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Medical Nutrition Therapy in Neurological Disorders Part 2.

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Presentation on theme: "Medical Nutrition Therapy in Neurological Disorders Part 2."— Presentation transcript:

1 Medical Nutrition Therapy in Neurological Disorders Part 2

2 Epilepsy Intermittent derangement of the nervous system caused by sudden discharge of cerebral neuronsIntermittent derangement of the nervous system caused by sudden discharge of cerebral neurons 2.3 million Americans have epilepsy; 15% under age 152.3 million Americans have epilepsy; 15% under age 15 May be caused by head injury, congenital defects, metabolic disorders, other illnessesMay be caused by head injury, congenital defects, metabolic disorders, other illnesses Many are idiopathic (cause unknown)Many are idiopathic (cause unknown)

3 Onset of Seizures by Age Source: University of Cincinnati Department of Neurology http://www.med.uc.edu/neurology/

4 Causes of Seizures Source: University of Cincinnati Department of Neurology http://www.med.uc.edu/neurology/

5 Generalized Seizures

6 Epilepsy: Tonic-Clonic Seizure Formerly called grand mal.Formerly called grand mal. Generalized seizure that lasts 1-2 minutesGeneralized seizure that lasts 1-2 minutes Involves complete loss of muscle tone and consciousnessInvolves complete loss of muscle tone and consciousness More common in childrenMore common in children

7 Epilepsy: Absence Seizure Formerly called petit malFormerly called petit mal Also generalizedAlso generalized May appear to be daydreaming, but recovers after a few seconds with no postictal fatigue or disorientationMay appear to be daydreaming, but recovers after a few seconds with no postictal fatigue or disorientation More common in childrenMore common in children

8 Absence Seizure Pathology

9 Partial Seizures

10 Epilepsy: Partial Seizure Discrete focus of epileptogenic brain tissueDiscrete focus of epileptogenic brain tissue Simple partial seizure involves no loss of consciousnessSimple partial seizure involves no loss of consciousness Complex partial seizure involves change in consciousnessComplex partial seizure involves change in consciousness Most common, especially in adultsMost common, especially in adults Source: University of Cincinnati Department of Neurology http://www.med.uc.edu/neurology/

11 Types of Seizures and Prevalence Source: University of Cincinnati Department of Neurology http://www.med.uc.edu/neurology/

12 Epilepsy: Medical Treatment Generalized seizures managed with valproate, phenytoin, gabapentin managed with valproate, phenytoin, gabapentin Drug-drug and drug-nutrient interactionsDrug-drug and drug-nutrient interactions Liver damageLiver damage

13 Epilepsy: Medical Treatment Partial seizures Managed with carbamazepine or phenytoinManaged with carbamazepine or phenytoin Seizure surgery if fail to control with medicationsSeizure surgery if fail to control with medications Localized focus resected produces cure in 75% of patientsLocalized focus resected produces cure in 75% of patients Phenobarbital avoided as associated with  IQ in children; may be used in failure of other drugsPhenobarbital avoided as associated with  IQ in children; may be used in failure of other drugs

14 Epilepsy: Drug-Nutrient Interactions Phenobarbital, phenytoin, primidone interfere with absorption of calcium by increasing vitamin D metabolismPhenobarbital, phenytoin, primidone interfere with absorption of calcium by increasing vitamin D metabolism Long term therapy may lead to osteomalacia in adults or rickets in childrenLong term therapy may lead to osteomalacia in adults or rickets in children Vitamin D supplementation is essentialVitamin D supplementation is essential

15 Epilepsy: Drug-Nutrient Interactions Folic acid supplementation interferes with phenytoin metabolism; may not reach therapeutic levelsFolic acid supplementation interferes with phenytoin metabolism; may not reach therapeutic levels Phenytoin and phenobarbital are bound to albumin in the bloodstream; malnutrition results in  free drug and possible toxicityPhenytoin and phenobarbital are bound to albumin in the bloodstream; malnutrition results in  free drug and possible toxicity Alcohol interferes with phenytoin, possibly resulting in seizuresAlcohol interferes with phenytoin, possibly resulting in seizures

16 Epilepsy: Drug-Nutrient Interactions Continuous enteral feeding slows absorption of oral phenytoin; may increase therapeutic doseContinuous enteral feeding slows absorption of oral phenytoin; may increase therapeutic dose If enteral feeding is discontinued,  risk of toxicityIf enteral feeding is discontinued,  risk of toxicity Window enteral feedings around phenytoin administration (stop feeding 2 hours before and after)Window enteral feedings around phenytoin administration (stop feeding 2 hours before and after) Give phenytoin IV or use time-release formula to decrease time the feeding is offGive phenytoin IV or use time-release formula to decrease time the feeding is off

17 Epilepsy MNT: Ketogenic Diet Treatment of last resort in children with intractable seizuresTreatment of last resort in children with intractable seizures Will completely control epilepsy in one- third of children; significantly decrease activity in one-thirdWill completely control epilepsy in one- third of children; significantly decrease activity in one-third Ketones may exert anticonvulsant effect on bodyKetones may exert anticonvulsant effect on body

18 Ketogenic Diet Implementation Stop antiepileptic drugsStop antiepileptic drugs Child fasts in hospital for 24-72 hours until 4+ ketonuriaChild fasts in hospital for 24-72 hours until 4+ ketonuria Evaluate responseEvaluate response Fat: 75% of caloriesFat: 75% of calories Protein: sufficient to meet growth needs (1 g/kg)Protein: sufficient to meet growth needs (1 g/kg) CHO: added to make up rest of calorie needs (negligible)CHO: added to make up rest of calorie needs (negligible)

19 Ketogenic Diet Menu Using MCT Oil

20 Multiple Sclerosis Chronic disease affecting the CNSChronic disease affecting the CNS Destruction of the myelin sheath, which transmits nerve impulsesDestruction of the myelin sheath, which transmits nerve impulses Multiple areas of myelin are replaced with scar tissueMultiple areas of myelin are replaced with scar tissue May be genetic and environmental factors, including geographical latitude (northern hemisphere) and diet (high animal fats)May be genetic and environmental factors, including geographical latitude (northern hemisphere) and diet (high animal fats)

21 Multiple Sclerosis: Medical Tx Steroid therapy for exacerbations; ACTH and prednisolone; methotrexate (can cause weight gain, fluid retention) alpha- interferonSteroid therapy for exacerbations; ACTH and prednisolone; methotrexate (can cause weight gain, fluid retention) alpha- interferon Physical therapyPhysical therapy

22 Progression of Multiple Sclerosis

23 MS Controversial Therapies Shank diet: low in saturated fatShank diet: low in saturated fat MacDougal diet: no gluten, low sugar, and no refined sugarMacDougal diet: no gluten, low sugar, and no refined sugar Allergen-free, gluten-free, pectin-free, fructose-restricted, raw food Evers dietAllergen-free, gluten-free, pectin-free, fructose-restricted, raw food Evers diet Low fat diet high in linoleic acid may have some beneficial effectsLow fat diet high in linoleic acid may have some beneficial effects

24 MNT in MS Diet consistency modifications as needed if dysphagia developsDiet consistency modifications as needed if dysphagia develops Suggest prepackaged, single-serving or convenience foods if meal preparation becomes difficult due to impaired vision, poor ambulationSuggest prepackaged, single-serving or convenience foods if meal preparation becomes difficult due to impaired vision, poor ambulation High fiber diet for constipationHigh fiber diet for constipation Counseling regarding fluid intake, cranberry juice to prevent UTIsCounseling regarding fluid intake, cranberry juice to prevent UTIs Enteral nutrition support in end stageEnteral nutrition support in end stage

25 Nutrition Guidelines for Parkinson’s Disease Eat a variety of healthy foods consistent with the US Dietary GuidelinesEat a variety of healthy foods consistent with the US Dietary Guidelines Maintain a healthy body weightMaintain a healthy body weight Balance food with exerciseBalance food with exercise Eat foods high in fiberEat foods high in fiber

26 Food-Drug Interactions in Parkinson’s Disease Levodopa works best taken on an empty stomach ½ hour before or one hour after mealsLevodopa works best taken on an empty stomach ½ hour before or one hour after meals Protein competes with levodopa for absorption. Rarely, a high protein diet interferes with levodopaProtein competes with levodopa for absorption. Rarely, a high protein diet interferes with levodopa If so, reduce overall protein intake or divide into many small meals; eat protein late in the day (usually not recommended)If so, reduce overall protein intake or divide into many small meals; eat protein late in the day (usually not recommended) Source: Cleveland Clinic Health System, http://www

27 Food-Drug Interactions in Parkinson’s Disease Levodopa can cause nauseaLevodopa can cause nausea Doctor may change to combination of levodopa and carbidopa (Sinemet) or carbidopa by itselfDoctor may change to combination of levodopa and carbidopa (Sinemet) or carbidopa by itself Drink liquids between meals rather than with themDrink liquids between meals rather than with them Eat smaller more frequent mealsEat smaller more frequent meals Avoid fried, greasy or sweet foodsAvoid fried, greasy or sweet foods Eat foods at room temperature to minimize odorsEat foods at room temperature to minimize odors Rest after eating with head elevatedRest after eating with head elevated Source: Cleveland Clinic Health System, http://www.cchs.net/

28 Protein Redistribution in L-Dopa Therapy

29 Acute Spinal Cord Injury Source: www.spinal-cord-injury-resources.com/ spinal-i...www.spinal-cord-injury-resources.com/ spinal-i...

30 Spinal Cord Lying within the Vertebral Canal

31 Sequelae of Spinal Cord Injury and Rehabilitation Challenges

32 Acute Spinal Cord Injury (SCI) Energy requirement for SCI = H/B x 1.1 x 1.3 (Barco et al, NCP 17;309-313, 2002)Energy requirement for SCI = H/B x 1.1 x 1.3 (Barco et al, NCP 17;309-313, 2002) Pt with multi-traumas in addition to SCI may have higher needsPt with multi-traumas in addition to SCI may have higher needs Protein needs: 2 g/kg (Rodriguez DJ et al, JPEN 15:319-322, 1991Protein needs: 2 g/kg (Rodriguez DJ et al, JPEN 15:319-322, 1991 Provide enteral/parenteral support as neededProvide enteral/parenteral support as needed

33 MNT in Chronic Spinal Cord Injury Risk of weight gain, pressure ulcers due to immobilizationRisk of weight gain, pressure ulcers due to immobilization High fiber, adequate hydration to minimize constipationHigh fiber, adequate hydration to minimize constipation Dietary intake to maintain nutritional health and adequate weightDietary intake to maintain nutritional health and adequate weight

34 Brain Injury 400,000 new cases of brain injury occur each year in the United States400,000 new cases of brain injury occur each year in the United States Most result from motor vehicle crashes.Most result from motor vehicle crashes. Incidence is highest in young people and elderly; twice as often in males than femalesIncidence is highest in young people and elderly; twice as often in males than females Almost all patients with a severe head injury have some degree of disability.Almost all patients with a severe head injury have some degree of disability.

35 Glasgow Coma Scale (GCS) Strong prognostic value for neurologic recovery in head-injured patients (scale evaluating and quantitating the degree of coma by determining best responses to standardized stimuli) Eye opening (4 Spontaneous–1 None)Eye opening (4 Spontaneous–1 None) Verbal response (5 Oriented–1 None)Verbal response (5 Oriented–1 None) Motor response (6 Follows command–1 None)Motor response (6 Follows command–1 None) Severity of head injury: mild = GCS 13-15, moderate = GCS 9-12, severe = GCS 3-8 Severity of head injury: mild = GCS 13-15, moderate = GCS 9-12, severe = GCS 3-8

36 Strong Predictors of Poor Outcome after Head Injury Older ageOlder age Low Glasgow Coma Scale scoreLow Glasgow Coma Scale score Pupil dilatationPupil dilatation Low blood pressureLow blood pressure All these variables have an additive effect on morbidity and mortality Inadequate oxygenation early after injury Prolonged and/or difficult to control intracranial pressure

37 Neurological Deficits That Affect Nutritional Status Hemiparesis: weakness that affects one side of the bodyHemiparesis: weakness that affects one side of the body May increase risk of aspirationMay increase risk of aspiration Hemianopsia: blindness in one half of field of vision.Hemianopsia: blindness in one half of field of vision. Must compensate by turning his headMust compensate by turning his head

38 Normal Vision

39 Hemianopsia

40 Neurological Deficits That Affect Nutritional Status ApraxiaApraxia Patient has difficulty with perceptual motor planningPatient has difficulty with perceptual motor planning DysphagiaDysphagia Difficulty swallowingDifficulty swallowing

41 Symptoms of Dysphagia DroolingDrooling Choking or coughing during or following mealsChoking or coughing during or following meals Inability to suck from a strawInability to suck from a straw Gurgly voice qualityGurgly voice quality Holding pockets of food in the buccal recesses (patient may not be aware)Holding pockets of food in the buccal recesses (patient may not be aware)

42 Symptoms of Dysphagia Absent gag reflexAbsent gag reflex Chronic upper respiratory infectionsChronic upper respiratory infections Weight loss and anorexiaWeight loss and anorexia

43 Stages of Swallowing Oral Phase: (voluntary) food is chewed, mixed with saliva, tongue moves it to the back of the mouthOral Phase: (voluntary) food is chewed, mixed with saliva, tongue moves it to the back of the mouth Problems include inability to seal the lips around a cupProblems include inability to seal the lips around a cup Inability to suck through a strawInability to suck through a straw Food can become pocketedFood can become pocketed

44 Stages of Swallowing Pharyngeal phase: (involuntary) Soft palate closes off the nasopharynx; hyoid and larynx elevate, vocal cords adduct to protect the airway; pharynx contracts and cricopharyngeal sphincter relaxes allowing food to pass into the esophagusPharyngeal phase: (involuntary) Soft palate closes off the nasopharynx; hyoid and larynx elevate, vocal cords adduct to protect the airway; pharynx contracts and cricopharyngeal sphincter relaxes allowing food to pass into the esophagus Symptoms of poor coordination include gagging, choking, and nasopharyngeal regurgitationSymptoms of poor coordination include gagging, choking, and nasopharyngeal regurgitation

45 Stages of Swallowing (cont) Esophageal phase: (involuntary) bolus continues through esophagus into the stomachEsophageal phase: (involuntary) bolus continues through esophagus into the stomach Most difficulties due to mechanical obstructionMost difficulties due to mechanical obstruction Involuntary peristalsis affected by brain stem infarctInvoluntary peristalsis affected by brain stem infarct

46 Swallowing Occurs in Three Phases

47 Swallowing Occurs in Three Phases—cont’d

48 Swallow Animation http://greenfield.fortunecity.com/rattler/46/upali4.htm

49 Food Textures in Dysphagia Thin liquids: the most difficult to control in the mouth Easily aspirated into the lungsEasily aspirated into the lungs Often thickened to nectar thick, honey thick, or pudding thickOften thickened to nectar thick, honey thick, or pudding thick Essential for proper hydrationEssential for proper hydration

50 National Dysphagia Diet Survey Diet covered in Oral and Dental Health lectureDiet covered in Oral and Dental Health lecture ADA and ASHA surveyed RDs and SLPs regarding use of NDDADA and ASHA surveyed RDs and SLPs regarding use of NDD 30% had implemented NDD30% had implemented NDD Of those not using it, some were using modifications of itOf those not using it, some were using modifications of it Reported at FNCE 2007; Shirley L. McCallum

51 Thickened Liquids Issues No consistency across product lines within manufacturers or between competitorsNo consistency across product lines within manufacturers or between competitors Continuous hydration of the thickening agent in pre-thickened productsContinuous hydration of the thickening agent in pre-thickened products Issues with instant food thickener continuing to thickenIssues with instant food thickener continuing to thicken

52 Randomized Study of Two Interventions for Liquid Aspiration Short and Long-term Effects (“Protocol 201”) NIH-Funded Dysphagia Clinical Trial Presented at FNCE, Oct. 2007 JoAnne Robbins, PhD, CCC-SLP

53 Protocol 201 Patients with dementia and/or Parkinson’s diseasePatients with dementia and/or Parkinson’s disease 742 randomized; 711 analyzed742 randomized; 711 analyzed 70% male; 59% age 80 or above70% male; 59% age 80 or above 15% minority15% minority DiagnosisDiagnosis 32% Parkinson’s disease32% Parkinson’s disease 49% dementia49% dementia 19% PD with dementia19% PD with dementia

54 Protocol 201 Patients who aspirated on thin liquids were trialed on 3 interventionsPatients who aspirated on thin liquids were trialed on 3 interventions Chin tuck with thin liquidsChin tuck with thin liquids Nectar thick liquidsNectar thick liquids Honey thick liquidsHoney thick liquids

55 Protocol 201 Part 2 Those who aspirated on all three or did not aspirate on any of them were entered into part 2 of the trialThose who aspirated on all three or did not aspirate on any of them were entered into part 2 of the trial Patients were randomized toPatients were randomized to Chin-tuckChin-tuck Honey thick liquidsHoney thick liquids Nectar thick liquidsNectar thick liquids

56 Short Term Aspiration Results Chin Down NectarHoney Parkinson’s Disease 59%54%44% Dementia74%69%58% Parkinson’s w/dementia 69%64%53% Overall68%63%53%

57 Summary Higher proportion of dementia patients aspirated on all interventionsHigher proportion of dementia patients aspirated on all interventions Aspiration frequency: Chin down, nectar, then honeyAspiration frequency: Chin down, nectar, then honey Satisfaction: chin down or nectar, then honeySatisfaction: chin down or nectar, then honey

58 Protocol 201: Long Term Outcome Population: those who aspirated on all three interventions and those who aspirated on none; enrolled 515 study ptsPopulation: those who aspirated on all three interventions and those who aspirated on none; enrolled 515 study pts Primary outcome: 3-month pneumonia rate defined via chest x-ray, febrile illness, rales, positive sputumPrimary outcome: 3-month pneumonia rate defined via chest x-ray, febrile illness, rales, positive sputum

59 Pneumonia: Long-Term Findings Subjects with dementia with or without PD had significantly higher incidence of pneumonia than PD only (15% vs 5%, p<.05)Subjects with dementia with or without PD had significantly higher incidence of pneumonia than PD only (15% vs 5%, p<.05) Subjects who aspirated on all 3 interventions had a significantly higher incidence of pneumonia than those who aspirated on none of the interventions (14% vs 6%, p<.05)Subjects who aspirated on all 3 interventions had a significantly higher incidence of pneumonia than those who aspirated on none of the interventions (14% vs 6%, p<.05)

60 Pneumonia Long-Term Findings Patients with PD randomized to HT had greater pneumonia rates than those randomized to nectar thick (10% vs 0%)Patients with PD randomized to HT had greater pneumonia rates than those randomized to nectar thick (10% vs 0%) Despite differential effect of interventions on immediate elimination of aspiration in videofluoroscopic suite no difference in the 3-month incidence of pneumonia for chin down posture compared to thickened liquidsDespite differential effect of interventions on immediate elimination of aspiration in videofluoroscopic suite no difference in the 3-month incidence of pneumonia for chin down posture compared to thickened liquids

61 Current Assumption “The thicker the liquid, the safer the swallow.”“The thicker the liquid, the safer the swallow.” Not true in pts who aspirate thick liquids – worse health outcomesNot true in pts who aspirate thick liquids – worse health outcomes

62 Lessons Learned Risk factors for clinically significant aspiration DementiaDementia Patients who aspirate repeatedly while performing intervention attempts as visualized fluoroscopicallyPatients who aspirate repeatedly while performing intervention attempts as visualized fluoroscopically Evaluate all possible interventions and if none are best, avoid honey thick as a last resortEvaluate all possible interventions and if none are best, avoid honey thick as a last resort

63 Diet for Easy Chewing and Swallowing

64 Techniques for Improving Acceptance AromaAroma SeasoningSeasoning Layering/swirlingLayering/swirling PipingPiping Molding Slurries Garnishing

65 Localizing Signs of Mass Lesion Lesions in the central portion of the frontal lobes may cause speech impairment.Lesions in the central portion of the frontal lobes may cause speech impairment. Lesions of the occipital lobes affect the visual field.Lesions of the occipital lobes affect the visual field. Lesions of the cerebellum and brainstem affect the cranial nerves.Lesions of the cerebellum and brainstem affect the cranial nerves. Lesions in the spinal cord affect motor neuronsLesions in the spinal cord affect motor neurons Lesions of the pituitary gland and hypothalamus may induce electrolyte or metabolic abnormalities and/or visual disturbances.Lesions of the pituitary gland and hypothalamus may induce electrolyte or metabolic abnormalities and/or visual disturbances.

66 Medical Nutrition Therapy Cognitive and swallowing dysfunction usually affect nutritional management and place neurologic patients at risk for malnutrition.Cognitive and swallowing dysfunction usually affect nutritional management and place neurologic patients at risk for malnutrition. The nutritional assessment should emphasize patterns of normal chewing, swallowing, and ingestion in addition to traditional assessment components.The nutritional assessment should emphasize patterns of normal chewing, swallowing, and ingestion in addition to traditional assessment components.

67 Nutritional Support Enteral nutrition support is the preferred modality for nutrition support in patients who cannot swallow or eat because of deteriorating neurologic disease.Enteral nutrition support is the preferred modality for nutrition support in patients who cannot swallow or eat because of deteriorating neurologic disease.


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