Prevalence nutritional disorders among patients hospitalised for stroke and discopathy in the neurology department

Introduction

Nutritional disorders pose a huge health problem worldwide. Malnutrition is an indirect cause of many diseases and requires a long exhausting treatment that is not always effective. This increases the number of complications, mortality, and costs of treatment [1, 2]. In Poland, the symptoms of malnutrition on admission to hospital are found in about 30% of patients [3]. Eating disorders in neurological patients are characterised by an excess or deficiency of nutrients, often as a result of absorption and nutrition disorders. They may relate to progressive, acute and chronic degenerative diseases, impair food intake, swallowing, and mastication [4].
Among neurological disorders predisposing to malnutrition, brain injuries are the most frequent. The disease causes difficulties with self-care, disorientation, reduced intellectual capacity, as well as persistent swallowing disorders and dysphagia. Symptoms of dysphagia occur in 40–60% of patients with stroke, especially with bulbar and pseudobulbar palsy [5]. In addition, cognitive deficits after stroke are often accompanied by various kinds of emotional disorders. Depression worsens the prognosis, exacerbating the disorder. Natural nutrition may be difficult or impossible, which largely affects the development of malnutrition [4, 6, 7].
Literature provides poor data on nutritional status in patients with discopathy. However, acute spinal pain syndromes also have a huge impact on patients’ weight loss due to persistent severe pain, as well as dizziness and headaches together with nausea and vomiting, which frequently accompany cervical discopathy and impair food intake. Moreover, treatment of underlying diseases and diet customising have to be considered [6].
Assessment of nutritional status has to take into consideration data relating to the general health of the patient, the course of treatment, and social conditions, collected by means of interviews, questionnaires, physical examination, anthropometric measurements, and biochemical analyses [8]. Anthropometric measurements, designed to detect anatomical abnormalities caused by malnutrition as a result of negative energy balance, exhibit changes in body fat and the occurrence of oedema. Weight, height, arm circumference, thickness of skin folds on the triceps muscle, and fat tissue content are used to calculate body mass index and the percentage of body fat [9]. The diagnostic procedure allows assessment of the degree and type of malnutrition, and choice of appropriate form of therapy [10, 11].

Aim of the research

The aim of the study was to assess the degree of malnutrition in patients with stroke and discopathy, hospitalised in the neurology department.

Material and methods

The study group consisted of 141 patients, including 90 patients with stroke and 51 with discopathy, hospitalised in the J. Sniadecki Provincial Hospital in Bialystok. The study was conducted from November 2012 to May 2013 and was approved by the Bioethics Committee of the Medical University of Bialystok.
Medical records and a proprietary questionnaire were used to collect research material. The first part of the questions of the survey referred to gender, age, weight, height, education, occupational status, and place of residence. The rest of the questions of the survey were related to diagnosis, comorbidities, type of nutrition during hospitalisation, patient’s capacity for self-care, and time of hospitalisation. The study involved patients treated for at least 7 days. Before recruitment to the study, respondents were informed about the anonymous nature of participation. Body mass index (BMI) was calculated and assessed for each patient on admission and after hospitalisation. The analysis of medical records focused on current and coexisting diseases as well as dietary habits.
Body mass index was calculated on the basis of the generally accepted formula, assuming the BMI standard to range from 18.5 to 24.9 kg/m²: BMI = body weight (kg)/height2 (m)2.

Statistical analysis

Statistical analysis was performed using the nonparametric Pearson chi-square (c2) test of independence. The result of the statistical test is test probability (p-value), where low values indicate statistical significance. The p-value was considered statistically significant for p < 0.05, and highly significant for p < 0.01. To calculate this value the Mann-Whitney test was used, and to calculate the correlation coefficient the Spearman nonparametric test was applied.

Results

The study sample consisted of a similar group of women (49%) and men (51%) aged from 30 to over 70 years. Ischaemic stroke was diagnosed more often in women (66.2%) and discopathy more in men (43.4%). A statistically significant difference was found between the patients’ age and diagnosis (p < 0.001). The highest percentage rate of stroke was noted in patients over 70 years of age. Discopathy was most common in patients aged 56–60 years (60%).
In the group of pensioners, the incidence of ischaemic (75.3%) and haemorrhagic stroke (7.1%) was significantly more frequent than in other occupational groups. Among patients working physically (66.7%) and mentally (72.2%), an analogous correlation was found for discopathy problems (Table 1).
The type of disease was shown to affect nutrition significantly. Patients with discopathy received meals only by mouth. Among the patients studied, 17% required enteral nutrition and these were patients with stroke (Table 2).
The scope of self-care among neurological patients depends on the type of diagnosis. The vast majority of patients with discopathy (63.3%) were self-reliant. Patients after ischaemic (87.9%) and haemorrhagic (17.2%) stroke needed a varied degree of help from others, which was statistically significant (Table 3).
Differences in BMI were shown on admission and after hospitalisation in both men and women, and a downward trend was indicated. A slightly greater drop in BMI was found in women after hospital stay (from 24.1 to 23.3 kg/m²). There was no relationship between BMI and place of residence (Table 4).
On admission, the highest BMI (40.0 kg/m²) was displayed by patients with discopathy, and the lowest (16.2 kg/m²) by patients with ischaemic stroke. A falling tendency in BMI was observed during hospitalisation in all the diseases studied. The greatest falling tendency was found in haemorrhagic stroke patients (–1.17) (Table 5).
Patients with neurological disorders frequently followed a specific dietary treatment. Those who did not follow any high protein diet exhibited greater weight loss on discharge from hospital (Table 6).
Data in Table 7 indicate the existence of statistically significant correlation between age and BMI in both groups of patients with stroke (p < 0.05). In the group of patients with ischaemic stroke a negative correlation in the measurement of BMI at discharge was seen (p < 0.05), which was not observed on admission to the hospital. This may suggest that older patients after ischaemic stroke are more likely to have malnutrition while in hospital. In the case of patients with haemorrhagic stroke force depending statistically significant in age decreased at discharge.
Age was found to have no effect on the level of BMI; however, a long hospitalisation significantly influenced weight reduction. The longer the patients were hospitalised, their BMI was lower (Table 7).

Discussion

Malnutrition currently affects 35–55% of the population of highly developed countries, including 20% who require immediate, intensive nutritional treatment. In Poland, the number of patients with nutrition disorders is increasing. The problem relates primarily to chronically ill patients and is caused by deficiency of nutrients. Weight loss is a direct symptom. Malnutrition leads to reduced immunity and apathy, and contributes to general weakness of the body, which prolongs hospitalisation and increases financial expenditure [5, 12, 13]. Patients with stroke and severe chronic back pain often have no appetite, display low mood because of their health situation, and limited mobility. Rigidly fixed meal times are another difficulty, as they prevent patients from eating when they feel hungry [2].
It has been estimated that at the time of admission to hospital, 20–50% of all patients are malnourished. The percentage of patients whose nutritional status deteriorates during the hospital stay varies between 30% and 90%, whereas hospitalisation of undernourished patients is longer by 40–70% compared to those with normal BMI [1, 12]. A detailed assessment of the degree of malnutrition requires a number of anthropometric and biochemical examinations [13].
A multicentre study was carried out in Poland in the years 1999–2000, using BMI, arm circumference, peripheral blood erythrocyte/leukocyte/lymphocyte counts, serum haemoglobin, and albumin levels [14]. Over 3000 patients from medical treatment wards, including neurology, were recruited to the study. The results showed a correlation between the length of hospitalisation and the decrease in body weight, BMI, and arm circumference. Body weight reduction by 2% was observed in more than half of the patients. There was an evident decrease in haemoglobin, average albumin level, and lymphocyte count.
The present study used simple methods to assess medical documentation, and a questionnaire and anthropometric measurements in order to examine malnutrition. They were sufficient to confirm a falling tendency in BMI during hospitalisation in all the diseases studied. The greatest downward trend was found in haemorrhagic stroke patients (–1.17). Pensioners were a specific group, where weight deficiency was already higher at the time of admission to the neurology ward. The range of self-care and application of an individual diet was found to affect the degree of malnutrition.
Hafsteinsdottir et al. [15] conducted a study in a group of 73 patients after stroke, hospitalised in a university hospital in the Netherlands. The results showed that the risk and the incidence of malnutrition increased dramatically during the first 10 days in hospital. On admission, 5% of patients were undernourished, 14% were at risk of malnutrition, and 81% had normal BMI. On discharge from hospital, 26% of patients suffered from malnutrition, 39% were at risk of malnutrition, and 35% had normal body weight.
Malnutrition in Sweden was examined by Westergren et al. [16] in 2000 patients from nine hospitals. The researchers found reduced body weight and dietary abnormalities in 22–34% of the patients, noting the greatest weight loss in large hospitals. Similar results have been reported from Germany [17], Denmark [18], and Spain [19].
Potentially deteriorating nutritional status in the group of patients may be affected by other factors that were not studied, such as: lifestyle, physical activity, drugs, the primary prevention of cardiovascular disease, and pain. They need to be adaptable and to improve nursing and medical care, regardless of dietary treatment. An important role in reducing these factors should be played by patient education.

Conclusions

After hospitalisation, a decrease in BMI was observed in all patients regardless of diagnosis. The greatest falling tendency was noted in haemorrhagic stroke patients. The data suggest the need for preventive action to be taken in patients with neurological diseases diagnosed with malnutrition. Preliminary assessment of nutrition on admission to hospital and establishing a customised diet may help reduce the effects of malnutrition.

Conflict of interest

The authors declare no conflict of interest.

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Address for correspondence

Regina Sierżantowicz
Department of Surgical Nursing
Medical University of Bialystok
ul. Waszyngtona 15 A, 15-269 Bialystok, Poland
Phone: +48 85 745 07 77
E-mail: renatasierz@wp.pl