Journal of Neuroscience Nursing:
Malnutrition and Risk of Malnutrition in Patients With Stroke: Prevalence During Hospital Stay
Mosselman, Machteld J.; Kruitwagen, Cas L. J. J.; Schuurmans, Marieke J.; Hafsteinsdóttir, Thóra B.
Machteld J. Mosselman, RN MSc, is a Staff Member at the Geriatric Consultation Team, St. Antonius Hospital, Nieuwegein, The Netherlands.
Cas L. J. J. Kruitwagen, MSc, is a Biostatistician at the Julius Center for Health Sciences and Primary Care, Clinical Health Sciences, Faculty of Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
Marieke J. Schuurmans, PhD RN, is a Professor of Nursing at the Department of Rehabilitation, Nursing Science and Sport, Clinical Health Sciences, Faculty of Medicine, University Medical Center Utrecht, Utrecht University, and at the Research Centre for Innovations in Health-care, University of Applied Sciences Utrecht, Utrecht, The Netherlands.
Questions or comments about this article may be directed to Thóra B. Hafsteinsdóttir, PhD RN at T.Hafsteinsdottir@umcutrecht.nl. She is an Associate Professor at the Department of Rehabilitation, Nursing Science and Sport, Clinical Health Sciences, Faculty of Medicine, University Medical Center Utrecht, Utrecht University, and at the Research Centre for Innovations in Health-care, University of Applied Sciences Utrecht, The Netherlands, and is an Adjunct Associate Professor at the Faculty of Nursing, University of Iceland, Reykjavík, Iceland.
The authors declare no conflicts of interest.
Background: Although various studies have shown high prevalence of malnutrition in hospitalized patients with stroke, recent studies on how the nutritional status of patients with acute stroke develops during the first weeks of hospital stay are scarce. Information is lacking concerning the identification of patients with stroke who are at risk of malnutrition during an acute hospital stay, because these patients may have a significant chance to improve their nutritional status.
Purpose: This study aimed to investigate the prevalence of malnutrition and risk of malnutrition of patients with acute stroke during the first 10 days of hospitalization.
Methods: A prospective, descriptive study was conducted in a neurological department of a university hospital in The Netherlands. Seventy-three patients with acute stroke were included, of which 23 patients could be followed up after 10 days. The nutritional status was determined with the Mini Nutritional Assessment at admission and after 10 days.
Results: At admission, 5% of the patients (n = 73) were malnourished, 14% were at risk of malnutrition, and 81% were well nourished. Of the patients who could be followed up (n = 23), at admission, no patients were malnourished, 9% were at risk of malnutrition, and 91% were well nourished; whereas 10 days later, 26% of these patients were malnourished, 39% were at risk of malnutrition, and 35% were well nourished. This means that, within the followed-up group, the proportion of patients with malnutrition or risk of malnutrition increased significantly during hospital stay from 9% to 65%.
Conclusions: Our study shows that the prevalence of malnutrition and risk of malnutrition in patients with acute stroke increases strongly during the first 10 days of admission. Therefore, screening of the nutritional status of these patients throughout this period is highly recommended to enable timely nutritional intervention and nutritional management of these patients.
Malnutrition of hospitalized patients with stroke is a serious problem. Studies have shown malnutrition to increase the risk of infections, pressure ulcers, and gastrointestinal bleeding, and it is associated with a lower functional status, poststroke depression, increased length of stay in the hospital, and higher mortality (FOOD Trial Collaboration, 2003; Dávalos et al., 1996; Davis et al., 2004; Gariballa, Parker, Taub, & Castleden, 1998a, 1998b; Shen et al., 2011; Westergren, Karlsson, Andersson, Ohlsson, & Hallberg, 2001; Yang et al., 2009; Yoo et al., 2008). Malnutrition also raises the costs for healthcare (Correia & Waitzberg, 2003). The prevalence of malnutrition among hospitalized patients with stroke, measured at varying periods after stroke, varies from 6% to 62% (Brynningsen, Damsgaard, & Husted, 2007; Choi-Kwon, Yang, Kim, Jeon, & Kim, 1998; Crary, Carnaby-Mann, Miller, Antonios, & Silliman, 2006; Dávalos et al., 1996; Davis et al., 2004; FOOD Trial Collaboration, 2003; Foley, Salter, Robertson, Teasell, & Wodbury, 2009; Gariballa et al., 1998b; Hama et al., 2005; Martineau, Bauer, Isenring, & Cohen, 2005; Nip, Perry, McLaren, & Mackenzie, 2011; Poels, Brinkman-Zijlker, Dijkstra, & Postema, 2006; Shen et al., 2011; Tsai & Shih, 2009; Westergren et al., 2001; Yang et al., 2009). The great variation in prevalence found in these studies can be attributed for a substantial part to the heterogeneity of the patient population, the nutritional assessment methods as well as the time of measurement (Foley et al., 2009).
Nurses, in collaboration with other healthcare professionals, have an important responsibility in the nutritional management of patients and in optimizing patients’ nutritional status. Pryor and Smith (2002) defined “observation assessment and interpretation” as well as “administering and monitoring therapeutic interventions” as two important domains of rehabilitation nursing practice. In spite of proven negative clinical outcomes of malnutrition, the screening of nutritional status and treatment of malnutrition during hospital stay is still not a standard practice. In more than half of malnourished patients staying in various settings including hospitals, malnutrition is not recognized or refereeing for treatment does not take place (Elia, Zellipour, & Stratton, 2005). Studies have also shown that there is a lack of nutrition-related information in nursing and medical documents (Rasmussen et al., 2004; Waitzberg, Caiaffa, & Correia, 2001), whereas the use of nutritional guidelines emphasizing standardized early nutritional screening improved the recognition of malnutrition and nutritional status of patients (Kondrup, Allison, Elia, Vellas, & Plauth, 2003). Also, patients at risk of malnutrition have a good chance to improve their nutritional status provided that interventions are taken timely (Guigoz, 2006).
Knowing the prevalence of malnutrition of patients with acute stroke at admission and during hospital stay gives insight in the importance of preventive nutritional interventions during hospitalization. Studies have shown that, at admission to the hospital, 16%–49% of patients with acute stroke were already malnourished (Crary et al., 2006; Davis et al., 2004; Gariballa et al., 1998a, 1998b; Martineau et al., 2005; Yoo et al., 2008). The average length of hospital stay for patients with hemorrhagic stroke in 2005 was 8.4 days, and for patients with ischemic stroke, it was 5.6 days in the United States (Russo & Andrews, 2008). The average length of hospital stay of patients with stroke was 13 days in the Netherlands in 2004 (Franke, Wieren, & Poos, 2008). An important question is: How does the nutritional status of patients with stroke develop during the hospital stay? Studies detecting patients with acute stroke who are at risk of malnutrition during the first weeks of hospital stay are very scarce, and insight into this group is needed. Only three studies were found investigating how the nutritional status of these patients develops during the hospital admission period. Yoo et al. (2008) in Korea found an increase in malnutrition from 12% to 20% during the first week of hospitalization, and Dávalos et al. (1996) in Spain found an increase from 16% to 35% during the first two weeks. Also, Gariballa and colleagues (1998a, 1998b) found a significant deterioration of nutritional parameters in patients with acute stroke during the first four weeks of hospitalization, with the most dramatic deterioration in nutritional status being seen in the first two weeks. However, no recent study has been conducted on how the nutritional status of patients with stroke develops during hospital stay. On the basis of this knowledge, the aim of this study was to assess the nutritional status and the risk of malnutrition of patients with stroke at admission to the hospital and to explore how the nutritional status of these patients develops during the first 10 days of hospitalization and if there was a relationship between the clinical outcomes and the nutritional status of patients.
A prospective, descriptive design was used to measure the nutritional status and nutritional risk of patients during hospitalization. The study took place on a stroke unit of a university hospital in the Netherlands. The study was approved by the local research ethics committee.
Included in the study were patients with the diagnosis of a stroke, defined by the World Health Organization as a clinical syndrome consisting of “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin” (World Health Organization, 1989). Patients were excluded if they were too ill, bed bound, or not able to communicate.
Nutritional status was measured at admission (t1 = day 2–5) and again at day 10 (t2 = day 9–12). Also, functional status was measured, and demographic data and information on clinical variables were collected. Data were obtained from patients, their relatives, nurses, or medical records. All measures were recorded by specially trained research nurses (MM, YU).
Demographic Data and Health Characteristics
Demographic data and outcome measures reflecting intact functions were recorded including the patient’s age, gender, type of stroke, other chronic disorders, medications, swallowing problems, communication problems, length of stay, and other data that were collected from patient records.
Nutritional status was measured using the Mini Nutritional Assessment (MNA; Vellas et al., 1999). The MNA is a two-step procedure: (1) the MNA-SF (short form) is used to screen for malnutrition and risk of malnutrition, whereas (2) the full MNA is used to assess nutritional status. The MNA includes 18 items, including anthropometric measurements: body mass index (BMI), mid-arm circumference, calf circumference, weight loss, a global assessment (six questions related to lifestyle, medication, and mobility), a dietary questionnaire (eight questions related to number of meals, food, and fluid intake), and a subjective assessment (self-perception of health and nutrition). The MNA-SF is composed of 6 of the 18 items, with a maximum score of 14 and scores of ≥12 indicating a satisfactory nutritional status. A screening score of ≤11 indicates possible malnutrition and a need to proceed to the assessment stage of the MNA (Rubenstein, Harker, Salva, Guigoz, & Vellas, 2001). The assessment stage has 12 questions, with a maximum score of 16, and the maximum score of the complete MNA is 30. The MNA total score distinguishes between elderly patients who are well nourished (score ≥ 24), have malnutrition (score < 17), or are at risk of malnutrition (score = 17–23.5). Nearly three quarters of patients with stroke are aged 65 years or older (Internet Stroke Center, 2011); and for this age category, the MNA’s sensitivity was found to be 96%, its specificity was 98%, and its predictive value was 97% (Vellas et al., 1999). Concerning reliability of the MNA, a Cronbach’s coefficient of 0.65 was found in a study of 59 Swedish adults with memory impairment (Holm & Soderhamn, 2003), whereas the interobserver reliability of the MNA ranged from 0.51 to 0.89 (Bleda, Bolibar, Parés, & Salvà, 2002). Concerning the validity of the MNA, a number of studies have shown that the MNA is a moderate-to-good predictor of malnutrition and the risk of developing malnutrition, although its predictive value increased when biochemical markers were added or assessment by a physician was done to corroborate the findings (Guigoz, 1994).The sensitivity of the MNA, referring to its ability to identify people who are malnourished or at risk of malnutrition, was found to be 70% or higher in nine studies (Christensson, Unosson, & Ek, 2002; Delacorte et al., 2004; Donini et al., 2002; Murphy, Brooks, New, & Lumbers, 2000; Read et al., 2005; Thomas et al., 2002; Thorsdottir et al., 2005; Visvanathan, Penhall, & Chapman, 2004; Wikby, Ek, & Christensson, 2006). The sensitivity of the MNA-SF ranges from 86% to 100% compared with the full MNA or other nutritional parameters (Cohendy, Rubenstein, & Eledjam, 2001; Rubenstein et al., 2001; Visvanathan et al., 2004). The specificity of the MNA, referring to its accuracy in identifying those who are not malnourished, was investigated in three studies and found to be 70% or higher compared with other nutritional parameters (Delacorte et al., 2004; Thomas et al., 2002; Visvanathan et al., 2004). The specificity of the MNA-SF ranges from 30% to 100% as compared with other nutritional parameters (Azad, Murphy, Amos, & Toppan, 1999; Murphy et al., 2000; Vivanathan et al., 2004). To optimize reliability, the two researchers were trained in using the MNA. Nutritional status at admission was measured by relating the questions of the MNA to the prestroke period. Nutritional status at day 10 was measured by relating these questions to the hospital stay period.
Weight was measured with a portable, mechanical, calibrated chair scale (Seca, model 927) or a standing scale (Tefal Sence, PP 1015BO/26E-2606 R), and patients were weighed in their pyjamas (nightgown or t-shirt and simple light trousers or light tracksuit). The height was measured with the patient standing, when possible. Alternatively, the patient was measured stretched out in bed and not by demispan as prescribed in the MNA, because of the hemiparesis in part of the patients with stroke.
The functional status of the patients, representing disability and handicap, was measured at admission with the Barthel Index (BI; Mahoney & Barthel, 1965) and the Rankin Scale (RS; Bamford, Sandercock, Warlow, & Slattery, 1989). The BI rates 10 functions on a scale from 0 (fully dependent) to 20 (independent), representing the patient’s ability to carry out the everyday activities (Mahoney & Barthel, 1965). The RS is one of the most used measures in stroke outcome research. It is a 6-point scale that grades patients on their overall level of independence with reference to previous activities. The reliability of the RS in terms of interobserver agreement and reproducibility has been evaluated with satisfactory results (Bamford et al., 1989).
Means and percentages were calculated for demographic and clinical outcome measures at admission. To check whether there were significant differences between the included and excluded patients, we compared these using Pearson’s chi square test and the independent samples t test. To assess the significance of differences between the patients of whom complete data were available and the drop-out patients, we used the Fisher’s exact test, the Pearson’s chi square test, and the Mann–Whitney test. The significance of the change in nutritional status was tested by using the McNemar test. To assess if nutritional status (T2) was associated with clinical outcome of patients (T1), the Barnard’s test and the Fisher’s exact test (two sided) were used. A p value of <.05 was considered significant. All analyses were performed with the Statistical Package for the Social Sciences (SPSS) 14.
Inclusion of Patients and Demographic Data
Of the 165 patients with acute stroke admitted to the ward in the study period, 73 patients could be assessed for their nutritional status at admission (t1). After 10 days (t2), 23 patients were assessed for nutritional status as 50 patients were lost to follow up because of various reasons including early discharge, of which the researchers were not timely warned about discharge measurement, functional handicaps, and inability to communicate, or death. Therefore, complete data at t1 and t2 were available from 23 patients (32%; Figure 1).
The baseline (t1) characteristics of the total group of patients included and the group of complete cases are summarized in Table 1. Comparison between the included and not-included patients showed significant differences on the length of stay in the hospital (p = .005), type of stroke (p < .0005), and discharge destination (p = .001). Comparison of the 23 complete cases with the 50 drop-out patients showed differences on aphasia (p = .023), length of stay (p = .005), and discharge at home (p = .012).
Nutritional Status at Admission (t1)
Of the total group of patients, 59 patients (81%) were well nourished, 10 patients (14%) were at risk of malnutrition, and four patients (5%) were malnourished according to the MNA. Hence, at admission, 14 (19%) of the patients were malnourished or were at risk of malnutrition. Of the total group of patients, the mean MNA-SF screening score was 12.0 (±2.2), the mean weight was 79.7 kg (±14.9), and the mean BMI was 26.4 (±4.8; Table 2).
Change in Nutritional Status for the Complete Cases of Patients During Hospital Stay (t1 and t2)
In the final group, at admission, 21 patients (91%) were well nourished, two patients (9%) were at risk of malnutrition, and no patients were malnourished. After 10 days, eight patients (35%) were well nourished, nine patients (39%) were at risk of malnutrition, and six patients (26%) were malnourished. Fifteen patients (65%) were malnourished or at risk of malnutrition at t2, which was significantly higher than at t1 (p ≤ .005; Table 2). Analysis at individual level shows that, of the 21 well-nourished patients (91%) at admission, nine patients (39%) became at risk of malnutrition and four patients became malnourished. The two patients at risk of malnutrition at t1 both became malnourished at t2. There was no significant change in mean weight and BMI between t1 and t2 (p = .180 and p = .168, respectively; Table 3).
Nutritional Status in Relation to Clinical Outcome Variables
Considering if there was a relationship between clinical outcomes of patients at T1 and nutritional outcome at T2, no significant association was found for the following variables measured: gender (p = .32), living situation (p = .45), discharge destination (p = .89), type of stroke (p = .45), swallowing disorders (p = .41), walking abilities (p = .11), functional status measured with the RS (p = .46), or functional status measured with the BI (p = .064). These associations were measured with the Barnard’s test, except for walking abilities and BI-functional status that were measured with the Fisher’s exact test.
This study was designed to investigate the prevalence of malnutrition and risk of malnutrition among patients with acute stroke during their first 10 days of hospital stay. At admission, 5% of the included patients were malnourished, 14% of the patients were at risk of malnutrition, and 81% of the patients were well nourished. Among the patients who could be followed up, the prevalence of malnutrition and risk of malnutrition together was significantly higher at day 10 (65%) than at the beginning of the hospital stay (9%).
The findings of the study are important because there is a lack of studies investigating the change in nutritional status of patients with stroke during the hospital stay and concerning the prevalence of malnutrition or undernourishment in these patients. Detecting patients at risk of malnutrition during this time is highly important because these patients are more likely to have a decrease in caloric intake (Vellas et al., 1999). If nutritional interventions are timely provided by nurses and other healthcare professionals, malnutrition may be prevented.
In our study, 19% of the patients were malnourished or at risk of malnutrition on admission to the hospital. This prevalence falls within the prevalence range of 6%–62% found in earlier studies with patients with stroke conducted during admission (Brynningsen et al., 2007; Choi-Kwon et al., 1998; Crary et al., 2006; Dávalos et al., 1996; Davis et al., 2004; FOOD Trial Collaboration, 2003; Foley et al., 2009; Hama et al., 2005; Martineau et al., 2005; Nip et al., 2011, Poels et al., 2006; Shen et al., 2011; Tsai & Shih, 2009; Westergren et al., 2001; Yang et al., 2009). The great variation in the prevalence in these studies makes it difficult for any meaningful comparison. There is no clear definition of malnutrition or a gold standard for measuring malnutrition, which results in the use of a wide range of criteria (Foley et al., 2009). Likewise, a comparison of the prevalence of the groups at risk of malnutrition is also difficult. When “suspected of malnutrition” or “having moderate malnutrition” is considered similar to being at risk of malnutrition, the 16% in this category found by Martineau and colleagues (2005) is consistent with our findings. However, our findings differ considerably from the 0.5% moderately malnourished patients found by Davis and colleagues (2004). We cannot compare our findings with those found by Crary et al. (2006) who used the MNA also for patients with stroke, because they did not differentiate between patients at risk of malnutrition and those who were malnourished. Because elderly patients at risk of malnutrition can generally be treated successfully when interventions are begun in a timely manner (Vellas et al., 1999) and based on the evidence from this study and other studies, a significant number of patients with stroke have a chance of improvement if interventions occur promptly.
Considering the change in nutritional status during hospital stay within the followed-up group, we found a significant increase of the group of patients with malnutrition or at risk of malnutrition from 9% to 65% between admission and day 10. This matches the findings of an earlier study showing a significant decline of nutritional status during the first two and four weeks of admission (Gariballa et al., 1998a, 1998b). However, Nip and colleagues (2011) found that 7% of the patients were malnourished and 66% were at risk of malnutrition during admission to the hospital, and at discharge, only 5% of the patients were malnourished; whereas the group of patients at risk had increased to 74%. In this study, however, the median stay at the hospital was 24 days, whereas in our study, the length of stay was 15 days (n = 73) and 19.5 days (n = 23). Concerning the BMI, there is no consensus on BMI criteria for malnourishment among older groups; lower limits as high as 24 kg/m2 have been advocated (Beck & Ovesen, 1998), and findings based on a cut point of 20 kg/m2 may be regarded as conservative. Although the BMI and weight of patients in our study declined during hospital stay, this was not significant (p = .168 and p = .180, respectively) as measured with the Wilcoxon matched-pairs test. This apparent contradiction with our MNA results may be explained by the fact that the MNA is able to detect people at risk of malnutrition who do not have weight loss yet (Vellas et al., 1999).
Although prior studies have found significant associations between nutritional status and various clinical outcome parameters of patients with stroke, this was not the case in our study. Other studies showed that malnourished patients with stroke had lower functional status, more risk of complications including gastrointestinal bleeding, more risk of infections including pneumonia, more risk of pressure sores, higher stress reactions, longer length of hospital stay, and higher mortality (Dávalos et al., 1996; Davis et al., 2004; FOOD Trial Collaboration, 2003; Gariballa et al., 1998a; Shen et al., 2011; Westergren et al., 2001; Yang et al., 2009; Yoo et al., 2008). The lack of association between the nutritional status and clinical outcomes in our study may be because of the small sample size. Nip and colleagues (2011), however, found that younger age, worse functional status measured with the BI, and a higher energy intake in the early stages of admission predicted the extent and rate of restoration of functional abilities by discharge.
One limitation of this study is the small number of patients that could be included and followed up for the second measurement after 10 days. The difficulties of recruitment and drop of patients with acute stroke are well known (Gariballa et al., 1998a, 1998b; Nip et al., 2011). Gariballa et al. (1998b) included 201 patients with stroke and had 96 patients after 2 weeks and 51 patients after 4 weeks for follow-up measures (Gariballa et al., 1998b). Nip et al. (2011) included 100 patients with stroke and, after about 3 weeks of admission, had 38 participants. We tried to estimate the influence that this would have on the generalizability of our results. Patients who could not be included were more ill than those included, had a significant higher prevalence of hemorrhage, and were significantly more often discharged to another ward or hospital instead of home. Because illness is a risk factor for malnutrition (Stratton et al., 2003), this may indicate that the prevalence of and risk for malnutrition may even be higher in patients with acute stroke than those found in our study. Within the included group, patients who dropped out for measurement at day 10 in comparison with those who could be followed up had a significantly shorter length of stay, had less aphasia and paresis at the right side of the body, and were more frequently discharged home, which indicates that they were less ill. This may indicate an overestimation in the prevalence of being at risk for malnutrition or undernourishment that we found at t2. It is impossible to determine which of these opposite aspects had more influence on our results. In any case, the large deterioration in nutritional status found in the patients in our study remains. We do, however, recommend repeating or replicating the study with a large sample. Another limitation concerns the lack of validation of the MNA for the assessment of patients with stroke (Foley et al., 2009) and for measuring change in the nutritional status over a 10-day period. The MNA was originally developed for healthy or frail elderly people and not for the acutely ill (Guigoz, 2006). It contains nutritional items concerning appetite and food intake as well as items concerning the functional and psychological statuses. Half of the six screening items relate to the previous 3 months. In our first measurement, we chose to relate the questions in the MNA to the prestroke period, although we realize that not taking into account the effect of the stroke might have resulted in a slight underestimate of patients at risk of malnutrition. However, because 90% of the patients were admitted to the hospital at the day of stroke onset, we assumed that their actual nutritional status had not been influenced by the stroke at that time. For the second measurement, we related the questions to the situation in the 10 days after the stroke. This short time period, compared with the 3-month period of some of the items of the MNA, might have caused an overestimation of the deterioration of nutritional status at t2. However, we think that the overall influences of the sudden decline of the functional and psychological statuses, the appetite, and the nutritional intake, which occurred simultaneously in many of the patients, exerted a negative influence on the nutritional status quite fast. On the basis of this, we consider our findings concerning the nutritional deterioration to be valid.
Although, in other studies, the MNA was found to be easy and fast to use (Vellas et al., 2000), it appeared to be moderately applicable in our study. Weighing, measuring height, and obtaining adequate and useful answers for the MNA questions often appeared too time consuming and difficult. Dicke and Rasmussen (2004), who tested the applicability of the MNA for elderly hospitalized patients, and Bauer et al. (2005), who used the MNA for screening elderly acute patients at admission, also had a dropout of patients because patient problems like aphasia sometimes made use of the MNA difficult. These and our findings indicate that the MNA is moderately applicable for patients with acute stroke. Tsai and Shih (2009) used a population-adapted MNA without BMI, which enhanced the application of the MNA among patients with stroke in the rehabilitation phase. Whether this would also improve the applicability for use in patients with stroke in the acute phase is not known, but based on our experience, this might prove to be an improvement in the applicability.
On the basis of our study and other studies, we conclude that a considerable part of patients with acute stroke are malnourished or at risk of malnutrition when admitted and their nutritional status deteriorates strongly during hospital stay. Because of the negative clinical outcomes in malnourished patients with stroke, the higher health costs for healthcare, and the growing incidence of stroke worldwide, it is of utmost importance to follow the advice of many clinical practice groups such as the American Society of Parenteral and Enteral Nutrition, the European Society of Parenteral and Enteral Nutrition, and the British Society of Parenteral and Enteral Nutrition to screen the nutritional status of all patients at admission (Kubrak & Jensen, 2007), so that timely interventions may be provided in an efficient way and as early as possible. Also, clinical practice guidelines, like the Clinical Rehabilitation Nursing Stroke Guideline, present a total of 19 evidence-based recommendations focusing on detecting, preventing, and treating malnutrition in patients after stroke (Hafsteinsdóttir & Schuurmans, 2009). This guideline includes interventions focusing on the observation of symptoms of malnutrition in patients with stroke, the screening of nutritional status using valid and reliable screenings instruments, interventions that nurses can use when assisting patients with eating problems, how to improve the patient’s position while eating, and how to provide patients with extra meals and snacks during the day. Also, a continuous monitoring of the nutritional status in patients at risk is emphasized. Furthermore, the guideline includes interventions based on qualitative studies exploring the experiences of patients with stroke while eating (Hafsteinsdottir & Schuurmans, 2009). Jacobsson, Axelsson, Osterlind, and Norberg (2000) found that 53% of the patients experienced problems with eating because they were afraid of choking, experienced pain in the mouth and throat, had thirst, experienced changes in taste, and experienced shame humiliation. Describing mealtime preparation, eating, fatigue, mood, and nutritional status among persons with stroke 6 months after discharge from hospital, Westergren et al. (2001) found that difficulties with swallowing, ingestion, and energy to eat occurred among 27%, 20%, and 7% of the patients, respectively. Difficulties with cooking and buying food occurred among 57% and 56% of the patients, respectively, and 41% of the patients were at nutritional risk. Sixty-one percent of the patients experienced feeling full of energy less than some of the time, whereas 15% had felt gloomy and sad at least some of the time during the past 4 weeks. The study showed that patients with stroke and fatigue are more prone to have poor nutritional status and those with poor nutritional status are at a greater risk of fatigue. Besides fatigue, also, difficulties with buying food and ingestion were associated with nutritional risk. Because nutritional deficits occur a long time after stroke onset, it is important to assess aspects of the mealtime preparation and the eating process and, when necessary, provide food delivery service and eating assistance to prevent a vicious circle of undernourishment and fatigue to develop.
Nutritional support of malnourished patients can improve patient outcomes and the effect of hospital treatment. A Cochrane review showed positive effects of various nutritional interventions on nutritional status and various patient outcomes (Milne, Potter, & Avenell, 2005), and positive effects were found on clinical outcomes of patients with stroke (Gariballa et al., 1998c; Perry & McLaren, 2003). All patients with acute stroke need to be screened at admission, and as the nutritional status often deteriorates, as shown in our study, screening should be repeated weekly. This recommendation was also included in the report of the Public Health Committee (2001, p. 20). Nutritional management is a fundamental aspect of nursing practice and should include nutritional screening into their standard nursing assessment of patients with stroke (Arrowsmith, 1999; Corish & Kennedy, 2000).
Conclusions and Recommendations
Although this study showed that only a small number of patients with stroke are malnourished on admission, a substantial number of patients are at risk of malnutrition, and the nutritional status of most of these patients deteriorates significantly in the first 10 days of hospitalization. Because of its negative impact on patient outcomes, malnutrition should be prevented and treated as soon as possible. One of the most important aspects of nursing is nutritional management, and nurses need not only to conduct nutritional screening of all patients with stroke on admission and repeat this weekly but also to provide timely interventions for patients at risk or those who are already malnourished. Given the growing incidence of stroke and the serious consequences of malnutrition on patient outcome after stroke and taking into account increased healthcare costs for malnourished patients, this will become even more important in the future.
Malnutrition is related to worsening or negative clinical outcomes in patients hospitalized after stroke. In this study, the rate of malnutrition and risk of malnutrition among this category of patients during the first 10 days of hospital stay was examined. At admission, the main part of the patients had a sufficient nutritional status. But during hospital stay, the prevalence of malnutrition and risk of malnutrition together increased significantly. Because of this, screening of the nutritional status of patients with stroke at admission and during hospital stay is necessary to take timely interventions. Other studies related to changes in the nutritional status of patients with stroke during an acute hospital stay need to be undertaken in larger samples.
We thank the patients who participated in the study and the nurses and other professionals on the neurological ward of the UMC Utrecht for assisting with and facilitating the study. We specially thank Yvette Riedstra and Coby Schoneveld for their contribution to the data collection.
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acute cerebrovascular accident; hospitalization; malnutrition; prevalence; prospective studies
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