Download as PDF, PPTX
Uploaded byKrizia Ferrini
Stroke and Nutrition - Dr. Krizia Ferrini
The document presents an overview of nutrition support for stroke rehabilitation, emphasizing the nutrition care process, artificial nutrition options, and management of dysphagia. Key points include the importance of nutritional assessment, hydration management, and tailored dietary recommendations for stroke patients, as well as guidelines for enteral feeding. It also highlights the significance of screening for malnutrition and using standardized dysphagia diets to ensure safe swallowing.
More Related Content
Similar to Stroke and Nutrition - Dr. Krizia Ferrini
Stroke and Nutrition - Dr. Krizia Ferrini
- 1. Stroke and Nutrition Dr. KriziaFerrini RDN, MSc, PhD
- 2. Disclosure of speaker‘s interest •No conflict of interest • Nutrition Scientific Commettee Council member - American Society for Nutrition (ASN) • Member - European Society for Parenteral and Enteral Nutrition (ESPEN)
- 3. Outline –Nutrition support afterstroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 4. Outline –Nutrition support afterstroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 5. Nutrition Care Process •Nutrition Assessment • Food and/or Nutrient Delivery • Nutrition Education • Nutrition Counselling
- 6.
- 7. Nutritional Assessment The purposeof nutritional assessment is to: • Identify individuals at risk of becoming malnourished • Identify individuals who are malnourished
- 8. Nutritional Assessment 1. History 2.Physical examination 3. Laboratory Data in Nutrition Assessment
- 9. Nutritional Assessment 1. History •↓ weight in last 6 months – e.g. Malnutrition Universal Screening Tool (MUST) • Changes in dietary intake (e.g. Dietary History, Food diary, Observed Food Consumption) • Hydration Status • Quality of diet (e.g. Mediterranean Diet Score)
- 10. Nutritional Assessment 1. History •Gastrointestinal symptoms (i.e. Bristol Stool Chart) • Functional capacity – i.e. Eating Assessment Tool (EAT-10) (if the VFS or FEES not possible) • Disease and its relation to nutritional requirements
- 11. Nutritional Assessment 2. Physicalexamination Detection of relevant signs helps in establishing the nutritional diagnosis • Subcutaneous fat (i.e. waist circumference, bio impedance analysis) • Muscle wasting • Ankle edema • Sacral edema • Ascites
- 12. Nutritional Assessment Classification Source: Adaptedfrom WHO, 1995, WHO, 2000 and WHO 2004. BMI- Principal cut off points Additional cut-off points Underweight <18.50 <18.50 Severe malnutrition <16.00 <16.00 Moderate malnutrition 16.00–16.99 16.00–16.99 Mild malnutrition 17.00–18.49 17.00–18.49 Normal range 18.50–24.99 18.50–22.99 23.00–24.99 Overweight >25.00 >25.00 Pre-obese 25.00–29.99 25.00–27.49 27.50–29.99 Obese >30.00 >30.00 Obese class I 30.00–34.99 30.00–32.49 32.50–34.99 Obese class II 35.00–39.99 35.00–37.49 37.50–39.99 Obese class III (morbid obesity) >40.00 >40.00
- 13. Nutritional Assessment 2. Physicalexamination Health risk Women Men Low 0.80 or lower 0.95 or lower Moderate 0.81–0.85 0.96–1.0 High 0.86 or higher 1.0 or higher Online Image Online Image
- 14.
- 15. Nutritional Assessment 3. Evaluationof Laboratory Data in Nutrition Assessment • Used in nutrition assessment (a clinical sign supporting nutrition diagnosis) • Assessment for Protein-Calorie Malnutrition • Used in Monitoring and Evaluation of the patient response to nutritional intervention
- 16. Nutritional Assessment 3. Evaluationof Laboratory Data in Nutrition Assessment • Hormonal and cell-mediated response to stress • Negative acute-phase respondents • Positive acute-phase respondents • Nitrogen balance
- 17. Nutritional Assessment 3. Evaluationof Laboratory Data in Nutrition Assessment • Hepatic transport proteins • Albumin • Transferrin • Prealbumin • Retinol-binding protein • C-reactive protein • Creatinine
- 18. Nutritional Assessment 3. Evaluationof Laboratory Data in Nutrition Assessment • Inflammation: • hs-CRP • Homocysteine • Markers of Malabsorption • Fecal fat • Fat-soluble vitamins • Vitamin D
- 19. Nutritional Assessment 3. Evaluationof Laboratory Data in Nutrition Assessment • Lipid Indices of Cardiovascular Risk • Total cholesterol • LDL • HDL: HDL2a, HDL2b, HDL2c, HDL3a, HDLdb • IDL • VLDL • Lp(a)
- 20. Nutritional Assessment 3. Evaluationof Laboratory Data in Nutrition Assessment 2018AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA /AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
- 21. Outline –Nutrition support afterstroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 22.
- 23. Clinical Activities- Interfaces •Medical doctors (understanding of the aetiology, treatment, prognosis and comorbidities associated with neurological patients) • Clinical researchers (i.e. providing remote monitoring at home with mobile Health technology application) • Nurses (Artificial Nutrition Management + weekly anthropometric assessments) • Speech therapists (dysphagia - diagnosis and treatment) • Neuropsychologists (Nutrition Counselling Guidelines in Neurological Patients) • Movement therapists (development energy expenditure concept) • Occupational therapists (counselling methods helpful for daily life, cooking groups)
- 24. Outline –Nutrition support afterstroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 25. Artificial Nutrition (enteraland parenteral Nutrition) http://www.crohnscolitisfoundation.org
- 26. Artificial Nutrition (enteraland parenteral Nutrition) • Partial Enteral Nutrition (PEN) = 30-50 % calories through formula and the remainder is from solid food or a regular diet • Exclusive Enteral Nutrition (EEN) = 100 % calories through formula; you do not eat any regular food • Dietetic Products and Foods for Special Medical Purposes
- 27. Artificial Nutrition (enteraland parenteral Nutrition) • Patients with prolonged severe dysphagia after stroke that presumably last for more than 7 days should receive early (not more than 72 h) enteral tube feeding • Critically ill stroke patients with decreased level of consciousness that need mechanical ventilation should receive early (not more than 72 h) enteral tube feeding • If enteral feeding is likely necessary for a longer period of time (>28 days), a PEG should be chosen and placed in a stable clinical phase (after 14-28 days)
- 28. Outline –Nutrition support afterstroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 29.
- 30. Dysphagia Signs of swallowingproblems: • coughing or choking when patient is eating or drinking • food or drink going down the wrong way • still having food or drink left in the mouth after swallowed
- 31. Dysphagia Signs of swallowingproblems: • not being able to chew food properly • taking a long time to swallow or finish a meal • being short of breath when the patient is swallowing
- 32.
- 33. Dysphagia : International DysphagiaDiet Standardisation Initiative (IDDSI) • 2013 • Goal: developing new global standardised terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and all cultures
- 34. Dysphagia : International DysphagiaDiet Standardisation Initiative (IDDSI) • Final dysphagia diet framework consisting of a continuum of 8 levels (0-7) • Levels are identified by numbers, text labels and colour codes
- 35. Dysphagia New Dysphagia Dietsand Fluids https://iddsi.org/framework/
- 36. Outline –Nutrition support afterstroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 37. Healthy Nutrition Guidelines • MINDdiet • ↓cognitive decline in stroke survivors • rich in whole foods, including fruits and vegetables • elements of the Mediterranean-style diet and the DASH diet American Stroke Association's International Stroke Conference 2018
- 38.
- 39. Outline –Nutrition support afterstroke • Nutrition Care Process in Stroke Rehabilitation • Clinical Activities- Interfaces • Artificial Nutrition (enteral and parenteral Nutrition) • Dysphagia (IDDSI Framework) • Healthy Nutrition Guidelines • Recommendations
- 40. Recommendations • All patientsshould be screened for malnutrition at the time of admission and weekly thereafter • Stroke patients should also have their hydration assessed on admission, reviewed regularly and managed so that normal hydration is maintained • Nutrition support should be initiated for people with stroke who are at risk of malnutrition. This may include oral nutritional supplements (ONS), specialist dietary advice and/or enteral tube feeding (ETF)
- 41. Recommendations • People withdysphagia should be given food, fluids and medications modified in a form that can be swallowed without aspiration • Ensure palatable diet, presented in a way to promote nutritional intake
- 42. Recommendations References • Burgos R.et al, ESPEN Guideline Clinical Nutrition in Neurology. Clin Nutr 37 (2018) 354- 396 • 2018AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines • The International Dysphagia Diet Standardisation Initiative (http://iddsi.org/) • Morris MC et al. , MIND diet slows cognitive decline with aging, Alzheimers Dement 2015 September ; 11(9): 1015–1022. doi:10.1016/j.jalz.2015.04.011 • Guideline Clinical Nutrition in Neurology. Clin Nutr (in press) Hookway C., Gomes F., Weekes C.E. (2015) Royal College of Physicians Intercollegiate Stroke Working Party evidence-based guidelines for the secondary prevention of stroke through nutritional or dietary modification. J Hum Nutr Diet. 28(2):107-125.
- 43.