Medical Nutrition Therapy in Neurological Disorders Part 1

Nutrition and Neurologic Disease May have nutritional etiologies resulting from deficiency or excessMay have nutritional etiologies resulting from deficiency or excess May be nonnutritional in origin but have significant nutritional implicationsMay be nonnutritional in origin but have significant nutritional implications

Stroke Statistics Stroke is the third leading cause of death ranking behind diseases of the heart and cancersStroke is the third leading cause of death ranking behind diseases of the heart and cancers Killed 150,147 people in 2004; females accounted for 60.9 percent of stroke deaths.Killed 150,147 people in 2004; females accounted for 60.9 percent of stroke deaths. About 5,700,000 stroke survivors are alive today. 2,400,000 are males and 3,300,000 are females.About 5,700,000 stroke survivors are alive today. 2,400,000 are males and 3,300,000 are females. Data from GCNKSS studies show that about 700,000 people suffer a new or recurrent stroke each year. About 500,000 of these are first attacks and 200,000 are recurrent attacks. (GCNKS studies)Data from GCNKSS studies show that about 700,000 people suffer a new or recurrent stroke each year. About 500,000 of these are first attacks and 200,000 are recurrent attacks. (GCNKS studies) online

Stroke Statistics From 1992 to 2002 the death rate from stroke declined 13.8 percent, but the actual number of stroke deaths rose 6.9 percent.From 1992 to 2002 the death rate from stroke declined 13.8 percent, but the actual number of stroke deaths rose 6.9 percent. A leading cause of functional disability – 15-30% permanently disabledA leading cause of functional disability – 15-30% permanently disabled Primary Prevention of Ischemic Stroke, AHA/ASA Guideline, Stroke 2006;37: , accessed online

Risk Factors for Ischemic Stroke Non-Modifiable AgeAge GenderGender Low Birth WeightLow Birth Weight Race/ethnicityRace/ethnicity Genetic factorsGenetic factors Modifiable Hypertension Exposure to cigarette smoke Diabetes Atrial fib and other cardiac conditions Dislipidemia (ischemic stroke) Post-menopausal hormone therapy Poor diet Obesity/body fat distribution Inactivity Primary Prevention of Ischemic Stroke, AHA/ASA Guideline, Stroke 2006;37: , accessed online

Pathophysiology of Stroke 85% of strokes caused by a thromboembolic event (related to atherosclerosis, hypertension, diabetes, gout)85% of strokes caused by a thromboembolic event (related to atherosclerosis, hypertension, diabetes, gout) Embolic stroke: cholesterol plaque is dislodged from vessel, travels to the brain, blocks an arteryEmbolic stroke: cholesterol plaque is dislodged from vessel, travels to the brain, blocks an artery Thrombotic stroke: cholesterol plaque within an artery ruptures, platelets aggregate and clog a narrow arteryThrombotic stroke: cholesterol plaque within an artery ruptures, platelets aggregate and clog a narrow artery

Nutrition-Related Factors and Stroke Risk (BMI = body mass index)

Thromboembolic Stroke

Hemorrhagic Stroke Intraparenchymal hemorrhage: prevalence of hypertension is 80%; vessel inside the brain rupturesIntraparenchymal hemorrhage: prevalence of hypertension is 80%; vessel inside the brain ruptures Subarachnoid hemorrhage (SAH): ruptured aneurism in the subarachnoid space; or due to head traumaSubarachnoid hemorrhage (SAH): ruptured aneurism in the subarachnoid space; or due to head trauma 15% of all strokes15% of all strokes

Hemorrhagic Stroke

Medical Treatment for Stroke Thrombolytic or “clot-busting” drugs to restore perfusion to affected areas within 6 hours of onset of strokeThrombolytic or “clot-busting” drugs to restore perfusion to affected areas within 6 hours of onset of stroke Controlling intracranial pressure (ICP) while maintaining sufficient perfusion of the brainControlling intracranial pressure (ICP) while maintaining sufficient perfusion of the brain

Nutritional Management in Stroke Primary preventionPrimary prevention Acute management (screening for dysphagia and nutritional risk)Acute management (screening for dysphagia and nutritional risk) Intervention for swallowing disorders via consistency changesIntervention for swallowing disorders via consistency changes

AHA Guidelines for Primary Prevention of CVD and Stroke: 2006 Update Smoking: complete cessation (Class I, evidence level BSmoking: complete cessation (Class I, evidence level B Avoid exposure to environmental tobacco smoke (Class IIA, evidence C)Avoid exposure to environmental tobacco smoke (Class IIA, evidence C) BP control: goal <140/90 mmHg with lower targets in some subgroups (<130/80 in diabetes)BP control: goal <140/90 mmHg with lower targets in some subgroups (<130/80 in diabetes) Goldstein et al, Primary Prevention of Ischemic Stroke, Stroke 2006;37: )

AHA Guidelines for Primary Prevention of CVD and Stroke: 2006 Update Blood lipid mgt:Blood lipid mgt: NCP III guidelines for pts who have not had a stroke and have high TC or non-HDL-C w/ high TGNCP III guidelines for pts who have not had a stroke and have high TC or non-HDL-C w/ high TG Pts with known CAD and high risk HTN even w/ normal LDL treat with lifestyle/statin (Class I, evidence A)Pts with known CAD and high risk HTN even w/ normal LDL treat with lifestyle/statin (Class I, evidence A) Rec wt loss, ↑ physical activity, smoking cessation, niacin or gemfibrozil (Class IIA, evidence B)Rec wt loss, ↑ physical activity, smoking cessation, niacin or gemfibrozil (Class IIA, evidence B) Goldstein et al, Primary Prevention of Ischemic Stroke, Stroke 2006;37: )

AHA Diet/Lifestyle Guidelines for Primary Prevention of CVD/Stroke: 2006 Update Reduced intake of sodium and increased intake of potassium to lower blood pressure (Class I, evidence A)Reduced intake of sodium and increased intake of potassium to lower blood pressure (Class I, evidence A) Recommended sodium intake 4.7g/dayRecommended sodium intake 4.7g/day DASH diet emphasizing fruits, vegetables, lowfat dairy products is recommended to lower BP (Class I, evidence A)DASH diet emphasizing fruits, vegetables, lowfat dairy products is recommended to lower BP (Class I, evidence A) High fruit and vegetable intake may lower risk of stroke (Evidence C)High fruit and vegetable intake may lower risk of stroke (Evidence C) Wt reduction is recommended because it lowers BPWt reduction is recommended because it lowers BP Increased physical activity (>30 minutes of moderate- intensity activity daily)Increased physical activity (>30 minutes of moderate- intensity activity daily) Pearson et al. (Circulation. 2002;106: )

Lipids and Stroke Cholesterol is a very weak risk factor for ischemic stroke, in contrast to CADCholesterol is a very weak risk factor for ischemic stroke, in contrast to CAD Cholesterol reduction with diet and nonstatin drugs is not effective in stroke prevention, although reductions in levels of cholesterol are modestCholesterol reduction with diet and nonstatin drugs is not effective in stroke prevention, although reductions in levels of cholesterol are modest Statins produce a statistically significant 25% reduction in the risk of strokeStatins produce a statistically significant 25% reduction in the risk of stroke Briel M, et al Am J Med 2004;117:

Lipids and Stroke in MRFIT

Lipids and Stroke: ARIC Study Cohort study of 14,175 men and womenCohort study of 14,175 men and women After 10-year followup, there were weak and inconsistent associations between ischemic stroke and LDL-C, HDL-C, apo- B, apo-A-1, triglyceridesAfter 10-year followup, there were weak and inconsistent associations between ischemic stroke and LDL-C, HDL-C, apo- B, apo-A-1, triglycerides Most consistent relationship was lower risk in women with higher HDL and higher risk with lower TGMost consistent relationship was lower risk in women with higher HDL and higher risk with lower TG Shahar E, et al. Stroke, 2003;34:

Lipids and Stroke Problem may be the heterogenicity of stroke, although even when looking at homogeneous ischemic stroke, relationship is weakProblem may be the heterogenicity of stroke, although even when looking at homogeneous ischemic stroke, relationship is weak The protective effect of statins may be due to their non-cholesterol-lowering effects.The protective effect of statins may be due to their non-cholesterol-lowering effects.

Relationship Between Fat/Cholesterol and Stroke Risk Dietary cholesterol, MFA, PUFA not related to risk of strokeDietary cholesterol, MFA, PUFA not related to risk of stroke Low intake of SFA and animal protein associated with  risk of intraparenchymal hemorrhageLow intake of SFA and animal protein associated with  risk of intraparenchymal hemorrhage In DCCT trial, intensive treatment lowered LDL, TC and TG and cerebrovascular eventsIn DCCT trial, intensive treatment lowered LDL, TC and TG and cerebrovascular events

Guidelines for Management of Acute Stroke Rehab (AHA/ASA) Dysphagia occurs in 45% of all hospitalized stroke patients; can lead to aspiration pneumonia and death.Dysphagia occurs in 45% of all hospitalized stroke patients; can lead to aspiration pneumonia and death. Malnutrition is present in 15% of patients admitted to the hospital, and this percentage doubles during the first week after stroke.Malnutrition is present in 15% of patients admitted to the hospital, and this percentage doubles during the first week after stroke. A bedside swallow screening should be completed before oral intake (Evidence Level=B).A bedside swallow screening should be completed before oral intake (Evidence Level=B). If the patient’s swallow screening is abnormal, a complete bedside swallow examination is recommended (Evidence Level=I).If the patient’s swallow screening is abnormal, a complete bedside swallow examination is recommended (Evidence Level=I). AHA/ASA Endorsed Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care (Stroke. 2005;36:2049.)

Dysphagia Treatment- AHA/ASA Dysphagia treatment may involve posture changes, heightening sensory input, swallow maneuvers, active exercise programs, or diet modifications.Dysphagia treatment may involve posture changes, heightening sensory input, swallow maneuvers, active exercise programs, or diet modifications. Dysphagia management may include nonoral feeding and psychological support.Dysphagia management may include nonoral feeding and psychological support. At this time, it is unclear how dysphagic patients should be fed after acute stroke.At this time, it is unclear how dysphagic patients should be fed after acute stroke. AHA/ASA Endorsed Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care (Stroke. 2005;36:2049.)

Dysphagia Treatment- AHA/ASA The literature supports the use of tube feeding for patients who cannot sustain sufficient oral caloric and/or fluid intake to meet nutritional needs.The literature supports the use of tube feeding for patients who cannot sustain sufficient oral caloric and/or fluid intake to meet nutritional needs. Limited evidence suggests that percutaneous endoscopic gastrostomy feeding compares favorably with nasogastric tube feeding (Evidence Level=B).Limited evidence suggests that percutaneous endoscopic gastrostomy feeding compares favorably with nasogastric tube feeding (Evidence Level=B). AHA/ASA Endorsed Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care (Stroke. 2005;36:2049.)

FOOD (Feed or Ordinary Diet) Trial Tested feeding strategies after acute stroke including oral supplementation, early vs delayed NG feeding, and NG vs PEG feedingTested feeding strategies after acute stroke including oral supplementation, early vs delayed NG feeding, and NG vs PEG feeding Poor baseline nutritional status is associated with worse outcomes at 6 months.Poor baseline nutritional status is associated with worse outcomes at 6 months. This relationship persists after adjustment for pt’s age, prestroke functional level, living conditions, and severity of stroke.This relationship persists after adjustment for pt’s age, prestroke functional level, living conditions, and severity of stroke. AHA/ASA Guidelines for the Early Management of Patients with Ischemic Stroke. (Stroke. 2005;36:916.)

FOOD (Feed or Ordinary Diet) Trial Found no benefit to routine oral supplementation of post-stroke patients who had not been identified as malnourished (1)Found no benefit to routine oral supplementation of post-stroke patients who had not been identified as malnourished (1) Early tube feeding was associated with an absolute reduction in risk of death of 5.8% (p=0.09) and a reduction in death or poor outcome of 1.2% (p=0.7) (2)Early tube feeding was associated with an absolute reduction in risk of death of 5.8% (p=0.09) and a reduction in death or poor outcome of 1.2% (p=0.7) (2) PEG feeding (vs NG) was associated with an absolute increase in risk of death of 1.0%, p=0.9) and an increased risk of death or poor outcome of 7.8% (p=0.05).PEG feeding (vs NG) was associated with an absolute increase in risk of death of 1.0%, p=0.9) and an increased risk of death or poor outcome of 7.8% (p=0.05). 1: Lancet Feb 26-Mar 4;365(9461): : Lancet Feb 26- Mar 4;365(9461):764-72

AHA Guidelines for Early Management of Pts with Ischemic Stroke A poor nutritional status was associated with an increased risk of infections including pneumonia, gastrointestinal bleeding, and pressure sores.A poor nutritional status was associated with an increased risk of infections including pneumonia, gastrointestinal bleeding, and pressure sores. These data provide a strong rationale for assessment of the patient’s nutritional status at the time of admission.These data provide a strong rationale for assessment of the patient’s nutritional status at the time of admission. AHA/ASA Guidelines for the Early Management of Patients with Ischemic Stroke. (Stroke. 2005;36:916.)

Alzheimer’s Disease Most common form of dementiaMost common form of dementia Increases exponentially after age 40Increases exponentially after age 40 Prevalence in white males at age 100 is 41.5%Prevalence in white males at age 100 is 41.5% Higher prevalence in women (3X) due to lower mortalityHigher prevalence in women (3X) due to lower mortality

Symptoms of Alzheimer’s Disease Forgetfulness: may forget recent events, activities, names of familiar people or things (anomia).Forgetfulness: may forget recent events, activities, names of familiar people or things (anomia). Forget how to do simple tasks, such as brushing teeth, brushing hairForget how to do simple tasks, such as brushing teeth, brushing hair Get lost in familiar surroundingsGet lost in familiar surroundings Repeat words spoken by others (echolalia)Repeat words spoken by others (echolalia) Loss of comprehension (agnosia)Loss of comprehension (agnosia)

Symptoms of Alzheimer’s Disease (cont) Motor skills deteriorate: loss of reflexes and shuffling gaitMotor skills deteriorate: loss of reflexes and shuffling gait Bowel and bladder control lostBowel and bladder control lost Limb weakness and contracturesLimb weakness and contractures Intellectual activity ceasesIntellectual activity ceases Vegetative stateVegetative state

Alzheimer’s Disease Risk Factors Age: risk doubles every five years after age 65Age: risk doubles every five years after age 65 Family history: early onset strongly hereditary; late onset has a genetic componentFamily history: early onset strongly hereditary; late onset has a genetic component Those with a parent or sibling with AD are 2-3 times more likely to develop ADThose with a parent or sibling with AD are 2-3 times more likely to develop AD

Alzheimer’s Disease Risk Factors Head injuryHead injury Down syndromeDown syndrome Low level of educationLow level of education Female genderFemale gender

Alzheimer’s Disease Prevention: Research Areas  AD risk is associated with CVD, hypertension, diabetes  AD risk is associated with CVD, hypertension, diabetes  AD risk associated with exercise, staying mentally active, social engagement  AD risk associated with exercise, staying mentally active, social engagement Research ongoing into use of antioxidants (vitamins E and C), ginkgo bilobaResearch ongoing into use of antioxidants (vitamins E and C), ginkgo biloba Research into estrogen and AD suggests that estrogen treatment in postmenopausal women may  risk of dementiaResearch into estrogen and AD suggests that estrogen treatment in postmenopausal women may  risk of dementia

Treatment of Alzheimer’s Disease No drug can stop or reverse ADNo drug can stop or reverse AD Some drugs may slow progress (tacrine (Cognex®), donepezil (Aricept®), rivastigmine (Exelon®), or galantamine (Razadyne®)Some drugs may slow progress (tacrine (Cognex®), donepezil (Aricept®), rivastigmine (Exelon®), or galantamine (Razadyne®) Other medications may treat symptoms such as sleeplessness, agitation, wandering, anxiety, and depressionOther medications may treat symptoms such as sleeplessness, agitation, wandering, anxiety, and depression National Institutes on Aging, Alzheimer’s Disease Education and Referral Center

Nutritional Consequences of Alzheimer’s Disease Weight loss is common possibly due to  activity (pacing)Weight loss is common possibly due to  activity (pacing) Decreased independence and impaired self- feedingDecreased independence and impaired self- feeding Inability to recognize hunger, thirst and satietyInability to recognize hunger, thirst and satiety Meals forgotten as soon as eaten or may not be eaten at allMeals forgotten as soon as eaten or may not be eaten at all Inability to recognize food when presentedInability to recognize food when presented Risk for dehydrationRisk for dehydration

MNT in Alzheimer’s Disease Vitamin-mineral supplementation; assure intake of antioxidantsVitamin-mineral supplementation; assure intake of antioxidants Minimize distractions at mealtime (turn off radio or television)Minimize distractions at mealtime (turn off radio or television) Place foods on small plates and give one at a timePlace foods on small plates and give one at a time Serve food on plates of contrasting colorServe food on plates of contrasting color

MNT in Alzheimer’s Disease Model use of eating utensils, provide verbal cuesModel use of eating utensils, provide verbal cues Allow patient to use eating utensils as long as possibleAllow patient to use eating utensils as long as possible Finger foods may be helpful, but monitor for swallowing problems and chokingFinger foods may be helpful, but monitor for swallowing problems and choking Frequent snacks, nutrient-dense foods, nutritional supplements may be helpfulFrequent snacks, nutrient-dense foods, nutritional supplements may be helpful

Practical Interventions for Eating-Related Behavioral Problems Common in Individuals with Dementia

Migraine Headache Thought to be vascular in originThought to be vascular in origin Throbbing, episodic, and intenseThrobbing, episodic, and intense History of intercurrent nausea, vomiting, photophobia, visual or olfactory aurasHistory of intercurrent nausea, vomiting, photophobia, visual or olfactory auras Treated with NSAIDs, sympathomimetics, seritonin agonists; prophylaxis with calcium channel blockers, beta-adrenergic blockers, serotonin antagonistsTreated with NSAIDs, sympathomimetics, seritonin agonists; prophylaxis with calcium channel blockers, beta-adrenergic blockers, serotonin antagonists

Migraine Headache Headaches may be triggered by foodHeadaches may be triggered by food Varies by individual and tolerance thresholds vary over timeVaries by individual and tolerance thresholds vary over time No general recommendations about food avoidanceNo general recommendations about food avoidance Foods often cited are citrus fruits, tea, coffee, pork, chocolate, milk, nuts, vegetables, cola drinksFoods often cited are citrus fruits, tea, coffee, pork, chocolate, milk, nuts, vegetables, cola drinks Evaluate through food and symptom diaryEvaluate through food and symptom diary

Myasthenia Gravis (MG) Autoimmune disorder of the neuromuscular junctionAutoimmune disorder of the neuromuscular junction Body makes antibodies to acetylcholine receptors; make them unresponsive to AchBody makes antibodies to acetylcholine receptors; make them unresponsive to Ach Nervous system signal to the muscle is garbledNervous system signal to the muscle is garbled Relapsing and remitting weakness and fatigability; diplopia, facial muscle weakness, dysphagia (33%)Relapsing and remitting weakness and fatigability; diplopia, facial muscle weakness, dysphagia (33%)

Myasthenia Gravis (MG) Medical Treatment Anticholinesterases inhibit acetylcholesterase and increase the amount of AchAnticholinesterases inhibit acetylcholesterase and increase the amount of Ach Removal of the thymus glandRemoval of the thymus gland CorticosteroidsCorticosteroids

Myasthenia Gravis (MG) MNT Nutritionally dense foods at the beginning of meals before the patient tiresNutritionally dense foods at the beginning of meals before the patient tires Small frequent mealsSmall frequent meals Time medication with feeding to facilitate optimal swallowingTime medication with feeding to facilitate optimal swallowing Limit physical activity before mealsLimit physical activity before meals Don’t encourage food consumption when patient is tired; may aspirateDon’t encourage food consumption when patient is tired; may aspirate

Wernicke-Korsakoff syndrome MNT Cause Chronic thiamin deficiency with continued carbohydrate ingestionChronic thiamin deficiency with continued carbohydrate ingestionTreatment ThiaminThiamin Adequate hydrationAdequate hydration Diet liberal in high-thiamin foodsDiet liberal in high-thiamin foods Eliminate ETOHEliminate ETOH Dietary protein may need to be restrictedDietary protein may need to be restricted

Amyotrophic Lateral Sclerosis Also called Lou Gehrig’s DiseaseAlso called Lou Gehrig’s Disease Most common motor system diseaseMost common motor system disease Progressive denervation atrophy and weakness of musclesProgressive denervation atrophy and weakness of muscles Both upper and lower motor neurons are lost in the spinal cord, brain stem, and motor cortexBoth upper and lower motor neurons are lost in the spinal cord, brain stem, and motor cortex Progresses to death in 2 to 6 yearsProgresses to death in 2 to 6 years

Amyotrophic Lateral Sclerosis Prevalence constant throughout the worldPrevalence constant throughout the world Men affected more than womenMen affected more than women Age of onset mid-50s (40-70)Age of onset mid-50s (40-70) Cause unknownCause unknown 5% familial, rest sporadic5% familial, rest sporadic

Amyotrophic Lateral Sclerosis Presentation Muscle weakness commences in the legs and hands and progresses to the proximal arms and oropharynxMuscle weakness commences in the legs and hands and progresses to the proximal arms and oropharynx Voluntary skeletal muscles are at risk for atrophy and complete loss of functionVoluntary skeletal muscles are at risk for atrophy and complete loss of function Spasticity of jaw muscles resulting in slurred speechSpasticity of jaw muscles resulting in slurred speech Dysphagia, difficulty chewing  weight lossDysphagia, difficulty chewing  weight loss Death from respiratory failureDeath from respiratory failure

Amyotrophic Lateral Sclerosis Nutritional Implications Dysphagia, chewing, swallowing problemsDysphagia, chewing, swallowing problems Decreased body fat, lean body mass, nitrogen balance and increased REE as death approachesDecreased body fat, lean body mass, nitrogen balance and increased REE as death approaches Late stage patients may not tolerate PEG placement d/t respiratory compromiseLate stage patients may not tolerate PEG placement d/t respiratory compromise Initiate discussions about whether to place a feeding tube early in disease processInitiate discussions about whether to place a feeding tube early in disease process Enteral feedings do not prolong lifeEnteral feedings do not prolong life

Amyotrophic Lateral Sclerosis MNT Correlates with ALS Severity Scale (pp )Correlates with ALS Severity Scale (pp ) Emphasize fluids as patients may limit fluids d/t toileting difficultiesEmphasize fluids as patients may limit fluids d/t toileting difficulties Get baseline weight; 10% loss  increased riskGet baseline weight; 10% loss  increased risk Modify consistency as eating problems develop using easy-chew foods, thickened liquids, using small frequent meals, cool food temperaturesModify consistency as eating problems develop using easy-chew foods, thickened liquids, using small frequent meals, cool food temperatures

Amyotrophic Lateral Sclerosis MNT If nutrition support is planned, use ENIf nutrition support is planned, use EN Initiate early rather than later; dehydration occurs before malnutritionInitiate early rather than later; dehydration occurs before malnutrition Purpose of nutrition support should be to enhance quality of lifePurpose of nutrition support should be to enhance quality of life Eventually patients will not be able to manage oral secretionsEventually patients will not be able to manage oral secretions