Medical Nutrition Therapy in Neurological Disorders Part 2

Epilepsy

• Intermittent derangement of the nervous Intermittent derangement of the nervous system caused by sudden discharge of system caused by sudden discharge of cerebral neuronscerebral neurons

• 2.3 million Americans have epilepsy; 15% 2.3 million Americans have epilepsy; 15% under age 15under age 15

• May be caused by head injury, congenital May be caused by head injury, congenital defects, metabolic disorders, other illnessesdefects, metabolic disorders, other illnesses

• Many are idiopathic (cause unknown)Many are idiopathic (cause unknown)

Onset of Seizures by Age

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

Causes of Seizures

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

Generalized Seizures

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 Involves complete loss of muscle tone and

consciousnessconsciousness• More common in childrenMore common in children

Epilepsy: Absence Seizure

• Formerly called petit malFormerly called petit mal• Also generalizedAlso generalized• May appear to be daydreaming, but May appear to be daydreaming, but

recovers after a few seconds with no recovers after a few seconds with no postictal fatigue or disorientationpostictal fatigue or disorientation

• More common in childrenMore common in children

Absence Seizure Pathology

Partial Seizures

Epilepsy: Partial Seizure

• Discrete focus of epileptogenic brain tissueDiscrete focus of epileptogenic brain tissue• Simple partial seizure involves no loss of Simple partial seizure involves no loss of

consciousnessconsciousness• Complex partial seizure involves change in Complex partial seizure involves change in

consciousnessconsciousness• Most common, especially in adultsMost common, especially in adults

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

Types of Seizures and Prevalence

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

Epilepsy: Medical Treatment

Generalized seizuresGeneralized seizures• managed with valproate, phenytoin, managed with valproate, phenytoin,

gabapentingabapentin• Drug-drug and drug-nutrient interactionsDrug-drug and drug-nutrient interactions• Liver damageLiver damage

Epilepsy: Medical Treatment

Partial seizuresPartial 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% Localized focus resected produces cure in 75% of patientsof patients

• Phenobarbital avoided as associated with Phenobarbital avoided as associated with IQ in IQ in children; may be used in failure of other drugschildren; may be used in failure of other drugs

Epilepsy: Drug-Nutrient Interactions• Phenobarbital, phenytoin, primidone Phenobarbital, phenytoin, primidone

interfere with absorption of calcium by interfere with absorption of calcium by increasing vitamin D metabolismincreasing vitamin D metabolism

• Long term therapy may lead to Long term therapy may lead to osteomalacia in adults or rickets in childrenosteomalacia in adults or rickets in children

• Vitamin D supplementation is essentialVitamin D supplementation is essential

Epilepsy: Drug-Nutrient Interactions• Folic acid supplementation interferes with Folic acid supplementation interferes with

phenytoin metabolism; may not reach phenytoin metabolism; may not reach therapeutic levelstherapeutic levels

• Phenytoin and phenobarbital are bound to Phenytoin and phenobarbital are bound to albumin in the bloodstream; malnutrition albumin in the bloodstream; malnutrition results in results in free drug and possible toxicity free drug and possible toxicity

• Alcohol interferes with phenytoin, possibly Alcohol interferes with phenytoin, possibly resulting in seizuresresulting in seizures

Epilepsy: Drug-Nutrient Interactions• Continuous enteral feeding slows absorption of Continuous enteral feeding slows absorption of

oral phenytoin; may increase therapeutic doseoral phenytoin; may increase therapeutic dose• If enteral feeding is discontinued, If enteral feeding is discontinued, risk of toxicity risk of toxicity• Window enteral feedings around phenytoin Window enteral feedings around phenytoin

administration (stop feeding 2 hours before and administration (stop feeding 2 hours before and after)after)

• Give phenytoin IV or use time-release formula to Give phenytoin IV or use time-release formula to decrease time the feeding is offdecrease time the feeding is off

Epilepsy MNT: Ketogenic Diet

• Treatment of last resort in children with Treatment of last resort in children with intractable seizuresintractable seizures

• Will completely control epilepsy in one-Will completely control epilepsy in one-third of children; significantly decrease third of children; significantly decrease activity in one-thirdactivity in one-third

• Ketones may exert anticonvulsant effect on Ketones may exert anticonvulsant effect on bodybody

Ketogenic Diet Implementation

• Stop antiepileptic drugsStop antiepileptic drugs• Child fasts in hospital for 24-72 hours until Child fasts in hospital for 24-72 hours until

4+ ketonuria4+ ketonuria• Evaluate responseEvaluate response• Fat: 75% of caloriesFat: 75% of calories• Protein: sufficient to meet growth needs (1 Protein: sufficient to meet growth needs (1

g/kg)g/kg)• CHO: added to make up rest of calorie CHO: added to make up rest of calorie

needs (negligible)needs (negligible)

Ketogenic Diet Menu Using MCT Oil

Multiple Sclerosis

• Chronic disease affecting the CNSChronic disease affecting the CNS• Destruction of the myelin sheath, which Destruction of the myelin sheath, which

transmits nerve impulsestransmits nerve impulses• Multiple areas of myelin are replaced with Multiple areas of myelin are replaced with

scar tissuescar tissue• May be genetic and environmental factors, May be genetic and environmental factors,

including geographical latitude (northern including geographical latitude (northern hemisphere) and diet (high animal fats)hemisphere) and diet (high animal fats)

Multiple Sclerosis: Medical Tx

• Steroid therapy for exacerbations; ACTH Steroid therapy for exacerbations; ACTH and prednisolone; methotrexate (can cause and prednisolone; methotrexate (can cause weight gain, fluid retention) alpha-weight gain, fluid retention) alpha-interferoninterferon

• Physical therapyPhysical therapy

Progression of Multiple Sclerosis

MS Controversial Therapies

• Shank diet: low in saturated fatShank diet: low in saturated fat• MacDougal diet: no gluten, low sugar, and MacDougal diet: no gluten, low sugar, and

no refined sugarno refined sugar• Allergen-free, gluten-free, pectin-free, Allergen-free, gluten-free, pectin-free,

fructose-restricted, raw food Evers dietfructose-restricted, raw food Evers diet• Low fat diet high in linoleic acid may have Low fat diet high in linoleic acid may have

some beneficial effectssome beneficial effects

MNT in MS

• Diet consistency modifications as needed if Diet consistency modifications as needed if dysphagia developsdysphagia develops

• Suggest prepackaged, single-serving or Suggest prepackaged, single-serving or convenience foods if meal preparation becomes convenience foods if meal preparation becomes difficult due to impaired vision, poor ambulationdifficult due to impaired vision, poor ambulation

• High fiber diet for constipationHigh fiber diet for constipation• Counseling regarding fluid intake, cranberry juice Counseling regarding fluid intake, cranberry juice

to prevent UTIsto prevent UTIs• Enteral nutrition support in end stageEnteral nutrition support in end stage

Nutrition Guidelines for Parkinson’s Disease• Eat a variety of healthy foods consistent Eat a variety of healthy foods consistent

with the US Dietary Guidelineswith 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

Food-Drug Interactions in Parkinson’s Disease• Levodopa works best taken on an empty stomach Levodopa works best taken on an empty stomach

½ hour before or one hour after meals½ hour before or one hour after meals• Protein competes with levodopa for absorption. Protein competes with levodopa for absorption.

Rarely, a high protein diet interferes with Rarely, a high protein diet interferes with levodopalevodopa

• If so, reduce overall protein intake or divide into If so, reduce overall protein intake or divide into many small meals; eat protein late in the day many small meals; eat protein late in the day (usually not recommended)(usually not recommended)

Source: Cleveland Clinic Health System, http://www

Food-Drug Interactions in Parkinson’s Disease • Levodopa can cause nauseaLevodopa can cause nausea• Doctor may change to combination of levodopa Doctor may change to combination of levodopa

and carbidopa (Sinemet) or carbidopa by itself 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/

Protein Redistribution in L-Dopa Therapy

Acute Spinal Cord Injury

Source: www.spinal-cord-injury-resources.com/ spinal-i...

Spinal Cord Lying within the Vertebral Canal

Sequelae of Spinal Cord Injury and Rehabilitation Challenges

Acute Spinal Cord Injury (SCI)

• Energy requirement for SCI = H/B x 1.1 x Energy requirement for SCI = H/B x 1.1 x 1.3 (Barco et al, NCP 17;309-313, 2002)1.3 (Barco et al, NCP 17;309-313, 2002)

• Pt with multi-traumas in addition to SCI may Pt with multi-traumas in addition to SCI may have higher needshave higher needs

• Protein needs: 2 g/kg (Rodriguez DJ et al, Protein needs: 2 g/kg (Rodriguez DJ et al, JPEN 15:319-322, 1991JPEN 15:319-322, 1991

• Provide enteral/parenteral support as neededProvide enteral/parenteral support as needed

MNT in Chronic Spinal Cord Injury• Risk of weight gain, pressure ulcers due to Risk of weight gain, pressure ulcers due to

immobilizationimmobilization• High fiber, adequate hydration to minimize High fiber, adequate hydration to minimize

constipationconstipation• Dietary intake to maintain nutritional health Dietary intake to maintain nutritional health

and adequate weightand adequate weight

Brain Injury• 400,000 new cases of brain injury occur each 400,000 new cases of brain injury occur each

year in the United Statesyear in the United States• Most result from motor vehicle crashes.Most result from motor vehicle crashes.• Incidence is highest in young people and Incidence is highest in young people and

elderly; twice as often in males than femaleselderly; twice as often in males than females• Almost all patients with a severe head injury Almost all patients with a severe head injury

have some degree of disability.have some degree of disability.

Glasgow Coma Scale (GCS)Strong prognostic value for neurologic recovery in Strong prognostic value for neurologic recovery in

head-injured patients (scale evaluating and head-injured patients (scale evaluating and quantitating the degree of coma by determining quantitating the degree of coma by determining best responses to standardized stimuli)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, Severity of head injury: mild = GCS 13-15,

moderate = GCS 9-12, severe = GCS 3-8moderate = GCS 9-12, severe = GCS 3-8

Strong Predictors of Poor Outcome after Head Injury

• Older ageOlder age• Low Glasgow ComaLow Glasgow Coma

Scale scoreScale score• Pupil dilatationPupil dilatation• Low blood pressureLow blood pressure

All these variables have an additive effect on All these variables have an additive effect on morbidity and mortalitymorbidity and mortality

• Inadequate Inadequate oxygenation early oxygenation early after injuryafter injury

• Prolonged and/or Prolonged and/or difficult to control difficult to control intracranial pressureintracranial pressure

Neurological Deficits That Affect Nutritional Status

• Hemiparesis: weakness that affects one side Hemiparesis: weakness that affects one side of the bodyof the body• May increase risk of aspirationMay increase risk of aspiration

• Hemianopsia: blindness in one half of field Hemianopsia: blindness in one half of field of vision.of vision.• Must compensate by turning his headMust compensate by turning his head

Normal Vision

Hemianopsia

Neurological Deficits That Affect Nutritional Status

• ApraxiaApraxia• Patient has difficulty with perceptual Patient has difficulty with perceptual

motor planningmotor planning• DysphagiaDysphagia

• Difficulty swallowingDifficulty swallowing

Symptoms of Dysphagia

• DroolingDrooling• Choking or coughing during or following Choking or coughing during or following

mealsmeals• Inability to suck from a strawInability to suck from a straw• Gurgly voice qualityGurgly voice quality• Holding pockets of food in the buccal Holding pockets of food in the buccal

recesses (patient may not be aware)recesses (patient may not be aware)

Symptoms of Dysphagia

• Absent gag reflexAbsent gag reflex• Chronic upper respiratory infectionsChronic upper respiratory infections• Weight loss and anorexiaWeight loss and anorexia

Stages of Swallowing

• Oral Phase: (voluntary) food is chewed, Oral Phase: (voluntary) food is chewed, mixed with saliva, tongue moves it to the mixed with saliva, tongue moves it to the back of the mouthback of the mouth• Problems include inability to seal the lips Problems include inability to seal the lips

around a cuparound a cup• Inability to suck through a strawInability to suck through a straw• Food can become pocketedFood can become pocketed

Stages of Swallowing

• Pharyngeal phase: (involuntary) Soft palate closes Pharyngeal phase: (involuntary) Soft palate closes off the nasopharynx; hyoid and larynx elevate, off the nasopharynx; hyoid and larynx elevate, vocal cords adduct to protect the airway; pharynx vocal cords adduct to protect the airway; pharynx contracts and cricopharyngeal sphincter relaxes contracts and cricopharyngeal sphincter relaxes allowing food to pass into the esophagusallowing food to pass into the esophagus• Symptoms of poor coordination include Symptoms of poor coordination include

gagging, choking, and nasopharyngeal gagging, choking, and nasopharyngeal regurgitationregurgitation

Stages of Swallowing (cont)

• Esophageal phase: (involuntary) bolus Esophageal phase: (involuntary) bolus continues through esophagus into the continues through esophagus into the stomachstomach• Most difficulties due to mechanical Most difficulties due to mechanical

obstructionobstruction• Involuntary peristalsis affected by brain Involuntary peristalsis affected by brain

stem infarctstem infarct

Swallowing Occurs in Three Phases

Swallowing Occurs in Three Phases

Swallowing Occurs in Three Phases—cont’dSwallowing Occurs in Three Phases—cont’d

Swallow Animation

http://greenfield.fortunecity.com/rattler/46/upali4.htm

Food Textures in Dysphagia

Thin liquids: the most difficult to control in Thin liquids: the most difficult to control in the mouththe mouth

• Easily aspirated into the lungsEasily aspirated into the lungs• Often thickened to nectar thick, honey Often thickened to nectar thick, honey

thick, or pudding thickthick, or pudding thick• Essential for proper hydrationEssential for proper hydration

National Dysphagia Diet Survey

• Diet covered in Oral and Dental Health Diet covered in Oral and Dental Health lecturelecture

• ADA and ASHA surveyed RDs and SLPs ADA and ASHA surveyed RDs and SLPs regarding use of NDDregarding use of NDD

• 30% had implemented NDD30% had implemented NDD• Of those not using it, some were using Of those not using it, some were using

modifications of itmodifications of it

Reported at FNCE 2007; Shirley L. McCallum

Thickened Liquids Issues

• No consistency across product lines within No consistency across product lines within manufacturers or between competitorsmanufacturers or between competitors

• Continuous hydration of the thickening Continuous hydration of the thickening agent in pre-thickened productsagent in pre-thickened products

• Issues with instant food thickener Issues with instant food thickener continuing to thickencontinuing to thicken

Randomized Study of Two Interventions for Liquid Aspiration

Short and Long-term Effects (“Protocol 201”) NIH-Funded

Dysphagia Clinical Trial

Presented at FNCE, Oct. 2007Presented at FNCE, Oct. 2007

JoAnne Robbins, PhD, CCC-SLPJoAnne Robbins, PhD, CCC-SLP

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

Protocol 201• Patients who aspirated on thin liquids were Patients who aspirated on thin liquids were

trialed on 3 interventionstrialed on 3 interventions• Chin tuck with thin liquidsChin tuck with thin liquids• Nectar thick liquidsNectar thick liquids• Honey thick liquidsHoney thick liquids

Protocol 201 Part 2

• Those who aspirated on all three or did not Those who aspirated on all three or did not aspirate on any of them were entered into aspirate on any of them were entered into part 2 of the trialpart 2 of the trial

• Patients were randomized toPatients were randomized to• Chin-tuckChin-tuck• Honey thick liquidsHoney thick liquids• Nectar thick liquidsNectar thick liquids

Short Term Aspiration Results

Chin DownChin Down NectarNectar HoneyHoney

Parkinson’s Parkinson’s DiseaseDisease

59%59% 54%54% 44%44%

DementiaDementia 74%74% 69%69% 58%58%

Parkinson’s Parkinson’s w/dementiaw/dementia

69%69% 64%64% 53%53%

OverallOverall 68%68% 63%63% 53%53%

Summary

• Higher proportion of dementia patients Higher proportion of dementia patients aspirated on all interventionsaspirated on all interventions

• Aspiration frequency: Chin down, nectar, Aspiration frequency: Chin down, nectar, then honeythen honey

• Satisfaction: chin down or nectar, then Satisfaction: chin down or nectar, then honeyhoney

Protocol 201: Long Term Outcome

• Population: those who aspirated on all three Population: those who aspirated on all three interventions and those who aspirated on interventions and those who aspirated on none; enrolled 515 study ptsnone; enrolled 515 study pts

• Primary outcome: 3-month pneumonia rate Primary outcome: 3-month pneumonia rate defined via chest x-ray, febrile illness, rales, defined via chest x-ray, febrile illness, rales, positive sputumpositive sputum

Pneumonia: Long-Term Findings

• Subjects with dementia with or without PD Subjects with dementia with or without PD had significantly higher incidence of had significantly higher incidence of pneumonia than PD only (15% vs 5%, pneumonia than PD only (15% vs 5%, p<.05)p<.05)

• Subjects who aspirated on all 3 Subjects who aspirated on all 3 interventions had a significantly higher interventions had a significantly higher incidence of pneumonia than those who incidence of pneumonia than those who aspirated on none of the interventions (14% aspirated on none of the interventions (14% vs 6%, p<.05)vs 6%, p<.05)

Pneumonia Long-Term Findings

• Patients with PD randomized to HT had Patients with PD randomized to HT had greater pneumonia rates than those greater pneumonia rates than those randomized to nectar thick (10% vs 0%)randomized to nectar thick (10% vs 0%)

• Despite differential effect of interventions Despite differential effect of interventions on immediate elimination of aspiration in on immediate elimination of aspiration in videofluoroscopic suite no difference in the videofluoroscopic suite no difference in the 3-month incidence of pneumonia for chin 3-month incidence of pneumonia for chin down posture compared to thickened liquidsdown posture compared to thickened liquids

Current Assumption

• ““The thicker the liquid, the safer the The thicker the liquid, the safer the swallow.”swallow.”

• Not true in pts who aspirate thick liquids – Not true in pts who aspirate thick liquids – worse health outcomesworse health outcomes

Lessons Learned

Risk factors for clinically significant aspirationRisk factors for clinically significant aspiration• DementiaDementia• Patients who aspirate repeatedly while performing Patients who aspirate repeatedly while performing

intervention attempts as visualized intervention attempts as visualized fluoroscopicallyfluoroscopically

• Evaluate all possible interventions and if none are Evaluate all possible interventions and if none are best, avoid honey thick as a last resortbest, avoid honey thick as a last resort

Diet for Easy Chewing and Swallowing

Techniques for Improving Acceptance• AromaAroma• SeasoningSeasoning• Layering/swirlingLayering/swirling• PipingPiping

• MoldingMolding• SlurriesSlurries• GarnishingGarnishing

Localizing Signs of Mass Lesion

• Lesions in the central portion of the frontal Lesions in the central portion of the frontal lobes may cause speech impairment.lobes may cause speech impairment.

• Lesions of the occipital lobes affect the Lesions of the occipital lobes affect the visual field.visual field.

• Lesions of the cerebellum and brainstem affect Lesions of the cerebellum and brainstem affect the cranial nerves.the cranial nerves.

• Lesions in the spinal cord affect motor neuronsLesions in the spinal cord affect motor neurons• Lesions of the pituitary gland and Lesions of the pituitary gland and

hypothalamus may induce electrolyte or hypothalamus may induce electrolyte or metabolic abnormalities and/or visual metabolic abnormalities and/or visual disturbances.disturbances.

Medical Nutrition Therapy• Cognitive and swallowing dysfunction usually Cognitive and swallowing dysfunction usually

affect nutritional management and place affect nutritional management and place neurologic patients at risk for malnutrition. neurologic patients at risk for malnutrition.

• The nutritional assessment should emphasize The nutritional assessment should emphasize patterns of normal chewing, swallowing, and patterns of normal chewing, swallowing, and ingestion in addition to traditional assessment ingestion in addition to traditional assessment components.components.

Nutritional Support• Enteral nutrition support is the preferred modality Enteral nutrition support is the preferred modality

for nutrition support in patients who cannot for nutrition support in patients who cannot swallow or eat because of deteriorating neurologic swallow or eat because of deteriorating neurologic disease.disease.