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Europa Medicophysica 2000 June;35(2):75-83

Copyright © 2000 EDIZIONI MINERVA MEDICA

lingua: Inglese

Nutrition and diet in stroke rehabilitation

Finestone H. M., Greene-Finestone L. S.

Department of Physical Medicine and Rehabilitation, London Health Sciences Centre, University Campus, University of Western Ontario, London, Ontario, Canada

Nutri­tional and die­tary ­issues are impor­tant to con­sider in the reha­bil­i­ta­tion of ­patients who ­have sus­tained a ­stroke. ­Stroke ­patients are nutri­tion­ally vul­ner­able ­because ­they ­have a ­large ­number of neu­ro­logic def­i­cits ­that can con­tribute to ­decreased die­tary ­intake and, even­tu­ally, mal­nu­tri­tion. ­This ­article ­focuses on gen­eral prin­ci­ples of nutri­tional assess­ment and the spe­cific nutri­tional and die­tary con­cerns of ­stroke ­patients. ­Among fac­tors con­trib­uting to ­eating dif­fi­cul­ties and nutri­tional impair­ment, dys­phagia is ­common ­after ­acute ­stroke. ­Other neu­ro­logic def­i­cits ­that may ­adversely ­affect the ­stroke ­patient’s ­ability to ­self-­feed ­include ­upper ­extremity par­al­ysis or ­paresis, ­apraxia, ­agnosia, ­right and ­left dis­or­ien­ta­tion, depres­sion, and ­visual ­neglect or ­denial of the par­a­lysed ­extremity. ­Stroke ­patients some­times ­exhibit ­eating-­related beha­viour prob­lems ­such as atten­tion-con­cen­tra­tion def­icits, ­eating too ­fast or too ­slowly, or for­get­ting to ­swallow. In the ­acute meta­bolic ­response to gen­eral ­injury, ­initially ­there is a ­decline in ­energy (­caloric) expen­di­ture and ­increased ­activity of the sym­pa­thetic ner­vous ­system, ­including ele­vated cor­tisol ­output. A hyper­met­a­bolic ­phase fol­lows in ­which ­energy expen­di­ture and ­nitrogen excre­tion are ­increased. ­This ­results in net ­losses ­from the pro­tein and fat com­part­ments of the ­body. The ­goal of the nutri­tional assess­ment is to ­help the ­patient ­attain or main­tain a suf­fi­cient ­level of ­energy and nutri­ents (­normal nutri­tion ­status) to ­reduce the ­risk of ­adverse out­comes asso­ciated ­with ­poor nutri­tion and pro­mote an ­optimal ­level of ­health. The nutri­tional assess­ment may ­take dif­ferent ­forms, ­ranging ­from ­brief ­screening ­tools to com­pre­hen­sive eval­u­a­tion. Anthro­po­metric and bio­chem­ical meas­ure­ments as ­well as phys­ical exam­ina­tion and med­ical and die­tary his­to­ries are ­useful in ­assessing nutri­tional ­status. ­Even ­though die­tary ­intakes can some­times ­appear to be ade­quate on assess­ment, cer­tain ­drugs, dis­ease ­states, or die­tary com­po­nents can ­affect inges­tion, absorp­tion, trans­por­ta­tion, util­iza­tion, or excre­tion of nutri­ents. One of the ­easiest ­ways to esti­mate nutri­tional ­status is to mon­itor ­weight and ­degree of ­weight ­change ­over ­time. The ­Body ­Mass ­Index (BMI) ­scale is a rec­om­mended ­method of ­assessing ­weight ­status. Unfor­tu­nately, it is not val­i­dated for ­adults ­over 65 ­years, who ­form the ­majority of ­stroke ­patient pop­u­la­tion. Under­nu­tri­tion is pre­dic­tive of ­poorer func­tional ­status out­come and ­reduced func­tional improve­ment ­rate in ­acute ­stroke ­patients and ­those under­going reha­bil­i­ta­tion. Fine­stone et al. ­studied the rela­tion­ship ­between MBI ­scores and mal­nu­tri­tion on a reha­bil­i­ta­tion ser­vice: mal­nour­ished ­patients con­sis­tently dem­on­strated ­lower MBI ­scores ­than ade­quately nour­ished ­patients at all inter­vals at ­which ­they ­were eval­u­ated: admis­sion, 1 ­month, 2 ­months, and 2-4 ­months of ­follow-up. ­They ­also had sig­nif­i­cantly ­longer ­lengths of ­stay (p<0.01). The ­risk of dehy­dra­tion in ­stroke ­patients is ­often under­ap­pre­ciated. ­This is par­tic­u­larly ­true of dys­phagic ­patients ­receiving all nutri­tion by ­mouth. ­Guide-­lines for the nutri­tional man­age­ment of ­stroke ­patients are ­described.