nutrition in acute stroke andreas h. leischker, m.d., m.a. head working group „neurology“,...

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

andreas.leischker@alexianer.de

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)

andreas.leischker@alexianer.de

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

andreas.leischker@alexianer.de

3 years later…..

Expiry date of guideline is exhausting.

andreas.leischker@alexianer.de

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

andreas.leischker@alexianer.de

Oral Nutritional Supplements(ONS)

andreas.leischker@bonifatius-lingen.de

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

andreas.leischker@bonifatius-lingen.de

Average amount of ONS per patient

14 liters 34 days

FOOD Trial Part 1Dennis M, Lewis, S, Cranswick G:

Health Technology Assessment 2006

27,9 %

of patients did not tolerate ONS

andreas.leischker@bonifatius-lingen.de

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)

andreas.leischker@alexianer.de

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

andreas.leischker@alexianer.de

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

andreas.leischker@alexianer.de25 andreas.leischker@alexianer-krefeld.de

Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS)

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

andreas.leischker@alexianer.de

Nasogastric or PEG ?

andreas.leischker@alexianer.de

Randomization within 1 week

FOOD Trial 3 - PEG vs NG

321 pts with dysphagia

162PEG

159nasogastral

andreas.leischker@alexianer.de

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@bonifatius-lingen.de

NG tube

15.9.2006 andreas.leischker@bonifatius-lingen.de

“Food for Thought ?”

andreas.leischker @maria-hilf.de

How are patients fed 6 months later ?

andreas.leischker@bonifatius-lingen.de

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

andreas.leischker@alexianer.de

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

andreas.leischker@alexianer.de

“Tube feeding does not interfere with swallow training. Therefore, dysphagia therapy shall

start as early as possible also in tube fed patients”

Grade A

andreas.leischker@maria-hilf.de

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)

andreas.leischker@bonifatius-lingen.de

What to do if patients put out the NG tube

15.9.2006 andreas.leischker@bonifatius-lingen.de

15.9.2006 andreas.leischker@bonifatius-lingen.de

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

andreas.leischker@alexianer.de

Nasal Bridle/Loop

A nasal bridle ( nasal loop) is an effective

alternative”

Anderson Meet al 2004

Beavan J et al 2010

andreas.leischker@alexianer.de

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!