Neurological Disorders part 1


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Neurological Disorders part 1

  1. 1. Medical Nutrition Therapy in Neurological Disorders Part 1
  2. 2. Nutrition and Neurologic Disease <ul><li>May have nutritional etiologies resulting from deficiency or excess </li></ul><ul><li>May be nonnutritional in origin but have significant nutritional implications </li></ul>
  3. 3. Stroke Statistics <ul><li>Stroke is the third leading cause of death ranking behind diseases of the heart and cancers </li></ul><ul><li>Killed 150,147 people in 2004; females accounted for 60.9 percent of stroke deaths. </li></ul><ul><li>About 5,700,000 stroke survivors are alive today. 2,400,000 are males and 3,300,000 are females. </li></ul><ul><li>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) </li></ul> online 11-16-07
  4. 4. Stroke Statistics <ul><li>From 1992 to 2002 the death rate from stroke declined 13.8 percent, but the actual number of stroke deaths rose 6.9 percent .  </li></ul><ul><li>A leading cause of functional disability – 15-30% permanently disabled </li></ul>Primary Prevention of Ischemic Stroke, AHA/ASA Guideline, Stroke 2006;37:1583-1633, accessed online 11-16-06
  5. 5. Risk Factors for Ischemic Stroke <ul><li>Non-Modifiable </li></ul><ul><li>Age </li></ul><ul><li>Gender </li></ul><ul><li>Low Birth Weight </li></ul><ul><li>Race/ethnicity </li></ul><ul><li>Genetic factors </li></ul><ul><li>Modifiable </li></ul><ul><li>Hypertension </li></ul><ul><li>Exposure to cigarette smoke </li></ul><ul><li>Diabetes </li></ul><ul><li>Atrial fib and other cardiac conditions </li></ul><ul><li>Dislipidemia (ischemic stroke) </li></ul><ul><li>Post-menopausal hormone therapy </li></ul><ul><li>Poor diet </li></ul><ul><li>Obesity/body fat distribution </li></ul><ul><li>Inactivity </li></ul>Primary Prevention of Ischemic Stroke, AHA/ASA Guideline, Stroke 2006;37:1583-1633, accessed online 11-16-06
  6. 6. Pathophysiology of Stroke <ul><li>85% of strokes caused by a thromboembolic event (related to atherosclerosis, hypertension, diabetes, gout) </li></ul><ul><ul><li>Embolic stroke: cholesterol plaque is dislodged from vessel, travels to the brain, blocks an artery </li></ul></ul><ul><ul><li>Thrombotic stroke: cholesterol plaque within an artery ruptures, platelets aggregate and clog a narrow artery </li></ul></ul>
  7. 7. Nutrition-Related Factors and Stroke Risk (BMI = body mass index)
  8. 8. Thromboembolic Stroke
  9. 9. Hemorrhagic Stroke <ul><li>Intraparenchymal hemorrhage: prevalence of hypertension is 80%; vessel inside the brain ruptures </li></ul><ul><li>Subarachnoid hemorrhage (SAH): ruptured aneurism in the subarachnoid space; or due to head trauma </li></ul><ul><li>15% of all strokes </li></ul>
  10. 10. Hemorrhagic Stroke
  11. 11. Medical Treatment for Stroke <ul><li>Thrombolytic or “clot-busting” drugs to restore perfusion to affected areas within 6 hours of onset of stroke </li></ul><ul><li>Controlling intracranial pressure (ICP) while maintaining sufficient perfusion of the brain </li></ul>
  12. 12. Nutritional Management in Stroke <ul><li>Primary prevention </li></ul><ul><li>Acute management (screening for dysphagia and nutritional risk) </li></ul><ul><li>Intervention for swallowing disorders via consistency changes </li></ul>
  13. 13. AHA Guidelines for Primary Prevention of CVD and Stroke: 2006 Update <ul><li>Smoking: complete cessation (Class I, evidence level B </li></ul><ul><li>Avoid exposure to environmental tobacco smoke (Class IIA, evidence C) </li></ul><ul><li>BP control: goal <140/90 mmHg with lower targets in some subgroups (<130/80 in diabetes) </li></ul>Goldstein et al, Primary Prevention of Ischemic Stroke, Stroke 2006;37:1583-1633)
  14. 14. AHA Guidelines for Primary Prevention of CVD and Stroke: 2006 Update <ul><li>Blood lipid mgt: </li></ul><ul><ul><li>NCP III guidelines for pts who have not had a stroke and have high TC or non-HDL-C w/ high TG </li></ul></ul><ul><ul><li>Pts with known CAD and high risk HTN even w/ normal LDL treat with lifestyle/statin (Class I, evidence A) </li></ul></ul><ul><ul><li>Rec wt loss, ↑ physical activity, smoking cessation, niacin or gemfibrozil (Class IIA, evidence B) </li></ul></ul>Goldstein et al, Primary Prevention of Ischemic Stroke, Stroke 2006;37:1583-1633)
  15. 15. AHA Diet/Lifestyle Guidelines for Primary Prevention of CVD/Stroke: 2006 Update <ul><li>Reduced intake of sodium and increased intake of potassium to lower blood pressure (Class I, evidence A) </li></ul><ul><li>Recommended sodium intake <2.3g/day; potassium >4.7g/day </li></ul><ul><li>DASH diet emphasizing fruits, vegetables, lowfat dairy products is recommended to lower BP (Class I, evidence A) </li></ul><ul><li>High fruit and vegetable intake may lower risk of stroke (Evidence C) </li></ul><ul><li>Wt reduction is recommended because it lowers BP </li></ul><ul><li>Increased physical activity ( > 30 minutes of moderate-intensity activity daily) </li></ul>Pearson et al. ( Circulation. 2002;106:388-391.)
  16. 16. Lipids and Stroke <ul><li>Cholesterol is a very weak risk factor for ischemic stroke, in contrast to CAD </li></ul><ul><li>Cholesterol reduction with diet and nonstatin drugs is not effective in stroke prevention, although reductions in levels of cholesterol are modest </li></ul><ul><li>Statins produce a statistically significant 25% reduction in the risk of stroke </li></ul>Briel M, et al Am J Med 2004;117:596-606
  17. 17. Lipids and Stroke in MRFIT
  18. 18. Lipids and Stroke: ARIC Study <ul><li>Cohort study of 14,175 men and women </li></ul><ul><li>After 10-year followup, there were weak and inconsistent associations between ischemic stroke and LDL-C, HDL-C, apo-B, apo-A-1, triglycerides </li></ul><ul><li>Most consistent relationship was lower risk in women with higher HDL and higher risk with lower TG </li></ul>Shahar E, et al. Stroke, 2003;34:623-631
  19. 19. Lipids and Stroke <ul><li>Problem may be the heterogenicity of stroke, although even when looking at homogeneous ischemic stroke, relationship is weak </li></ul><ul><li>The protective effect of statins may be due to their non-cholesterol-lowering effects. </li></ul>
  20. 20. Relationship Between Fat/Cholesterol and Stroke Risk <ul><li>Dietary cholesterol, MFA, PUFA not related to risk of stroke </li></ul><ul><li>Low intake of SFA and animal protein associated with  risk of intraparenchymal hemorrhage </li></ul><ul><li>In DCCT trial, intensive treatment lowered LDL, TC and TG and cerebrovascular events </li></ul>
  21. 21. Guidelines for Management of Acute Stroke Rehab (AHA/ASA) <ul><li>Dysphagia occurs in 45% of all hospitalized stroke patients; can lead to aspiration pneumonia and death. </li></ul><ul><li>Malnutrition is present in 15% of patients admitted to the hospital, and this percentage doubles during the first week after stroke. </li></ul><ul><li>A bedside swallow screening should be completed before oral intake (Evidence Level=B). </li></ul><ul><li>If the patient’s swallow screening is abnormal, a complete bedside swallow examination is recommended (Evidence Level=I). </li></ul>AHA/ASA Endorsed Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care (Stroke. 2005;36:2049.)
  22. 22. Dysphagia Treatment- AHA/ASA <ul><li>Dysphagia treatment may involve posture changes, heightening sensory input, swallow maneuvers, active exercise programs, or diet modifications. </li></ul><ul><li>Dysphagia management may include nonoral feeding and psychological support. </li></ul><ul><li>At this time, it is unclear how dysphagic patients should be fed after acute stroke. </li></ul>AHA/ASA Endorsed Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care (Stroke. 2005;36:2049.)
  23. 23. Dysphagia Treatment- AHA/ASA <ul><li>The literature supports the use of tube feeding for patients who cannot sustain sufficient oral caloric and/or fluid intake to meet nutritional needs. </li></ul><ul><li>Limited evidence suggests that percutaneous endoscopic gastrostomy feeding compares favorably with nasogastric tube feeding (Evidence Level=B). </li></ul>AHA/ASA Endorsed Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care (Stroke. 2005;36:2049.)
  24. 24. FOOD (Feed or Ordinary Diet) Trial <ul><li>Tested feeding strategies after acute stroke including oral supplementation, early vs delayed NG feeding, and NG vs PEG feeding </li></ul><ul><li>Poor baseline nutritional status is associated with worse outcomes at 6 months. </li></ul><ul><li>This relationship persists after adjustment for pt’s age, prestroke functional level, living conditions, and severity of stroke. </li></ul>AHA/ASA Guidelines for the Early Management of Patients with Ischemic Stroke. ( Stroke. 2005;36:916.)
  25. 25. FOOD (Feed or Ordinary Diet) Trial <ul><li>Found no benefit to routine oral supplementation of post-stroke patients who had not been identified as malnourished (1) </li></ul><ul><li>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) </li></ul><ul><li>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). </li></ul>1: Lancet. 2005 Feb 26-Mar 4;365(9461):755-63. 2: Lancet. 2005 Feb 26-Mar 4;365(9461):764-72
  26. 26. AHA Guidelines for Early Management of Pts with Ischemic Stroke <ul><li>A poor nutritional status was associated with an increased risk of infections including pneumonia, gastrointestinal bleeding, and pressure sores. </li></ul><ul><li>These data provide a strong rationale for assessment of the patient’s nutritional status at the time of admission. </li></ul>AHA/ASA Guidelines for the Early Management of Patients with Ischemic Stroke. ( Stroke. 2005;36:916.)
  27. 27. Alzheimer’s Disease <ul><li>Most common form of dementia </li></ul><ul><li>Increases exponentially after age 40 </li></ul><ul><li>Prevalence in white males at age 100 is 41.5% </li></ul><ul><li>Higher prevalence in women (3X) due to lower mortality </li></ul>
  28. 28. Symptoms of Alzheimer’s Disease <ul><li>Forgetfulness: may forget recent events, activities, names of familiar people or things (anomia). </li></ul><ul><li>Forget how to do simple tasks, such as brushing teeth, brushing hair </li></ul><ul><li>Get lost in familiar surroundings </li></ul><ul><li>Repeat words spoken by others (echolalia) </li></ul><ul><li>Loss of comprehension (agnosia) </li></ul>
  29. 29. Symptoms of Alzheimer’s Disease (cont) <ul><li>Motor skills deteriorate: loss of reflexes and shuffling gait </li></ul><ul><li>Bowel and bladder control lost </li></ul><ul><li>Limb weakness and contractures </li></ul><ul><li>Intellectual activity ceases </li></ul><ul><li>Vegetative state </li></ul>
  30. 30. Alzheimer’s Disease Risk Factors <ul><li>Age: risk doubles every five years after age 65 </li></ul><ul><li>Family history: early onset strongly hereditary; late onset has a genetic component </li></ul><ul><li>Those with a parent or sibling with AD are 2-3 times more likely to develop AD </li></ul>
  31. 31. Alzheimer’s Disease Risk Factors <ul><li>Head injury </li></ul><ul><li>Down syndrome </li></ul><ul><li>Low level of education </li></ul><ul><li>Female gender </li></ul>
  32. 32. Alzheimer’s Disease Prevention: Research Areas <ul><li> AD risk is associated with CVD, hypertension, diabetes </li></ul><ul><li> AD risk associated with exercise, staying mentally active, social engagement </li></ul><ul><li>Research ongoing into use of antioxidants (vitamins E and C), ginkgo biloba </li></ul><ul><li>Research into estrogen and AD suggests that estrogen treatment in postmenopausal women may  risk of dementia </li></ul>
  33. 33. Treatment of Alzheimer’s Disease <ul><li>No drug can stop or reverse AD </li></ul><ul><li>Some drugs may slow progress ( tacrine (Cognex®), donepezil (Aricept®), rivastigmine (Exelon®), or galantamine (Razadyne®) </li></ul><ul><li>Other medications may treat symptoms such as sleeplessness, agitation, wandering, anxiety, and depression </li></ul>National Institutes on Aging, Alzheimer’s Disease Education and Referral Center
  34. 34. Nutritional Consequences of Alzheimer’s Disease <ul><li>Weight loss is common possibly due to  activity (pacing) </li></ul><ul><li>Decreased independence and impaired self-feeding </li></ul><ul><li>Inability to recognize hunger, thirst and satiety </li></ul><ul><li>Meals forgotten as soon as eaten or may not be eaten at all </li></ul><ul><li>Inability to recognize food when presented </li></ul><ul><li>Risk for dehydration </li></ul>
  35. 35. MNT in Alzheimer’s Disease <ul><li>Vitamin-mineral supplementation; assure intake of antioxidants </li></ul><ul><li>Minimize distractions at mealtime (turn off radio or television) </li></ul><ul><li>Place foods on small plates and give one at a time </li></ul><ul><li>Serve food on plates of contrasting color </li></ul>
  36. 36. MNT in Alzheimer’s Disease <ul><li>Model use of eating utensils, provide verbal cues </li></ul><ul><li>Allow patient to use eating utensils as long as possible </li></ul><ul><li>Finger foods may be helpful, but monitor for swallowing problems and choking </li></ul><ul><li>Frequent snacks, nutrient-dense foods, nutritional supplements may be helpful </li></ul>
  37. 37. Practical Interventions for Eating-Related Behavioral Problems Common in Individuals with Dementia
  38. 38. Practical Interventions for Eating-Related Behavioral Problems Common in Individuals with Dementia
  39. 39. Migraine Headache <ul><li>Thought to be vascular in origin </li></ul><ul><li>Throbbing, episodic, and intense </li></ul><ul><li>History of intercurrent nausea, vomiting, photophobia, visual or olfactory auras </li></ul><ul><li>Treated with NSAIDs, sympathomimetics, seritonin agonists; prophylaxis with calcium channel blockers, beta-adrenergic blockers, serotonin antagonists </li></ul>
  40. 40. Migraine Headache <ul><li>Headaches may be triggered by food </li></ul><ul><li>Varies by individual and tolerance thresholds vary over time </li></ul><ul><li>No general recommendations about food avoidance </li></ul><ul><li>Foods often cited are citrus fruits, tea, coffee, pork, chocolate, milk, nuts, vegetables, cola drinks </li></ul><ul><li>Evaluate through food and symptom diary </li></ul>
  41. 41. Myasthenia Gravis (MG) <ul><li>Autoimmune disorder of the neuromuscular junction </li></ul><ul><li>Body makes antibodies to acetylcholine receptors; make them unresponsive to Ach </li></ul><ul><li>Nervous system signal to the muscle is garbled </li></ul><ul><li>Relapsing and remitting weakness and fatigability; diplopia, facial muscle weakness, dysphagia (33%) </li></ul>
  42. 42. Myasthenia Gravis (MG) Medical Treatment <ul><li>Anticholinesterases inhibit acetylcholesterase and increase the amount of Ach </li></ul><ul><li>Removal of the thymus gland </li></ul><ul><li>Corticosteroids </li></ul>
  43. 43. Myasthenia Gravis (MG) MNT <ul><li>Nutritionally dense foods at the beginning of meals before the patient tires </li></ul><ul><li>Small frequent meals </li></ul><ul><li>Time medication with feeding to facilitate optimal swallowing </li></ul><ul><li>Limit physical activity before meals </li></ul><ul><li>Don’t encourage food consumption when patient is tired; may aspirate </li></ul>
  44. 44. Wernicke-Korsakoff syndrome MNT <ul><li>Cause </li></ul><ul><li>Chronic thiamin deficiency with continued carbohydrate ingestion </li></ul><ul><li>Treatment </li></ul><ul><li>Thiamin </li></ul><ul><li>Adequate hydration </li></ul><ul><li>Diet liberal in high-thiamin foods </li></ul><ul><li>Eliminate ETOH </li></ul><ul><li>Dietary protein may need to be restricted </li></ul>
  45. 45. Amyotrophic Lateral Sclerosis <ul><li>Also called Lou Gehrig’s Disease </li></ul><ul><li>Most common motor system disease </li></ul><ul><li>Progressive denervation atrophy and weakness of muscles </li></ul><ul><li>Both upper and lower motor neurons are lost in the spinal cord, brain stem, and motor cortex </li></ul><ul><li>Progresses to death in 2 to 6 years </li></ul>
  46. 46. Amyotrophic Lateral Sclerosis <ul><li>Prevalence constant throughout the world </li></ul><ul><li>Men affected more than women </li></ul><ul><li>Age of onset mid-50s (40-70) </li></ul><ul><li>Cause unknown </li></ul><ul><li>5% familial, rest sporadic </li></ul>
  47. 47. Amyotrophic Lateral Sclerosis Presentation <ul><li>Muscle weakness commences in the legs and hands and progresses to the proximal arms and oropharynx </li></ul><ul><li>Voluntary skeletal muscles are at risk for atrophy and complete loss of function </li></ul><ul><li>Spasticity of jaw muscles resulting in slurred speech </li></ul><ul><li>Dysphagia, difficulty chewing  weight loss </li></ul><ul><li>Death from respiratory failure </li></ul>
  48. 48. Amyotrophic Lateral Sclerosis Nutritional Implications <ul><li>Dysphagia, chewing, swallowing problems </li></ul><ul><li>Decreased body fat, lean body mass, nitrogen balance and increased REE as death approaches </li></ul><ul><li>Late stage patients may not tolerate PEG placement d/t respiratory compromise </li></ul><ul><li>Initiate discussions about whether to place a feeding tube early in disease process </li></ul><ul><li>Enteral feedings do not prolong life </li></ul>
  49. 49. Amyotrophic Lateral Sclerosis MNT <ul><li>Correlates with ALS Severity Scale (pp 1102-1103) </li></ul><ul><li>Emphasize fluids as patients may limit fluids d/t toileting difficulties </li></ul><ul><li>Get baseline weight; 10% loss  increased risk </li></ul><ul><li>Modify consistency as eating problems develop using easy-chew foods, thickened liquids, using small frequent meals, cool food temperatures </li></ul>
  50. 50. Amyotrophic Lateral Sclerosis MNT <ul><li>If nutrition support is planned, use EN </li></ul><ul><li>Initiate early rather than later; dehydration occurs before malnutrition </li></ul><ul><li>Purpose of nutrition support should be to enhance quality of life </li></ul><ul><li>Eventually patients will not be able to manage oral secretions </li></ul>
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