DRAFT: This module has unpublished changes.


Neurological Disorders and Dementia

 

Definitions

 

  • TIA: A Transient Ischemic Attack is similar to a stroke in that blood flow to the brain is stopped. However, the blockage that caused the attack is broken up quickly and normal flow resumes.
  • Glascow coma scale: A scale based on various tests which is used to measure a person’s state of consciousness. 
  • Aphasia: Language problems that develop most commonly following a stroke.
  • FEEST: A Flexible Endoscopic Evaluation of Swallowing and Sensory Testing is used to measure the motor and sensory aspects of the swallowing. The test combines an endoscopic swallowing exam with a flexible endoscopic exam in which air pulse stimuli are delivered to the mucosa. 
  • Modified barium swallow: A procedure in which a patient swallows liquid and has an X-ray video taken which shows where the liquid goes and how swallowing occurs.
  • Aspiration: When fluid is inhaled into the lungs. 

Pathophysiology

 

For each of the following, describe the etiology, clinical symptoms and nutritional management.

 

Multiple Sclerosis:

 

  • Etiology: It is generally recognized that Multiple Sclerosis involves an autoimmune response in which cells destroy the myelin sheath of nerve cells however the cause is not currently established. It is believed that genetics, autoimmune processes, and infectious factors may play a role in causation.
  • Clinical symptoms: Numbness, tingling, ataxia, and weakness. Some people may experience visual problems, difficulty swallowing, constipation, bladder dysfunction. 
  • Nutritional management: Omega 3 supplementation and a saturated fat restricted diet. Address nutritional intake problems as appropriate. Intake problems may include difficulty swallowing, drug nutrient interactions, nausea, vomiting, constipation, etc. Consider tube feeding if necessary to ensure adequate intake.

Parkinson’s disease

 

  • Etiology: With Parkinson’s disease there is a progressive loss of dopamine which causes an imbalance between excitatory and inhibitory communication in the brain. It is believed that genetics, environmental toxins, prions, oxidative stress, and an imbalance of neurotransmitters may play a role.
  • Clinical symptoms: Dysfunctional motor function, resting tremor, slowed movement, stooped posture, postural instability, depression, anxiety, sensory abnormalities, and pain. 
  • Nutritional management: Evaluate drug-nutrient interactions and maximize absorption of the medication. Ensure adequate oral intake and take appropriate measures to ensure gastrointestinal symptoms do not decrease intake. Alter food as appropriate to ensure adequate intake. Monitor hydration status. Consider tube feeding if necessary to ensure adequate intake.

Huntington’s disease

 

  • Etiology: Huntington’s disease is a genetic disorder that is passed down from generations. Children with parents who have Huntington’s disease have a 50% chance of inheriting the disorder.
  • Clinical symptoms: Huntington’s patients have behavioral, cognitive, and motor symptoms. The symptoms include problems with coordination and motor movements, involuntary movement, irritability, depression, problems with cognitive functioning and memory.
  • Nutritional management: Ensure adequate intake. Alter food texture as necessary for swallowing. Make foods more calorically dense as appropriate. Consider tube feeding if necessary to ensure adequate intake.  

Alzheimer’s disease

 

  • Etiology: The cause of Alzheimer’s is not known however it is believed that genetics and environmental factors play a role. The various types of Alzheimer’s disease appear to have different genetic abnormalities.  
  • Clinical symptoms: Memory loss, disorientation, personality changes, problems with language, reasoning, and sensory processing. 
  • Nutritional management: Ensure adequate intake. This may include having food provided manually, altering food texture, arranging for a way to determine food preferences. Consider tube feeding if necessary to ensure adequate intake.

ALS

 

  • Etiology: The cause of ALS is unknown however it is believed to involve genetic, biological, and environmental factors.
  • Clinical symptoms: Asymmetric muscle weakness and atrophy, stiffening of the muscles, uncontrolled twitching of the muscles, and as the disease progresses paralysis may occur. 
  • Nutritional management: Meet the needs of the patient to ensure appropriate intake. This may include altering food texture or increasing nutrient density. Consider tube feeding if necessary to ensure adequate intake.

 

Nutritional Management

 

How does the pathological state of swallowing (dysphagia) differ from the normal swallowing function?  What conditions commonly lead to dysphagia?  What are the signs and symptoms of dysphagia?  What are some of the nutritional problems associated with dysphagia?  Describe the optimal eating conditions for the patient with dysphagia.

A person with dysphagia experiences difficulty controlling food in their mouth. This may lead them to choke, cough, or have difficulty swallowing. Stroke, Parkinson’s disease, Multiple sclerosis, muscular dystrophy, Huntington’s disease, myopathy, Cerebral palsy, Alzheimer’s disease, head injuries, Esophageal spasm, Dementia, tracheostomy patients, prolonged intubation, and structural lesions are conditions that commonly lead to dysphagia.The signs and symptoms of dysphagia depend upon the phase in which problems occur. However signs and symptoms include aspiration before swallowing, food returning from the esophagus into the pharynx, food remaining in the esophagus, narrowing of the esophagus, excessive saliva, mouth soreness during chewing or swallowing, food remains in areas of reduced feeling, difficulty chewing, inability to form a food bolus or to move it to the back of the throat, nonexistent airway protextion, food stays at the base of the tongue and high in the throat. Patients with dysphagia may experience significant weight loss and develop nutritional deficiencies because of inadequate intake. Optimal eating conditions include: a person is seated appropriately close to the table with good posture. Food is within reaching distance. Fluid is on hand of appropriate consistency. Unpleasant smells are not present. A person is present to monitor eating to ensure choking does not occur. Food is of appropriate consistency. Noise is not present. The meal time environment is pleasant to the patient. 

 

When would a tube feeding be the selected method of nutrition support for a patient with a neurological deficit?


A patient should be assessed to see if they are capable of consuming food by mouth with assistance. If consuming food with assistance is not possible and all other support methods have been shown to be ineffective and the patient has lost significant weight and is not able to consume adequate amounts of calories than tube feeding should be considered.

 

 

 

 

 

DRAFT: This module has unpublished changes.

 Click here to review the Neurological Disorder and Dementia chart review.


INTERN’S NAME: Melissa Cannon

INSTITUTION: Cooler-Goldwater

ROTATION AREA: Neuro/Dementia

CHARTING TYPE: Not specified 

 

PRECEPTOR’S COMMENTS / CORRECTIONS OF CHARTING

Always list out total volume and total calories in the diet prescription/supplements section when listing formulas

List nutrient needs based on ideal body weight

If lab values are not available state in addition to stating that no recent lab values are present indicate the last day lab values were present

 

INTERN’S COMMENTS ABOUT NUTRITIONAL INTERVENTION(S):

As this was an initial assessment I would have liked to see a push for a dysphagia consult and pushed to have this patient receive PO feeding with supervision. Patients who have dementia may have better outcomes if they are eating PO. Many dementia patients are placed on tube feeding when they are not gaining weight and eating adequate amounts. However, placing a patient on a GT feed may not prevent the patient from loosing weight.  

 

WAS THE NUTRITION INTERVENTION SUCCESSFUL? WHY/WHY NOT?:

There were no changes made so there was no intervention to measure the success of. However, as stated above I would have liked to see a greater push for attempting to feed PO. 

DRAFT: This module has unpublished changes.