Chapter 22: Neurologic Impairment

Question 1

(TRUE/FALSE) Nutrition support is understood to be a therapy to attenuate the metabolic response to stress, prevent metabolic oxidative stress, and modulate the immune response.

Answer 1

TRUE.

Question 2

**What are the nutrition requirements for TBI?

Answer 2

• ENERGY: IC, if unable use 140% x the Harris-Benedict equation.
• PROTEIN: 1.3 to 1.5 g/kg/d
• Early nutrition is key, start EN ASAP
• Supplementation with zinc and IGF-1 has been shown to improve outcomes after TBI.

Question 3

Define hyponatremia. What can it contribute to?

Answer 3

• Serum sodium less than 135 mg/dL.
• Contributes to worsening cerebral edema, intracranial pressure elevations and death from herniation

Question 4

Define SIAD. How does it relate to TBI? What is the primary treatment?

Answer 4

• SIAD = Syndrome of Inappropriate Anti-Diuresis
• TBI is a common cause of SIAD, which results in euvolemic hyponatremia
• FR is primary treatment

Question 5

Define CSW (Cerebral Salt Wasting). How does it relate to TBI? What is the treatment/management?

Answer 5

• A rare hypovolemic hyponatremia characterized by increased natriuresis (excretion of sodium in the urine).
• Like SAID, CSW is usually transient after TBI
• CSW is a diagnosis of exclusion
• Managed with IV Sodium supplemention

Question 6

Define diabetes insipidus.

Answer 6

• A hypernatremic state characterized by a deficiency in vasopressin (neurogenic- most common type), lack of response to vasopressin (nephrogenic), OR accelerated degradation of vasopressin (gestational).
• BASICALLY: DAMAGE TO THE HYPOTHALAMUS OR POSTERIOR PITUITARY, usually as a result of rotational forces sustained in MVC, reduces central vasopressin production leading to neurogenic diabetes insipidius after TBI.
• Supplementation of salt-free water and replacement of vasopressin can reduce serum sodium to normal levels

Question 7

(FILL IN THE BLANKS)

As with hyponatremia, hypernatremia should be corrected NO FASTER than X to X mEq/L/d to avoid worsening of cerebral edema.

Answer 7

• 10 to 12 mEq/L/day
• (relates to previous 3 conditions: SIAD, CSW, Diabetes insipidus).

Question 8

What medications (4) used in TBI treatment have been shown to reduce measured energy expenditure?

Answer 8

• Proproanolol
  
  • Reduced by 5 to 18%
• Morphine
  
  • Reduced up to 8%
• Pentobarbital (used to reduce intracranial pressure)
  
  • Reduced up to 32%
• NMBAS (also used to reduce intracranial pressure)

Question 9

At present, which pharmaconutrients lack the available information to recommend specific dosing strategies for patients with TBI?

Answer 9

• L-arginine
  
  • Clinical research has not found that arginine supp in trauma and TBI improves outcomes
• Glutamine
  
  • Low plasma glutamine concentration at ICU admission is an independent risk factor for post-ICU morality in critically ill patients; but early provision of glutamine did not improve outcomes in large-scale study
• Omega-3 FA
  
  • No clinical data available
• Antioxidants
  
  • Ascorbic acid and alpha-tocopheral levels; not enough information

Question 10

**What are the nutrition recommendations for energy and protein for patients with SCI (spinal cord injury?)

Answer 10

• ** ENERGY: IC first, or 15% less than Harris-Benedict equation (no validated predictive equation best determines the SCI energy expenditure)
• PROTEIN: 1.5 to 2.0 g/kg/d (immediately following a SCI)

Question 11

**What are the general energy recommendations for weight maintenance for quadriplegic patients?

Answer 11

** 20 to 22 kcal/kg/d OR 55 to 90% of the Harris-Benedict equation.

Question 12

**What are the general energy recommendations for weight maintenance for paraplegic patients?

Answer 12

** Energy recommendations are increased slightly to 22 to 24 kcal/kg/d OR 80 to 90% of the Harris-Benedict equation)

Question 13

**What is the protein intake for patients in long-term care after a SCI?

Answer 13

**Healthy patients; 0.8 to 1.0 g/kg/d

If pressure injuries: 1.25 to 1.5 g/kg/d with energy (30 to 35 kcal/kg/d), sufficient daily fluid, and vitamin/mineral supplementation if intake is poor or deficiencies are suspected.

Question 14

**Healthy patients; 0.8 to 1.0 g/kg/d

If pressure injuries: 1.25 to 1.5 g/kg/d with energy (30 to 35 kcal/kg/d), sufficient daily fluid, and vitamin/mineral supplementation if intake is poor or deficiencies are suspected.

Answer 14

**

EN start within 24 to 48 hours of admission.

Question 15

**What are the energy requirements for patients with acute stroke?

Answer 15

• **IC is the gold standard; no equation has been validated to precisely determine the energy expenditure for the stroke population.
• Based on available data, the energy requirements following an ischemic stroke are likely close to estimated BMR via Harris-Benedict equation or Penn-State equation.
• Patients with hemorrhagic stroke, especially SAH, have elevated energy needs as compared with estimates of BMR.

Question 16

**What are the protein requirements for patients following an acute stroke?

Answer 16

** Recommended protein goals range from 1.0 to 1.5 g/kg/d

Question 17

If hypernatremia protocols aim for serum sodium ranges of 140 to 150 mg/dL to minimize cerebral edema, what should you recommend?

Answer 17

A concentrated enteral formula with 1.5 to 2.0 kcal/mL may be appropriate to provide less water. Then advancing to a standard formula as the patient progresses.

Question 18

Explain the level 1 dysphagia diet.

Answer 18

PUREED (homogenous, very cohesive, and pudding-like in texture, requiring very little chewing ability.

Question 19

Explain the level II dysphagia diet.

Answer 19

MECHANICALLY ALTERED

• Cohesive, moist, semisolid foods, requiring some chewing

Question 20

Explain the level III dysphagia diet.

Answer 20

SOFT FOODS that requiring more chewing; most advanced dysphagia diet.

Question 21

(TRUE/FALSE)

Although overeating creates risks for SCI patients, poor intake may increase the risk of pressure ulcers. When pressure ulcer incidence was examined in SCI patients, a higher percentage of underweight patients developed pressure ulcers compared to healthy weight, overweight or obese patients with SCI.

Answer 21

TRUE.

Monitoring weekly weight changes throughout the rehab program is useful in guiding adjustments in energy requirements.

Question 22

Explain implication of nutrition status in patients with ALS.

Answer 22

• ALS = Lou Gehrig’s disease; a rapidly progressing, degenerative motor neuron disease that results in significant muscle weakness and atrophy
• 75% of ALS patients will experience bulbar involvement (includes muscles that control speech, swallowing, and chewing, that can lead to substantial weight loss)
• Malnutrition is an independent prognostic factor of ALS survival; 8-fold increase in poor nutrition status
• Early nutrition interventions has been shown to maintain good nutrition status for a longer period of time.
• PEG placement earlier in the disease process is more effective at preserving nutrition status for a longer period of time.
  
  • ***It is recommended that PEG is placed whle forced vital capacity is more than 50% of predicted value or when patients has dysphagia or a BMI less than 20 or loses 5 to 10% of UBW.

Question 23

**What are the energy requirements for patients with ALS?

Answer 23

• **Mifflin St. Jeor and Harris-Benedict equations have been shown to be the most accurate methods, with HB being the most practical
• Some research supports increasing the calculated resting energy expenditure by 10%
  
  • Others: recommend energy needs to be 120% greater than BMR by IC and 130% x HB equation.
• As the ratio of organ mass to muscle mass increases, patients may require 34 to 35 kcal/kg/d

Question 24

**What are the protein requirements for patients with ALS?

Answer 24

** Ranges from 0.8 to 1.2 g/kg/day

Question 25

Explain the ketogenic diet.

Answer 25

• Well documented use for therapy in controlling seizures in the pediatric population
• To decrease seizures, a 4:1 ratio of fat to CHO and protein is recommended; which can be titrated down as the disease state stabilizes.
• Note many medications contain CHOs and must be taken into account when calculating diet.

Question 26

Explain the modified Atkins diet.

Answer 26

• A 1:1 ratio fat to protein and CHO can be used once a patient’s seizure frequency is more stable.
• Shown to reduce seizures in adults and adolescents with drug-resistant epilepsy.

Question 27

Limited information is known about nutrition and Parkinson’s disease. What is the overall pattern with body weight patterns in Parkinsons?

Answer 27

• In the beginning stages of the disease, body weight increases, likely due to a decrease in motor function.
• As the disease progresses, weight loss occurs. It is theorized that the metabolic rate increases because of worsening rigidity and dyskinesia.

Question 28

Explain the relationship between carbidopa/levodopa drug therapy and protein intake.

Answer 28

• The medication and protein compete for transport in the SI and blood-brain barrier.
• Fluctuations in absorption in leveodopa can affect motor function, and this drug therapy. has been associated with decreased intake of protein.
• Higher levodopa requirements have been associated with increased constipation, and diet mgmt is recommended.