medical nutrition therapy in neurological disorders part 2 l.
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Medical Nutrition Therapy in Neurological Disorders Part 2. Epilepsy. Intermittent derangement of the nervous system caused by sudden discharge of cerebral neurons 2.3 million Americans have epilepsy; 15% under age 15

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  • Intermittent derangement of the nervous system caused by sudden discharge of cerebral neurons
  • 2.3 million Americans have epilepsy; 15% under age 15
  • May be caused by head injury, congenital defects, metabolic disorders, other illnesses
  • Many are idiopathic (cause unknown)
onset of seizures by age
Onset of Seizures by Age

Source: University of Cincinnati Department of Neurology

causes of seizures
Causes of Seizures

Source: University of Cincinnati Department of Neurology

epilepsy tonic clonic seizure
Epilepsy: Tonic-Clonic Seizure
  • Formerly called grand mal.
  • Generalized seizure that lasts 1-2 minutes
  • Involves complete loss of muscle tone and consciousness
  • More common in children
epilepsy absence seizure
Epilepsy: Absence Seizure
  • Formerly called petit mal
  • Also generalized
  • May appear to be daydreaming, but recovers after a few seconds with no postictal fatigue or disorientation
  • More common in children
epilepsy partial seizure
Epilepsy: Partial Seizure
  • Discrete focus of epileptogenic brain tissue
  • Simple partial seizure involves no loss of consciousness
  • Complex partial seizure involves change in consciousness
  • Most common, especially in adults

Source: University of Cincinnati Department of Neurology

types of seizures and prevalence
Types of Seizures and Prevalence

Source: University of Cincinnati Department of Neurology

epilepsy medical treatment
Epilepsy: Medical Treatment

Generalized seizures

  • managed with valproate, phenytoin, gabapentin
    • Drug-drug and drug-nutrient interactions
    • Liver damage
epilepsy medical treatment13
Epilepsy: Medical Treatment

Partial seizures

  • Managed with carbamazepine or phenytoin
  • Seizure surgery if fail to control with medications
    • Localized focus resected produces cure in 75% of patients
  • Phenobarbital avoided as associated with  IQ in children; may be used in failure of other drugs
epilepsy drug nutrient interactions
Epilepsy: Drug-Nutrient Interactions
  • Phenobarbital, phenytoin, primidone interfere with absorption of calcium by increasing vitamin D metabolism
  • Long term therapy may lead to osteomalacia in adults or rickets in children
  • Vitamin D supplementation is essential
epilepsy drug nutrient interactions15
Epilepsy: Drug-Nutrient Interactions
  • Folic 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 toxicity
  • Alcohol interferes with phenytoin, possibly resulting in seizures
epilepsy drug nutrient interactions16
Epilepsy: Drug-Nutrient Interactions
  • Continuous enteral feeding slows absorption of oral phenytoin; may increase therapeutic dose
  • If enteral feeding is discontinued,  risk of toxicity
  • 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 off
epilepsy mnt ketogenic diet
Epilepsy MNT: Ketogenic Diet
  • Treatment of last resort in children with intractable seizures
  • Will completely control epilepsy in one-third of children; significantly decrease activity in one-third
  • Ketones may exert anticonvulsant effect on body
ketogenic diet implementation
Ketogenic Diet Implementation
  • Stop antiepileptic drugs
  • Child fasts in hospital for 24-72 hours until 4+ ketonuria
  • Evaluate response
  • Fat: 75% of calories
  • Protein: sufficient to meet growth needs (1 g/kg)
  • CHO: added to make up rest of calorie needs (negligible)
multiple sclerosis
Multiple Sclerosis
  • Chronic disease affecting the CNS
  • Destruction of the myelin sheath, which transmits nerve impulses
  • Multiple areas of myelin are replaced with scar tissue
  • May be genetic and environmental factors, including geographical latitude (northern hemisphere) and diet (high animal fats)
multiple sclerosis medical tx
Multiple Sclerosis: Medical Tx
  • Steroid therapy for exacerbations; ACTH and prednisolone; methotrexate (can cause weight gain, fluid retention) alpha-interferon
  • Physical therapy
ms controversial therapies
MS Controversial Therapies
  • Shank diet: low in saturated fat
  • MacDougal diet: no gluten, low sugar, and no refined sugar
  • Allergen-free, gluten-free, pectin-free, fructose-restricted, raw food Evers diet
  • Low fat diet high in linoleic acid may have some beneficial effects
mnt in ms
  • Diet consistency modifications as needed if dysphagia develops
  • Suggest prepackaged, single-serving or convenience foods if meal preparation becomes difficult due to impaired vision, poor ambulation
  • High fiber diet for constipation
  • Counseling regarding fluid intake, cranberry juice to prevent UTIs
  • Enteral nutrition support in end stage
nutrition guidelines for parkinson s disease
Nutrition Guidelines for Parkinson’s Disease
  • Eat a variety of healthy foods consistent with the US Dietary Guidelines
  • Maintain a healthy body weight
  • Balance food with exercise
  • Eat foods high in fiber
food drug interactions in parkinson s disease
Food-Drug Interactions in Parkinson’s Disease
  • Levodopa 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 levodopa
  • 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

food drug interactions in parkinson s disease27
Food-Drug Interactions in Parkinson’s Disease
  • Levodopa can cause nausea
  • Doctor may change to combination of levodopa and carbidopa (Sinemet) or carbidopa by itself
  • Drink liquids between meals rather than with them
  • Eat smaller more frequent meals
  • Avoid fried, greasy or sweet foods
  • Eat foods at room temperature to minimize odors
  • Rest after eating with head elevated

Source: Cleveland Clinic Health System,

acute spinal cord injury
Acute Spinal Cord Injury

Source: spinal-i...

acute spinal cord injury sci
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)
  • Pt with multi-traumas in addition to SCI may have higher needs
  • Protein needs: 2 g/kg (Rodriguez DJ et al, JPEN 15:319-322, 1991
  • Provide enteral/parenteral support as needed
mnt in chronic spinal cord injury
MNT in Chronic Spinal Cord Injury
  • Risk of weight gain, pressure ulcers due to immobilization
  • High fiber, adequate hydration to minimize constipation
  • Dietary intake to maintain nutritional health and adequate weight
brain injury
Brain Injury
  • 400,000 new cases of brain injury occur each year in the United States
  • Most result from motor vehicle crashes.
  • Incidence 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.
glasgow coma scale gcs
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)
  • Verbal response (5 Oriented–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

strong predictors of poor outcome after head injury
Older age

Low Glasgow ComaScale score

Pupil dilatation

Low 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

Strong Predictors of Poor Outcome after Head Injury
neurological deficits that affect nutritional status
Neurological Deficits That Affect Nutritional Status
  • Hemiparesis: weakness that affects one side of the body
    • May increase risk of aspiration
  • Hemianopsia: blindness in one half of field of vision.
    • Must compensate by turning his head
neurological deficits that affect nutritional status40
Neurological Deficits That Affect Nutritional Status
  • Apraxia
    • Patient has difficulty with perceptual motor planning
  • Dysphagia
    • Difficulty swallowing
symptoms of dysphagia
Symptoms of Dysphagia
  • Drooling
  • Choking or coughing during or following meals
  • Inability to suck from a straw
  • Gurgly voice quality
  • Holding pockets of food in the buccal recesses (patient may not be aware)
symptoms of dysphagia42
Symptoms of Dysphagia
  • Absent gag reflex
  • Chronic upper respiratory infections
  • Weight loss and anorexia
stages of swallowing
Stages of Swallowing
  • Oral 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 cup
    • Inability to suck through a straw
    • Food can become pocketed
stages of swallowing44
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 esophagus
    • Symptoms of poor coordination include gagging, choking, and nasopharyngeal regurgitation
stages of swallowing cont
Stages of Swallowing (cont)
  • Esophageal phase: (involuntary) bolus continues through esophagus into the stomach
    • Most difficulties due to mechanical obstruction
    • Involuntary peristalsis affected by brain stem infarct
swallow animation
Swallow Animation

food textures in dysphagia
Food Textures in Dysphagia

Thin liquids: the most difficult to control in the mouth

  • Easily aspirated into the lungs
  • Often thickened to nectar thick, honey thick, or pudding thick
  • Essential for proper hydration
national dysphagia diet survey
National Dysphagia Diet Survey
  • Diet covered in Oral and Dental Health lecture
  • ADA and ASHA surveyed RDs and SLPs regarding use of NDD
  • 30% had implemented NDD
  • Of those not using it, some were using modifications of it

Reported at FNCE 2007; Shirley L. McCallum

thickened liquids issues
Thickened Liquids Issues
  • No consistency across product lines within manufacturers or between competitors
  • Continuous hydration of the thickening agent in pre-thickened products
  • Issues with instant food thickener continuing to thicken
presented at fnce oct 2007 joanne robbins phd ccc slp

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

protocol 201
Protocol 201
  • Patients with dementia and/or Parkinson’s disease
  • 742 randomized; 711 analyzed
  • 70% male; 59% age 80 or above
  • 15% minority
  • Diagnosis
    • 32% Parkinson’s disease
    • 49% dementia
    • 19% PD with dementia
protocol 20154
Protocol 201
  • Patients who aspirated on thin liquids were trialed on 3 interventions
    • Chin tuck with thin liquids
    • Nectar thick liquids
    • Honey thick liquids
protocol 201 part 2
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 trial
  • Patients were randomized to
    • Chin-tuck
    • Honey thick liquids
    • Nectar thick liquids
  • Higher proportion of dementia patients aspirated on all interventions
  • Aspiration frequency: Chin down, nectar, then honey
  • Satisfaction: chin down or nectar, then honey
protocol 201 long term outcome
Protocol 201: Long Term Outcome
  • Population: 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 sputum
pneumonia long term findings
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 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)
pneumonia long term findings60
Pneumonia Long-Term Findings
  • 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 liquids
current assumption
Current Assumption
  • “The thicker the liquid, the safer the swallow.”
  • Not true in pts who aspirate thick liquids – worse health outcomes
lessons learned
Lessons Learned

Risk factors for clinically significant aspiration

  • Dementia
  • Patients 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 resort
techniques for improving acceptance







Techniques for Improving Acceptance
localizing signs of mass lesion
Localizing Signs of Mass Lesion
  • 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 cerebellum and brainstem affect the cranial nerves.
  • Lesions in the spinal cord affect motor neurons
  • Lesions of the pituitary gland and hypothalamus may induce electrolyte or metabolic abnormalities and/or visual disturbances.
medical nutrition therapy
Medical Nutrition Therapy
  • 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.
nutritional support
Nutritional Support
  • Enteral nutrition support is the preferred modality for nutrition support in patients who cannot swallow or eat because of deteriorating neurologic disease.