Week 4

Neurological Disorders & Dysphagia

Assigned Readings

• Nelms. Chapter 20, Chapter 14 (p. 362-365)

• College of Dietitians of Ontario. Scope of Practice for Registered Dietitians
caring for Clients with Dysphagia in Ontario. On OWL.
Objectives

Identify Identify key features of the various neurological conditions

Identify Identify key nutritional issues related to these conditions

Understand what dysphagia is and the modifications used in dietary

Understand intervention
Nutrition
Assessment for
Disorders of the
Neurological
System
 • Spontaneous, uncontrolled
electrical activity among cerebral
neurons resulting in a seizure
Definition • Generalized
• Partial
• Symptoms vary based on area of
Epilepsy and brain affected

Seizure
Disorders
• Worldwide prevalence of
epilepsy estimated at 1%
Epidemiology • 10% of population will have a
seizure at some time in their life
Epilepsy and Seizure Disorders – Etiology and
Pathophysiology

Etiology
• Head trauma, CNS infection,
drug and alcohol abuse, CNS
tumors, cerebrovascular
disease
• Majority have no known
precipitating event
Pathophysiology
• Few seconds to several
minutes
• Generalized and partial
• Single seizure vs. epilepsy
 Epilepsy and Seizure Disorders – Medical
Diagnosis and Treatment
• Medical Diagnosis
• Imaging with MRI or CT
• EEG
• Treatment
• Anti-epileptic Drugs (AEDs)
• Phenytoin (Dilantin): inhibits vit D and folate metabolism and thiamine absorption (enteral
feeds held)
• Major issue in hospitalized patients
• Valproic acid, Carbamazepine (Tegretol), Gabapentin : weight gain
• Zonisamide & Topiramate: weight loss
• Surgical Treatments
Nutrition Therapy for Epilepsy and Seizure
Disorders
• Ketogenic diet for intractable epilepsy
• High-fat, low-carbohydrate diet
• Mechanisms poorly understood but effective
• Current variations of ketogenic diet
• Medium-chain triglyceride (MCT) diet; low-glycemic-index
treatment (LGIT); and modified Atkins diet (MAD)
Keto Diet in Practice

http://www.aboutkidshealth.ca/En/News/Video/Epilepsy-Videos/Pages/Video-Epilepsy-The-Magic-Diet.aspx
 Low Glycemic
Traditional: MCT: Modified Atkins:
Diet
•Ratio of 3-4g •MCT oil •No more than •All CHO must
Keto Diets fat/ 1 g PRO +
CHO
included
•Allows for
10% CHO to
start
be low
glycemic
•About 90% more PRO & •~65% kcal from •Uses
kcal from fat CHO foods fat household
•Mostly fatty measures
foods like
butter/cream,
 starchy
foods
 •Inadequate nutrient intake
•Ensure adequate protein and energy
Nutrition to promote growth of child
•Limited food choices
implications •Drug-nutrient interactions (Vit D, Ca,
folate, thiamine)
Epilepsy and •Potential weight gain or loss

Seizure
Disorders –
Nutrition Monitoring •Β-hydroxybutyrate in addition to
standard labs
Intervention and •Vitamin/mineral deficiencies, nutritional
status, proper growth
Evaluation •Seizure frequency records
 Stroke and Aneurysm

• Definition
• Stroke: Disruption of brain function d/t blockage or interruption of
blood flow
• Ischemic stroke
• Hemorrhagic stroke
• TIA
• Aneurysm
• Epidemiology
• > 400,000 Canadians living with long-term stroke disability
• 4th largest killer

www.heartandstroke.c
Stroke and Aneurysm - Etiology
• Non-modifiable risk factors
• Age, gender, ethnicity, genetics
• Previous stroke or TIA

• Modifiable risk factors

• Management of HTN, CVD, DM,
hyperlipidemia
• Carotid stenosis, cigarette smoking,
alcohol use, illicit drug use, diet, oral
contraceptive use, exercise
CT Scan: Diagnosis of
Stroke
 Nutrition Therapy for
Stroke and Aneurysm
• Nutrition Implications
• Impairment of ability to chew, swallow, self-feed
• Dysphagia
• Individualize nutrition support

• Typical diagnoses:
• Inadequate energy intake, inadequate oral intake, inadequate fluid
intake, inadequate protein-energy intake, swallowing difficulty, and
self-feeding difficulty
 • Enteral nutrition support
• Modify consistency of food or
Nutrition liquids, positioning of patient,
Intervention swallow exercises
• Manage dysphagia
• Manage modifiable risk factors
Stroke and
Aneurysm –
Nutrition Monitoring • Swallowing status and ability to
Intervention and self feed
Evaluation • Adequacy of intake
Progressive Neurological Disorders

• Neurodegenerative disorders
• Nutrition needs and status affected by progression of disease
• Ethical decisions regarding nutrition support
• Nutrition therapy similar among progressive disorders
 •Affect mental cognitive tasks:
memory, reasoning, language, visual
perception
Clinical •Cause disorientation, abstract
manifestations thinking, personality disorders, loss of
purposeful action
Dementia •Alzheimer’s disease most common

•750 000 Canadians in 2011- 14.9% of

Canadians > 65 yr
Epidemiology • 1.4 million by 2031
•47.5 million people worldwide
 Most important risk factor is age

5% associated with genetic variations in small

number of families
Dementia -
Etiology
Apolipoprotein E (APOE) gene is risk factor
(Alzheimers)

Other risk factors include: gender, cardiovascular

disease, stroke, diabetes, free radical oxidative
damage, Down syndrome, and a history of previous
head injury
Neurological Conditions
• Alzheimer’s Disease (AD)
• Increased age is the most important risk factor (<65 y.o referred to early-onset)
• Build-up of β amyloid plaque & neurofibrillary tangles in the brain associated
with damage and loss of neurons & brain shrinkage
• Progressive neurodegenerative disorder of the CNS
• Confusion, aggression, etc
• Motor function losses, wt loss, inability to self-feed
• Malnutrition occurs as disease progresses
• Dysphagia

http://www.alz.org/braintour/healthy_vs_alzheimers.asp
Type 3 Diabetes • Growing evidence
Alzheimer’s may be
metabolic disease
• Impaired
• Brain insulin
responsiveness
• Glucose utilization
• Energy metabolism
• inflammation

Yarchoan & Arnold. Diabetes. 2014;63(7):2253

 Dementia
• Nutrition Diagnoses
• Related to inadequate intakes, underweight and malnutrition, impaired abilities
• Nutrition Implications / Management
• Progressive loss of memory affecting shopping, food preparation, memory of
eating
• Eventual need for assistance
• Manage dysphagia and prevent aspiration pneumonia
• Prevent excessive weight loss
• Prevent excessive loss of lean tissue & malnutrition
Nutrition Goals
and Interventions
for Forms of
Dementia
 Neurodegenerative
• Amyotrophic Lateral Sclerosis (ALS)
• AKA Lou Gehrig’s disease
• Neurodegenerative disorder (etiology
unknown)
• Loss of motor neurons in the spinal cord
and brain resulting in loss of voluntary
movement
• Muscular atrophy leading to paralysis and
death
• Decline of respiratory function
• Prognosis: 2-5 years after first symptoms
appear
• Dysphagia, loss of motor control (e.g.
problem self-feeding), hypermetabolism
 Neuro-degenerative

• Amyotrophic Lateral Sclerosis (ALS)

• Nutrition Implications / Management
• Main goal: prevent malnutrition
• EN is often indicated and warranted to promote optimal nutrition
• PEG tube insertion
• Other supportive treatments:
• Mechanical ventilation
• Medications to control excessive saliva or secretions, muscle spasms,
depression/anxiety and pain.
Neuro- • Guillain-Barré Syndrome (GBS)

degenerative • An acute onset often occurring 3-4 hrs following

a gastrointestinal or upper respiratory tract
infection (autoimmune response)
• Characterized by progressive paralysis,
demyelination, sensory loss
• ~25% will need to be mechanically ventilated
• Recovery rate is high (85% will completely
recover within 18 mos), although some may
experience lasting neurological deficiencies
• 3-4% mortality rate

https://pedclerk.uchicago.edu/page/guillain-barr%C3%A9-syndrome-gbs
Neuro-degenerative
Guillain-Barré Syndrome (GBS)
• Nutrition Implications / Management
• Chewing and swallowing difficulties and GI motility dysfunction often
lead to compromised oral intake
• Preservation of lean tissue is critical
• Aggressive nutrition support needed due to hypermetabolism and
hypercatabolism
• May require >40-45 kcal/kg and >2g pro/kg
• Respiratory muscle atrophy leads to poor outcomes
• Hypermetabolism,  protein requirements, dysphagia
 Multiple Sclerosis
• Etiology
• Unknown, genetic, environmental
• Pathophysiology
• Demyelination, damage to axons
• Communication between neurons is lost
• Clinical manifestations
• Symptoms vary depending on nerve affected
• Numbness, tingling, ataxia, weakness, visual
problems, dysphagia, constipation, bladder
dysfunction….
• Treatment
• Immunosuppressive therapy, corticosteroids, other
meds
 Nutrition Therapy for Multiple Sclerosis
• Medication side effects
• dry mouth, nausea / vomiting, diarrhea

• Challenges to meal preparation

• Fatigue/weakness, depression

• Dysphagia (consistency modifications)

• Weight gain (inactivity, meds)
• Highly variable due to high individual variability and stage of disease
• As disease progresses, dietary intervention for dysphagia or
nutrition support may be warranted
• Declining nutritional status may be related to:
• Side effects from drugs
• Stage of disease progression
• Role of PUFA’s, antioxidants, vitamin B12 and vitamin D still
being investigated
 • Neuromuscular, neurodegenerative disease caused by
loss of dopamine-producing cells
• characterized by “TRAP”
• “T” tremors
• “R” rigidity
• “A” akinesia (loss of voluntary movement)
• “P” postural instability
• In addition to bradykinesia (slow movement ), mask-like
Parkinson’s facial features, shuffling while walking, depression,
Disease (PD) anxiety, pain, cognitive dysfunction
• Development of PD dementia in some patients
• Progressive disease with few effective treatment options
• Epidemiology
• Affect approximately 1% of North Americans over age 70
• Etiology
• Unclear, proposed contributing factors
 Treatment

•Focus on medications that improve supply of

dopamine to the brain
•Primarily treated with L-dopa, other medications,
surgery, diet

Parkinson’s Nutrition Intervention

Disease •High protein may interfere with L-dopa levels

•Limit supplement levels of B6
•Pyridoxine enhances extracerebral metabolism of
Levodopa –prevents therapeutic effects
•Closely monitor weight status
•Manage GI symptoms; swallowing impairment and
gastroparesis

Monitoring and Evaluation

 Progressive neuromuscular disorder
affecting skeletal muscles

Epidemiology

Myasthenia • One of the more common neuromuscular

disorders
Gravis • 1 in 7,500 individuals
• More prevalent in females prior to age 60

Etiology

• Autoimmune reaction destroys cellular receptors

for acetylcholine
Myasthenia Gravis
• Pathophysiology
• Muscles tire easily, muscle weakness with physical
activity
• Clinical Manifestations
• May affect face, eyes, arms, legs
• Periods of remission and exacerbation

• Nutritional Implications / Management

• Compromised chewing & swallowing
• Bolus formation difficulties
• Lip spill from weak jaw, tongue, lips
 Traumatic Brain Injury (TBI)
• Definition
• Penetrating brain injuries or closed head injuries
due to accidents, falls, violence, firearms, sports
• falls most common
• Shaken baby syndrome
• Epidemiology
• Annual incidence in Canada is 44X more
common than spinal injury, 30X more common
than breast cancer, 400x more common than
HIV/AIDS
• 1 person injured every 3 minutes
• 60% males
• Leading cause of seizure disorders
• Etiology
• Lacerations, crushed brain tissue, cerebral
edema, hemorrhage, hematoma, infection
 Neurotrauma and Spinal Cord Injury
• Traumatic Brain Injury
• Pathophysiology
• Primary
• Lacerations, crushed tissue
• Secondary
• Edema, hemorrhage etc
•  intracranial pressure, impaired blood
flow can affect brain function
• Clinical Manifestations
• Swelling, bleeding, seizure, stroke, coma
• Evaluate severity of TBI
Nutrition Therapy for Traumatic Brain Injury

Nutritional Implications
• Hypermetabolism
• Hyperglycemia
• Insulin resistance
• Increased gluconeogenesis
• Lipolysis
• Catabolism as evidenced by nitrogen excretion
 Nutrition Therapy for
Traumatic Brain Injury

Monitoring and
Nutrition Diagnoses Nutrition Intervention
Evaluation
• Related to • Requires early • Progress nutrition care
hypermetabolism, aggressive nutrition as appropriate
inadequate intake, therapy
motor and cognitive • Energy needs highly
impairments variable
• Protein 1.5-2.0 g/kg/d
Spinal Cord Injury (SCI)

• Injury to the spinal cord involving fracture or compression of the

vertebrae with consequent damage to nerve cells
• Paraplegia
• Quadriplegia
• Etiology
• Most are a result of trauma and accidents
The Spinal
Cord
Spinal Cord Injuries: Pathophysiology
and Treatment

Pathophysiology
• Level of injury determines
signs and symptoms
• Complications may
include autonomic
dysreflexia, spasticity
Treatment
• Treat underlying cause
• Corticosteroids,
stabilization
 Nutritional needs similar
to TBI

Nutritional Implications

Nutrition
Obesity and CVD
Therapy for
Spinal Cord
Injury Vary from the acute
care to rehabilitation
Nutrition Diagnoses settings as well as by
individual status and
complications
 Nutrition Diagnoses

• Vary from the acute care to rehabilitation

settings as well as by individual status and
complications

Nutrition Nutrition Intervention

Therapy for • Energy requirements via indirect calorimetry

Spinal Cord • Rehabilitation concerns

• Prevent excessive weight gain
Injury Monitoring and Evaluation

• Prevention of pressure ulcers

• Energy needs
• Weight management

Dysphagia
Difficulty chewing and/or
swallowing due to physiological
or anatomical abnormalities
Causes:
Neurogenic (e.g. CVA,
cerebral palsy, Parkinson’s
disease, Huntington’s disease,
Alzheimer’s disease)
Structural lesions (e.g. stricture,
PUD, tumor, inflammation)
Motility disorders (GERD,
achalasia)
Iatrogenic conditions: induced
by treatment itself ( Meds, post-
intubation, side-effects of
chemotherapy & radiotherapy)
VideoFluoroscopic Swallow Study

https://www.youtube.com/watch?v=Ri8bBhw9msQ
 Dysphagia

• Swallowing problems can

occur anywhere along the
path from the
mouth to stomach
• Incidence
* • 40% older individuals
• Half of acute care Pts
• 2/3 of long-term care Pts

* U.E.S. =
Upper Esophageal
Sphincter
Lower Esophageal Sphincter (L.E.S.)
or cardiac sphincter
Physiology of swallow

Abnormal
swallow
with
nasal reflux

Normal swallow

Abnormal swallow
with aspiration
Anatomy of head & neck

UES=
Upper
Esophageal
Sphincter

Food bolus

Tooth Epiglottis

Vestibule Interarytenoid
muscle UES
Larynx
Cricopharynge
Thyroid cartilage al
muscle
Cricoid cartilage
Lungs
Physiology of Normal Swallow

1) Oral preparatory phase

2) Oral transport phase 2 1
3
3) Pharyngeal phase
4) Esophageal phase

4
Signs & Symptoms 1) Oral preparatory phase
of Dysphagia: • Food pocketing e.g.:  cheek tone,  sensitivity
• Poor bolus formation
• e.g.: Poor tongue control, partial glossectomy
• Food leaks, drooling
• e.g.:  lip tone, excessive saliva
• Difficulty chewing
• e.g.: Poor jaw movement, edentulous
• Excessive saliva
• Xerostomia (thick saliva & dry mouth)
• Aspiration
 2) Oral transport phase
Signs &
Symptoms of ✓Aspiration due to delayed or absent
Dysphagia swallow reflex

3) Pharyngeal phase
✓Coughing and/or wet “gurgly” vocal
quality
(airway protection incomplete or
non-existent)
✓Aspiration due to  laryngeal closure
Signs &
Symptoms of 4) Esophageal phase
Dysphagia ✓Bolus remains in
esophagus
e.g. due to  esophageal peristalsis
narrowing of esophageal passage

✓Aspiration after the swallow

e.g. weakened / lazy L.E.S.
GERD
Meds
• Can cause / exacerbate dysphagia
• Occurrence:
• Drug side effects
• Effect
• muscle function
• mucosa sensitivity
• Complication of Treatment
• immuno-suppressive drugs
→ viral/fungal esophagitis
• Vulnerability to drug-induced dysphagia:
• CNS impairments
• Frail elderly
• Neuro-developmental disability
 Passage of material below vocal cords
into larynx & trachea

Silent: Does not elicit cough or

Overt: Elicits cough reflex
choking sensation
Aspiration

Associated with:
Chronic
expectoration of Recurrent Rapid  in
mucopurulent pulmonary infection respiratory function
sputum
 Prandia:
Salivary:
Occurs
Aspiration
through
of own
chewing &
Types of swallowing
saliva
Aspiration
Reflux:
Refluxate Different
into lungs → types may
chemical coexist
irritation
Evaluation of Swallowing Disorders
• Interdisciplinary approach:
• Primary physician
• Speech-language pathologist (SLP)
• R.D.
• 1st consulted for dysphagia assessment in some
settings
• Dietitians at an advanced practice level can
act as the primary dysphagia therapist
• Radiologist
• Nurse
 Bedside Swallowing Assessment
Swallowing
(BSA)
Evaluation • Swallowing therapist
• Physical exam:
• Oro-pharyngeal motor fn
• S&S of dysphagia
• Drooling, pocketing, poor control, weakness,
slurred speech, wet/’gurgly’ voice, etc
• Tolerance to food & fluid consistencies
• Clinical evaluation: oral &
pharyngeal phases
 2. Video-Fluoroscopy
Swallowing
Swallow Study (VFSS)
Evaluation • Modified Barium Swallow
(MBS)
• Barium added to foods &
liquids
• Observation:
Oral cavity
Pharynx
Esophagus
Swallowing
Evaluation Fiberoptic Endoscopic
Evaluation of Swallowing
(FEES)
• Endoscope inserted
trans-nasally
• View: larynx & pharynx
 Inadequate oral intake

Inadequate fluid intake

Nutrition
Diagnoses Malnutrition

Inadequate protein/energy intake

Swallowing difficulty
Nutrition • Basis:
Management • Initial nutrition assessment
• Swallowing assessment

• Possibly involves:
• Altered
• food texture
• fluid viscosity/consistency
• Oral supplementation
• EN, PN
• Adjustments to eating / feeding techniques
• Modification of positioning / environment
 Diet highly
individualized &
progressive
Dysphagia Diet
Considerations May change with
swallowing capabilities

Solids & liquids Many have problems

evaluated separately swallowing thin liquids
 Compensatory
Strategies
Eating / feeding techniques
• Positioning
• Encouraging lip closure
• Chewing on strong side
• Self / assisted feeding
• Environment
• Amount & rate
• Pt orientation
• Assistive & adaptive feeding equipment
Standardizing Dysphagia Diet Terminology
Viscosity of Liquids

• Thin

• Slightly thick (Nectar-like) -semi-liquid

• Mildly thick (Honey-like)- thick liquid

• Moderately-Extremely thick (Spoon-thick)-

pudding-like, very thick liquid
Diets for Dysphagia
• Stage 4: Puréed Diet
• Stage 5: Ground / Minced Diet
• Stage 6: Soft / Easy-to-Chew Diet
• Stage 7: Regular Diet

All consistency of liquids as tolerated:

• 0-Thin
• 1-Slightly thick
• 2-Mildly thick
• 3-Moderately thick
• 4-Extremely thick
Examples of commercial products

http://www.privaterecipes.com
 Stage 4: Puréed Diet
• Indication:
• Severely  oral preparatory stage abilities
• Impaired lip & tongue control
• Delayed swallowing reflex triggering
• Oral hypersensitivity
•  pharyngeal peristalsis
• Cricopharyngeal dysfunction
Stage 4: Puréed Diet
• Description:
• Thick, smooth, homogenous, semi-liquid textures
• Purée = spoon-thick or pudding-like
• No coarse textures, nuts, raw fruits/vegetables
• No sticky foods
• No foods requiring bolus-intensive formation
• Liquid / crushed meds in purées
• Thickened liquids as needed
 Stage 5: Minced
& Moist Diet
• Indication:
• Pt tolerating easily
chewed foods
• Moderately impaired oral preparatory phase
• Edentulous oral cavity
•  pharyngeal peristalsis
• Cricopharyngeal muscle
dysfunction
Stage 5: Minced
& Moist Diet
• Description:
• Mashed, minced, ground foods
• Smooth / soft / moist foods
• No coarse texture, nuts,
raw fruits & vegetables
• Puréed or slurried bread if needed
• cohesive
Stage 6: Soft / Easy-to-Chew Diet
• Indication:
• Difficulty chewing,
manipulating & swallowing
certain foods
• Persons beginning to chew
• Mild oral preparatory
stage deficits
Stage 6: Soft / • Description:
Easy-to-
• Soft foods without need for
Chew Diet
blenderizing or puréeing
• Soft textures, no tough skins
• No nuts or dry, crispy, raw, or stringy
foods
Special • Food preparation:

Considerations Blenders / food processors

- Quality; food safety
Addition of fluids:  Volume
• Thickening agents:
Commercial thickeners
➢ More reliable
Non-commercial
Thickening of Liquids
• Mashed potato flakes • Puréed fruits

• Skim milk powder • Corn starch

• Puréed vegetables
• Instant powders
• Plain yogurt
• Cream cheese • Flour
• Infant cereals

Moistening Agents: Add liquids, fats

Special Monitor
Considerations • Energy, protein, fluids, &
micronutrient intake
• Hydration
Thin liquids usually the
most difficult consistency
• Need for Nutrition support
Water Protocol • http://www.kentuckyonehealth.or
g/frazier-water-protocol
• Premise
• Oropharyngeal dysphagia
• Good mobility &
cognitive ability
• Human body 60% water
• Small amounts water
between meals
• Free access to water –no
increase in aspiration
pneumonia
Useful References
✓ Dhal, W. 2004. Textured-Modified Foods: A Manual for Food
Production for Long Term Care Facilities. Dietitians of Canada,
Toronto, ON.
✓ Dietitians of Canada. The role of the registered dietitian in
dysphagia assessment and treatment. A discussion paper.
http://www.dietitians.ca/Downloads/Public/Role-DC-in-Dysphagia-
Assessment-n-Treatment.aspx
✓ Dietitians of Canada – Dysphagia Management On-line course
✓ http://www.dietitians.ca/Knowledge-Center/Events-and-
Learning/Online-Courses/Dysphagia-Management.aspx