1. 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

3. Nutrition in Acute Stroke: How it started

4. Baseline No national and no international Guidelines on nutrition in acute stroke

5. Ten years ago… First meeting of a interdisciplinary working group „ Nutrition in patients with acute stroke“ August 2005 Frankfurt/Germany

6. 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)

7. German Guideline- Societyes German sociréty for Neurology(DGN) German Society for Geriatrics (DGG) German Society for Nutritional medicine (DGEM)

8. 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

9. andreas.leischker@alexianer.de 3 years later….. Expiry date of guideline is exhausting.

10. andreas.leischker@alexianer.de DGEM Guideline Clinical Nutrition „Neurology“ Stroke Parkinsons Disease Huntingtons Disease Multiple Sclerosis

11. “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

12. Oral Nutritional Supplements (ONS)

13. 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 2007 Normal nutrition 2016 Normal nutrition PLUS ONS

14. andreas.leischker@bonifatius-lingen.de Average amount of ONS per patient 14 liters 34 days

15. FOOD Trial Part 1 Dennis M, Lewis, S, Cranswick G: Health Technology Assessment 2006 27,9 % of patients did not tolerate ONS

16. andreas.leischker@bonifatius-lingen.de Modified Rankin Scale after 6 month´s 0% 20% 40% 60% 80% 100% Normal dietNormal diet plus supplements Allocated treatment Percentage of patients Rankin 0 Rankin 1 Rankin 2 Rankin 3 Rankin 4 Rankin 5 Dead

17. FOOD Trial Part 1: Pressure sores during hospital stay No ONS: 1,3 % ONS: 0,7 % P= 0,05

18. Recommendation ONS ONS is not recommended in general

19. Who should recieve ONS Patients with malnutrition risk for malnutrition Risk for pressure sores AWMF Leitlinie Ernährung des Schlaganfallpatienten 2007

20. Enteral Nutrition: When?

21. „Patients with prolonged dysphagia anticipated to last for more than 7 days should receive tube feeding (within 72 hours) (C)

22. andreas.leischker@alexianer.de Dysphagia Screening Water Swallowing Test ( WST) Multiple Consistency Test( Gugging Swallowing Screen,GUSS) Swallowing Provocation Test

23. 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

24. 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

25. andreas.leischker@alexianer.de 25 andreas.leischker@alexianer-krefeld.de Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS)

26. 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 !

27. Dysphagia follow up after discharge At least once per month during the first 6 months

28. andreas.leischker@alexianer.de Nasogastric or PEG ?

29. andreas.leischker@alexianer.de Randomization within 1 week FOOD Trial 3 - PEG vs NG 321 pts with dysphagia 162 PEG 159 nasogastral

30. andreas.leischker@alexianer.de Food Trial 3 – Outcome at Follow-Up 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NGPEG Allocated treatment Percentage of patients 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)

31. andreas.leischker@bonifatius-lingen.de NG tube

32. 15.9.2006andreas.leischker@bonifatius-lingen.de “ Food for Thought ?”

33. andreas.leischker @maria-hilf.de How are patients fed 6 months later ?

34. 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% NGPEG Allocated treatment Percentage of patients Normal NG PEG Dead

35. 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

36. 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

37. 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

38. Who should get a PEG earlyer? Mechanically ventilated stroke patients should receive a PEG at an early stage (B)

39. andreas.leischker@bonifatius-lingen.de What to do if patients put out the NG tube

40. 15.9.2006 andreas.leischker@bonifatius-lingen.de

41. 15.9.2006 andreas.leischker@bonifatius-lingen.de

42. 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

43. 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

44. andreas.leischker@alexianer.de

45. With or without pump?

46. In stroke patients tube feed should preferably be applied with a feeding pump (C). AWMF Leitlinie Enterale Ernährung des Schlaganfallpatienten 2007

47. Outlook European Society for Parenteral and Enteral Nutrition ( ESPEN) European Guideline on nutrition in stroke „in progress“…

49. Stroke Prevention :News

50. 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]

51. 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

52. Take Home Messages

53. ONS Only for patients with risk for malnutrition or risk for pressure sores

54. Place nasogastric tube early if enteral nutrition is still necessary : place PEG in stable phase

55. Repeat Dysphagia Assessment regulary for at least 6 months- including time after discharge

56. Take coffee breaks for prevention!