Nutrition for Stroke Patients

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Nutrition for Stroke Patients

• Adèle Lloyd
• Stroke Dietitian

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Feeding options

• 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. Decision made
  
• for either
• Oral diet Nil By Mouth (NBM)
• (Normal or Modified)
  Requires artificial feeding

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Oral Nutrition

• Potential issues faced by stroke patients,
• Making them more vulnerable to malnutrition
• Loss of appetite
• Dysphagia fear of choking
• Visual neglect
• Depression apathy
• Dysgeusia (distortion of taste smell)
• Unable to self feed (upper extremity paresis)
• Apraxia (inability to use objects properly)
• Cognitive deficits (Confusion)
• Unappetising food

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Texture Modified Diet

• Role of Speech Language therapist
• regularly assess safety of swallow (oral and
• pharyngeal stages) recommend the safest
• consistency diet and fluids
• Role of dietitian
• Asses and monitor nutritional status
• Estimate nutritional requirements
• Provide guidance on food consumption of
  appropriate texture and consistency
• Recommending additional nutritional support
  measures when necessary

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Texture Modification - Fluid
TEXTURE DESCRIPTION OF FLUID TEXTURE
Thin Fluid Still Water E.G. Water, tea, coffee without milk, diluted squash, spirits, wine
Naturally Thick Fluid Product leaves a coating on an empty glass E.G. Full cream milk, Complan, Build Up (made to instructions), Nutriment, commercial sip feeds
Thickened Fluid Stage 1 Stage 2 Stage 3 Fluid to which a commercial thickener has been added to thicken consistency. Can be drunk through a straw from a cup if advised Leaves a thin coat on the back of a spoon Cannot be drunk through a straw Can be drunk from a cup Leaves a thick coat on the back of a spoon Cannot be drunk through a straw or from a cup Needs to be taken with a spoon
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Texture Modification - Food
TEXTURE DESCRIPTION OF FOOD TEXTURE FOOD EXAMPLES
A A smooth, pouring, uniform consistency A food that has been pureed and sieved to remove particles A thickener may be added to maintain stability Cannot be eaten with a fork Tinned tomato soup Thin custard
B A smooth, uniform consistency A food that has been pureed and sieved to remove particles A thickener may be added to maintain stability Cannot be eaten with a fork Drops rather than pours from a spoon but cannot be piped and layered Thicker than A Soft whipped cream Thick custard
C A thick, smooth, uniform consistency A food that has been pureed and sieved to remove particles A thickener may be added to maintain stability Can be eaten with a fork or spoon Will hold its own shape on a plate, and can be moulded, layered and piped No chewing required Mousse Smooth fromage frais
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TEXTURE DESCRIPTION OF FOOD TEXTURE FOOD EXAMPLES
D Food that is moist, with some variation in texture Has not been pureed or sieved These foods may be served or coated with a thick gravy or sauce Foods easily mashed with a fork Meat should be prepared as C Requires very little chewing Flaked fish in thick sauce Stewed apple and thick custard
E Dishes consisting of soft, moist food Foods can be broken into pieces with a fork Dishes can be made up of solids and thick sauces or gravies Avoid foods which cause a choking hazard (see list of High Risk Foods) Tender meat casseroles (approx 1.5 cm diced pieces) Sponge and custard
Normal Any foods Include all foods from High Risk Foods list
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HIGH RISK FOODS
Stringy, fibrous texture e.g. pineapple, runner beans, celery, lettuce
Vegetable and fruit skins including beans e.g. broad, baked, soya, black-eye, peas, grapes
Mixed consistency foods e.g. cereals which do not blend with milk e.g. muesli, mince with thin gravy, soup with lumps
Crunchy foods e.g. toast, flaky pastry, dry biscuits, crisps
Crumbly items e.g. bread crusts, pie crusts, crumble, dry biscuits
Hard foods e.g. boiled and chewy sweets and toffees, nuts and seeds
Husks e.g. sweetcorn and granary bread
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Colchester Hospital currently has

• Texture C menu
• Texture D menu
• Texture E menu
• Texture modification of fluids is achieved using
  a
• thickening agent (Fresenius Thick easy)
• Also pre-thickened drinks nutritional
  supplements
• are now available.
• Modifying diets may lead to reduction in intake
  /
• dilution of nutrients (particularly with pureed
  diet)

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Examples of CHUFT C-diet

• Shepherd's Pie (Lamb)
• Traditional Lancashire Hotpot (Lamb)
• Chicken and Mushroom Pie
• Chicken and Potato Bake
• Traditional Lancashire Hotpot (Lamb)
• Chicken in Tomato and Onion Sauce
• Chicken, Leek and Cheese Casserole
• Fish Pie
• Spaghetti with Tomato and Mushroom Sauce
• Cauliflower Cheese
• Leek and Lentil Bake
• Marvellous Macaroni Cheese

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Nutritional consequences of dysphagia

• Increased difficulty / discomfort in swallowing
  leads to
• Dehydration
• Under nutrition
• Aspiration

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Malnutrition is

• A state in which a deficiency of nutrients such
• as energy, protein, vitamins and minerals
• causes measurable adverse effects on tissue
• composition, function or clinical
• outcome.

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Malnutrition

• Malnutrition costs the UK more than 7.3 billion
  each year - double the cost of obesity
• Mainly from the treatment of malnourished
  patients in hospital (3.8 billion) Other
  associated costs arise from GP visits, outpatient
  visits and artificial feeding and oral
  nutritional supplementation in the community.
• Malnourished individuals stay in hospital longer,
  succumb to infection more often, visit their GP
  on more occasions and require longer-term care
  and more intensive nursing care than individuals
  who are adequately nourished, accounting for an
  estimated additional cost of 5.3 billion.

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Consequences of malnutrition

• Depression
• Loss of will to recover
• Decreased immune system
• ? pressure sores infections
• Muscle wasting
• Slower less successful rehabilitation
• Increased length of stay ()
• Higher likelihood of re-admissions
• ? Mortality

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Benefits of treating malnutrition

• Reduced risk of infection
• Reduced length of stay
• Improved muscle function
• Improved ability to cough and mobilise
• Improved wound healing
• Improved ADLs
• Improved mental health and quality of life
• Saves money!!

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How can we reduce and avoid malnutrition?

• Nutritional Screening is a good way to identify
• patients at risk and ensure prompt treatment or
• referral onto a dietitian.
• CHUFT uses a locally adapted version of
  Malnutrition Universal Screening Tool (MUST)
• Uses 5 steps
• Steps 1-3 Measure BMI, weight loss and ability
  to eat
• Step 4 Add scores
• Step 5 Management plan

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Malnutrition Universal Screening Tool MUST

• Designed to help identify adults who are
  underweight and at risk of malnutrition, as well
  as those who are obese.
• Needs to be completed for every patient within 24
  hours of admission and once weekly thereafter
• How all patients are referred to Dietitians
• (if MUST score gt4 or other risk factors)

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The 5 'MUST' Steps

• Step 1 Measure height and weight to get a BMI
• score using chart provided. If unable to obtain
• height and weight, use the alternative procedures
  
• shown in this guide.
• Step 2 Note percentage unplanned weight loss
• and score using tables provided.
• Step 3 Establish acute disease effect and score.
• Step 4 Add scores together to obtain overall risk
  
• of malnutrition.
• Step 5 Use management guidelines and/or local
• policy to develop care plan

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Local Care Plans

• Keep a food chart for 3 days and if the food
  chart shows
• POOR INTAKE follow Care Plan A
• Aim To reduce risk of malnutrition to improve
  nutritional status
• If dietary intake is poor, ask the following
  questions
• Is the patient nauseous and/or vomiting?
• ? Cause to be investigated. Regular anti-emetics
  to be prescribed
• Is the patient constipated? ? Cause to be
  investigated and laxatives to be prescribed.
• Does the patient have a sore mouth? ? Cause to be
  investigated. Regular mouth care to be given.
• Can the patient manage a soft diet? order a soft
  diet
• Does the patient have diarrhoea? ? Cause to be
  investigated. Bulking agents to be given if
  appropriate.

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Adult, post-surgical, Oedematous malnutrition
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Recovery from oedema (same patient as previous
slide)!
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If the problem persists follow the plan below

• Commence food record chart record intake
• Ensure patient receives a High Protein Menu and
  is assisted to complete it
• Establish food preferences
• Offer encourage high protein milkshake snacks
  from menu / ward
• Ensure that food is accessible assist patient
  as required
• Reweigh weekly and compare to previous weight
• Check food record chart for adequacy of intake
  each week
• If at risk on discharge provide Nourishing
  Nibbles leaflet
• If the weight isnt improving, ask the following
• Is the patient on/receiving the high protein
  menu?
• Are the high protein milkshakes being offered?
• Are snacks being made available and intake
  encouraged?
• Is the appropriate assistance with eating and
  drinking being offered?

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Issues with nutritional screening in stroke
Issue MUST issue Solution
Bed bound Unable to weigh Use hoist - built in scales Use Mid Upper Arm Circumference (MUAC) to estimate BMI Or MUAC trends over time Use professional judgement for nutritional risk visible signs of weight loss
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Estimating BMI category from mid upper arm
circumference (MUAC)
If MUAC is lt 23.5 cm, BMI is likely to be lt20
kg/m2. If MUAC is gt 32.0 cm, BMI is likely to be
gt30 kg/m2
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Nutritional supplements

• These are prescribable products by Dr or
  Dietitian
• If patients come in on them ok to
• continue until we review and
• prescribe
• Ward milkshakes can be given without prescription
  (high protein menu)
• Constantly bringing new types out so always check
  the label as most bottles look same but have
  different nutritional content

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Different Nutritional supplements
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Try Nutritional Supplements

• -Juice or milk style
• -Different Flavours
  (consider patients preference)
• -Different temperatures
• (which do you prefer?)
• -Aftertaste?
• -Texture?

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Problems with supplements

• Serving temperature
• -room temp or fridge
• Too sweet -Dilute with water/
  lemonade /milk to improve taste
• Flavour fatigue -variety of flavours
  available
• Unable to manage with straw
• -use cup or beaker

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Artificial Nutrition

• Use when patients are unable to take adequate
  nutrition orally, or are completely NBM
• Different routes of feeding

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Type of feed

• Continuous pump feeding
• Bolus feeding
• Timing of feed breaks in feeding
• Stomach need rest periods (Jejunum no rest
  slower rate)
• Different tolerances

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Types of feed
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MDT
Diet, supplements, artificial feeding, monitor
nutritional status
Diagnosis and treatment of underlying cause
of dysphagia
Dietitian
Clinicians
SALT
O.T.
Swallow safety, Texture modification NBM
Aids for maintaining posture and independence
Patient
Family / carers
Pharmacist
Meds in appropriate Form.
Assist patient decisions and care. Provide
valuable info.
Nursing staff
Physio
Daily care of patient assist with food
choices and feeding
Posture for feeding
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Any questions?

• Thank you!