LONG-TERM NASOGASTRIC TUBE FEEDING IN ELDERLY STROKE PATIENTS AN ASSESSMENT OF NUTRITIONAL ADEQUACY AND ATTITUDES TO GASTROSTOMY FEEDING IN ASIANS

Transcription

1 08 MAHADEVA/c/p_04 LORD_c 28/09/12 14:48 Page701 LONG-TERM NASOGASTRIC TUBE FEEDING IN ELDERLY STROKE PATIENTS AN ASSESSMENT OF NUTRITIONAL ADEQUACY AND ATTITUDES TO GASTROSTOMY FEEDING IN ASIANS F. ZAHERAH MOHAMED SHAH 1, H.-S. SURAIYA 2, P.J.-H. POI 1, K.S. TAN 1, P.S.M. LAI 3, K. RAMAKRISHNAN 4, S. MAHADEVA 1 1. Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603, Malaysia; 2. Department of Dietetics, University Malaya Medical Centre, Kuala Lumpur 59100, Malaysia; 3. Medical Education Research Development Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia; 4. Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603, Malaysia. Address for correspondence: Dr Sanjiv Mahadeva, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, sanjiv@ummc.edu.my Abstract: Background: Gastrostomy feeding is superior to long-term nasogastric (NG) feeding in patients with dysphagic stroke, but this practice remains uncommon in Asia. We sought to examine the nutritional adequacy of patients on long term NG feeding and identify barriers to gastrostomy feeding in these patients. Methodology: A prospective comparison of Subjective Global Assessment (SGA), and anthropometry (mid-arm muscle circumference, MAMC; triceps skinfold thickness, TST) between elderly stroke patients on long-term NG feeding and matched controls was performed. Selected clinicians and carers of patients were interviewed to assess their knowledge and attitudes to gastrostomy feeding. Results: 140 patients (70 NG, 70 oral) were recruited between September 2010 and February Nutritional status was poorer in the NG compared to the oral group (SGA grade C 38.6% NG vs 0% oral, p<0.001; TST males mm NG vs mm oral, p<0.001; MAMCmales mm NG vs mm oral, p<0.001). 45 (64.3%) patients on longterm NG feeding reported complications, mainly consisting of dislodgement (50.5%), aspiration of feed content (8.6%) and trauma from insertion (4.3%). Among 20 clinicians from relevant speciliaties who were interviewed, only 11 (55%) clinicians would routinely recommend a PEG. All neurologists (100%) would recommend a PEG, whilst the response was mixed among non-neurologists. Among carers, lack of information (47.1%) was the commonest reason stated for not choosing a PEG. Conclusion: Elderly patients with stroke on long term NG feeding have a poor nutritional status. Lack of recommendation by clinicians appears to be a major barrier to PEG feeding in these patients. Key words: Stroke, dysphagia, nasogastric tube, gastrostomy, PEG, elderly, malnutrition, Asia. Introduction Malnutrition is common among patients with stroke, with prevalence rates of 8-49% having been reported in the literature (1). Malnourished patients with stroke are recognised to develop more complications such as infections and pressure ulcers, and require longer in-hospital stays compared to well nourished patients with stroke. Additionally, the mortality rates of patients post stroke have been shown to be affected by the degree of malnutrition in these patients. Among 2,194 poststroke patients followed-up in the Feed Or Ordinary Diet (FOOD) trial, undernourished poststroke patients had a significantly higher risk of dying than normal poststroke patients at a median follow-up period of 196 days (2). Dysphagia post stroke is thought to occur in up to 45% of all strokes, compounding the problem of malnutrition (3). Gastrointestinal access in the short term, for up to 4 6 weeks is usually achieved via nasogastric tubes. If enteral feeding is likely to be needed for periods of more than 6 weeks, most international guidelines recommend a feeding gastrostomy (4). Gastrostomy tubes, commonly inserted by percutaneous endoscopic gastrostomy (PEG), allow feeding without the inconvenience, discomfort, and embarrassment of NG access, and patients receive more of their prescribed feed (5). There is Received October 13, 2011 Accepted for publication November 28, less interruption from tube displacement and fewer complications compared with NG feeding. The superiority of gastrostomy feeding over NG feeding in stroke has been demonstrated in a few studies, demonstrating an improvement in both nutritional status and clinical outcome compared with NG feeding (4, 6, 7). Despite the evidence supporting the role of gastrostomy feeding in post stroke patients, there are large numbers of patients, particularly in Asian societies, who appear to remain on long term NG tube feeding. Barriers to gastrostomy feeding are recognised to include patients or caregivers reservations, or even physician factors. In a study done to explore patients and their carers perceptions in the U.K., it was found that poor communication, lack of and inappropriate information, and attitudes of health care professionals were key barriers to gastrostomy feeding (8). Data on the preferences and practices of enteral tube feeding in elderly patients in South East Asia, the majority of whom have stroke, is sparse at present. It has been our personal observation that PEGs are less popular among our patients compared to long-term NGTs. This study aimed to identify post-stroke elderly patients on long term enteral tube feeding, to determine their nutritional status, and explore attitudes to gastrostomy feeding among carers and physicians looking after these patients.

2 08 MAHADEVA/c/p_04 LORD_c 28/09/12 14:48 Page702 LONG-TERM NASOGASTRIC TUBE FEEDING IN ELDERLY STROKE PATIENTS Methods Local institutional ethics committee approval was obtained before commencement of the study. A prospective study was conducted in a tertiary hospital, University Malaya Medical Centre (UMMC) and feeder residential/ long-term care institutions between September 2010 and February This study was divided into 2 components: i) a quantitative study of nutritional parameters in patients with long-term NG tube feeding, and ii) a survey of care-givers and clinicians on their knowledge and attitudes towards gastrostomy feeding. Quantitative study of nutrition parameters Nutritional parameters in patients with long term NG feeding were compared to controls in this component of the study. The inclusion criteria were as follows: elderly (aged > 60 years) stroke patients in inpatient, outpatient settings or in feeder longterm residential institutions during the period of study, and patients on NG tube feeding for more than 8 weeks. Age and sex-matched adults with stroke who did not require NG feeding were identified as controls for nutritional parameter comparisons. All the patients (study and control groups) had assessment of severity of stroke made by the Modified Rankin Scale (mrs). The mrs is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke (9). The scale runs from 0-6 as follows: 0 - No symptoms, 1 - No significant disability. Able to carry out all usual activities, despite some symptoms, 2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities, 3 - Moderate disability. Requires some help, but able to walk unassisted, 4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted, 5 - Severe disability. Requires constant nursing care and attention, bedridden, incontinent and 6 - Dead. Nutritional assessment of all patients was made using anthropometric measurements and Subjective Global Assessment (SGA) tool. Both of these instruments have previously been shown to be reliable and valid methods for assessing nutritional status in Malaysian patients with chronic disease (10). Anthropometry Anthropometric measurements taken included the following: midarm circumference (MAC), triceps skinfold thickness (TST) and midarm muscle circumference (MAMC). MAC was measured to the nearest centimeter with a measuring tape at the midpoint of the upper arm. TST, an established measure of fat stores, was measured to the nearest millimeter at the right arm using Harpenden skinfold caliper (Baty Ltd, British Indicators) in a standard manner. Three measurements were taken for both TST and MAC, with average values calculated and recorded. Mid-arm muscle circumference (MAMC), an established measure of muscle protein mass, was calculated from MAC and TST using a standard formula: MAMC = MAC - (3.1415*TSF) (11). Although a crude measure of nutritional status, all patients in the study also had a baseline body mass index (BMI) performed. Subjective global assessment Subjective global assessment (SGA) is a simple evaluation tool that allows physicians to incorporate clinical findings and subjective patient history into a nutritional assessment (12). Based on history taking and physical examination, nutritional ratings of patients are obtained as follows: well-nourished-a, moderately malnourished-b and severely malnourished-c. The SGA has been shown to be a valid and useful clinical nutritional assessment tool for assessing malnutrition in patients with stroke disease (1). Dietary intake and assessment The energy requirements and calorie intake of all patients were calculated to determine adequacy of dietary intake. A computerised software, Nutribase 8 (CyberSoft, Phoenix, AZ), was utilized for the purpose of this study. Generally, 30 kcal/kg/day (30 ml/kg/day of standard feeds) was taken as the amount of calories required, and the caloric requirements and estimation of the basal energy expenditure (B.E.E) was also calculated using the Harris-Benedict equation (13). Observations of feeding route and NG complications As no official data on the preferred choice of feeding route currently exists locally, we prospectively collected data on the frequency of either NG and PEG tubes in-situ among residents of long term institutional care during this period of study. The specific complications encountered by patients with long term NG feeding were additionally documented during the period of study. Survey on attitudes to PEG In the second part of this study, clinicians and care givers of patients on long-term NG feeding were interviewed using a structured questionnaire which enquiried about knowledge, awareness and barriers to gastrostomy feeding (Appendix 1). 20 clinicians from this institution were approached to participate in the study. In addition all carers of patients enrolled in the earlier part of the study were interviewed as well. Statistical analysis Sample size for the quantitative component of the study was calculated based on an estimated 30% level of malnutrition among cases (14) and approximately 10% malnutrition among controls (15). We calculated that a minimum number of 62 patients and 62 controls would have an 80% power to detect a significant difference in malnutrition between both groups, with an α value of An uncorrected chi-squared statistic was utilized to evaluate this null hypothesis. All continuous data was expressed as means with standard deviation and categorical 702

3 08 MAHADEVA/c/p_04 LORD_c 28/09/12 14:48 Page703 JNHA: CLINICAL TRIALS AND AGING data presented as proportions where appropriate. Continuous variables were analysed by student s t-test or Mann-Whitney U test where appropriate and categorical data analysed with the chi-square test. Statistical analysis was performed using SPSS (version 16; SPSS Inc., Chicago, IL) and significance assumed at a p value of < Results Choice of feeding route in long-term care institutions Fifteen long-term care homes, official feeder institutions for this hospital, were visited during the period of study. A total of 105 stroke patients were resident in these institutions at the time of visiting. Among these 105 patients, 52 (49.5%) were able to eat normally and 53 patients required enteral tube feeding. Among those who required tube feeding, 44 (83.0%) patients were on long-term NG feeding, whilst only 9 (17.0%) patients were on PEG feeding. Nutritional parameters in patients with long term NGT 140 patients (70 NG feeding, 70 controls) were recruited for this component of the study. The patients from the control arm (i.e. oral feeding) were recruited from various outpatient clinics as follows: Neurology clinic (n= 23, 16.4%), geriatric clinic (n= 29, 20.7%), and the Rehabilitation clinic (n= 6, 4.3%). In contrast, the majority of study patients (i.e. on long term NG) were recruited from residential homes (n= 54, 38.6%), and a smaller number from the stroke daycare centre (n= 6, 4.3%). The basic demographic and clinical characteristics of both the study and control groups are highlighted in Table 1. The mean age of the patients with long-term NG feeding was slightly higher compared to the control group (77.56 ± 8.01 NG vs ± 7.55 oral (years), p=ns), but no differences in gender nor ethnicity were observed. Patients on long term NG feeding had a shorter duration (51.4% NG vs 14.3% oral < 1 year duration) but a greater severity of stroke (34.3% NG vs 0% oral with severe disability) and were less likely to reside at home (40% NG vs 72.9% oral) (Table 1). Among the study patients, the mean calorie intake required was calculated at ± Kcal/ day. However, the mean calories received by patients was ± Kcal/ day, which was only 89.2 % of the required calories. 50 (71.4%) patients on long-term NG feeding did not achieve the required calories needed. Table 2 highlights the differences in nutrition parameters between study and control patients. A significantly lower proportion of SGA Grade A (24.3% NG vs 91.4% control) and higher proportion of SGA Grade C (38.6% NG vs 0% control) indicated greater malnutrition in the patients with long term NG feeding. Furthermore, significantly lower levels of MAC, MAMC, TST and BMI for both genders in the study patients compared to controls further confirmed the poorer nutrition status in these patients (Table 2). For all measurements, patients in the control group had similar values compared to the normal reference ranges for both male and female gender. Table 1 Demographics and characteristics of study and control group Characteristics Patient group Control group p-value (n=70) (n=70) Mean age ± SD (yrs) ± ± Age range (yrs) Gender [n(%)] Male 27 (38.6) 30 (42.9) 0.73 Female 43 (61.4) 40 (57.1) Ethnicity [n(%)] Malay 15 (21.4) 14 (20.0) 0.98 Chinese 37 (52.9) 38 (54.3) Indian 18 (25.7) 18 (25.7) Duration post stroke / on NG [n(%)] < 1 yr 36 (51.4) 25 (35.7) yrs 28 (40.0) 19 (27.1) yrs 3 (4.3) 10 (14.3) yrs 2 (2.9) 13 (18.6) > 10 yrs 1 (1.4) 3 (4.3) Residence Home 28 (40.0) 51 (72.9) Residential home 42 (60.0) 19 (27.1) Modified Rankin Scale [n(%)] (0) 42 (60.0) (65.7) 28 (40.0) 5 24 (34.3) 0 (0) Table 2 Differences in nutritional parameters between study patients and controls Parameters Patient Group Control Group p-value Normal Reference (Kcal/day) (Kcal/day) (n=70) (n=70) SGA* [n(%)] Grade A 17 (24.3) 64 (91.4) <0.001 NA Grade B 26 (37.9) 6 (8.6) Grade C 27 (38.6) 0 (0) Mean MAC ± SD (cm) Male ± ± 3.77 < ± 3.73 Female ± ± 4.79 < ± 3.85 Mean MAMC# ± SD (mm) Male ± ± < ± 35.1 Female ± ± < ± 27.3 Mean TST a ± SD (mm) Male ± ± 4.62 < ± 5.10 Female ± ± 5.29 < ± 7.12 Mean BMI b (kg/m 2 ) Male ± ± 3.39 < ± 4.07 Female ± ± ± 4.54 * Subjective Global Assessment; # Mid-arm muscle circumference. a. Triceps skinfold thickness. b. Body mass index Complications of NG tubes in study patients The frequency of complications of NG tube feeding was enquired from carers of patients in the study group. A total of 45 (64.3%) patients developed at least one complication, and a minority (n=25, 35.7%) had no complications. The complications encountered were: intentional tube dislodgement, n= 30 (42.9%), accidental tube dislodgment, n= 6 (8.6%), aspiration of feed content, n=6 (8.6%) and traumatic 703

4 08 MAHADEVA/c/p_04 LORD_c 28/09/12 14:48 Page704 LONG-TERM NASOGASTRIC TUBE FEEDING IN ELDERLY STROKE PATIENTS insertion of tube, n=3 (4.3%). Survey of attitudes towards PEG Clinician response A total of 20 clinicians from 4 specialties were chosen to participate in this study: 5 each from Neurology, Geriatrics, Rehabilitation Medicine, and Residential Home physicians. The median duration of clinical experience was 10 years, with a range from 8-23 years. Among the 20 clinicians, 11 (55%) answered "yes" to a question if they would routinely recommend PEG in patients requiring long term enteral feeding, whilst the other 9 (45%) answered "no". Among the four specialties, a positive recommendation for a PEG was as follows: neurology 5/5, rehabilitation medicine 2/5, residential home physicians 3/5 and geriatricians 1/5 (Figure 1). The attitude towards recommending a PEG or not was not found to be associated with years of clinical experience (5/11 10 years vs 6/11 > 10 years experience answered "yes"). Figure 1 Recommendation for PEG (i.e. "Yes" or "No") among clinicians from four specialities involved in the care of elderly stroke patients Clinicians were then asked to provide reasons for their decision regarding PEG recommendation. Among clinicians who recommended a PEG, the common reasons were as follows: convinced of benefit (54.5%); low risk of procedure (18.2%); previous good experience (9.1%); and combination of reasons (18.2%). Among clinicians who did not recommend a PEG, the common reasons were as follows: reluctance from family members (60%); risk of procedure (20%); and high cost and unavailability (10%). Care giver response The carers of all 70 patients on long term NG tube feeding in this study were interviewed. The basic demography of the carers were as follows: mean age 55.9 ± 9.0 years, 47 (67.1%) were female, 15 (21.4%) had secondary level and 55 (78.6%) had tertiary level education. Reasons given by carers for not opting for PEG for patients were as follows: not informed about a PEG by clinician n=33 (47.1%), fear of complications n=18 (25.7%), too invasive a procedure n=9 (12.9%), inadequate family consensus n=6 (8.6%) and deemed unhygienic n=4 (5.7%). Discussion This study has provided much needed data in relation to elderly Asian patients with stroke and enteral tube feeding. It has confirmed that the majority of elderly stroke patients remain on long-term NG feeding, despite recognised benefits of PEG (4). This study has also demonstrated that most elderly stroke patients on long-term NG feeding have significant malnutrition (37.9% SGA grade B and 38.6% SGA grade C) despite NG feeding. The nutritional status of NG fed patients were significantly less than patients with stroke who could eat normally. Whilst the study patients and controls were clearly not matched for stroke severity, the purpose of comparison was purely to illustrate the level of malnutrition present in patients on long term NG feeding. A better comparison may have been between only dysphagic stroke patients on long-term NG and those on PEG feeding. However, this was not possible due to the low numbers of stroke patients on PEG feeding in our population, as highlighted from our observation. Whilst the severity of stroke alone may have been responsible for the poorer nutritional status of patients on long term NG feeding (16), it is possible that NG feeding could have contributed to this. We demonstrated that 71.4% of NG fed patients were not able to meet their calorie requirements in this study, i.e. an inadequate intake may have led to persistence of malnutrition in these patients. One of the main reasons for this inadequate intake would have been due to disruption of enteral feeding as a result of NG tube complications. Frequent tube dislodgement, together with a delay in re-insertion, may have resulted in an inadequate time and volume of feeding in many patients. This disadvantage of NG tube feeding has been observed in randomised trials (RCT) evaluating nutritional status on nasogastric tube versus PEG. Nasogastric tubes were associated with a higher risk of death and worse outcomes such as being malnourished and more feeding interruptions due to mechanical failures, blockages and dislodgements when compared with PEG tubes (6, 7). In the light of these inadequacies associated with NG feeding, and the benefits of PEG feeding that have been described elsewhere, we sought to examine the barriers to PEG feeding in our patients. Our study demonstrated that clinicians involved in the long-term management of elderly stroke patients, i.e. geriatricians, rehabilitation medicine specialists and residential home physicians, were less likely to recommend a PEG compared to neurologists, who are usually more involved in the early management of patients with stroke in our 704

5 08 MAHADEVA/c/p_04 LORD_c 28/09/12 14:48 Page705 JNHA: CLINICAL TRIALS AND AGING setting. The non-neurologists cited "family reluctance" as the main reason for not pursuing PEGs in the patients with stroke. However, when we interviewed patients' carers, the message regarding benefits of PEG had clearly not been transmitted by clinicians, as almost 50% of these carers reported that they had not been informed about a PEG option. Most of these carers had tertiary education and hence should have been more receptive to modern medical practices. Attitudes to gastrostomy feeding in dysphagic patients with stroke have been mostly explored in Western countries. In a study of general practitioner's attitudes in Northern Ireland, it was reported that despite lack of formal education regarding PEGs in 90% of practitioners, a quarter of them had referred patients for PEG insertion (17). In the UK, exploring patient and their carers perception to PEG feeding found that only four out of sixteen patients and 11 out of 27 carers reported having a choice in the decision for PEG placement and only four patients and ten carers received sufficient information regarding the PEG. Poor communication, lack or inappropriate information and exclusion were key themes for not considering PEG (8). In another study assessing patients and family members attitudes towards PEG, it was found that the patients already on PEG feeding were positive about PEG placement, but the patients without PEGs were apathetic towards the value of PEG placement and were more concerned that the PEG would be embarrassing, look bad or be painful. Lack of objective knowledge about PEGs was expressed by patients and family members in the group without PEG, and was mentioned as a reason for not being more enthusiastic about the procedure, leading the authors to conclude that it is essential to provide education to patients and family members regarding PEG and education needs to be focused on the positive benefits of PEG placement, such as improved growth and increased energy (18). In Asia, few studies have explored the attitudes and barriers towards PEG feeding in elderly patients with dysphagia. In a recent qualitative study of community nursing institutions in Taiwan, Lin et al reported that 93.4% of the 427 tube-fed subjects were fed with a NG tube. The most common reasons for refusing to use PEG were 'too old to suffer from an operation', 'worried about wound infection or leakage after performing percutaneous endoscopic gastrostomy' and 'to keep subjects' body integrity' (19). The concept of a PEG being "too invasive" as reported in this Taiwanese study was also observed among carers in our study. This is largely a result of poor knowledge regarding PEG techniques on the part of the clinicians and carers alike and suggests that more education is warranted. However, the overwhelming use of NG feeding in long-term care institutions for the elderly in developed Asian nations like Taiwan (> 90% in this study) and even in Singapore (20) suggests that a "cultural" barrier to PEG may exist as well. This study is not without its' limitations. Clinicians interviewed in the study, although from varied specialities, were mostly from a single centre. Hence, their attitudes towards PEG may not be representative to other clinicians in this country. As mentioned earlier, the controls used for nutritional parameter comparisons were not matched for stroke severity as well. Nevertheless, this study remains novel for several reasons. It has provided valuable data on the nutritional status of elderly stroke patients on long term NG feeding, highlighting that feeding remains inadequate in this group of patients. Furthermore, we have highlighted that barriers to PEG feeding in our setting are mostly a result of poor-recommendation by clinicians, particularly non-neurologists. We believe that more education for these clinicians are needed to convince them of the benefits of PEG feeding. However, the possibility of a cultural barrier to PEG feeding in Asia needs further study and exploration. Appendix 1 Structured questionnaire used in the study to interview clinicians and carers on their knowledge and attitudes to PEG Attitudes to Gastrostomy Feeding - CARER Name Age Race Date Social (Education level) Have you heard regarding percutaneous gastrostomy (PEG) feeding? YES NO If yes, what are your reason(s) for not opting for PEG insertion and feeding? Please number your five top reasons: 1 most important, to 5 least important Inadequate information Attitude of healthcare givers eg: Cultural/Religious reason Heard frightening experiences Altered body image Fear of the procedure/complications Inadequate consensus among family members Cosmetic Hygienic purposes Financial constraints Poor support Others Please state : Attitudes to Gastrostomy Feeding - PHYSICIAN Name Subspecialty Date Years (Level) of experience Although it is generally recommended that patients receiving long term enteral feeding be on gastrostomy feeding, there are still a large number of patients on long term nasogastric feeding. We are conducting a study to evaluate possible causes for this. Please fill up this questionnaire as it will help us analyze this problem. In patients requiring long term enteral feeding (>8 weeks), do you routinely consider gastrostomy feeding? YES / NO If YES Why? Easy availability Cost is not an issue Convinced of benefit Low risk Family members keen Previous good experience Others : References If NO Why Unavailability High cost Not convinced of benefit Risk of procedure/complications Reluctance of family members Previous bad experience Others : 1. Martineau J, Bauer JD, Isenring E, Cohen S. Malnutrition determined by the patientgenerated subjective global assessment is associated with poor outcomes in acute stroke patients. Clin Nutr Dec;24(6):

6 08 MAHADEVA/c/p_04 LORD_c 28/09/12 14:48 Page706 LONG-TERM NASOGASTRIC TUBE FEEDING IN ELDERLY STROKE PATIENTS 2. Food Trial Collaboration. Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial. Stroke Jun;34(6): Gordon C, Hewer RL, Wade DT. Dysphagia in acute stroke. Br Med J (Clin Res Ed) Aug 15;295(6595): Gomes CA, Jr., Lustosa SA, Matos D, Andriolo RB, Waisberg DR, Waisberg J. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. Cochrane Database Syst Rev. 2010(11):CD Vanek VW. Ins and outs of enteral access: part 2--long term access--esophagostomy and gastrostomy. Nutr Clin Pract Feb;18(1): Park RH, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJ, et al. Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. BMJ May 30;304(6839): Norton B, Homer-Ward M, Donnelly MT, Long RG, Holmes GK. A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMJ Jan 6;312(7022): Brotherton A, Abbott J. Clinical decision making and the provision of information in PEG feeding: an exploration of patients and their carers' perceptions. J Hum Nutr Diet Aug;22(4): Farrell B, Godwin J, Richards S, Warlow C. The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. J Neurol Neurosurg Psychiatry Dec;54(12): Tai ML, Goh KL, Mohd-Taib SH, Rampal S, Mahadeva S. Anthropometric, biochemical and clinical assessment of malnutrition in Malaysian patients with advanced cirrhosis. Nutr J. 2010;9: Jones JM. Reliability of nutritional screening and assessment tools. Nutrition Mar;20(3): Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr Jan-Feb;11(1): Harris J, Benedict F. A biometric study of basal metabolism in man. Washington D.C.: Carnegie Institute of Washington; Unosson M, Ek AC, Bjurulf P, von Schenck H, Larsson J. Feeding dependence and nutritional status after acute stroke. Stroke Feb;25(2): Finestone HM, Greene-Finestone LS, Wilson ES, Teasell RW. Malnutrition in stroke patients on the rehabilitation service and at follow-up: prevalence and predictors. Arch Phys Med Rehabil Apr;76(4): Brynningsen PK, Damsgaard EM, Husted SE. Improved nutritional status in elderly patients 6 months after stroke. J Nutr Health Aging Jan-Feb;11(1): Heaney A, Tham TC. Percutaneous endoscopic gastrostomies: attitudes of general practitioners and how management may be improved. Br J Gen Pract Feb;51(463): Hasan M, Meara RJ, Bhowmick BK, Woodhouse K. Percutaneous endoscopic gastrostomy in geriatric patients: attitudes of health care professionals. Gerontology. 1995;41(6): Lin LC, Li MH, Watson R. A survey of the reasons patients do not chose percutaneous endoscopic gastrostomy/jejunostomy (PEG/PEJ) as a route for longterm feeding. J Clin Nurs Mar;20(5-6): Chan M, Lim YP, Ernest A, Tan TL. Nutritional assessment in an Asian nursing home and its association with mortality. J Nutr Health Aging Jan;14(1):