Feeding and Nutrition after Stroke

Learning objectives

Learning
Understand
Integrate
Reflect

Introduction

Feeding after stroke is a difficult issue and brings into it many medical, nursing and ethical problems. It must be managed holistically and as part of a team in an effort to respect the patient's wishes.
There are many reasons for poor nutritional input and these are tabled below.
Swallowing dysfunction (dysphagia) is common and disabling after acute stroke and can lead to complications most notably aspiration.

All patients need

Initial swallowing screen
Initial weight and monitoring
Mood screening
Screening for malnutrition

Malnutrition and stroke

Prevalence of malnutrition in patients admitted to hospital following a stroke ranges from 6% to 62% (Foley et al., 2009)
Quarter of patients become more malnourished in the first weeks after a stroke (Yoo et al., 2008)
Malnutrition is an independent predictor of poor outcomes after stroke (FOOD Trial, 2003)
Malnutrition is an independent predictor of mortality, LOS, and hospitalization costs at 6 months post stroke (Gomes, Emery & Weekes, 2015)

Dehydration and stroke

More than half of stroke patients dehydrated at some point during their admission
Associated with severe stroke and poor outcomes
Predictor of institutionalisation and death (Rowat, Graham & Dennis, 2012)
Commoner with Greater age, Female, Stroke severity, Prescribed diuretics
Dehydrated patients more likely to require parenteral fluids or enteral tube feeding
Dysphagia significantly more prevalent in dehydrated that hydrated patients

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 (National clinical guideline for stroke, 2016)

Dysphagia

Prevalence of dysphagia in stroke patients between 28 and 65%
In some patients it may be the only symptom
It is potentially serious with risks of aspiration and malnutrition and dehydration
It improves significantly during the early days
After two weeks 90% of patients swallow safely
Associated with increased mortality, morbidity, and institutionalization due to increased risk of aspiration, pneumonia, malnutrition and dehydration

A water swallow test is often used to identify aspiration risk. The patient is given teaspoonfuls of water and the initiation of the swallow and any occurrence of coughing or alteration in voice quality are observed. If there are no adverse signs, the patient is given a larger quantity to drink from a glass. This test has a reported sensitivity of >70% and a specificity of 22-66% for prediction of aspiration and has been found to be a useful and reasonably sensitive screening test. Remember these tests are snapshot and swallowing might be good in the morning when patient is rested but unsafe late in the day when patient is fatigued. Always be ready to reassess. The patient should be sitting up and be alert enough to cooperate with the test. Language and cognitive issues may hinder comprehension and so care and time must be taken. If any doubt then needs formal SLT referral.

Risk of aspiration is suggested by the following

Wet, hoarse voice, weak voluntary cough
any indication of reduced laryngeal function
Reduced conscious level is also an indicator of aspiration risk.

Videos showing basics of swallow screen

Swallow screen Stanford

Swallow screen BC

Further evaluation for swallowing

Bedside specialist assessment by a Speech and language therapist
Videoflouroscopy - (Modified barium swallow (MBS) is a dynamic assessment of the oral, pharyngeal and upper oesophageal phases of swallowing using videofluoroscopy. It is regarded as the “gold standard” in the assessment of dysphagia, both diagnostically and therapeutically.
Fibre optic endoscopic evaluation of swallowing (FEES): assessment of swallowing using a flexible nasendoscope, which is passed into the nares, over the velum and into the pharynx. It is as effective as MBS in detecting laryngeal penetration, aspiration and residue. FEES allows visualisation of the bolus movement through the hypopharynx and airway protection manoeuvres. It cannot be used to assess oral stage of swallowing disorders or determine bolus movement at the point of swallowing.

Different causes of Feeding issues post stroke

Cause	Actions
Poor swallow	This is a challenge initially as swallow due to neuromuscular weakness or incoordination or dyspraxia often improves. All patients should have swallow assessment done before any oral intake and preferably from the stroke specialist nurse in the Emergency department or on the HASU. A failure warrants a speech and language therapy review.
Painful eating	Check dentition and oral cavity and treat for candidal infections. Maxillofacial assessment may be needed.
Poor Mood/Cognition	Low mood or a disinterest in food or simply lack of huger can all contribute to poor intake. Antidepressant therapy and psychological support may help
Eating disorders	May have preceded the stroke and needs expert support.
Mechanical dysphagia	Usually can manage fluids and less so solids. The exception is achalasia. May require an Upper GI endoscopy. An oropharyngeal tumour or oesophageal tumour can affect swallowing. Strictures and pouches can also make it difficult. Oesophageal spasm.

Enteral feeding

This can be assessed by one of two methods: pH testing and CXR. The whoosh test should not be used as it is unreliable. NG tubes can be placed on the ward by experienced medical or nursing staff [link], without x rays to check position. NG aspirates at pH 5.5 or below will indicate correct placement of NGTs in most patients. The pH reading should be between 1-5.5. However, if you obtain a result of between 5-6 do not administer anything down the nasogastric tube and either escalate and repeat or take advice as the aspirate reading will need to be reconfirmed. Failure is usually due to inability to get an aspirate. This may require advancing the nasogastric tube, 1cm at a time, to ensure that the exit port/s enter the fluid pool. Injecting air through the NGT can also be useful (Metheny and Meert, 2004) by dislodging the NGT exit port from the gastric mucosa and expelling. Flush the tube using a 60ml syringe before and after the administration of feed and medication, or every 4–6 hours if feeding is not in progress (except during the night). Flush with 30ml of water (type and volume as recommended by your managing healthcare professional) to prevent your tube from blocking.

The tube must remain in the midline and cross the diaphragm

When to check tube position?

On initial placement
Before feeding, flushing or giving medications (unless feed in progress)
Following wretching, vomiting, coughing or suctioning
If the tube appears to have moved
After a patient has pulled at the tube
With new, unexplained respiratory symptoms

Management of Dysphagia

Screen needs expert review by SLT who may supplement this with VF or FEES
Severe: Consider NG feeding and ongoing assessments. Often poorly tolerated and tubes block or get displaced needing replacement but in some they are the only early option.
All patients who have dysphagia for more than one week should be assessed to determine their suitability for a rehabilitative swallowing therapy programme
Diet modification is the alteration of the texture or viscosity of food and fluids
Compensatory techniques refer to postures (the manipulation of head or body posture) or manoeuvres (the manipulation of an isolated aspect of the swallowing mechanism)
Food and fluid intake should be monitored and, if indicated, a referral made to the dietitian
Severe persisting dysphagia: Usual pathway is to consider percutaneous endoscopic gastrostomy (PEG). PEG placement is an invasive procedure requiring sedation and endoscopy and has a number of potential complications. Mortality is high in those with post stroke PEG. PEG is recommended for long term (>4 weeks) enteral feeding. The PEG can be removed when no longer neeeded.
Hospital and community pharmacists or medicines information centres should be consulted by the professional managing the patient’s dysphagia, on the most appropriate method of administering medication