MNT Stroke

MNT Stroke
pada pasien Geriatri

Vergie Ryoto, S.Gz
Stroke is the leading cause of permanent disability in
adulthood. Many of the patients who survive do so with
significant sequelae that limit them in their activities of daily
living.
The nutritional status of patients admitted for stroke often
deteriorates during hospitalization. It is necessary to perform a
nutritional assessment of the patient in the early hours of
admission, to determine both the nutritional status and the
presence of dysphagia.
Dysphagia, through alteration of the safety and efficacy of
swallowing, is a complication that has an implication for
nutritional support, and must be treated to prevent aspiration
pneumonia, which is the leading cause of mortality in the stroke
patient. (Burgos, et al, 2014)
Nutrition support in acute stroke, R. Wirth, 37th ESPEN Congress, Lisbon 2015
Medical and Nutritional
Management
Medical Management Nutritional Management
Embolic
Hemorrhage Maintaining
Thrombolytic Managing
Neurosurgery adequate
drugs dysphagia
to relieve nutrition
Supportiv
pressure
treatment
Algorithm content developed by John Anderson, PhD, Sanford C, Garner. PhD, 2000.
ROLE OF THE DIETITIAN
Raise awareness of the impact of malnutrition on recovery
Implement and monitor nutritional screening
Assess nutritional requirements, and advise on using artificial
nutrition, food fortification or supplements as appropriate
Advise on a texture modified diet
Adapt the nutrition care to existing or newly diagnosed medical
conditions (i.e. diabetes mellitus, hyperlipidemia)
Liaise with catering department to ensure provision of nutritionally
adequate meals for dysphagic patients
Facilitate discharge for patient requiring ongoing artificial nutrition
Liaise closely with SLT (Speech and Language Therapy)
SIGN 118, 2010
Post stroke problems related to
nutritional status
• Dysphagia
• Restricted arm function, ability to self feed or drink
• Communication problems
• Cognition problems (memory, attention, perception)
• Visual problems
• Absence of teeth and dentures and poor mouth hygiene
• Depression/ axiety
Nutrition Assessment
• Height, current weight, usual body weight, weight history, and
significant changes in weight (>5% in 30 days, or >10% in 180 days)
• Current food and fluid intake adequacy compared with calculated
nutritional needs
• Eating ability (able to feed self, requires assistance, needs total
assistance)
• Interview with the individual and/or family for food preferences and
tolerances
• Medications that may affect food/fluid intake or tolerance (food-
medication interactions)
• Other factor that may impact nutritional status (such as
chewing/swalloing ability, gastrointestinal problems, depression,
pressure ulcers, wounds)
• Signs/symptoms of dehydration
GERIATRIC NUTRITIONAL RISK INDEX (GNRI)
GNRI= (1.489xalbumin)+(41.7x(weight/WLo)
Wlo for men : H(cm)-100-(H-150/4)
Wlo for women : H-100-(H-150/2.5)
GNR score:
<82 major risk
82 to 92 moderate risk
92 to <98 low risk
> 98 no risk
Nutrition Management
Maintain adequate nutrition
Assess and manage dysphagia
Vitamin and mineral supplementation as needed
Enteral nutrition support may be necessary
Nutritional needs
Sufficient energy intake
Acutely
Former studies suggested stroke as a hypermetabolic clinical condition
Recent studies suggest that REE in acute phase and after 10-15 days
remain unchanged
Stress factor of 10-12% if using equations to calculate needs
Finestone, et al, Stroke, 2003:54:502-507
Long-term energy needs depend on the level of mobilization of
the patients
Usually lower due to lower physical activity
Corrigan et al, Nutr Clin Pract 2011 26 : 242
Energy intake : 25-45 kcal/kg

Individualized protein needs (taking into account co-morbidities)
1.0-1.5 g/kg
Nutritional needs
Lemak :
20-30% dari total kebutuhan.
35-55% dari total kebutuhan pada gangguan nafas
Cairan
Nutrisi enteral
diberikan jika hasil tes fungsi menelan baik
Nutrisi parenteral
diberikan pada kondisi khusus
Medical Nutrition Therapy
Weight loss, anorexia, and dehydration are key concerns with
dysphagia.
Observation during meals allows the nurse or RDN to screen
informally for signs of dysphagia and bring them to the
attention of the health care team.
Changing the consistency of foods served may be beneficial
while keeping the diet palatable and nutritionally adequate also
are important. A soft, blended, or pureed consistency can
reduce the need for oral manipulation and conserve energy
while eating.
Nutritional
management for stroke
patient
High risk of High risk of

Low/ medium risk of
Nil by mouth malnutrition and malnutrition (No
malnutrition
dysphagia dysphagia)
Texture modified diet,

Dietary assesment.
Thickeners, pre- Dietary advice and
Enteral tube feeding Optimize access to
thickened ONS. Enteral ONS
food
tube Feeding
Regular Screening and monitoring

Stroke patients with dysphagia
have 3fold risk to develop
aspiration pneumonia
Patients with severe dysphagia
have an 11fold higher risk of
aspiration pneumonia.
Martino, R, et al(2009). Stroke. 40;555-561.
Dysphagia often leads to malnutrition because of
inadequate intake.
Symptoms of dysphagia include :

drooling, choking, or coughing during or following meals;
inability to suck from a straw; a gurgly voice quality; holding
pockets of food in the buccal recesses (of which the patient
may be unaware); absent gag reflex; and chronic upper
respiratory infections.
A common result is dysphagia (difficulty swallowing), and the
ability to obtain, prepare, and present food to the mouth can
be compromised. Modified food textures are often required for
the individual with swallowing problems.
Early recognition of signs and symptoms, implementation of an

appropriate care plan to meet the nutritional requirements of
the individual, and counseling for the patient and family
members on dietary choices are essential.
Proper positioning for effective swallowing should be
encouraged (i.e., sitting bolt upright with the head in a chin-
down position). Concentrating on the swallowing process can
also help reduce choking.
Mealtime Tips
Feed when alert
Dentures in
Feed at eye level, not standing over the patient
Ensure mouth is empty between spoonfuls
Avoid environmental distractions and conversations during
mealtime.
Prescribed, adapted equipment utensils
Multidisciplinary team
Dokter /
Neurolog
Perawat Apoteker
Dentures in
Terapi
wicara Pasien Dietisien
Keluarga Fisioterapi
Okupasi
terapi
Terima Kasih

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MNT Stroke

pada pasien Geriatri

Energy intake : 25-45 kcal/kg

High risk of High risk of

Texture modified diet,

Regular Screening and monitoring

Symptoms of dysphagia include :

Early recognition of signs and symptoms, implementation of an

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