Neurodegenerative Diseases: Stroke, Motor Neurone Disease, Dementia

Question 1

What is a stroke?

Answer 1

Stroke: life threatening medical condition that occurs when the blood supply to part of the brain is cut off

Question 2

What are the 3 main types of stroke?

Answer 2

3 main types of stroke: Ischaemic stroke (80% of strokes), Haemorrhagic stroke (10% of strokes), Transient Ischaemic Attack (mini stroke)

Question 3

Ischaemic stroke definition

Answer 3

Ischaemic strokes:
80% of strokes
• Brain cell death due to lack of oxygen from blockage of cerebral blood vessel
- One main blood vessel is blocked

Question 4

Haemorrhagic stroke (intracranial haemorrhage) definition:

Answer 4

Haemorrhagic stroke (intracranial haemorrhage)
• 10% strokes
- Bleed on the brain
• Brain cell death due to lack of oxygen from a weak cerebral blood vessel bursting

Question 5

Transient Ischaemic attack definition

Answer 5

Transient Ischaemic attack:
- Temporary disruption to the brain blood supply
- Mini stroke
- Blood supply recovers

Question 6

Stroke Diagnosis

Answer 6

Stroke diagnosis:
To RECOGNISE a stroke (all symptoms may not be present):
B: Balance
E: Eyes (double vision, vision loss, drooping)
F: Face (drooping)
A: Arms (numbness, unable to lift)
S: Speech (slurred, lack of understanding, lack of tongue control)
T: Time

Question 7

Stroke prevalence: GLOBAL

Answer 7

Global stroke prevalence
- 1 in 4 people will have a stroke in their lifetime
- 2019: 63% of strokes occurred in people <70 years
- 1 stroke every 3 seconds
- 101 million worldwide living with stroke aftermath
- Up to 80% of strokes and heart attacks occur in people with low or moderate CVD absolute risk

Question 8

Stroke prevalence: UK

Answer 8

Stroke prevalence: UK
- 1 stroke every 5 minutes
- 100,000 strokes per year
- 400 childhood strokes per year
- 4th leading cause of death in the UK
- 1 person dies from stroke every 17minute
- Death rates are declining
- >55 years more likely to have a stroke
- 1.2million stroke survivors:
2/3 survivors leave hospital with a disability
2/3 of working age survivors never return to work
- More likely to have another stroke after 1st stroke

Question 9

What are the 10 leading risk factors for a stroke?

Answer 9

10 leading stroke risk factors:
- Elevated systolic blood pressure
- Poor diet
- High body mass index
- High fasting glucose
- High LDL cholesterol
- Alcohol use
- Low physical activity
- Air pollution
- Smoking
Metabolic risks (high BP, high BMI, high FPG, high total cholesterol and low glomerular filtration rate)= 71% of stroke burden
Behavioural factors (smoking, poor diet and low physical activity)= 47% of stroke burden
High systolic blood pressure is the largest single risk for stroke.
Risk factors still apply if someone has already had a stroke.

Question 10

Guidelines for stroke management (ESPEN 2018):

Answer 10

Guidelines for stroke management (ESPEN 2018):
- Screen for malnutrition within 48 hours of admission. Screen weekly after.
- Acute stroke: assess hydration within 4 hours of admission. Review regularly.
- Screen for dysphagia. Failed screen or signs of dysphagia? Formal swallow assessment should take place.
- Acute stroke: if adequately nourished and can meet nutritional needs orally, don’t give oral supplements routinely.

Question 11

ABCDEF assessment of a stroke patient

Answer 11

ABCDEF assessment of a stroke patient:
Anthropometric: Weight loss, current status, muscle mass
Biochemistry: Cholesterol (lipids), kidney function, blood glucose, hydration
Clinical: Medical management and rehabilitation (speech and language therapist), bowels, organ function, hydration
Dietary: Dysphagia, intake, requirements
Environmental: Discharge planning, social support, psychological well-being
Functional: Ability to care for self

Question 12

Dysphagic stroke nutrition interventions

Answer 12

Dysphagic stroke nutrition interventions
- IV fluids
- Nasogastric feeding within 24 hours to be considered
- Specialist nutritional assessment if swallowing difficulties present. Swallow can be rehabilitated.
- Alternative feeding routes: nasal route (short term), gastrostomy (long term >6 months). What about DoLs?
- Early feeeding may support increased survival
- Adapt to changes
- At risk of malnutrition? Care plan should be individualised

Question 13

What are the considerations for dysphagic stroke nutrition interventions?

Answer 13

Dysphagic stroke nutrition interventions:
- Ethics of feeding
-Monitioring and adapting to changes
- Refeeding syndrome
- Discharge planning
- Patient preference and requirements

Question 14

What is Motor Neurone Disease (MND)?

Answer 14

Motor Neurone Disease (MND):
- Group of diseases that affect the brain stem and spinal cord (nerves)
- Types: Amyotrophic lateral sclerosis, Progressive Bulbar Palsy/ Bulbar Onset MND, Progressive Atrophy
- 80% have communication issues
- MND attacks nerves that control movement> muscles no longer work

Question 15

MND prevalence

Answer 15

Motor neurone disease prevalence:
- Lifetime risk 1 in 300
- More than 5,000 adults affected in UK at one time
- 6 people diagnosed every day
- 6 people die from MND each day
- Incidence: 2 in 100,000
- Most diagnosed >40 years.
- Highest prevalence 50-70 years.

Question 16

What are the causes of MND?

Answer 16

MND causes:
- Uncertain
Maybe a mixture of:
- Genetic factors
- Lifestyle and environment
- Mechanical and/or electrical trauma
- High levels of exercises
- Exposure to agricultural chemicals
- Exposure to a variety of heavy metals

Question 17

Motor Neurone Disease Management

Answer 17

Motor Neurone Disease Management:
- Medication: Riluzole/ Rilutek (glutamate receptor blocker). Preserves breathing pathway
- Symptom management/relief:
- Speech communication (speech boards, AAC devices)
- Seating (specific wheelchairs, stand support, foot support)
- Position and comfort (head collar to help keep neck upright)
- Mobility (wheelchair/hoist)
- Breathing support (NIV)
- Nutrition (feeding support, tubes?)
- Saliva management (reduction) to reduce aspiration risk
- Palliative care to ensure good life until death

Question 18

Effect of MND on nutrition

Answer 18

Effect of MND on nutrition
- High malnutrition risk (under nutrition)
- Increased risk of death if malnourished
- Loss of BMI, Loss of 5% BW, Loss of 10% BW can increase risk of death
MND cause:
- Dysphagia
- Cognitive impairment
- Depression
- Anxiety
- Salivary issues (aspiration risk)
- Difficulty masticating
- Loss of limb dexterity (positioning)
- Hypermetablism
- Respiratory insufficiency
-Nausea
- Appetite loss
- Fatigue
- Constipation
- Polypharmacy (too much medication)

Question 19

Guidelines for MND management

Answer 19

Guidelines for MND management:
- Baseline BMI < 25 kg/m2: weight gain recommended
- Baseline BMI 25-35 kg/m2 weight stabilisation recommended
- Baseline BMI >35kg/m2: weight loss recommended to improve passive and active mobilisation
- Dysphagia screening recommended
- Malnutrition screening at diagnosis.
- Follow up malnutrition screening every 3 months
- If EN is proposed: pros and cons should be discussed with patient, family and care givers.

Question 20

When are artificial nutrition and hydration indicated in MND?

Answer 20

Artificial nutrition and hydration is indicated in MND patients who have:
- Severe Dysphagia with risk of aspiration pneumonia or recurring chest infections
- Malnutrition with weight loss of >10% from pre-diagnosis weight
- Suboptimal energy intake

Question 21

Nutritional Intervention of MND

Answer 21

Nutritional Intervention of MND:
Quality of ethics and lifestyle are at the centre of decision making
Ensure nutritional requirements are met
• Food fortification
• Palatability
• Texture modification as per SLT
• Fluid (thickener)
• Artificial nutrition and hydration

Question 22

What are the goals of artificial nutrition and hydration in MND?

Answer 22

Artificial nutrition and hydration goals in MND:
Meet nutritional needs - Stabilise body weight - Correct/prevent malnutrition - A route for medications and hydration - Decrease risk of aspiration - Quality of life (eg lack of hunger)

Question 23

What is dementia?

Answer 23

Dementia:
* Collection of symptoms including memory loss, problems with reasoning and communication, and reduction in ability to carry out daily activities
* a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities. Alzheimer’s disease is the most common type of dementia.

Question 24

Support a patient may require to manage their nutrition after a stroke

Answer 24

Support a patient may require to manage their nutrition after a stroke
* Patient may have: limb weakness, paralysis, numbness, blurred vision, confusion, communication issues, memory issues, co-ordination issues, headaches, dizziness, nausea, anxiety, depression, reduced safety awareness or dysphagia
* At risk of undernutrition
* Must assess to establish if dysphagic or not and malnutrition risk
* Might need support with preparing meals, might need food fortification to combat undernutrition, may need supplementation,
* Sensory impairment: add flavour, contrasting colours, reduce distractions, texture modification if dysphagic, new foods
* Physical impairment: adjusted cutlery, finger food, may need support with feeding,
* Memory: routine, visual cues, involve in food preparation,
* Nausea: little and often
* If dysphagic: IV fluids, nasogratric feeding possibly, SLT assessment

Question 25

What are the symptoms of dementia?

Answer 25

What are the symptoms of dementia?
* Memory loss
* Reasoning issues
* Communication issues
* thinking speed
* mental sharpness and quickness
* language, such as using words incorrectly, or trouble speaking
* understanding
* judgement
* mood
* movement
* difficulties doing daily activities

Question 26

Which nutrients might prevent dementia?

Answer 26

Nutrients that might prevent dementia:
* B vitamins (B6, B9, B12). Not enough evidence to conclude use. But may be protective in cognitive ageing as low levels of B12 or folate can lead to high homocysteine levels which are associated with cognitive decline and cell apoptosis.
* Omega-3s intake from the diet of marine sources decreases risk of cognitive impairment and dementia. Might be linked to vascular, inflammatory and amyloid pathways of dementia.

Question 27

Dementia nutritional management

Answer 27

Dementia nutritional management
* Sensory impairment: add flavour, contrasting colours, reduce distractions, texture modification if dysphagic, new foods
* Physical impairment: adjusted cutlery, finger food, may need support with feeding,
* Memory: routine, visual cues, involve in food preparation,
* Low appetite: little and often, high energy and protein foods
* Carer support: education, eating assistance, emotional support

Question 28

Artificial nutrition and hydration in dementia

Answer 28

Artificial nutrition and hydration in dementia
* Person with dementia at the centre of decision making
* Will quality of life be improved if its implemented?
* Communication should be early
* No evidence to support artificial feeding use: to reduce aspiration risk or pressure sore development. Increase survival time or improvement in patients ability to manage daily activities

Question 29

ESPEN Dementia Nutrition guidelines

Answer 29

ESPEN Dementia Nutrition guidelines
* Oral nutrition may supported in all disease stages
* Single nutrient supplementation only recommended if there is deficiency
* Oral nutritional supplements for: nutritional status improvement only.
* Artificial nutrition suggested in: mild or moderate dementia for LIMITED time to overcome a crisis.
* Artificial nutrition not recommended in severe dementia or terminal life phase.