The Journal of the International Society of Physical and Rehabilitation Medicine

REVIEW ARTICLE
Year
: 2022  |  Volume : 5  |  Issue : 4  |  Page : 121--128

Nutrition management across the stroke continuum of care to optimize outcome and recovery


Anne Holdoway1, Ethem Murat Arsava2, Stephen A Ashford3, Emanuele Cereda4, Rainer Dziewas5, Gerard E Francisco6,  
1 Bath Clinic, Bath BA2 7BR, United Kingdom
2 Department of Neurology, Hacettepe University, Ankara, Turkey
3 The Regional Hyper-Acute Rehabilitation Unit, Northwick Park Hospital, London North West University Healthcare NHS Trust; Centre for Nursing, Midwifery and Allied Health Led Research, University College London Hospitals; Department of Palliative Care, Policy and Rehabilitation, The Cicely Saunders Institute, King's College, London, United Kingdom
4 Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
5 Department of Neurology and Neurorehabilitation, Klinikum Osnabrück - Academic Teaching Hospital of the WWU Münster, Am Finkenhügel 1, 49076 Osnabrück, Germany
6 The University of Texas Health Science Center, McGovern Medical School, Houston; NeuroRecovery Research Center, TIRR Memorial Hermann Hospital, Houston, Texas, USA

Correspondence Address:
Dr. Anne Holdoway
Bath Clinic, Bath, BA2 7BR
United Kingdom

Abstract

Stroke and the resulting long-term disability impose a substantial socio-economic burden. Stroke survivors have nutritional challenges at many stages along their care pathway, and the role of nutritional therapy and medical nutrition in stroke recovery is often overlooked. Appropriate nutrition is a prerequisite for optimizing short-term outcome and recovery from stroke and should be integral across the continuum of care, with management intervention if needed. Nutrition should be reviewed as part of the care for all people post-stroke. If nutrition support is required, it should be initiated at the acute phase and adjusted according to the ability to eat and drink throughout the care pathway. A range of complications arising post-stroke including malnutrition, dysphagia, sarcopenia, and pressure injuries can be prevented or improved by timely appropriate nutritional therapy. This also improves physical and mental function, increases strength and mobility which facilitates effective neurorehabilitation, reduces the risk of infection and pressure injuries, promotes wound healing, and improves the quality of life. An appropriately trained nutrition specialist or dietitian should assess and monitor the individual, but all members of the multidisciplinary team have a role in delivering, monitoring, and supporting the nutritional status and changing needs of the stroke survivor. This review by authors from multidisciplinary fields in stroke care is a consensus based on serial, open discussion meetings. The review explores the interrelationship between malnutrition, sarcopenia, nutrition, and pressure injuries, and seeks to raise awareness among all health professionals who manage the stroke survivor, of the supportive role of nutritional therapy.



How to cite this article:
Holdoway A, Arsava EM, Ashford SA, Cereda E, Dziewas R, Francisco GE. Nutrition management across the stroke continuum of care to optimize outcome and recovery.J Int Soc Phys Rehabil Med 2022;5:121-128


How to cite this URL:
Holdoway A, Arsava EM, Ashford SA, Cereda E, Dziewas R, Francisco GE. Nutrition management across the stroke continuum of care to optimize outcome and recovery. J Int Soc Phys Rehabil Med [serial online] 2022 [cited 2023 Jan 27 ];5:121-128
Available from: https://www.jisprm.org/text.asp?2022/5/4/121/363466


Full Text



 Introduction



Stroke is the second leading cause of death worldwide[1] and a leading cause of adult disability.[2] The costs of treatment and post-stroke care are substantial.[3]

Optimal stroke recovery depends on managing the common problems that arise post-stroke. Malnutrition has a reported prevalence of up to 62%,[4] dysphagia up to 60%,[5] skeletal muscle loss or sarcopenia is 42%,[6] and the prevalence of pressure injuries is 22%.[7],[8] These problems are all influenced by nutrition which is crucial in optimizing the stroke survivor's recovery. Based on existing evidence and multiprofessional opinion, this review aims to raise awareness, among the interdisciplinary team, of the role of nutritional therapy and why it should be considered, adjusted, and sustained following a stroke, from the acute phase through to recovery, to maximize clinical and patient-centered outcomes.

 Methodology



Authors from multidisciplinary fields in stroke care shared their expertise to review central topics: medical nutrition in stroke, stroke management, and stroke-related complications (malnutrition, dysphagia, sarcopenia, and pressure injury).

A literature search was carried out focusing on medical nutrition in stroke. Studies were identified from the PubMed database of the US National Library of Medicine at the National Institutes of Health. Only studies published in English and related to the central topics were reviewed. Consensus was reached with serial, open discussion meetings without the use of formal discussion-making methodology. This approach was applied because of the lack of data in the field of medical nutrition and stroke, and because data are often heterogeneous depending on the time point along the stroke recovery pathway.

 Multidisciplinary Post-Stroke Rehabilitation Team



Multidisciplinary team (MDT) working is fundamental to delivering effective care across the stroke pathway [Table 1].[9] Once the stroke survivor is stabilized, an appropriate individual care plan is developed with a key focus on inpatient neurorehabilitation, delivered by the MDT. This is followed through into the community with further rehabilitation, home-based care, and self-management.{Table 1}

The dietary and nutritional needs of stroke survivors vary greatly throughout the care pathway. Nutritional therapy must be tailored by the dietitian or nutrition specialist, with regular nutrition reviews by the MDT. This facilitates early identification of nutritional issues and timely provision of nutrition support, tube feeding or oral nutritional supplementation (ONS) to treat or prevent malnutrition, the need for texture-modified food and fluids to achieve a safe swallow and prevent aspiration, and the promotion of healthy eating and positive dietary habits that are essential for maximizing long-term health.

The access and availability of dietitians or nutrition specialists qualified to undertake comprehensive nutrition assessments and interventions varies within hospitals and countries. In addition to nutrition specialists, effective nutritional therapy across the continuum of care relies on nurses, speech and language therapists (SALTs), physical therapists, and occupational therapists to provide assistance, equipment and encouragement at mealtimes, regular monitoring of food, protein calories, and fluid intake, and to work together to facilitate care plan monitoring.

In addition to good communication and collaboration, the MDT requires the relevant nutrition knowledge to assess and monitor the individual along their care pathway [Table 2].{Table 2}

 Problems Post-Stroke Requiring Nutrition Management



Malnutrition

Malnutrition refers to deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients. In this document, the term malnutrition refers to undernutrition arising from insufficient energy, protein, and micronutrients.[10]

Being malnourished, or at risk of malnourishment, on admission to hospital is associated with an increased risk of mortality, stroke-related morbidities including infections and bed sores, increased length of stay, and associated health-care costs.[4],[11],[12] The high risk of malnutrition and dehydration throughout the stroke survivor's recovery journey, and the inadequate nutritional intake over a prolonged period, particularly of protein, contributes to significant poor neurological outcomes and increased dependency rates.[13]

Post-stroke malnutrition is serious and insidious; it is rarely perceived to be life-threatening and may receive less focus and attention from health professionals. The prevalence of malnutrition post-stroke varies widely, not least because of the considerable variation in the timing and assessment method used.[4],[14] A recent systematic review and meta-analysis provides considerable insights into the high prevalence of malnutrition and impaired nutritional condition post-stroke using Bernhardt's recovery phase definition [Table 3].[15],[16] A substantial proportion of stroke patients (up to 26%) are malnourished on admission,[14] and between 56% and 62% develop malnutrition at some point during hospital stays of more than 3 weeks.[13],[14] The 1st week post-stroke is a critical window for nutritional status to deteriorate[17] with consciousness, dysphagia, and physical issues playing a significant role in impeding satisfactory oral intake. Malnutrition and impaired nutritional condition are highly prevalent at the later stages post-stroke,[15] hence nutrition assessment and the identification of factors likely to hinder adequate nutrient intake should be considered and supported along the entire care pathway to ensure an optimum outcome.{Table 3}

Many factors contribute to a high risk of malnutrition post-stroke including physical, social, and psychological issues; if left untreated, they can impact on the stroke survivor's quality of life [Table 4].[4],[13],[18] Severe stroke, dysphagia, and consciousness problems are closely related to malnutrition risk in the post-stroke setting. Stroke-related features, polypharmacy, preexisting chronic diseases, as well as advanced age and female gender are all associated with a high risk of malnutrition at the time of admission.[4]{Table 4}

Persistent dysphagia following a stroke can have a profound effect on nutritional intake,[19] and a plethora of other factors can compound the risk of suboptimal intake including delayed neurorehabilitation,[4] poor oral hygiene, cognitive and visual problems, reduced mobility, and depression.[20] Post-stroke depression reduces appetite and has a deleterious influence on the recovery of daily living activities. Stroke survivors with hemiplegia may not be able to maintain their head or body in an upright position and may have to eat with the nondominant arm, all of which negatively impact on oral intake.

Fatigue, frequently observed in individuals with stroke, also causes difficulties with eating. Patients may stop eating before they have satisfied their hunger, because they need to rest or may even fall asleep. Visual, speech, and language difficulties all hinder adequate communication by the stroke survivor including preferences regarding food choices. The importance of engaging with family members to gain an insight into patient's desires should not be underestimated. Cognitive deficits also limit their ability to carry out the activities required to eat a meal and increase the risk for malnutrition.

Dysphagia

Dysphagia, defined as the difficulty or inability to swallow normally or freely, is a common problem post-stroke. It has a reported prevalence of up to 60%, which may increase to 100% if minor deficits such as tongue weakness are accepted as evidence of dysphagia.[5]

Avoidable complications arising from dysphagia include malnutrition, dehydration, weight loss, reduced stamina, poor physical and psychological recovery, pressure injuries, reduced wound healing, infections, increased mortality, and care costs.[13],[21],[22],[23],[24] Dysphagia and malnutrition frequently co-exist and are associated with poor outcomes post-stroke.[14] Individuals with dysphagia are more likely to develop pneumonia and are particularly at high risk for aspiration pneumonia.[17],[25]

Within the first 3 days of a stroke, 64%–78% of individuals have dysphagia.[22] In the acute phase, up to 20% of individuals may require tube feeding, and of these, 8% need tube feeding for more than 6 months. The stroke survivor with dysphagia has a reduced incidence of being discharged home, and less favorable outcomes.[26]

Dysphagia is also a predictor of caregiver quality of life;[27] ensuring optimal nutrition to manage post-stroke problems is important for the stroke survivor and for reassuring carers.

Sarcopenia

Sarcopenia is characterized by progressive and generalized loss of skeletal muscle mass, muscle strength, and reduced physical performance resulting in a risk of adverse outcomes such as physical disability, frailty, falls, poor quality of life, and death.[6],[28],[29],[30],[31]

The prevalence of sarcopenia in stroke is 42% with a pooled prevalence estimate from a range of studies of 16.8%–60.3% and a higher prevalence of 50% found during the early phase post-stroke.[6],[32]

The effect of sarcopenia is poorly understood but may be the result of several factors including insulin resistance, immobility, older age, and a reduction in anabolism. Poor mobility or inactivity might also impair insulin sensitivity, which affects glucose-dependent energy metabolism and decreases insulin-induced anabolic stimulation. It has been estimated that 10 days of bed rest, even in healthy older adults, decreases muscle protein synthesis by 30%, and leg lean mass by 6%, with a subsequent 16% reduction in muscle strength.[32] The resulting muscle weakness contributes to reduced physical function and prolonged disability with considerable consequences for mobilization in the recovery phase, resumption of daily living activities, and returning to prestroke independence status. The detrimental effects of immobility on muscle size and function are more pronounced in bedridden stroke patients who also have stroke-related neurological deficits. The presence of sarcopenia 2 weeks post-stroke may increase the risk of poor functional outcome for up to 6 months.[33] The presence of sarcopenia post-stroke can also exacerbate dysphagia due to the weakness in the muscles involved in the oropharyngeal phase of swallowing.[34]

Pressure injuries

A pressure injury is defined as localized damage to the skin and/or underlying tissues, because of pressure, or pressure in combination with shear. Pressure injuries usually occur over a bony prominence but may also be related to a medical device or other objects.[35] Malnutrition impairs wound healing and reduces skin integrity and can influence the risk of pressure injuries.[8],[36],[37]

The prevalence of pressure injuries post-stroke is high, i.e., 18.1% in hospital[38] and 31.4% in nursing homes.[39] Within 12 months post-stroke, 22% of stroke survivors were found to have pressure injuries.[7] The clinical consequences of pressure injuries include increased morbidity and mortality for inpatients, increased length of hospital stays, re-admission rates and hospital costs, and reduced quality of life.[40],[41],[42]

 Nutritional Care along the Stroke Care Pathway



Timely and accurate nutrition screening, assessment, management, and monitoring is required for the prevention and management of malnutrition, dysphagia, sarcopenia, and pressure injuries, with dietary modifications or specific therapeutic strategies to safely ensure adequate nutritional intake to optimize recovery [Figure 1].[4],[17]{Figure 1}

Screening for malnutrition and nutritional assessment

All patients should be screened to identify the presence or risk of malnutrition within 48 h of admission to hospital as the prevalence of malnutrition, and risk of malnutrition in acute stroke, increases significantly during the first 10 days of admission.[17],[19],[43],[44] Close attention to the individual's nutrition status throughout this period is recommended to enable timely nutritional intervention and management.[45] As malnutrition can develop beyond the acute phase, individuals should be screened at least weekly in the inpatient setting and community settings providing rehabilitation.[17],[19],[43],[44]

Obesity or being overweight is a contributory factor in stroke. The development of malnutrition may be masked by a high body mass index (BMI) and excess adiposity. Evaluating unintentional weight loss and monitoring food intake is a useful method of assessing the risk of developing malnutrition not only in those of normal BMI but also in those who are overweight or obese [Table 5].[46] While excess weight and adiposity can impede mobilization and increase cardiovascular risk, unplanned weight loss and nutritional deficits may result in malnutrition and its sequelae including exacerbation of sarcopenia.{Table 5}

Screening should be undertaken by a trained health professional using a validated screening tool such as the Nutritional Risk Screening 2002,[47] the Malnutrition Universal Screening Tool,[48] or the Mini Nutritional Assessment Short Form.[49] For those identified with malnutrition, or at risk of malnutrition, a nutritional assessment needs to be performed. This detailed investigation to identify and quantify specific nutritional problems includes subjective and objective parameters such as medical history, current and past dietary intake, physical examination and anthropometric measurements, functional and cognitive assessment, quality of life, medications, and laboratory values.[50]

A nutritional care plan should be developed based on the results of the assessment using a multidisciplinary approach and implemented to maintain and improve the patients' nutritional condition.[4],[51]

Nutritional care is a term used to describe the form of nutrition, nutrient delivery, and the systems used for meal service or the delivery of clinically assisted nutrition and hydration such as enteral tube feeding.[17],[19],[43] For those able to consume oral food, the meals need to be the correct consistency and texture, nutritionally balanced with the aim of meeting an individual's requirements for all essential nutrients (protein, calories, vitamins, and minerals). For those who are malnourished or at risk of malnutrition where a deficit against requirements is observed or anticipated, nutrition support should be considered to prevent further deterioration and optimize nutritional status. Nutritional care may include the fortification of food and drink to enhance nutrient density, mealtime assistance, addressing the issues interfering with the ability to eat and drink [Table 4], increased frequency of nutritious meals, snacks and nourishing fluids, the use of ONS, or tube feeding via the nasogastric route for short-term feeding or consideration for a gastrostomy for long-term enteral tube feeding. Adequate fluids are also required for maintenance of hydration and if using the oral route should be of suitable consistency based on a swallowing assessment by a SALT or suitably trained practitioner.

Key aspects of nutrition such as oral intake, food preferences, physical issues impeding intake (e.g., paresis, sensory disturbance, or inattention), hydration status, weight and functional outcomes, tolerance to, and efficacy of, ONS or enteral tube feeding formulae, and the acceptability of feeding methods to care settings and patient routine, should be monitored and adjusted throughout the care pathway.[46] Monitoring guides the adjustments to the nutritional care plan and enables goals to be updated and communicated within health-care teams particularly as patients are transferred across care settings.

Dysphagia

Individuals with a stroke should be screened within a maximum of 2 h of admission for the presence of dysphagia by an appropriately trained healthcare professional before being given any oral fluid, food, or medication.

If the admission screen indicates swallowing problems, a specialist assessment of swallowing should take place, preferably within 24 h of admission, and no more than 72 h later.[52] The SALT will ideally use the fiber-optic endoscopic evaluation of swallowing test.[53],[54] The assessment will guide decision-making on the need for full or partial tube feeding, the use of texture-modified food and fluids, and the use of suitable consistency ONS.[5],[17] If dysphagia is severe and precludes sufficient safe oral intake, full enteral feeding via a nasogastric tube should be initiated to provide nutrition, fluids, and a route for the administration of medications. The individual should be referred for specialist nutritional assessment, advice, and monitoring by a suitably qualified health professional.

The MDT should be alert to the stroke survivor coughing during eating and drinking, or having a respiratory infection, as this is an indication of dysphagia developing.[21]

Sarcopenia

The revised European consensus on the definition and diagnosis of sarcopenia recommends a range of screening and diagnostic tools.[29] Tool selection depends on the individual's capacity to participate in the assessment and the availability of the technologies in the care setting.[29] The Strength, Assistance with walking, Rising from a chair, Climbing stairs and Falls questionnaire can be used for case finding, and is useful in clinical environments and easily incorporated into the care plan. Skeletal muscle strength evaluation is also recommended and can be applied in routine practice with measures such as grip strength.[29],[55] Skeletal muscle mass is a useful direct measure of sarcopenia and evaluated using dual-energy X-ray absorptiometry or whole-body skeletal muscle mass, or appendicular skeletal muscle mass predicted by bioelectrical impedance analysis. These measures provide more direct measurement and potential accuracy for determining sarcopenia but are more difficult to use in routine clinical settings.

The impact of sarcopenia on functional performance (activity and participation) is the primary clinical concern for stroke survivors.[56] Although the focus is usually on the paretic side, the unaffected side is also important during the rehabilitation process. If one-sided weakness is present, strength training should be encouraged in the unaffected side, and in general, as well as cardiovascular training. Gait speed evaluation (e.g., National Institutes of Health Toolbox 4-Meter Walk Gait Speed Test) is regularly used in stroke rehabilitation units, and a useful indicator if the data are considered in the context of sarcopenia.[29] The Short Physical Performance Battery, Timed-up-and-go Test, and the 400-m walk are also recommended. These measures are supported by stroke-specific work, particularly related to timed walking, which can readily be applied in practice.[56],[57] The consumption of a muscle targeted whey protein-based nutritional formula enriched with leucine and Vitamin D has been shown to improve physical performance and function, as well as muscle mass, and to reduce rehabilitation intensity and care costs.[58] Nutritional intervention involving an adequate intake of high-quality protein, preferably in combination with a tailored physical rehabilitation program, is beneficial in managing muscle loss.[29],[59],[60],[61]

Pressure injuries

Nutrition is an important consideration when treating individuals at risk, or with, pressure injuries. A validated nutrition screening tool should be used to identify nutrition status and referral for nutrition assessment and a patient-centered nutrition plan as required.[62] Several scales are available for assessing the risk of developing pressure injuries; however, it is important to use those that include a question on nutritional status, i.e., the Braden and Waterlow Scales. Several guidelines discuss the importance of nutrition in pressure injuries and provide graded evidence-based recommendations.[35],[62],[63]

Adequate provision of nutrients, especially those that play an important role in preserving skin and tissue viability, is essential to facilitate tissue repair for the prevention and healing of pressure injuries.[62] A balanced diet based on individual requirements, supplemented between meals if necessary, is required and nutrition support is offered for those who cannot consume adequate intake, assuming that this is compatible with the individual's goals and wishes.[63] Many individuals may be unable to consume their nutrient requirements through normal food consumption, and some nutrients, e.g., protein and specifically arginine, Vitamin C, and zinc, play a key role in the healing process.[35],[64] Nutritional therapy including the provision of medical nutrition, together with nursing care and pressure relief, can help prevent pressure injuries and contribute to faster healing.[36],[65]

 Conclusion



The provision of nutritional care following a stroke is complex and requires multimodal management. Post-stroke malnutrition is serious and insidious and impacts on the stroke survivor's recovery and quality of life. Aside from those individuals who may be malnourished on admittance to hospital, the nutritional status of patients may worsen in the 1st week post-stroke and continue over time. Inadequate nutritional intake over a prolonged period leads to significant poor neurological outcomes, increased dependency rates, an increased risk of mortality, stroke-related morbidities, increased length of stay, and associated health-care costs.

In addition to malnutrition, several problems post-stroke benefit from nutrition management including dysphagia, sarcopenia, and pressure injuries. Timely and accurate assessment of nutrition status, nutrition requirements, and dietary intake are all key to optimizing recovery. Optimal nutritional care is required across the patient journey from hospital admission, high dependency care to step-down care, and onward in the community. In countries where a dietitian is not part of the stroke MDT, a nutrition specialist or trained health professional is required to assess, manage, and monitor the nutrition needs of the stroke survivor throughout their care pathway.

Stroke survivors should be re-screened, nutritional intake monitored, and their care plan adjusted throughout recovery, particularly as they transfer from one setting to another.

Maximizing stroke survivor outcomes requires optimal acute management and post-stroke care, with nutrition as a prerequisite and integral component across the continuum of care.

"Let thy food be thy medicine, and medicine be thy food" – Hippocrates.

Financial support and sponsorship

All authors received an Honoraria from Nutricia, Danone Trading Medical B.V., for the initial virtual, round-table discussion from which all authors felt a narrative review would be beneficial to health care practitioners involved in stroke care and rehabilitation. Thereafter, work by the authors on the manuscript was unfunded. Editorial support was provided by Louise Blakeborough and funded by Nutricia, Danone Trading Medical B.V.

Conflicts of interest

There are no conflicts of interest.

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