteral nutrition should be preferably given via a nasogastric tube
“Tube feeding does not interfere with swallow training. Therefore, dysphagia therapy shall
start as early as possible also in tube fed patients”
Grade A
If enteral feeding is likely for a longer period of time (> 28 days),
a PEG should be chosen and placed in a stable clinical phase
(after 14 – 28 days) (A).
AWMF Leitlinie Enterale Ernährung des Schlaganfallpatienten 2007
Who should get a PEG earlyer?
Mechanically ventilated
stroke patients should receive a PEG
at an early stage (B)
15.9.2006 [email protected]
15.9.2006 [email protected]
If a nasogastric tube is rejected, not tolerated or repeatedly removed by the patient and if artificial nutrition will probably be necessary for more than 14 days, early feeding via PEG
should be started (C).
AWMF Leitlinie Enterale Ernährung des Schlaganfallpatienten 2007
Nasal Bridle/Loop
A nasal bridle ( nasal loop) is an effective
alternative”
Anderson Meet al 2004
Beavan J et al 2010
With or without pump?
In stroke patients tube feed should preferably be applied with a
feeding pump (C).
AWMF Leitlinie Enterale Ernährung des Schlaganfallpatienten 2007
Outlook
European Society for Parenteral and Enteral Nutrition ( ESPEN)
European Guideline on nutrition in stroke „in progress“…
Stroke Prevention :News
The Coffee Paradox in Stroke• > 3 cups per day linked with fewer strokes (OR
0.44, 95% CI 0.22-0.87, P < 0.02) in healthy subjects
• “Heavier daily coffee consumption is associated with decreased stroke prevalence, despite smoking tendency in heavy coffee drinkers”
Liebeskind DS, Sanossian N, Fu KA, Wang HJ, Arab L. The coffee paradox instroke: Increased consumption linked with fewer strokes.
Nutr Neurosci. 2015 Jun 22. [Epub ahead of print]
Tea is o.k., too
“…Awaiting the results from further long-term RCTs and prospective studies,
moderate consumption of filtered coffee, tea, and dark chocolate seems prudent”
Larsson SC. Coffee, tea, and cocoa and risk of stroke.
Review.Stroke 2014
Take Home Messages
ONS
Only for patients with risk for malnutrition or risk for pressure sores
Place nasogastric tube early
if enteral nutrition is still necessary :
place PEG in stable phase
Repeat Dysphagia Assessment regulary for at least 6 months- including time after discharge
Take coffee breaks for prevention!
Take coffee breaks for prevention!