Guideline Clinical Nutrition in Patients With Stroke
Experimental & Translational Stroke Medicine
Wirth, R., Smoliner, C., et al. (2013).
Experimental & Translational Stroke Medicine, 5(1), Article ID 14.
This guideline provides recommendations for the assessment and management of nutrition in individuals with stroke. As the guideline spans various interventions for nutrition management (e.g., tube feeding, nutritional supplementation), some recommendations are outside of the scope of speech-language pathology and audiology. However, pertinent recommendations are provided on screening, assessment, and management of dysphagia.
German Society for Clinical Nutrition (DGEM)
<p>This publication is an English translation and summary of the first chapter of a larger guideline that addresses clinical nutrition in neurology. The full guideline, available <a href="http://www.dgem.de/leitlinien" title="http://www.dgem.de/leitlinien" class="ApplyClass">here</a>, is published in German only.</p>
<p>The data in this guideline are also included in another document which can be found in the Associated Article section below.</p>
Dysphagia assessment should be completed as early as possible post-stroke (CCP). If dysphagia continues past discharge, assessment may be repeated "at least once per month for 6 months after stroke manifestation" (Grade C; p. 4).
Dysphagia assessment can provide graded evaluation of severity, "linked to appropriate protective and rehabilitative measures and can systematically offer nutritional recommendations" (p. 4). Scales to consider for grading dysphagia include the Gugging Swallowing Screen (GUSS) or the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) (Grade C).
"During the first days of illness the [clinical bedside assessment] CBA can be repeated in dysphagic stroke patients on a daily basis. If dysphagia persists, CBA can be carried out thereafter at least twice per week and before discharge.... If the CBA is indicative of an improvement or a worsening of swallowing function an additional instrumental assessment ... can be considered" (p. 4). Instrumental assessment options provided are fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallowing study (VFSS) (Grade C).
"A reliable, timely, and cost effective instrumental swallow evaluation might be useful in acute stroke patients" (p. 3), since clinical bedside evaluation may have limited ability to detect silent aspiration or determine efficacy of specific interventions. A videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) can be used (Grade C).
Texture modified food and liquids of a safe texture should be given to individuals with dysphagia after stroke after swallowing assessment "e.g. careful evaluation by the speech-language pathologists and/or videofluoroscopic or endoscopic examination" (CCP; p. 8).
In individuals requiring dysphagia assessment post-stroke, "the [clinical bedside assessment] may be performed by trained personnel, typically a speech language pathologist, according to a [standardized] protocol" (Grade C; p. 3).
"The majority of conscious dysphagic stroke patients with tube feeding should have additional oral intake, according to the kind and severity of dysphagia" (Grade B; p. 7).
All individuals with stroke should receive formalized swallow screening (Grade B). The following instruments can be considered for individuals with acute stroke:
<ul>
<li>Water Swallowing Test (WST);</li>
<li>Multiple Consistency Test, originally published as the Gugging Swallowing Screen (GUSS); and</li>
<li>Swallowing Provocation Test (SPT).</li>
</ul>
Individuals with stroke who fail dysphagia screening should receive a thorough dysphagia assessment. Those who initially pass, but have "other known clinical predictors of dysphagia ... such as a severe neurological deficit, marked dysarthria or aphasia or a distinct facial palsy" (p. 3), should also receive further dysphagia assessment (Grade B).
"Nasogastric tube feeding does not interfere with swallowing training. Therefore, dysphagia therapy shall start as early as possible also in tube-fed patients" (Grade A; p. 7).
