Stroke's Malnutrition Link: Understanding The Unexpected Risk

how can stroke lead to malnutrition

Stroke is a leading cause of death and disability worldwide. Malnutrition is a common problem in stroke patients, with a prevalence of 6-62%. It is associated with poor outcomes, including increased risk of infection, longer hospital stays, poorer functional recovery, and higher mortality rates.

Malnutrition in stroke patients can be caused by a variety of factors, including dysphagia, which affects more than 50% of stroke survivors and can lead to aspiration pneumonia and subsequent malnutrition. Other factors include reduced food intake, neurological and cognitive deficits, depression, and comorbidities such as diabetes and hypertension.

The risk of malnutrition is higher in patients with a history of stroke, and it tends to worsen over time. Older age is also a significant risk factor, as aging is associated with changes that can affect nutritional status, such as loss of taste and smell, poor appetite, and poor oral health.

Nutritional status can be assessed using various tools, such as the Malnutrition Universal Screening Tool (MUST), Nutritional Risk Screening 2002 (NRS-2002), and the Mini Nutritional Assessment short form (MNA-SF). These tools consider factors such as body mass index (BMI), weight loss, food intake, and laboratory tests like albumin levels.

Identifying and managing malnutrition in stroke patients is crucial to reducing the risk of complications and improving outcomes.

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Dysphagia

The symptoms of dysphagia include coughing, choking, gagging, and a gurgly or wet-sounding voice during or after swallowing. People with dysphagia may also experience weight loss, frequent heartburn, and a feeling of food being stuck in the throat or chest.

The diagnosis of dysphagia is usually made through a combination of clinical evaluation, imaging tests (such as videofluoroscopy or fiberoptic endoscopic evaluation of swallowing), and swallowing tests (such as the water swallowing test or the multiple-consistency test).

The treatment of dysphagia in stroke patients aims to improve swallowing function and reduce the risk of complications such as aspiration pneumonia, dehydration, and malnutrition. Treatment options include compensatory strategies (such as postural adjustments and altering bolus characteristics) and rehabilitative approaches (such as tongue strengthening exercises, thermal-tactile stimulation, and neuromuscular electrical stimulation).

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Previous stroke

In addition to previous stroke, other risk factors for malnutrition in stroke patients include:

  • Malnutrition on admission
  • Dysphagia
  • Diabetes mellitus
  • Tube feeding
  • Reduced level of consciousness
  • Age
  • Sex
  • Smoking
  • Alcohol consumption
  • Hypertension
  • Depressed mood
  • Pneumonia
  • Infection

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Diabetes mellitus

The connection between diabetes and stroke relates to how the body handles blood glucose to make energy. Most food we eat is broken down into glucose to give us energy. Glucose enters a person's bloodstream and travels to cells throughout the body after food digestion. For glucose to enter cells and provide energy, it needs a hormone called insulin. The pancreas is responsible for producing this insulin in the right amounts. The pancreas does not make insulin for people with Type 1 diabetes. In people with Type 2 diabetes, the pancreas either makes too little insulin, or muscles, the liver and fat do not use insulin correctly. As a result, people with untreated diabetes end up with too much glucose in their blood, leaving their cells unable to receive enough energy. Over time, excessive blood glucose can increase fatty deposits or clots in blood vessels that may lead to stroke.

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Tube feeding

Enteral tube feeding is recommended to start within 24 hours of hospital admission as it is associated with improved survival rates. NGT is the preferred method for short-term feeding in the acute phase of a stroke as it can be easily placed at the bedside. However, insertion of an NGT can be difficult, and the tube can be easily dislodged by confused or agitated patients, which may lead to fatal complications.

PEG tube feeding is considered a more secure method for long-term nutritional support, but it is an invasive procedure with increased risks of morbidity and mortality. It is usually recommended for patients who require tube feeding for more than 28 days and should be placed after the patient's condition has stabilised (14-28 days after admission).

The decision to use NGT or PEG depends on the patient's condition and the expected duration of tube feeding. The benefits and risks of each method should be carefully considered, and the tube feeding process should be closely monitored to prevent complications.

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Reduced level of consciousness

A stroke can lead to a reduced level of consciousness, which is any measure of arousal other than normal. A stroke can cause an altered level of consciousness due to alterations in the chemical environment of the brain, insufficient oxygen or blood flow in the brain, or excessive pressure within the skull. A reduced level of consciousness can also be caused by sleep deprivation, malnutrition, allergies, environmental pollution, drugs, and infection.

The Glasgow Coma Scale (GCS) is a tool used to measure the level of consciousness and has become the method of choice for documenting neurologic findings over time and predicting functional outcomes. The GCS involves checking orientation, and people who are able to promptly and spontaneously state their name, location, and the date or time are said to be oriented. A normal sleep stage from which a person is easily awakened is also considered a normal level of consciousness.

A stroke can cause an early consciousness disorder (ECD), which refers to an acute disorder of consciousness in the early stages of an acute ischemic stroke. ECD is prevalent in Chinese patients with acute ischemic stroke, with risk factors including advanced age, stroke severity, and massive cerebral infarction. In a study, ECD was found in 35% of patients admitted within 24 hours of acute ischemic stroke onset, and nearly a third of those patients were in a state of decreased consciousness or coma upon admission.

Impairment in consciousness is common in acute stroke patients and is correlated with clinical outcomes. The underlying mechanism is not completely understood, but functional MRI (fMRI) studies have shown that changes in brain activity and connectivity are associated with altered states of consciousness in stroke patients. Disruptions in the default mode network (DMN), a functional network typically observed during resting-state imaging, have been linked to an impairment of consciousness. The DMN includes the posterior cingulate cortex, the precuneus, the inferior parietal, and the medial prefrontal cortex regions.

In summary, a stroke can lead to a reduced level of consciousness due to various factors, and this can be assessed using tools like the GCS. ECD is a common occurrence in acute ischemic stroke patients, with risk factors including advanced age and stroke severity. Impairment in consciousness in acute stroke patients is associated with clinical outcomes, and fMRI studies have shown disruptions in brain activity and connectivity, particularly in the DMN.

Frequently asked questions

The risk factors for malnutrition in stroke patients include:

- Malnutrition on admission

- Dysphagia

- Previous stroke

- Diabetes mellitus

- Tube feeding

- Reduced level of consciousness

- Alcohol consumption

- Hypertension

- Male sex

- Depressed mood

- Pneumonia

- Infection

- Smoking

- Age

- Stroke history

- Bilateral hemiplegia

- High modified Rankin score

- Low Korean Mini-Mental State Examination

- Stroke duration

- Brunnstrom stage of the proximal upper extremity

- Functional dysphagia score

- Penetration-aspiration scale

- Stroke progression

- Electrolyte abnormality

- Stroke history

- Bilateral hemiplegia

- Modified Rankin score

- Korean Mini-Mental State Examination

- Pneumonia

- Functional dysphagia score

The consequences of malnutrition in stroke patients include:

- Poor functional outcome

- Increased risk of infection and complications

- Prolonged length of hospital stay

- Reduced functional improvement during rehabilitation

- Exacerbated brain damage

- Increased mortality rates

Malnutrition in stroke patients can be prevented or treated through:

- Early identification and management of malnutrition

- Dietary modifications

- Specific therapeutic strategies to ensure adequate nutritional intake

- Nutritional interventions as part of a multidisciplinary team effort

- Enteral tube and oral feeding

- Strategies to wean from tube feeding

The limitations of current approaches to assessing and addressing malnutrition in stroke patients include:

- Lack of a universally accepted definition of malnutrition

- Lack of a gold standard for nutritional status assessment

- Non-nutritional metabolic stroke consequences that can mimic signs of malnutrition

- Inadequate consideration of nutritional care in the multidisciplinary approach to stroke diagnosis and management

- Lack of consistent attempts to compare the usefulness and reliability of different tools/procedures for assessing malnutrition

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