MNT for Neurologic Disorders

Neurologic Diseases Definition

Cognitive and swallowing dysfunction usually affect nutritional management and place neurologic patients at risk for malnutrition

Nutritional assessment for Neurologic diseases should

Emphasize patterns of normal chewing, swallowing, and ingestion in addition to traditional assessment components and weight history 

Patients with Neurologic diseases may need assistance with

• Grocery shopping

• Meal planning and preparation

• Feeding

Dysphagia Symptoms

• Drooling

• Choking

•  Coughing during or after meals

• Inability to suck from a straw

• Gurgly voice

• Pocketing food

• Chronic upper respiratory infections

Dysphagia Complications

• Aspirations

• Malnutrition 

• Dehydration

Dysphagia is common in patients with

• Parkinson’s disease (PD) 

• Multiple Sclerosis (MS)

• Amyotrophic lateral sclerosis (ALS) 

• Dementia 

• Stroke

Dysphagia requires a

swallow evaluation by a speech language pathologist (SLP)

Types of Swallowing Evaluation

• Bedside swallow eval 

• Modified barium swallow 

• Fiberoptic Endoscopic Evaluation of Swallowing (FEES) 

What is a Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Watching if any food is going into the wrong place, getting stuck, etc 

National Dysphagia Diet

Level 1 - Pureed

Level 2 - Mechanically Altered

Level 3 - Advanced

Types of Liquids

National Dysphagia Diet level 1 Pureed

• Food should be homogenous and cohesive 

• No whole foods

National Dysphagia Diet level 2 Mechanically Altered

• Foods should be soft and moist 

• Meats are ground or minced 

• Fruits and vegetables should be easily mashed with a fork 

• No bread, crackers, or dry foods

National Dysphagia Diet level 3 Advanced

• Foods should be soft and cut into bite size pieces 

• No hard, sticky, crunchy, or very dry foods

National Dysphagia Diet Liquids

• Thin liquids require more coordination and control 

• Easily aspirated into the lungs 

• Can be thickened to meet fluid requirements 

What are the types of liquids

• Thin 

• Nectar-thick

• Honey-thick

• Pudding thick

Nectar thick

• Boost/Esnure can be considered nectar thick 

• Often times, have to add thickening agent to make

• Scoop and little coating left on back of spoon  

Honey-thick

Scoop on spoon, drizzles off and leaves coating

Pudding thick

Scoop and wouldn’t fall off

Guidelines for Feeding Dysphagia Patients Textures

• Cold foods are easier to swallow

• Sauces and gravies help moisten foods

Guidelines for Feeding Dysphagia Patients Enteral Nutrition only if

• High risk for aspiration 

• Inadequate oral intake

Guidelines for Feeding Dysphagia Patients diet order

Diet order may include supervision or assistance during meals

How many levels for Transition to International Dysphagia Diet Standardisation Initiative (IDDSI)

7 levels

IDDSI Level 0 to 2

Liquid

• Dont use nectar thick, honey thick, and pudding thick evaluation scale 

• 0 thin 

• 1 slightly thick 

• 2 mildly thick 

IDDSI Level 3 to 4

Pureed and liquidized foods

• Works for both Drinks and Foods 

• 3 is moderately thick 

• 4 is extremely thick 

IDDSI levels 5 to 7

Stages of transitional foods

• 5 minced and moist 

• 6 soft and bite sized

• 7 regular

Stroke definition

• Cerebrovascular accident (CVA) 

  • Acute onset of neurologic deficit lasting more than 24 hours caused by diseases of intracranial or extracranial neurovasculature

Strokes are often preceded by

 transient ischemic attacks (TIAs)

Risk factors for stroke

• Obesity 

• Smoking 

• High blood pressure 

• Drug use 

• Insulin resistance Diabetes 

• Heart valve defect 

• Sedentary lifestyle or lack of physical activity 

• Atherosclerosis 

• Dyslipidemia 

• Age > 55

Stroke can be due to

• Heredity 

• Cardiac causes 

• Diet 

• Abdominal obesity 

• Alcohol abuse 

• Psychosocial factors - stress, depression

Thromboembolic (atherosclerotic)  definition

• Cholesterol plaque dislodges and blocks an artery 

Thromboembolic (atherosclerotic) symptoms

• Face dropping, arm weakness (hemiparesis), speech difficulty, changes in vision, losing balance 

• BEFAST

Thromboembolic treatment

Thrombolytic Drugs

Intracranial Hemorrhage definition

Rupture of a vessel inside the brain, often fatal immediately

Intracranial Hemorrhage Symptoms

headache, decreased or altered Level of consciousness, vomiting

Intracranial Hemorrhage Treatment

Surgery to relieve intracranial pressure (ICP)

MNT for Stroke Prevention

• Maintain healthy weight

• Low saturated fat vegan diet 

• High fiber 

• High in omega-3 and unsaturated fat 

• DASH diet 

• Mediterranean diet

• Exercise - moderate to vigorous intensity at least 40 minutes 3-4 days per week

Treatment for Stroke Prevention

• Dysphagia diet if necessary 

• Enetral nutrition if severe dysphagia

Head trauma/traumatic brain injury (TBI) Symptoms

• Headache 

• Dizziness 

• Decrease in LOC 

• Vomitting

Head trauma/traumatic brain injury (TBI) stress response in early phases

• Pro inflammatory cytokines 

• Hypermetabolism 

• Protein degradation

Head trauma/traumatic brain injury (TBI) MNT Energy

• Energy: Use Glasgow Coma Scale (GCS)

  • GCS<5: 40-50 kcals/kg/d

  • GCS 5-7: 35-40 kcals/kg/d

  • GCS 8-12: 30-35 kcals/kg/d

Head trauma/traumatic brain injury (TBI) MNT Protein

1.5-2 g/kg/d

Head trauma/traumatic brain injury (TBI) MNT Additional

• Nutrition support if indicated 

• Antiinflammatory foods 

• Choline and citicholine 

• EPA/DHA 

Spinal Cord Injury Definition

Lesion in which there’s no preservation of motor or sensory function more than 3 segments below the injury

What can possible occur with Spinal cord injury

• Ileus may occur, but it often resolves within 72 hours

  • May need nutrition support if longer

Acute Spinal Cord Injury Quadriplegia

Loss of movement and sensation in all four limbs

Acute Spinal Cord Injury Paraplegia

loss of movement and sensation in the lower hald of the body

Tetraplegia

• Affect all four extremities 

  • IBW minus 15-20#

  • Energy needs: 23 kcals/kg/d

Paraplegia

• Affects only lower extremities 

  • IBW minus 10-15#

  • Energy needs: 28 kcals/kg/d

Which of the following conditions may be improved by supplementation of long-chain omega-3 fatty acids?

Schizophrenia, Depression, Dementia

Which of the following is not a neurotransmitter: Epinephrine, Glutamine, Acetylcholine, and Dopamine? 

Glutamine

Folic acid supplementation in the methylated form is useful in some psychiatric disorders because of its role in

Production of serotonin and dopamine

Vitamin D Deficiency has been associated with

Anxiety, dementia, depression

What is the recommendation of the International Society for the Study of Fatty Acids and Lipids (ISSFAL) for the daily intake of DHA and EPA?

500 mg

Spinal Cord Injury Protein needs

• Acute phase:  2g/kg/d IBW

• Rehab phase: 0.8-1 g/kg/d IBW

Spinal Cord Injury Needs for Constipation

Fiber and fluids

Spinal Cord Injury Needs Osteopenia/Osteoporosis

Calcium and vitamin D

Pressure Injuries/Ulcers occur

 in patients who are bed or chair bound or have limited mobility 

Pressure Injuries Energy Needs

30-40 kcals/kg/d for stage 1 and 2

35-40 kcals for stage 3 and 4

Pressure Injuries Protein Needs

1.2-1.5 g/kg/d

Increased, maybe higher for stage 4 wound 

Pressure Injuries Supplements

Arginine, Glutamine, Vitamin C, Zinc

Arginine Importance

• helps preserve lean body mass and production of nitric oxide 

  • Arginine is a precursour to nitric oxide, which is a vasodialator 

    • Nitric oxide Increases blood flow to wound

Glutamine Importance

Amino acid for immune system

Vitamin C Importance

 Collagen synthesis

Zinc Importance

important for protein synthesis and immune system

If a patient drools, chokes, or coughs during or after meals; has a gurgly voice; and has chronic upper respiratory infection, he or she may have

Dysphagia

Dysarthria

slurred speech

Dysgeusia

difficulty swallowing

Dysnomia

inability to speak or understand words

Which of the following are signs of stroke?

1. Face drooping

2. Double vision

3. Arm weakness

Nutriton therapy for a patient with head trauma

Should aim to minimize hypermetabolism and hypercatabolism

Adrenoleukodystrophy (ALD)

• Rare genetic condition 

• “Congential enzyme deficiency affecting metabolism of VLCFAs in brain and adrenal glands”

  • Causes neurologic and physical problems

• Characterized by mental and physical deterioration

MNT for Adrenoleukodystrophy

Lorenzo’s oil

Amyotrophic Lateral Sclerosis (ALS) aka Lou Gehrig Disease

• Progressive denervation, atrophy, and weakness of muscles 

• Etiology unclear

  • Genetics 

  • Environmental factors

  • Homocysteine 

MNT for Amyotrophic Lateral Sclerosis (ALS) aka Lou Gehrig Disease

• 30-35 kcals/kg/d

• Ketogenic Mediterranean diet 

• Dysphagia diet and/or enteral nutrition 

• Folic Acid B12 B6 

Epilepsy Definition

Chronic condition characterized by seizures

Antiseizure medications interfere with

Calcium absorption and vitamin D metabolism

Food Drug interaction for Antiseizure medications

• Supplement with calcium and vitamin D

• Avoid folic acid supplementation and hold tube feeding with Dilantin (Phenytoin)

Medication for rare and severe forms of Epilepsy

• Epidiolex for rare and severe forms

  • Cannabidiol (CBD) oral solution

___ diet may inhibit neurotransmitters

Ketogenic

By far the ketogenic diet is the strongest/most evidence/research efficacy is with

Epilepsy

Ketogenic Diet for Epilepsy Energy Needs

based on age and weight

Ketogenic Diet for Epilepsy Protein Needs

Protein: 1g/kg/d

Ketogenic diet ratio

• 3:1 or 4:1 ratio of fat to combination of CHO and protein 

  • 80g Fat and 20 g of CHO + Protein

Ketogenic Diet for Epilespy Supplementation

Will need MVT with minerals and possibly additional supplements

Nutritional Consequencess for Epilepsy

• Hyperlipidemia 

• Linear growth 

• Bone health 

• Gi Issues 

• Acidosis 

• Kidney Stones

Multiple Sclerosis definition

Chronic Inflammatory disorder of the CNS Disease characterized by destruction of myelin sheath 

Types of Multiple Sclerosis

• Relapsing remitting

• Progressive

Multiple Sclerosis is associated with

vitamin D deficiency and decreased sun exposure

With Multiple Sclerosis, ___ can be used to treat exacerbations

Steroids

Multiple Sclerosis dietary components to prevent or control progression of disease

• Omega 3 fatty acids

• Vitamin D 

• Antioxidants

• Anti-inflammatory diet

With Multiple Sclerosis, may need

dysphagia diet

Multiple Sclerosis Fluid Recommendations for neurogenic bladder

• Distribute evenly throughout waking hours

• Limit before bed 

• Cranberry juice of extract for recurrent UTIs

Neurogenic bowel may cause

diarrhea or constipation

• Administer prebiotics/probiotics

Parkinson’s disease definition

Progressive, disabling neurodegenerative disease

Parkinson’s disease etiology

• Etiology involved interactions between genetics and environmental factors

  • Pesticides

  • PCBs

  • Heavy Metals 

Parkinson’s disease symptoms

• Resting tremor

• Muscular rigidty 

• Bradykinesia 

  • Slow movements

• Decreased dopamine transmission 

Parkinson’s disease often treated with

Levodopa

Levodopa

 Amino acid that promotes synthesis of dopamine

When supplementing with levodopa, avoid

• Fava beans 

  • High in levodopa

  • Traditional way to treat is put patients on medications and have them avoid levodopa

What nutrient should you limit with doses of levodopa

Limit protein with doses at breakfast and lunch