Neurological Disorders Part II Flashcards
Epilepsy/Seizure Disorder
Intermittent derangement of the nervous system caused by sudden discharge of cerebral neurons. May be caused by head injury, congenital defects, metabolic disorders, or other illnesses. Many are idiopathic (cause unknown). 2.3 Americans have epilepsy with 15% being under the age of 15.
Generalized Seizures
Abnormal electrical activity that involves the entire brain:
- Tonic clonic
- Absence
Tonic-Clonic Seizure
Formerly called a grand mal seizure. It is a generalized seizure that lasts 1-2 minutes and involves complete loss of muscle tone and consciousness. Common in children.
Absence Seizure
Formerly called a petit mal seizure. This type of seizure is also generalized and the person may appear to be daydreaming, but recovers after a few seconds with no postictal fatigue or disorientation. Also common in children.
Partial Seizure
Isolated to one section or lobe of the brain. The area of the brain affected will determine how the sz presents. Most common type of seizure especially in adults. Two types:
- Simple partial
- Complex partial
Simple Partial Seizure
Involves no loss of consciousness.
Complex Partial Seizure
Involves change in consciousness.
Medical Treatment for Generalized Seizures
Managed with valproate, phenytoin, and gabapentin. Beware of drug-drug and food-drug interactions and liver damage.
Medical Treatment for Partial Seizures
Managed with carbamazepine or phenytoin. If failed to be controlled with medications than surgery may be used. Localized focus resected procedures cure 75% of patients.
Phenobarbital with Partial Seizures
Avoided due to it being associated with decreased IQ in children. May be used if all other medications fail.
Ketogenic Diet for Epilepsy MNT
A high fat, low CHO diet induces a metabolic shift or energy utilization within some tissues of the brain and produces ketosis. In 1/3 of children and significantly decrease activity in another 1/3 of children.
Ketogenic Diet Implementation
- Stop antiepileptic drugs
- Child fasts in hospital for 24-72 hrs until 4+ ketonuria
- Evaluate response
- Fat: 75% of calories
- Protein: sufficient to meet growth need (1g/kg)
- CHO: added to make up rest of calorie needs (negligible)
MNT for Seizures
Correct nutritional deficits from long term anticonvulsant medications (vitamin D, Ca). Ketogenic diet may be used.
Multiple Sclerosis
Chronic disease affecting the CNS and causes destruction of the myelin sheath, which transmits nerve impulses. Multiple areas of myelin are replaced with scar tissue. May be genetic and environmental factors, including geographical latitude (northern hemisphere) and diet (high animal fats).
Medical Treatment for MS
- Steroid therapy for exacerbations
- Prednisolone
- Methotrexate (can cause wt gain and fluid retention)
- Alpha-interferon
- Physical therapy
The 3 Types of MS
- Relapsing-remitting MS
- Secondary progressive MS
- Primary progressive MS
Relapsing-Remitting MS
Symptom flare-ups followed by recovery. Stable in between attacks.
Secondary Progressive MS
Second phase of relapsing-remitting MS and has a progressive worsening of symptoms.
Primary Progressive MS
Gradual but steady accumulation of neurological problems from onset.
Controversial Therapies for MS
- Shank diet: low in saturated fat
- MacDougal diet: no gluten, low sugar, and no refined sugar
- Allergen-free, gluten-free, pectin-free, fructose-restricted, raw food Evers diet
- Low fat diet high in linoleic acid may have some beneficial effects
MNT in MS
- Diet consistency modifications as needed if dysphagia develops
- Suggest pre-packaged, single-serving or convenience foods if meal preparation becomes difficult due to impaired vision and poor ambulation
- High fiber diet for constipation
- Counseling regarding fluid intake, cranberry juice to prevent UTIs
- Enteral nutrition support in end stage
Parkinson’s Disease
Age related neurodegenerative disorder that affects 1-2% if people 60 years of age and older. Diminished levels of dopamine at the basal ganglia of the brain causes:
- Tremors in the hands, arms, legs, jaw, and face
- Rigidity of limbs and trunk
- Coordination difficulty
- Dysphagia
- Speech problems
Nutrition Guidelines for Parkinson’s Disease
- Eat a variety of healthy foods consistent with the US Dietary Guidelines
- Maintain a healthy body wt
- Balance food with exercise
- Eat foods high in fiber
Food-Drug Interactions in Parkinson’s Disease
- Levodopa works best taken on an empty stomach 1/2 hour before or one hour after meals
- Protein competes with levodopa for absorption. Rarely, a high protein diet interferes with levodopa
- If so, reduce overall protein intake or divide into many small meals; eat protein late in the day
Food-Drug Interactions in Parkinson’s Disease
- Levodopa can cause nausea
- Doctor may change to combination of levodopa and carbidopa (Sinemet) or carbidopa by itself
- Drink liquids between meals rather than with them
- Eat smaller more freq meals
- Avoid fried, greasy, and sweet meals
- Eat foods at room temp to minimize odors
- Rest after eating with head elevated
Adrenoleukodystrophy
Rare congenital enzyme deficiency affects very-long chain fatty acid (VLCFA) metabolism in young men. Causes accumulation of VLCFAs which causes:
-myelopathy
-peripheral neuropathy
-cerebral demyelination
Head trauma shown to be detrimental in those people with genetic risk. Lorenzo’s oil lowers the VLCFA level, and dietary avoidance has been shown not to be useful..
Energy Requirement for SCIs
H/B x 1.1 x 1.3
Pt with multiple traumas in addition to a SCI may have higher energy needs.
Provide EN/TPN support as needed.
Protein Needs for SCIs
2g/kg
MNT with a Chronic Spinal Cord Injury
- Risk of wt gain and pressure ulcers due to immobilization
- Higher fiber and adequate hydration to minimize constipation
- Dietary intake to maintain nutritional health and proper wt
Energy Requirements for a Chronic Spinal Cord Injury
Paraplegics: 28 kcal/kg
Quadriplegics: 23 kcal/kg
Protein Needs for a Chronic Spinal Cord Injury
Will need to be increased if pressure wounds are present.
Non-Traumatic Brain Injury
- Develops slowly
- Form of cancer
- Infections
- Degeneration of the vertebrae
Traumatic Brain Injury (TBI)
Results from head injury after a MVA, GSW, industrial accidents etc
TBI
400,000 new cases of brain injury occur each year in the U.S. Most result from MVAs. Incidence is highest in young people and the elderly, and twice as often in males than females. Almost all pts with a severe head injury have some degree of disability.
Glasgow Coma Scale (GCS)
Strong prognostic value for neurologic recovery in head-injured pts. The scale is evaluating and quantitating the degree of coma by determining best responses to standardized stimuli.
GCS Scores
Eye Opening: 4 spontaneous - 1 none
Verbal Response: 5 oriented - 1 none
Motor Response: 6 follows command - 1 none
Severity of head injury:
Mild: 13-15
Moderate: 9-12
Severe: 3-8
Strong Predictors of Poor Outcome After Head Injury
- Older age
- Low GCS score
- Pupil dilatation
- Low blood pressure
- Inadequate oxygenation early after injury
- Prolonged and/or difficult to control intracranial pressure
Neurological Deficits that Affect Nutritional Status
- Hemiparesis
- Hemianopsia
- Apraxia
- Dysphagia
Hemiparesis
Weakness that affects one side of the body. May increase the risk of aspiration.
Hemianopsia
Blindness in one half in the field of vision. Must compensate by turning their head.
Apraxia
Difficulty with perceptual motor planning.
Symptoms of Dysphagia
- Drooling
- Choking or coughing during or proceeding meals
- Inability to suck from a straw
- Gurgly voice quality
- Holding pockets of food in the buccal recesses. Pt may not be aware.
- Absent gag reflex
- Chronic upper respiratory infections
- Wt loss and anorexia
Oral Phase of Swallowing
Voluntary. Food is chewed, mixed with saliva and is moved to the back of the mouth by the tongue.
Problems During Oral Phase
- Inability to seal the lips around a cup
- Inability to suck through a straw
- Food can become pocketed
Pharyngeal Phase of Swallowing
Involuntary. Soft palate closes off the nasopharynx and the hyoid and larynx elevate. The vocal cords adduct to protect the airway, and the pharynx contracts and the cricopharyngeal sphincter relaxes allowing food to pass into the esophagus.
Problems During Pharyngeal Phase
Symptoms of poor coordination including gagging, choking, and nasopharyngeal regurgitation.
Esophageal Phase of Swallowing
Involuntary. Bolus continues through the esophagus into the stomach.
Problems During Esophageal Phase
Most difficulties are d/t mechanical obstruction. Involuntary peristalsis affected by brain stem infarction.
Thin Liquids
Are the most difficult to control in the mouth and can be easily aspirated into the lungs. Often thickened to nectar, honey, or pudding thick. Essential for proper hydration.
Issues with Thickened Liquids
- No consistency across product lines within manufactures or between competitors
- Continuous hydration of the thickening agent in pre-thickened products
- Issues with instant food thickeners continuing to thicken
MNT for Dysphagia
Cognitive and swallowing dysfunction usually affect nutritional management and place neurologic pts at risk for malnutrition.
- EN should begin as soon as pt is hemodynamically stable at 35-45 kcal/kg and 2-2.5g/kg protein
- Advance to oral feedings when possible
- altered diet consistency may be indicated
Guillain-Barre Syndrome
Acute inflammatory demyelinating polyneuropathy with rapidly increasing weakness, numbness, and paralysis of legs, arms, trunk, face and respiratory muscles. Often occurs after infection or flu and presents as bloody diarrhea, fever, cramping, and headache. Most recover fully from GBS in a few weeks, but may require intensive care, mechanical ventilation, and some may have residual effects.
MNT for GBS
For acute pts IV fluids indicated, EN or TPN may be needed, and increased energy or protein needs indicated. Diet progression to puree diet with dysphagia, and may need supplements if intake is poor.
Huntington’s Disease
Also known as Huntington’s Chorea, is a genetic autosomal dominant neurodegenerative disorder. It develops in middle to late life and is characterized by:
-involuntary, spasmodic, and irregular movements
-cerebral degeneration
-cognitive decline
-speech difficulties
Duration is 13-15 years before death which is usually related to pneumonia or complications from a fall.
MNT for Huntington’s Diease
- Provide sufficient energy and protein
- May need up to 5000 kcals/day
- May need 1-1.5 g/kg or protein a day
- Alter diet consistency as needed as the disease progresses
- Provide adequate fluids to prevent dehydration
- Adequate fiber
- Multivitamin/mineral supplement, folic acid, and a B complex may be especially important
