Medical Nutrition Therapy in
Neurological Disorders Part 1
Nutrition and Neurologic Disease
• May have nutritional etiologies resulting
from deficiency or excess
• May be nonnutritional in origin but have
significant nutritional implications
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
Stroke Statistics
• From 1992 to 2002 the death rate from
stroke declined 13.8 percent, but the
actual number of stroke deaths rose 6.9
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
Risk Factors for Ischemic Stroke
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
Primary Prevention of Ischemic Stroke, AHA/ASA Guideline, Stroke
2006;37:1583-1633, accessed online 11-16-06
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
Nutrition-Related Factors
and Stroke Risk
(BMI = body mass index)
Thromboembolic Stroke
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
Hemorrhagic Stroke
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
Nutritional Management in Stroke
• Primary prevention
• Acute management (screening for
dysphagia and nutritional risk)
• Intervention for swallowing disorders via
consistency changes
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;37:15831633)
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)
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 moderateintensity activity daily)
Pearson et al. (Circulation. 2002;106:388-391.)
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
Lipids and Stroke in MRFIT
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, apoB, 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
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.
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
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.)
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.)
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.)
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.)
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 26Mar 4;365(9461):764-72
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.)
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
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)
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
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
Alzheimer’s Disease Risk Factors
•
•
•
•
Head injury
Down syndrome
Low level of education
Female gender
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
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
Nutritional Consequences of
Alzheimer’s Disease
• Weight loss is common possibly due to  activity
(pacing)
• Decreased independence and impaired selffeeding
• 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
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
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
Practical Interventions for Eating-Related
Behavioral Problems Common in
Individuals with Dementia
Practical Interventions for Eating-Related
Behavioral Problems Common in
Individuals with Dementia
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
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
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%)
Myasthenia Gravis (MG)
Medical Treatment
• Anticholinesterases inhibit
acetylcholesterase and increase the amount
of Ach
• Removal of the thymus gland
• Corticosteroids
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
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
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
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
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
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
Amyotrophic Lateral Sclerosis
MNT
• Correlates with ALS Severity Scale (pp 11021103)
• 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
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