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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
• May be caused by head injury, congenital
defects, metabolic disorders, other illnesses
• 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.
• Generalized seizure that lasts 1-2 minutes
• Involves complete loss of muscle tone and
consciousness
• More common in children
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
Absence Seizure Pathology
Partial Seizures
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
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 seizures
• managed with valproate, phenytoin,
gabapentin
• Drug-drug and drug-nutrient interactions
• Liver damage
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
• 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
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
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
• Treatment of last resort in children with
intractable seizures
• Will completely control epilepsy in onethird of children; significantly decrease
activity in one-third
• Ketones may exert anticonvulsant effect on
body
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)
Ketogenic Diet Menu Using MCT Oil
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
• Steroid therapy for exacerbations; ACTH
and prednisolone; methotrexate (can cause
weight gain, fluid retention) alphainterferon
• Physical therapy
Progression of Multiple Sclerosis
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
• 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
• 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 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, 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
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
• 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
• 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)
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
• Inadequate
• Older age
oxygenation early
• Low Glasgow Coma
after injury
Scale score
• Prolonged and/or
• Pupil dilatation
difficult to control
• Low blood pressure
intracranial pressure
All these variables have an additive effect on
morbidity and mortality
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
Normal Vision
Hemianopsia
Neurological Deficits That Affect
Nutritional Status
• Apraxia
• Patient has difficulty with perceptual
motor planning
• Dysphagia
• Difficulty swallowing
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 Dysphagia
• Absent gag reflex
• Chronic upper respiratory infections
• Weight loss and anorexia
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 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)
• Esophageal phase: (involuntary) bolus
continues through esophagus into the
stomach
• Most difficulties due to mechanical
obstruction
• Involuntary peristalsis affected by brain
stem infarct
Swallowing Occurs in
Three Phases
Swallowing 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
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
• 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
• 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
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
•
•
•
•
•
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 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
• 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
Short Term Aspiration Results
Chin Down Nectar
Honey
Parkinson’s 59%
Disease
Dementia
74%
54%
44%
69%
58%
Parkinson’s 69%
w/dementia
Overall
68%
64%
53%
63%
53%
Summary
• 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
• 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
• 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 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
• “The thicker the liquid, the safer the
swallow.”
• Not true in pts who aspirate thick liquids –
worse health outcomes
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
Diet for Easy Chewing and
Swallowing
Techniques for Improving
Acceptance
•
•
•
•
Aroma
Seasoning
Layering/swirling
Piping
• Molding
• Slurries
• Garnishing
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
• 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
• Enteral nutrition support is the preferred modality
for nutrition support in patients who cannot
swallow or eat because of deteriorating neurologic
disease.