Medical Nutrition Therapy in Neurological Disorders Part 1

1. Medical Nutrition Therapy in Neurological Disorders Part 1

2. Nutrition and Neurologic Disease • May have nutritional etiologies resulting from deficiency or excess • May be nonnutritional in origin but have significant nutritional implications

3. Stroke Statistics • Stroke is the third leading cause of death ranking behind diseases of the heart and cancers • Killed 150,147 people in 2004; females accounted for 60.9 percent of stroke deaths. • About 5,700,000 stroke survivors are alive today. 2,400,000 are males and 3,300,000 are females. • 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) http://www.americanheart.org/presenter.jhtml?identifier=4725accessed online 11-16-07

4. Stroke Statistics • From 1992 to 2002 the death rate from stroke declined 13.8 percent, but the actual number of stroke deaths rose6.9 percent. • A leading cause of functional disability – 15-30% permanently disabled Primary Prevention of Ischemic Stroke, AHA/ASA Guideline, Stroke 2006;37:1583-1633, accessed online 11-16-06

5. Non-Modifiable Age Gender Low Birth Weight Race/ethnicity Genetic factors Modifiable Hypertension Exposure to cigarette smoke Diabetes Atrial fib and other cardiac conditions Dislipidemia (ischemic stroke) Post-menopausal hormone therapy Poor diet Obesity/body fat distribution Inactivity Risk Factors for Ischemic Stroke Primary Prevention of Ischemic Stroke, AHA/ASA Guideline, Stroke 2006;37:1583-1633, accessed online 11-16-06

6. Pathophysiology of Stroke • 85% of strokes caused by a thromboembolic event (related to atherosclerosis, hypertension, diabetes, gout) • Embolic stroke: cholesterol plaque is dislodged from vessel, travels to the brain, blocks an artery • Thrombotic stroke: cholesterol plaque within an artery ruptures, platelets aggregate and clog a narrow artery

7. Nutrition-Related Factors and Stroke Risk (BMI = body mass index)

8. Thromboembolic Stroke

9. Hemorrhagic Stroke • Intraparenchymal hemorrhage: prevalence of hypertension is 80%; vessel inside the brain ruptures • Subarachnoid hemorrhage (SAH): ruptured aneurism in the subarachnoid space; or due to head trauma • 15% of all strokes

10. Hemorrhagic Stroke

11. Medical Treatment for Stroke • Thrombolytic or “clot-busting” drugs to restore perfusion to affected areas within 6 hours of onset of stroke • Controlling intracranial pressure (ICP) while maintaining sufficient perfusion of the brain

12. Nutritional Management in Stroke • Primary prevention • Acute management (screening for dysphagia and nutritional risk) • Intervention for swallowing disorders via consistency changes

13. AHA Guidelines for Primary Prevention of CVD and Stroke: 2006 Update • Smoking: complete cessation (Class I, evidence level B • Avoid exposure to environmental tobacco smoke (Class IIA, evidence C) • BP control: goal <140/90 mmHg with lower targets in some subgroups (<130/80 in diabetes) Goldstein et al, Primary Prevention of Ischemic Stroke, Stroke 2006;37:1583-1633)

14. AHA Guidelines for Primary Prevention of CVD and Stroke: 2006 Update • Blood lipid mgt: • NCP III guidelines for pts who have not had a stroke and have high TC or non-HDL-C w/ high TG • Pts with known CAD and high risk HTN even w/ normal LDL treat with lifestyle/statin (Class I, evidence A) • Rec wt loss, ↑ physical activity, smoking cessation, niacin or gemfibrozil (Class IIA, evidence B) Goldstein et al, Primary Prevention of Ischemic Stroke, Stroke 2006;37:1583-1633)

15. AHA Diet/Lifestyle Guidelines for Primary Prevention of CVD/Stroke: 2006 Update • Reduced intake of sodium and increased intake of potassium to lower blood pressure (Class I, evidence A) • Recommended sodium intake <2.3g/day; potassium >4.7g/day • DASH diet emphasizing fruits, vegetables, lowfat dairy products is recommended to lower BP (Class I, evidence A) • High fruit and vegetable intake may lower risk of stroke (Evidence C) • Wt reduction is recommended because it lowers BP • Increased physical activity (>30 minutes of moderate-intensity activity daily) Pearson et al. (Circulation. 2002;106:388-391.)

16. Lipids and Stroke • Cholesterol is a very weak risk factor for ischemic stroke, in contrast to CAD • Cholesterol reduction with diet and nonstatin drugs is not effective in stroke prevention, although reductions in levels of cholesterol are modest • Statins produce a statistically significant 25% reduction in the risk of stroke Briel M, et al Am J Med 2004;117:596-606

17. Lipids and Stroke in MRFIT

18. Lipids and Stroke: ARIC Study • Cohort study of 14,175 men and women • After 10-year followup, there were weak and inconsistent associations between ischemic stroke and LDL-C, HDL-C, apo-B, apo-A-1, triglycerides • Most consistent relationship was lower risk in women with higher HDL and higher risk with lower TG Shahar E, et al. Stroke, 2003;34:623-631

19. Lipids and Stroke • Problem may be the heterogenicity of stroke, although even when looking at homogeneous ischemic stroke, relationship is weak • The protective effect of statins may be due to their non-cholesterol-lowering effects.

20. Relationship Between Fat/Cholesterol and Stroke Risk • Dietary cholesterol, MFA, PUFA not related to risk of stroke • Low intake of SFA and animal protein associated with  risk of intraparenchymal hemorrhage • In DCCT trial, intensive treatment lowered LDL, TC and TG and cerebrovascular events

21. Guidelines for Management of Acute Stroke Rehab (AHA/ASA) • Dysphagia occurs in 45% of all hospitalized stroke patients; can lead to aspiration pneumonia and death. • Malnutrition is present in 15% of patients admitted to the hospital, and this percentage doubles during the first week after stroke. • A bedside swallow screening should be completed before oral intake (Evidence Level=B). • If the patient’s swallow screening is abnormal, a complete bedside swallow examination is recommended (Evidence Level=I). AHA/ASA Endorsed Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care (Stroke. 2005;36:2049.)

22. Dysphagia Treatment- AHA/ASA • Dysphagia treatment may involve posture changes, heightening sensory input, swallow maneuvers, active exercise programs, or diet modifications. • Dysphagia management may include nonoral feeding and psychological support. • At this time, it is unclear how dysphagic patients should be fed after acute stroke. AHA/ASA Endorsed Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care (Stroke. 2005;36:2049.)

23. Dysphagia Treatment- AHA/ASA • The literature supports the use of tube feeding for patients who cannot sustain sufficient oral caloric and/or fluid intake to meet nutritional needs. • Limited evidence suggests that percutaneous endoscopic gastrostomy feeding compares favorably with nasogastric tube feeding (Evidence Level=B). AHA/ASA Endorsed Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care (Stroke. 2005;36:2049.)

24. FOOD (Feed or Ordinary Diet) Trial • Tested feeding strategies after acute stroke including oral supplementation, early vs delayed NG feeding, and NG vs PEG feeding • Poor baseline nutritional status is associated with worse outcomes at 6 months. • This relationship persists after adjustment for pt’s age, prestroke functional level, living conditions, and severity of stroke. AHA/ASA Guidelines for the Early Management of Patients with Ischemic Stroke. (Stroke. 2005;36:916.)

25. FOOD (Feed or Ordinary Diet) Trial • Found no benefit to routine oral supplementation of post-stroke patients who had not been identified as malnourished (1) • 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) • 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). 1: Lancet. 2005 Feb 26-Mar 4;365(9461):755-63. 2: Lancet. 2005 Feb 26-Mar 4;365(9461):764-72

26. AHA Guidelines for Early Management of Pts with Ischemic Stroke • A poor nutritional status was associated with an increased risk of infections including pneumonia, gastrointestinal bleeding, and pressure sores. • These data provide a strong rationale for assessment of the patient’s nutritional status at the time of admission. AHA/ASA Guidelines for the Early Management of Patients with Ischemic Stroke. (Stroke. 2005;36:916.)

27. Alzheimer’s Disease • Most common form of dementia • Increases exponentially after age 40 • Prevalence in white males at age 100 is 41.5% • Higher prevalence in women (3X) due to lower mortality

28. Symptoms of Alzheimer’s Disease • Forgetfulness: may forget recent events, activities, names of familiar people or things (anomia). • Forget how to do simple tasks, such as brushing teeth, brushing hair • Get lost in familiar surroundings • Repeat words spoken by others (echolalia) • Loss of comprehension (agnosia)

29. Symptoms of Alzheimer’s Disease (cont) • Motor skills deteriorate: loss of reflexes and shuffling gait • Bowel and bladder control lost • Limb weakness and contractures • Intellectual activity ceases • Vegetative state

30. Alzheimer’s Disease Risk Factors • Age: risk doubles every five years after age 65 • Family history: early onset strongly hereditary; late onset has a genetic component • Those with a parent or sibling with AD are 2-3 times more likely to develop AD

31. Alzheimer’s Disease Risk Factors • Head injury • Down syndrome • Low level of education • Female gender

32. Alzheimer’s Disease Prevention: Research Areas •  AD risk is associated with CVD, hypertension, diabetes •  AD risk associated with exercise, staying mentally active, social engagement • Research ongoing into use of antioxidants (vitamins E and C), ginkgo biloba • Research into estrogen and AD suggests that estrogen treatment in postmenopausal women may  risk of dementia

33. Treatment of Alzheimer’s Disease • No drug can stop or reverse AD • Some drugs may slow progress (tacrine (Cognex®), donepezil (Aricept®), rivastigmine (Exelon®), or galantamine (Razadyne®) • Other medications may treat symptoms such as sleeplessness, agitation, wandering, anxiety, and depression National Institutes on Aging, Alzheimer’s Disease Education and Referral Center http://www.alzheimers.org/treatment.htm

34. Nutritional Consequences of Alzheimer’s Disease • Weight loss is common possibly due to  activity (pacing) • Decreased independence and impaired self-feeding • Inability to recognize hunger, thirst and satiety • Meals forgotten as soon as eaten or may not be eaten at all • Inability to recognize food when presented • Risk for dehydration

35. MNT in Alzheimer’s Disease • Vitamin-mineral supplementation; assure intake of antioxidants • Minimize distractions at mealtime (turn off radio or television) • Place foods on small plates and give one at a time • Serve food on plates of contrasting color

36. MNT in Alzheimer’s Disease • Model use of eating utensils, provide verbal cues • Allow patient to use eating utensils as long as possible • Finger foods may be helpful, but monitor for swallowing problems and choking • Frequent snacks, nutrient-dense foods, nutritional supplements may be helpful

37. Practical Interventions for Eating-Related Behavioral Problems Common in Individuals with Dementia

38. Practical Interventions for Eating-Related Behavioral Problems Common in Individuals with Dementia

39. Migraine Headache • Thought to be vascular in origin • Throbbing, episodic, and intense • History of intercurrent nausea, vomiting, photophobia, visual or olfactory auras • Treated with NSAIDs, sympathomimetics, seritonin agonists; prophylaxis with calcium channel blockers, beta-adrenergic blockers, serotonin antagonists

40. Migraine Headache • Headaches may be triggered by food • Varies by individual and tolerance thresholds vary over time • No general recommendations about food avoidance • Foods often cited are citrus fruits, tea, coffee, pork, chocolate, milk, nuts, vegetables, cola drinks • Evaluate through food and symptom diary

41. Myasthenia Gravis (MG) • Autoimmune disorder of the neuromuscular junction • Body makes antibodies to acetylcholine receptors; make them unresponsive to Ach • Nervous system signal to the muscle is garbled • Relapsing and remitting weakness and fatigability; diplopia, facial muscle weakness, dysphagia (33%)

42. Myasthenia Gravis (MG) Medical Treatment • Anticholinesterases inhibit acetylcholesterase and increase the amount of Ach • Removal of the thymus gland • Corticosteroids

43. Myasthenia Gravis (MG) MNT • Nutritionally dense foods at the beginning of meals before the patient tires • Small frequent meals • Time medication with feeding to facilitate optimal swallowing • Limit physical activity before meals • Don’t encourage food consumption when patient is tired; may aspirate

44. Wernicke-Korsakoff syndrome MNT Cause • Chronic thiamin deficiency with continued carbohydrate ingestion Treatment • Thiamin • Adequate hydration • Diet liberal in high-thiamin foods • Eliminate ETOH • Dietary protein may need to be restricted

45. Amyotrophic Lateral Sclerosis • Also called Lou Gehrig’s Disease • Most common motor system disease • Progressive denervation atrophy and weakness of muscles • Both upper and lower motor neurons are lost in the spinal cord, brain stem, and motor cortex • Progresses to death in 2 to 6 years

46. Amyotrophic Lateral Sclerosis • Prevalence constant throughout the world • Men affected more than women • Age of onset mid-50s (40-70) • Cause unknown • 5% familial, rest sporadic

47. Amyotrophic Lateral Sclerosis Presentation • Muscle weakness commences in the legs and hands and progresses to the proximal arms and oropharynx • Voluntary skeletal muscles are at risk for atrophy and complete loss of function • Spasticity of jaw muscles resulting in slurred speech • Dysphagia, difficulty chewing  weight loss • Death from respiratory failure

48. Amyotrophic Lateral Sclerosis Nutritional Implications • Dysphagia, chewing, swallowing problems • Decreased body fat, lean body mass, nitrogen balance and increased REE as death approaches • Late stage patients may not tolerate PEG placement d/t respiratory compromise • Initiate discussions about whether to place a feeding tube early in disease process • Enteral feedings do not prolong life

49. Amyotrophic Lateral Sclerosis MNT • Correlates with ALS Severity Scale (pp 1102-1103) • Emphasize fluids as patients may limit fluids d/t toileting difficulties • Get baseline weight; 10% loss  increased risk • Modify consistency as eating problems develop using easy-chew foods, thickened liquids, using small frequent meals, cool food temperatures

50. Amyotrophic Lateral Sclerosis MNT • If nutrition support is planned, use EN • Initiate early rather than later; dehydration occurs before malnutrition • Purpose of nutrition support should be to enhance quality of life • Eventually patients will not be able to manage oral secretions