DGEM Leitlinie Klinische Ernährung AG Neurologie. Was wird in der neuen Leitlinie stehen?

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1 DGEM Leitlinie Klinische Ernährung AG Neurologie Was wird in der neuen Leitlinie stehen? Dr. Rainer Wirth, Borken Dr. Martin Jäger, Dinslaken C. Smoliner, Borken Prof. Rainer Dziewas, Münster PD Dr. Tobias Warneke, Münster Dr. Andreas H. Leischker, M.A. 1 andreas.leischker@alexianer-krefeld.de

2 Bestehende Leitlinien zu Ernährung bei neurologischen Erkrankungen ESPEN: Keine ASPEN: Keine 2 andreas.leischker@maria-hilf.de

3 Ausgangsbasis: S3 Leitlinie Ernährung von Patienten mit akutem Schlaganfall Erstes Arbeitsgruppentreffen im August 2005 Fertiggestellt im August Monate vor Ablauf des Haltbarkeitsdatums Anfrage bei der DGEM, ob eine Aktualisierung durchgeführt werden soll 3 andreas.leischker@alexianer-krefeld.de

4 Krankheitsbilder Akuter Schlaganfall Morbus Parkinson Chorea Huntington Multiple Sklerose 4 andreas.leischker@alexianer-krefeld.de

5 Akuter Schlaganfall 5 andreas.leischker@alexianer-krefeld.de

6 Neu: Detaillierte Aussagen zum Screening und Assessment auf Dysphagie 6 andreas.leischker@alexianer-krefeld.de

7 Dysphagiescreening A formalised screening for dysphagia should be performed in all stroke patients (B) Methoden: Water Swallowing Test (WST) Multiple-Consistency-Test Swallowing-Provocation-Test (SPT) 7 andreas.leischker@alexianer-krefeld.de

8 Water Swallowing Test (WST) Nur durchführen, wenn der Patient mindestens 15 Minuten sitzen kann Zunächst 3x1 Teelöffel dann bis zu 50 ml Bei klinischen Zeichen einer Aspiration Nahrungs- und Flüssigkeitskarrenz 8 andreas.leischker@alexianer-krefeld.de

9 Multiple-Consistency-Test ( Guggings Swallowing Screen GUSS) Speichelschlucken Angedickte Flüssigkeiten Flüssigkeiten Feste Nahrung Bei jeder der vier Stufen wird auf Aspirationszeichen und auf eine Verzögerung des Schluckaktes geachtet Es resultiert ein Score zwischen 0-20 mit konkreten Empfehlungen zur Ernährung in vier Stufen 9 andreas.leischker@alexianer-krefeld.de

10 Multiple-Consistency-Test ( Guggings Swallowing Screen GUSS) Semisolid, liquid and solid textures successful Slight/no dysphagia minimal risk of aspiration Normal diet Regular liquids (first time under supervision of the SLT or a trained stroke nurse) Semisolid and liquid texture successful and solid unsuccessful Slight dysphagia with a low risk of aspiration Dysphagia diet (pureed and soft food) Liquids very slowly (one sip at a time) Functional swallowing assessment Refer to a SLT 5-9 Semisolid swallow successful and liquids unsuccessful Moderate dysphagia with a risk of aspiration Semisolid textures (such as baby food) and additional parenteral feeding All liquids thickened Pills crushed and mixed with thick liquid No liquid medication Functional swallowing assessment Refer to a SLT 0-4 Preliminary investigation unsuccessful or semisolid swallow unsuccessful Severe dysphagia with a high risk of aspiration Non per os Functional swallowing assessment Refer to a SLT 10 andreas.leischker@alexianer-krefeld.de

11 Swallowing-Provocation-Test (SPT) Ein dünner Katether wird durch die Nasenhöhle geschoben und kurz vor dem Velum platziert Injektion von 0,4 ml sterilem Wasser Messung der Latenzzeit zwischen Injektion und Schluckreflex Normal: weniger als 3 Sekunden Sensitivität 74 %( falsch negativ bei Störung der oralen Phase), Spezifität 100 % 11 andreas.leischker@alexianer-krefeld.de

12 Dysphagieassessment All stroke patients failing the dysphagia screening should be evaluated with a more thorough assessment of swallowing function (C) 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 or a distinct facial palsy ( C) 12 andreas.leischker@alexianer-krefeld.de

13 Dysphagieassessment: Methoden Clinical bedside assessment (CBA) Instrumental assessment of dysphagia 13

14 Clinical bedside assessment (CBA) The CBA may be performed by trained personnel, typically a speech language pathologist, according to a standardised protocol (e.g. the protocols published by Logeman or by Bartolome) (C). 14 andreas.leischker@alexianer-krefeld.de

15 Instrumental assessment of dysphagia The limitations of clinical testing, in particular insufficient detection of silent aspiration and poor information on the efficacy of an intervention, imply that a reliable, timely and cost effective instrumental swallow evaluation might be useful in acute stroke patients (C) Assessment of dysphagia should be carried out as early as possible (KKP) 15 andreas.leischker@alexianer-krefeld.de

16 Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS):Score

17 Clinical Bedside Assessment (CBA): Verlaufsuntersuchungen Täglich in den ersten Tagen nach dem Akutereignis Dann zweimal wöchentlich vor Entlassung Einmal monatlich in den ersten 6 Monaten nach dem Akutereignis 17 andreas.leischker@alexianer-krefeld.de

18 Zeitpunkt der enteralen Ernährung bei Schlaganfallpatienten

19 Schwere Dysphagie Patients with prolonged severe dysphagia anticipated to last for more than 7 days should receive early tube feeding (at least within 72 hours) KKP 19 andreas.leischker@alexianer-krefeld.de

20 Nasogastrale Sonde oder PEG?

21 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 (Ib/A) andreas.leischker@maria-hilf.de

22 If enteral feeding is likely to be needed for a longer period of time (> 28 days), a PEG should be chosen and placed in a stable clinical phase (after days) andreas.leischker@alexianer-krefeld.de

23 Welche Patienten sollten frühzeitig eine PEG erhalten? Beatmete Schlaganfallpatienten sollten frühzeitig eine PEG- Sonde erhalten (Empfehlungsgrad B)

24 Food for Thought?

25 Was tun, wenn Patienten die Nasensonde herausziehen?

26 andrea s.leisc

27 andrea s.leisc

28 If a nasogastric tube is rejected or not tolerated by the patient and if artificial nutrition will probably be necessary for more than 14 days, early placement of a PEG should be considered (B). A nasal bridle ( nasal loop) is an effective alternative(b)

29 PEG oder PEJ? Gastric tube placement does not present a higher risk for aspiration pneumonia than duodenal or jejunal tube placement (Ib). 29 andreas.leischker@alexianer-krefeld.de

30 Schlucktraining Tube feeding does not interfere with swallow training. Therefore, dysphagia therapy shall start as early as possible also in tube fed patients (A) 30

31 Zusätzlich orale Ernährung The majority of conscious dysphagic stroke patients with tube feeding should have additional oral intake, according to the kind and severity of dysphagia 31

32 Orale Supplemente ( Trinknahrung )

33 Eine Verordnung von Trinknahrung für alle Schlaganfallpatienten kann generell nicht empfohlen werden.

34 Welche Schlaganfallpatienten sollten Trinknahrung erhalten? Patienten, bei denen eine perorale Nahrungsaufnahme möglich ist mit Einem Risiko für Mangelernährung Manifester Mangelernährung Risiko für Dekubitalulcera

35 Texturmodifikation After assessment of the swallowing act (e.g. careful evaluation by the speech-language pathologists and/ or videofluoroscopic or endoscopic examination) a texture modified diet and thickened fluids of the safe texture can be given to patients 35 andreas.leischker@alexianer-krefeld.de

36 Texturmodifikation Patients on texture modified diets tend to have lower nutrient and fluid intakes than patients on a normal diet (III), therefore a dietician should be consulted and nutrition support should be initiated in cases of insufficient intake over a prolonged period of time 36 andreas.leischker@alexianer-krefeld.de

37 Morbus Parkinson 37

38 Body weight should be monitored in a 3 month interval, when Parkinson`s disease is in stable condition. When changes in vigilance, progression of stages of disease, weight loss take place, body weight should be recorded acutely and monitored at least monthly.(c) The evaluation of nutritional status and dietary education should be part of the routine work-up of PD patients. Patients at risk for malnutrition or with malnutrition need dietary interventions in a multidisciplinary approach. (C) BM(Biomedical endpoints) 38 andreas.leischker@alexianer-krefeld.de

39 Dysphagieassessment Assessment for dysphagia should be done at Hoehn & Yahr stage 3. Assessment for dysphagia should be repeated every 12 months, when there are no clinical signs for dysphagia and when Parkinson`s disease is in a stable condition. When the clinical situation is worsening assessment for dysphagia should be done immediately. (C) 39 andreas.leischker@alexianer-krefeld.de

40 Vitamin D Patients with Parkinson s disease have an increased risk for hip fractures and osteoporosis (IIa) BM( Biomedical endpoints) Supplementation of vitamin D is recommended in PD to reduce risk of osteoporosis and fractures. (B) BM( Biomedical endpoints) 40 andreas.leischker@alexianer-krefeld.de

41 Medikamente Patients with PD should take their levodopa medication at least 30 minutes before meals or 60 minutes after meals. (A) It is an option to take the medication with a small snack, if taking the medication without food causes nausea 41 andreas.leischker@alexianer-krefeld.de

42 Protein Redistribution Diet ( PRD) In PD with motor fluctuations during levodopa treatment, redistribution of daily protein meal may be an option as soon as motor fluctuations occur. In a Protein Redistribution diet, most of the daily protein it eaten at time when no medication is taken, e.g. in the evening (B) PRD (Protein Redistribution Diet) resulted in improved motor symptoms in patients with motor fluctuations under levodopa. This may lead to an improvement in QOL.(III) 42 andreas.leischker@alexianer-krefeld.de

43 Eiweißreduzierte Kost(LPD) Low-protein diets (LPD, < 0.8 g/kg/day of ideal weight/day) are not based on sufficient evidence and are therefore not recommended (B) BM( Biomedical endpoints) 43

44 Weitere Kapitel Chorea Huntington Multiple Sklerose 44

45 Nächste Konsensuskonferenz /

46 46