How to manage post-stroke anorexia and fatigue?

From the Guidelines

Managing post-stroke anorexia and fatigue requires an individualized nutritional treatment plan and a multifaceted approach combining medical treatment, lifestyle modifications, and supportive care. For post-stroke anorexia, start with a nutritional assessment and implement small, frequent, nutrient-dense meals that are easy to swallow, as suggested by the ESPEN guideline on clinical nutrition in neurology 1. Consider appetite stimulants such as mirtazapine (15-30mg daily) or megestrol acetate (400-800mg daily) if appropriate. For fatigue, modafinil (100-200mg daily) or methylphenidate (5-10mg twice daily) may be prescribed, though evidence for their efficacy is limited. Implement energy conservation techniques including planned rest periods throughout the day and prioritizing essential activities.

Some key points to consider in managing post-stroke anorexia and fatigue include:

• Implementing an individualized nutritional treatment plan tailored to the specific needs of the patient, as this can help meet energy requirements and prevent weight and fat loss, and contribute to improvement of functional status and quality of life 1
• Addressing social isolation, which can be a significant barrier to exercise and physical activity in stroke patients, as highlighted in the American Heart Association scientific statement on physical activity and exercise recommendations for stroke survivors 1
• Assessing for depression and fatigue syndromes, as these can significantly impact patient motivation and ability to participate in physical activity and exercise, and treating underlying contributors such as depression, sleep apnea, or pain
• Ensuring adequate hydration and considering screening for vitamin deficiencies, particularly B12, folate, and vitamin D, supplementing as needed
• Regular reassessment is essential as these symptoms may improve over time with appropriate management and neurological recovery.

It is recommended that, whenever possible, a nutrition specialist should develop and monitor the individual nutrition care plan, as they have the skills required to understand the multiple causes of malnutrition or the factors that place the patient at risk of malnutrition, and can develop and monitor a nutrition care plan tailored to the specific needs of the patient 1.

From the Research

Post-Stroke Anorexia and Fatigue Management

To manage post-stroke anorexia and fatigue, several strategies can be employed:

• Nutritional support: Evidence-based guidelines for nutrition support following acute stroke can improve patient outcomes, including reducing infective complications and improving compliance with guidelines 2.
• Assessment of mealtime preparation and eating: Difficulties with mealtime preparation, eating, and fatigue are common among stroke survivors, and assessing these factors can help identify individuals at risk of nutritional deficits and fatigue 3.
• Treatment of associated conditions: Conditions such as depression, attentional impairment, and sleep apnoea syndrome can contribute to post-stroke fatigue, and treating these conditions can help alleviate fatigue 4.
• Pharmacological interventions: Modafinil, a wakefulness-promoting agent, has been shown to be effective in reducing post-stroke fatigue in some patients, particularly those with altered fronto-striato-thalamic functional connectivity 5.
• Management of dysphagia: Dysphagia is a common complication of stroke and can increase the risk of post-stroke fatigue; patient-tailored measures to reduce dysphagia and fatigue can enhance quality of life 6.

Risk Factors and Associations

Several risk factors and associations are relevant to post-stroke anorexia and fatigue:

• Age, single patients, female, disability, depression, attentional impairment, and posterior strokes are associated with post-stroke fatigue 4.
• Difficulties with buying food, ingestion, and lack of energy are associated with nutritional risk and fatigue 3.
• Dysphagia is independently associated with post-stroke fatigue, and the prevalence of fatigue increases with the severity of dysphagia 6.

Therapeutic Approaches

Therapeutic approaches to manage post-stroke anorexia and fatigue include:

• Low-intensity training and cognitive therapy to address fatigue and associated conditions 4.
• Treatment of associated depression and correction of risk factors such as inactivity, overweight, and sleep apnoea syndrome 4.
• Adaptation of activities to reduce fatigue and improve quality of life 4.
• Modafinil therapy for patients with post-stroke fatigue, particularly those with altered fronto-striato-thalamic functional connectivity 5.