p42-46w14 R_A&S Template 05/12/2011 10:06 Page 42

Art & science stroke series

Malnutrition and dehydration after stroke

Rowat A (2011) Malnutrition and dehydration after stroke. Nursing Standard. 26, 14, 42-46. Date of acceptance: August 17 2011.

Abstract
By identifying malnutrition and dehydration in patients who have had a stroke, nurses can intervene to prevent significant complications developing and so improve patient outcomes. Poor intake of fluid and food may result from difficulties in swallowing, as well as other physical and functional problems that occur as a result of a stroke. The aim of this article is to encourage nurses to identify the frequency and causes of malnutrition and dehydration, to consider the complications this can cause and to be aware of optimum feeding strategies for stroke patients.

Author
Anne Rowat Lecturer in nursing studies, School of Nursing, Midwifery and Social Care, Edinburgh Napier University, Edinburgh. Correspondence to: a.rowat@napier.ac.uk

Keywords
Dehydration, dysphagia, hydration, malnutrition, nutrition, stroke

It has been estimated that 6.1% to 62.0% of patients who have had a stroke are malnourished (Foley et al 2009), which is associated with an increased risk of death and dependency after stroke (FOOD Trial Collaboration 2003). The wide range of estimates of malnutrition is probably because of the different nutrition assessment tools in use, many of which have not been validated (Martino et al 2005). Dehydration is likely to be very common after stroke, but since there is no gold standard assessment for dehydration, estimation of the frequency of this problem is difficult (Kavouras 2002). A high blood osmolality (>296mOsm/kg) and a urea:creatinine ratio (mmol:mmol) of more than 80 in patients with acute stroke has been associated with stroke mortality at three months and an increased risk of venous thromboembolism (Bhalla et al 2000, Kelly et al 2004).

Review
All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Dysphagia after stroke

More than 50% of patients have dysphagia at the onset of stroke (Martino et al 2005). Most swallowing problems resolve in the first week after stroke, but problems persist in up to 19% of patients (Perry and McLaren 2003). Patients in whom swallowing problems resolve may relapse as a result of deterioration in their neurological condition; or they may have silent episodes of aspiration pneumonia, during which food and/or fluid enters the airway instead of the oesophagus, which may often go unnoticed because the patient does not cough or show signs of distress during swallowing (Ramsey et al 2005). Dysphagia can result in avoidable complications, such as malnutrition, dehydration, weight loss, reduced stamina, poor physical and psychological recovery, pressure ulcers, reduced wound healing, infections and increased mortality (Smithard et al 1996). The gold standard test to assess patients swallowing is videofluoroscopy, which is a radiological test that uses barium to examine the

Online
Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.

MALNUTRITION AND DEHYDRATION are common but often unrecognised problems after stroke (Intercollegiate Stroke Working Party 2008). Many patients are unable to eat or drink independently following a stroke because of (Dennis 2000): 4The inability to swallow (dysphagia). 4Weakness of limbs. 4The inability to communicate. 4Not recognising or lack of awareness of food, fluid or medications. 4Confusion. 4Reduced level of consciousness. 4Low mood. 42 december 7 :: vol 26 no 14 :: 2011

NURSINGSTANDARD / RCNPUBLISHING

p42-46w14 R_A&S Template 05/12/2011 10:06 Page 43

swallowing process. However, the test is not practical for many patients who have had a stroke because they need to be transferred to the X-ray department, be able to sit independently and tolerate movement of the head and trunk (Mann et al 1999). Although videofluoroscopy can be used to identify dysphagia, it is not considered a reliable method to determine how patients with dysphagia should be fed on the ward (Clayton et al 2006). Over the past 20 years, fibre optic endoscopic evaluation of swallowing (FEES) has been developed as a non-radiological technique that can be used at the bedside to determine the movement of fluid and food in the pharynx and/or larynx (but not at the point of swallowing) (Ramsey et al 2003). However, this technique requires skilled operators and involves the use of specialised equipment so it may not be available to all patients (Singh and Hamdy 2006). Pulse oximetry has also been considered as a screening tool for dysphagia. Oxygen desaturation of more than 2% may indicate aspiration due to bronchoconstriction and ventilation-perfusion imbalance, or a decrease in minute ventilation as a result of interrupted breathing during swallowing (Zaidi et al 1995, Collins and Bakheit 1997, Rowat et al 2000). However, the results from pulse oximetry studies are conflicting and often desaturation did not correspond to patients swallow or aspiration (Ramsey et al 2006, Scottish Intercollegiate Guidelines Network (SIGN) 2010a). Guidelines recommend that, to assess swallowing urgently, all stroke patients should undergo a water swallow test performed by a trained healthcare professional (usually a trained nurse) before giving any food, drink or oral medications on the day of admission (National Institute for Health and Clinical Excellence (NICE) 2008, SIGN 2010a). The water swallow test involves giving patients small volumes of water on a teaspoon (progressing to larger volumes) to assess aspiration risk by noting if the patient is dribbling, coughs, has laryngeal movement and/or poor voice quality (Logemann 1983). If the patient shows any of these problems in the water swallow test, they should be referred to a specialist, for example a speech and language therapist, for a more detailed bedside assessment of their swallow, with or without FEES, videofluoroscopy or oxygen saturation testing, within the first 24 hours of admission (NICE 2008). To be clinically useful, a dysphagia screening test needs to be accurate, reliable, quick, safe and easy to use. There are many non-invasive screening tools available, but their sensitivity

(whether the test correctly identifies patients as aspirating) and specificity (whether the test correctly identifies patients as not aspirating) range from zero to 100% (Perry 2001, Martino et al 2009). This wide variation in sensitivity and specificity can be attributable to patient selection, study methods and the timing of dysphagia screening (Perry 2001). Overall, it is essential that any person administering a swallow test must receive adequate education and training. A training package is available from Stroke Training and Awareness Resources (2011).

Maintaining nutrition after stroke

Screening An assessment of swallowing ability, body mass index (BMI), regular weight measurements, simple blood tests, for example albumin, and a record of food intake should be made within the first 48 hours of admission and should continue to be assessed during the patients stay in hospital to evaluate nutritional status after stroke (SIGN 2010b). However, there are many practical difficulties with assessing nutritional status in patients who have had a stoke. A clinical history and weight and height measurements (to estimate BMI) may be difficult to ascertain because of communication and mobility problems (FOOD Trial Collaboration 2003). Weight measurements may be inaccurate because of the unavailability of accurate scales, changes in clothing and time of day that measurements are taken. Blood indices, such as haemoglobin, serum protein, albumin and transferrin, may not reflect nutritional status and anthropometric tests, such as skinfold measures and bioelectrical impedance, are not widely used in clinical practice (Perry and Boaden 2010). However, as a high proportion of patients who have had a stroke experience malnutrition during hospital admission (Foley et al 2009), NICE (2008) has advocated the use of valid and reliable nutritional screening tools, such as the Malnutrition Universal Screening Tool (British Association for Parenteral and Enteral Nutrition 2011). Although this tool is not specific to stroke, it has been validated in acute and community settings and is useful for identifying those patients who need to be seen by a dietician (Hickson 2006). Management Dysphagia interventions can help prevent aspiration pneumonia and improve eating, oral movements, nutritional status and cost effectiveness of recovery after stroke (Jacobsson et al 2000). Techniques such as positioning of the trunk, balance training, head december 7 :: vol 26 no 14 :: 2011 43

NURSINGSTANDARD / RCNPUBLISHING

p42-46w14 R_A&S Template 05/12/2011 10:06 Page 44

Art & science stroke series

control and chin tucking may reduce the risk of aspiration, improve safety of eating and help patients to be more independent (Westergren 2006). Nurses and family members, however, often lack adequate knowledge of these techniques and may require training by a speech and language therapist (Carlsson et al 2004). Dietary texture modifications and/or alteration of fluid viscosity are common approaches to prevent aspiration pneumonia, but there is little evidence from randomised controlled trials of their effectiveness (Foley et al 2008). It is important to investigate all difficulties a patient may have that prevents him or her from completing meals, for example the solution may be as simple as ensuring the patient has food and drink within reach, assistance if required (including from family members), well-fitting dentures and cutlery with suitable grips (Dennis 2000). The Feed Or Ordinary Diet (FOOD) trials (Dennis et al 2005a, 2005b) addressed key issues such as which patients need help with feeding following a stroke, when to feed them and how to deliver the food. The first of three trials randomly allocated 4,023 patients who had had a stroke who could swallow to receive either oral protein energy supplementation or usual diet. The authors reported no significant difference in survival or functional outcome between the two groups at six months (Dennis et al 2005a), suggesting that oral supplements may only be useful in patients who are identified as being malnourished. However, the trial did highlight problems with patient compliance with oral supplementation over long periods. In the second trial, 859 stroke survivors were randomly assigned to receive either early enteral tube feeding or no tube feeding. The results suggest that early introduction of enteral tube feeding within seven days of stroke reduces the risk of death at six months, but this intervention may keep more patients alive who are severely disabled (Dennis et al 2005b). The third trial included 321 patients and examined how best to feed patients with dysphagia in the acute phase of stroke (Dennis et al 2005b). It found that early routine use of a percutaneous endoscopic gastrostomy tube was not associated with any survival benefit compared with nasogastric tube feeding (Dennis et al 2005b). Early enteral tube feeding and nasogastric tube feeding were not associated with an increased risk of chest infections, but both types of feeding were associated with an increased risk of gastrointestinal bleeding (Dennis et al 2005a, 2005b). Although this trial included fewer patients than required to reach statistical 44 december 7 :: vol 26 no 14 :: 2011 significance, the results provide practical information that can guide our decisions about feeding patients following stroke. Guidelines now recommend that nasogastric feeding of patients with dysphagia following a stroke should commence in the first 24 hours of hospital admission (NICE 2008). Insertion of nasogastric tubes in the first few hours after stroke, when the patients condition is likely to be unstable, raises several ethical issues, particularly when a patient is too confused or sick to give informed consent for the procedure. Insertion of nasogastric tubes is often difficult and, even if inserted successfully, they are not always well tolerated by patients. In the FOOD trials (Dennis et al 2005a, 2005b), patients frequently pulled out their nasogastric tubes (the maximum number of tubes per patient was 18) resulting in interruption of nutrition, hydration and/or medication (Professor Martin Dennis, Principal Investigator, FOOD Trial Collaboration, Division of Clinical Neurosciences, University of Edinburgh, 2004, personal communication). Patients may dislodge the tube, which can result in food or fluid entering the lungs, leading to poor outcomes such as death and severe disability (Horsburgh et al 2008). Continually checking that the nasogastric tube is in the correct position will increase demands on staff time and frequent repositioning of the tube may increase patient discomfort (Dennis 2000). To combat these problems, some healthcare practitioners may use interventions to prevent the removal or dislodgement of nasogastric tubes, such as taping the nasogastric tube to the face, application of one or two hand mittens or insertion of a nasal bridle or loop system (Horsburgh et al 2008, Beavan et al 2010).

Maintaining hydration after stroke

Screening Although there is no widely accepted definition of dehydration, it has been described as a decrease in total body water (Kavouras 2002). Dehydration after stroke is common and is caused by a lack of fluid intake due to drowsiness, dysphagia and fever that result from infection, physical inactivity, episodes of vomiting and diarrhoea or a reduction in thirst (Kedlaya and Brandstater 2002). Dehydration may result in reduced cerebral blood flow to potentially viable brain tissue surrounding the acute stroke lesion (the penumbra), thereby reducing the chances of a good clinical recovery after stroke (Bhalla et al 2001). Therefore identifying, preventing and/or correcting dehydration in the acute phase of stroke may improve stroke outcomes.

NURSINGSTANDARD / RCNPUBLISHING

p42-46w14 R_A&S Template 05/12/2011 10:06 Page 45

Clinical features of dehydration (poor skin turgor, low venous blood pressure and dry mucous membranes) are unreliable indicators because they are insensitive to mild-to-moderate dehydration and are difficult to elicit in older patients (Vivanti et al 2008). Hospital fluid balance charts are often inaccurate (Watkins et al 1997) because oral fluid intake is often not documented accurately and output is difficult to record in patients who are incontinent. Diagnosis is usually based on blood indices plasma osmolality and urea:creatine ratios. However, frequent blood testing can be painful and patients who have had a stroke may have comorbidities that could affect the accuracy of blood test results (Vivanti et al 2008). A small pilot study did not support the use of urine-specific gravity and urine colour as early indicators of dehydration when compared with blood urea:creatine ratios (Rowat et al 2011). Therefore, further research is required to develop a practical tool for the early detection of dehydration in patients following stroke.

Management Guidelines on the management of stroke have emphasised the importance of maintaining hydration in the acute phase, but few studies have examined how best to maintain adequate fluid intake to reverse or treat dehydration as well as prevent overhydration (Intercollegiate Stroke Working Party 2008, SIGN 2010a). The consensus of clinicians is that it is important for patients to be able to swallow safely and to be given regular access to fluids (ONeill et al 1992). To achieve this, nurses must be able to communicate effectively with patients, some of whom may have communication problems after stroke, and drinks should be placed within easy reach of patients, not on the side of weakness, neglect or hemianopia (loss of vision in either the right or left sides of both eyes). Patients who are unable or unwilling to take oral hydration should be hydrated via another route, for example, subcutaneously, intravenously, via a nasogastric tube or via a percutaneous

References
Beavan J, Conroy SP, Harwood R et al (2010) Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial. Age and Ageing. 39, 5, 624-630. Bhalla A, Sankaralingham S, Dundas R, Swaminathan R, Wolfe CD, Rudd AG (2000) Influence of raised osmolarity on clinical outcome after acute stroke. Stroke. 31, 9, 2043-2048. Bhalla A, Wolfe CD, Rudd AG (2001) Management of acute physiological parameters after stroke. Quarterly Medical Journal. 94, 3, 167-172. British Association for Parenteral and Enteral Nutrition (2011) Malnutrition Universal Screening Tool (MUST). www.bapen.org.uk/ musttoolkit.html (Last accessed: November 7 2011.) Carlsson E, Ehrenberg A, Ehnfors M (2004) Stroke and eating difficulties: long-term experiences. Journal of Clinical Nursing. 13, 7, 825-834. Challiner YC, Jarrett D, Hayward MJ, Al-Jubouri MA, Julious SA (1994) A comparison of intravenous and subcutaneous hydration in elderly acute stroke patients. Postgraduate Medical Journal. 70, 821, 195-197. Clayton J, Jack CI, Ryall C, Tran J, Hilal E, Gosney M (2006) Tracheal pH monitoring and aspiration in acute stroke. Age and Ageing. 5, 1, 47-53. Collins MJ, Bakheit AM (1997) Does pulse oximetry reliably detect aspiration in dysphagic stroke patients? Stroke. 28, 9, 1773-1775. Dennis M (2000) Nutrition after stroke. British Medical Bulletin. 56, 2, 466-475. Dennis MS, Lewis SC, Warlow C; FOOD Trial Collaboration (2005a) Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial. The Lancet. 365, 9461, 755-763. Dennis MS, Lewis SC, Warlow C; Food Trial Collaboration (2005b) Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. The Lancet. 365, 9461, 764-772. Foley N, Teasell R, Salter KL, Kruger K, Martino R (2008) Dysphagia treatment post stroke: a systematic review of randomised controlled trials. Age and Ageing. 37, 3, 258-264. Foley NC, Salter KL, Robertson J, Teasell RW, Woodbury MG (2009) Which reported estimate of the prevalence of malnutrition after stroke is valid? Stroke. 40, 3, e66-e74. FOOD Trial Collaboration (2003) Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial. Stroke. 34, 6, 1450-1456. Hickson M (2006) Malnutrition and ageing. Postgraduate Medical Journal. 82, 963, 2-8. Horsburgh D, Rowat A, Mahoney C, Dennis M (2008) A necessary evil? The use of interventions to prevent nasogastric tube-tugging after stroke. British Journal of Neuroscience Nursing. 4, 5, 230-234. Intercollegiate Stroke Working Party (2008) National Clinical Guideline for Stroke. Third edition. Royal College of Physicians, London. Jacobsson C, Axelsson K, sterlind PO, Norberg A (2000) How people with stroke and healthy older people experience the eating process. Journal of Clinical Nursing. 9, 2, 255-264. Kavouras SA (2002) Assessing hydration status. Current Opinion in Clinical Nutrition and Metabolic Care. 5, 5, 519-524. Kedlaya D, Brandstater ME (2002) Swallowing, nutrition, and hydration during acute stroke care. Topics in Stroke Rehabilitation. 9, 2, 23-38. Kelly J, Hunt BJ, Lewis RR et al (2004) Dehydration and venous thromboembolism after acute stroke. Quarterly Journal of Medicine. 97, 5, 293-296. Logemann JA (1983) Evaluation and Treatment of Swallowing Disorders. College Hill Press, San Diego CA. Mann G, Hankey GJ, Cameron D (1999) Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke. 30, 4, 744-748.

NURSINGSTANDARD / RCNPUBLISHING

december 7 :: vol 26 no 14 :: 2011 45

p42-46w14 R_A&S Template 05/12/2011 10:06 Page 46

Art & science stroke series

endoscopic gastrostomy tube. Subcutaneous fluids can maintain hydration, but patients who are severely dehydrated will require intravenous fluids and/or enteral feeding (Challiner et al 1994). Dextrose should be avoided in the first 48 hours after acute stroke because of the risks of hyperglycaemia (Bhalla et al 2001). A systematic approach to fluid management in patients with stroke is currently advocated (Intercollegiate Stroke Working Party 2008). Fluid replacement should be guided by regular monitoring of blood indices, such as urea:creatine ratio. However, further studies are required to identify effective interventions to reduce the frequency and duration of dehydration after stroke. for dysphagia, malnutrition and dehydration in all patients who have had a stroke on admission to hospital (NICE 2008, SIGN 2010a). Nurses should be aware that there are several challenges in ensuring patients who have had a stroke can swallow safely (without the risk of aspiration), particularly in those who are immobile, unable to communicate, cognitively impaired or unconscious. Nurses, in collaboration with the multidisciplinary team, have an important role in maintaining the nutrition and hydration status of patients after stroke. Management should be aimed at ensuring adequate oral intake in patients able to swallow and parenteral and/or enteral feeding in patients with dysphagia. Future research should focus on practical and effective interventions that will reduce the frequency and duration of malnutrition and/or dehydration, thereby improving patients outcomes after stroke NS

Conclusion
Malnutrition and dehydration are common complications that result in poor outcomes after stroke. Current guidelines advocate screening

Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R (2005) Dysphagia after stroke. Incidence, diagnosis, and pulmonary complications. Stroke. 36, 12, 2756-2763. Martino R, Silver F, Teasell R et al (2009) The Toronto Bedside Swallowing Screening Test (TOR_BSST): development and validation of a dysphagia screening tool for patients with stroke. Stroke. 40, 2, 555-561. National Institute for Health and Clinical Excellence (2008) Stroke: National Clinical Guidelines for the Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack. Clinical Guideline No. 68. NICE, London. ONeill PA, Davies I, Fullerton KJ, Bennett D (1992) Fluid balance in elderly patients following stroke. Age and Ageing. 21, 4, 280-285. Perry L (2001) Screening swallowing function of patients with acute stroke. Part one: identification, implementation and initial evaluation of a screening tool for use by nurses.

Journal of Clinical Nursing. 10, 4, 463-473. Perry L, Boaden E (2010) Nutritional aspects of stroke care. In Williams J, Perry L, Watkins C (Eds) Acute Stroke Nursing. Wiley-Blackwell, Oxford, 91-122. Perry L, McLaren S (2003) Implementing evidence-based guidelines for nutrition support in acute stroke. Evidence Based Nursing. 6, 3, 68-71. Ramsey DJ, Smithard DG, Kalra L (2003) Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke. 34, 5, 1252-1257. Ramsey D, Smithard D, Kalra L (2005) Silent aspiration: what do we know? Dysphagia. 20, 3, 218-225. Ramsey DJ, Smithard DG, Kalra L (2006) Can pulse oximetry or a bedside swallowing assessment be used to detect aspiration after stroke? Stroke. 37, 12, 2984-2988. Rowat AM, Wardlaw JM, Dennis MS, Warlow CP (2000) Does

feeding alter arterial oxygen saturation in patients with acute stroke? Stroke. 31, 9, 2134-2140. Rowat A, Smith L, Graham C, Lyle D, Horsburgh D, Dennis M (2011) Urine specific gravity as an indicator of dehydration in acute stroke patients. Journal of Advanced Nursing. 67, 9, 1976-1983. Scottish Intercollegiate Guidelines Network (2010a) Management of Patients with Stroke: Identification and Management of Dysphagia. SIGN Guideline 119. SIGN, Edinburgh. Scottish Intercollegiate Guidelines Network (2010b) Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications, and Discharge Planning. SIGN Guideline 118. SIGN, Edinburgh. Singh S, Hamdy S (2006) Dysphagia in stroke patients. Postgraduate Medical Journal. 82, 968, 383-391. Smithard DG, ONeill PA, Park C, Morris J (1996) Complications and outcome after acute stroke: does dysphagia matter? Stroke. 27, 7, 1200-1204.

Stroke Training and Awareness Resources (2011) Screening for Dysphagia: An Interactive Training Package. http://tiny.cc/screening_ for_dysphagia (Last accessed: November 7 2011.) Vivanti A, Harvey K, Ash S, Battistutta D (2008) Clinical assessment of dehydration in older people admitted to hospital: what are the strongest indicators? Archives of Gerontology and Geriatrics. 47, 3, 340-355. Watkins C, Lightbody E, Theofanidis D, Sharma AK (1997) Hydration in acute stroke: where do we go from here? Clinical Effectiveness in Nursing. 1, 2, 76-83. Westergren A (2006) Detection of eating difficulties after stroke: a systematic review. International Nursing Review. 53, 2, 143-149. Zaidi NH, Smith HA, King SC, Park C, ONeill PA, Connolly MJ (1995) Oxygen desaturation on swallowing as a potential marker of aspiration in acute stroke. Age and Ageing. 24, 4, 267-270.

46 december 7 :: vol 26 no 14 :: 2011

NURSINGSTANDARD / RCNPUBLISHING