Royal North Shore Hospital

Jessica MacKenzie (Clinical Dietitian)Rowena Brain (Speech Pathologist)

OverviewEvidence for practice

The neurology patient - NutritionAssessment

Nutrition therapy

Dysphagia

Neurological disorder specificnutrition

The Brain

The human brain is only 2% of the weight of thebody, but it consumes about 20% of the totalenergy in the body at rest

The brain receives 15% of the cardiac output,20% of total body oxygen consumption, and 25%of total body glucose utilization

Evidence for Practice The FOOD Trial Collaboration, 3 arms, best

evidence available for stroke patients, outcomemeasures at 6 months.

Arm 1 (approx 4000): Normal Hospital diet vs.Normal Hospital diet with supplementation = nobenefit in well nourished pts but showed reducedmortality & decreased LOS in malnourished pts (approx15% of sample)

Evidence for Practice

Arm 2 (approx 400): Early PEG vs. NGT = poorQOL (functional) outcome or death at 6 months withearly PEG group

Arm 3 (approx 900): Immediate IVF vs. NGFeeding = reduced mortality & decreased LOS in NGfed group for those who require alternative feedingdue to dysphagia, no ↑’d complications

Source: The FOOD Trial Collaboration. Effect of timing and method of enteral tube feeding for dysphagicstroke patients (FOOD): A multi-centre randomised controlled trial. Lancet 2005;365(9461):764-72

Evidence for Practice Milne et al Meta-Analysis: Protein & energy

supplementation in older people (incl 6000) Pts >75yrs malnourished, oral supp (>398kcal/day)

Reduced mortality (OR 0.66),

Reduced complications (infections, wound healing,pressure sores) (OR 0.72)

Trend towards shorter LOS (3days)

Source: Milne AC, Potter J, Avenell Ameta-analysis: Protein and energy supplementation in older people. Annalsof Internal Medicine 2006;144:37-48

Evidence for Practice www.strokefoundation.com.au

Clinical Guidelines for Acute Stroke Management

National Stroke Foundation 2007

NH&MRC endorsed

Best Practice - evidence based

Clinical Guidelines for AcuteStroke Management 2007

Clinical Guidelines for AcuteStroke Management 2007

Clinical Guidelines for AcuteStroke Management 2007

In Practice All pts with dysphagia preventing adequate oral intake

should be nasogastrically fed, early Need to identify malnourished patients Malnourished patients will benefit from consuming≥400kcal (1.5 Sustagen or 1 can of TwoCal) ofsupplements

No effect of oral nutrition support unlessmalnourished

NGT may need to stay in-situ to ensure adequatehydration while dysphagic patients swallow improves

The Neurology Stroke Patient

Stroke (CVA - cerebrovascular accident), Ischaemic or

Haemorrhagic

TIA - Transient Ischaemic Attack

The Neurology Stroke PatientPrimary nutrition concerns

Swallowing problems

Malnutrition

Hyperlipidemia

Hypertension

Diabetes management

Other co-morbidities

Basic structure of intervention Reason for referral

PMHx

Medications

Biochem - (F) BGL,HbA1c, chol, TG, EUC,CMP, LFTs, Alb, WBC,Hb, vitamins, eg iron

Social Hx

Weight Hx?

Bowel habits?

Physical activity?

Previous diet Hx?

Current appetite/intake?

S/b dietitian before?

Education - nutr support,chol/diab/HT/wt Mx

Order diet/preferences

D/C plan

Nutrition Assessment Reason for referral

Hyperlipidemia, diabetes/IGT, HT, Wt Mx,texture modified diet or enteral fed required,malnourished, inadequate intake, poor appetite

PMHx

CHD, CVD, DM, GI dysfunction/surgery, gout, OAetc

Nutrition Assessment Meds

Statins, OHA, insulin, steroids, Phenytoin,Warfarin

Biochemistry

(F) BGL, HbA1c, chol, TG, EUC, CMP, LFTs, Alb,WBC, Hb, iron, folate, B12, vit D

Social History

Cooking, shopping, EtOH, cigs

Nutrition Assessment Weight History

Stable/ increase/ decrease, current wt, ht, BMI

Bowel habits

Change in habit? Constipation or diarrhoea

Physical activity

Any? Type? Duration? Change?

Nutrition Assessment Previous diet History

Regular meals and snacks, EI, protein, sat’d fat,DF, water, EtOH, salt, Fe, Ca, supplements

Food aversions

Current appetite/intake

Check for risk of re-feeding syndrome

S/b dietitian before?

Nutrition Therapy Education

Nutrition support thickened drinks, preferences, food record, TwoCal med

pass program

Prevention cholesterol/diabetes/HT/wt management, CHO, SFA,

DF, water, GI, dairy Ca, Na, BGL monitoring, physicalactivity, behavior change

Discharge plan Outpatient follow-up, diabetes educator, written

info, family support, supplement distributors

Nutrition Therapy Speech pathology Ax - NBM Wt, Ht EER (Schofield/H-B, AF, IF) EPR Est H2O Rqmt

Fluid restriction?

Recommended feed type Target regimen - Phenytoin, 16h, 24h, o/n? Commencement regimen

Re-feeding risk?

Nutrition Therapy Transitional feeding Close monitoring

Food charts

Long-term NG feeding - > PEG Reduce likelihood of aspiration by

Feeding over 16hr Pt at > 30° Regular small H2O flushes, Jejunal feeding

Regular liaison with Nursing, AH and Drs

Limitations in Stroke Pts Communication

Verbal, written, menus, frustration

Cognitive Feeding independence, menus

Visual field deficit Feeding independence, nutritional status, menu completion

Depression Awareness of inability to manage oral intake

Motor function Modified utensils, dependent, oral intake

High Protein-High Energy Diets Skim milk powder - milk, soup, potato, desserts

Margarine - vegetables, gravies, extra onbread/toast

Avocado, nuts, peanut butter, oils

Cream - rolled oats, canned fruit

Cheese - grated on meals, snacks portions

Speech Pathology and Dietetics

Overview Useful speech path terms

Brief orientation to DYSPHAGIA

Normal swallow description

What can go wrong in swallowing?

Consequences of dysphagia

Managing dysphagia

Relevant Neuro conditions

Useful Speech Path Terms Dysphasia: difficulty using and understanding

language

Dysarthria: difficulty producing clear and intelligiblespeech

Dyspraxia: difficulty coordinating movements foreating / speaking

Dysphagia: difficulty swallowing

Penetration solids, liquids, or saliva entering the airway to the

level of the vocal folds

Aspiration solids, liquids, or saliva entering airway BELOW

the vocal folds (i.e. lungs)

MBS - Modified Barium Swallow Investigative procedure

Video x-ray of oro-pharyngeal swallow

Useful Speech Path Terms

Dysphagia… What is it? Difficulty

Moving food in mouth

Initiating/ completing swallow

Moving food from mouth to stomach

30 muscles and 6 cranial nerves are involved inswallowing – A complex action!

May be acute (stroke) or worsen slowly over time(tumours or progressive disease)

Today talking about oropharyngeal dysphagia

What is a ‘normal’ swallow? Four stages

Oral preparatory phase

Oral propulsive phase

Pharyngeal phase and

Oesophageal phase

1. Preparatory and Oral phase

Food is placed into mouth (lip seal)

Chewed and mixed with saliva

Formed into cohesive bolus

Moved to the back of the tongue

2. Oral propulsive phase

Bolus is pushed through thepharynx

Swallow is triggered!

Tongue closes oral and nasalcavities

Larynx rises, epiglottis inverts,vocal cords close to protectairway

Pharyngeal muscles squeezebolus down the pharynx, andinto the oesophagus

Bolus moves from the pharynxto the oesophagus

3. Pharyngeal phase 4. Oesophageal phase

Muscle at top of oesophagusrelaxes (cricopharyngeus)

Peristalsis propels food throughthe oesophagus

Muscle at bottom of oesophagusrelaxes

Food passes into stomach

8-10 seconds

Swallowing… what can go wrong?• Self imposed avoidance of certain food or fluids may

signal swallowing difficulty!

Drooling or loss of food from mouth

Inability to control/ manipulate/ transfer food inmouth

Decreased awareness of food or fluid in oral cavity

Impaired chewing

Pocketing of food in cheeks

Not enough saliva to form or transfer bolus

Swallowing… what can go wrong? Difficulty swallowing pills – sticking in throat,

choking

Complaining of: food sticking in throat, problemsswallowing, reflux or heartburn

Delayed swallow trigger

Choking on food

Coughing during meals

Slow, effortful eating

Shortness of breath, worsened on oral intake

Pharyngeal pooling penetration/ aspiration?

Consequences of dysphagia PHYSICAL

Inadequate intake weight loss

Nutritional deficiencies, dehydration increasedsusceptibility to illness?

PSYCHOSOCIAL Social isolation - loss of mealtimes as a social

interaction

loss of interest or enjoyment in eating

MEDICAL

Aspiration/ Penetration pneumonia?

Aspiration & Pneumonia

Aspiration followingstroke has long beenassociated withpneumonia, sepsis anddeath (Ramsey et al., 2003)

Detection of aspirationand adaptive managementstrategies are regarded asimportant in theprevention of pneumonia

Aspiration pneumonia… whatare the risk factors? Stroke,

reduced levels of consciousness,

tracheostomy,

gastric reflux or emesis,

nasogastric tubes

compromised immune system

Dziewas, Stögbauer & Lüdemann, 2003

Indicators of potentialaspiration Brainstem Stroke (affects the swallowing centre)

Difficulty swallowing oral secretions

Coughing/throat clearing/ wet, gurgly voice afterswallowing water

Choking more than once while drinking 50ml ofwater

Recurrent lower respiratory infections/ pneumonia

Temperature spikes, low-grade fever or leukocytosis

Auscultatory evidence of lower lobe congestionMetheny, 2002

Managing dysphagia

Penman & Thomson, 1998; Plat, 2001)

Non-invasive management Swallow therapy

compensatory techniques

direct swallow therapy

Diet modification individualised to patient’s needs

Oral hygiene

Patient/Carer/Nurse education

Invasive management Enteral feeding

NGT

PEG

Modified Barium Swallow Investigative

Managing dysphagia

Safe feeding Awareness of the physical/cognitive limitations of

the patient

ALERT

POSITIONING - Upright

ASSISTANCE REQUIRED?

Check dentures fit well

Speech and Nutrition Team

What a Speech Pathologist needs to know Dietary restrictions

What diets are possible

What a Dietitian needs to know When a patient has dysphagia

What consistencies they can manage

When consistency changes are made

Speech Pathology and Dietetics

Dysphagia data - stroke

Approx. 50% of hospitalised stroke patients willexperience dysphagia

Approx. 43-54% of stroke patients with dysphagiaexperience aspiration

Approx. 37% of these patients will developpneumonia

3.8% of these patients will die of pneumonia if notpart of a dysphagia management programme

Motor Neurone Disease (MND) Progressive muscle wasting and weakness

resulting from degeneration of brainstem andspinal cord motor neurones

Dietary management is essential in thisdisease

MND Clinic at RNSH is multidisciplinary Different types of MND - bulbar vs limb ? Cognition The pt’s goals need to be considered

Summary of symptoms of MND

Upper MotorNeuron

Lower MotorNeuron

Bulbar nerves Weakness, slowmovement, increasedtone of lips, tongue,soft palate, jaw; voicemay be strained-strangled.

Weakness, muscleatrophy, fasciculationof lips, tongue and softpalate; voice may bebreathy

Spinal nerves Weakness, slowmovement, increasedtone of arms and legs,cramps

Weakness, muscleatrophy, fasciculationof arms and legs

Dysphagia in MND In patients with BULBAR involvement

Common initial difficulty is with tongue movementand control of bolus around oral cavity

More solid foods are commonly more difficult tomanipulate and swallow

Decreased lip closure spillage from mouth, drooling

Weak swallow food / fluid remains in pharynx

Management Base management on pt wishes (Quality of life) Food enjoyment Balanced diet and adequate hydration Texture modification / thickened fluids Compensatory swallowing strategies, NOT active

exercises Bowel function Saliva Management

Drooling Excessive thin saliva (Botox) Thick, tenacious saliva

Enteral feeding - PEG / ventilation Independence/ family support

Parkinson’s Disease Progressive degeneration of the basal ganglia

and substantia nigra of the cerebrum Reduced dopamine produced Symptoms

Tremor Rigidity Slowing of voluntary movements Cognitive slowness/dementia Depression

Management - medical, surgical, nutritional

Raised energy requirements - uncontrolledmovement

LOW Medication side effects Constipation Nausea & vomiting Loss of appetite Fatigue

Dysphagia Dehydration

Nutritional Issues in PD

Managing Nausea & Vomiting

Eat when hungry

Don’t skip meals

Cool/salty/tart foods preferred

Avoid cooking smells, greasy/fatty foods

Liquids can boost intake

Comfortable clothing and environment

Medication - antiemetics

PD & low protein diet Low protein diets may be useful when response

to L-Dopa medication varies

Neutral a.a’s compete with L-Dopa for the carrierneeded for intestinal absorption and crossing theblood brain barrier

40-50g/d (0.8g/kg/IBW)

Diet could be restrictive

Dysphagia in PD Rigidity and slowness

Difficulty initiating swallow, difficulty moving bolus throughmouth, pharynx and oesophagus

Tend to swallow less often at rest, drooling common

Cognitive impairment Poor insight into swallowing difficulties, less compliance with

recommendations, increased risk of aspiration

Drug cycle effects Medications can significantly improve swallowing!

Rapid changes in symptom severity, importance to timemedications carefully to optimise swallow function

Swallow strategies and exercises

Multiple Sclerosis Characterised by relapsing-remitting cycle or

progressive neurologic deficits in multiple areasof the CNS over time

Unknown cause

Demylination of nerves

Twice as common in females

Involves OT, PT, bowel and bladder RN, psych,medical and rehab

Nutritional Concerns Food access

Nutritional inadequacy - food and fluids

Weight maintenance

Swallowing difficulties

Use of supplements

Multiple SclerosisMS Pattern of progression is variable Most common form is relapsing-remitting Symptoms include:

weakness spasticity inco-ordination ataxia tremor fatigue heat intolerance

Dysphagia in MS Dysphagia type dependent on specific

nerves involved

Problems reported to occur ‘fairly often’: Choking on food or drink (27%)

Difficulty swallowing solids (16%)

Difficulty swallowing liquids (13%)

Drink or saliva escaping from lips (13%)

Chewing difficulty (12%)

Hand tremor commonly interferes withself-feeding

Managing dysphagia in MS

Early stage Remove distractions from

mealtimes Concentration on eating Increased sensory input –

temperature, taste and texture Maintain optimal body posture Maintain adequate hydration Avoid very warm environments Teach assisted cough in event of

choking

Late stage Postural adjustments

Diet modifications

Supervision

PEG

Huntingtons Disease Chronic degenerative disease of the CNS

characteristed by involuntary movements,psychiatric symptoms, progressive cognitivedeterioration

Inherited autosomal dominant disease andcommonly presents in adult life (~95%)

Drug treatment can often lead to sedation,lethargy and depression

Lottie Stewart Hospital have an inpatient/outpatientservice linked with Westmead Hospital

Nutrition concerns linked to stage of disease Main concerns

Nutritional inadequacy Weight maintenance Swallowing difficulties

Similar management to MND except longer term lifeissues, family implications and greater cognitiveproblems

Huntingtons Disease

Dysphagia in Huntington’s Disease

Swallowing impairment is common but notuniversal

Dysphagia more typical of advanced stages ofdisease

Usual symptoms Rapid, uncontrolled swallowing Involuntary movements of respiratory system Swallowing of air Excessive belching Aspiration of food and/or fluids

Managing dysphagia in Huntington’s Disease

Cognitive impairment decreases ability toactively compensate for motor problems ofspeech and swallowing

Caregivers have much responsibility forimplementing dietary modifications andswallowing techniques Postural and position changes

Assistive devices/modified utensils

Supervision – verbal cues, swallowing sequence

Dietary modification

Enteral feeding

Summary Variety of issues to manage

Dysphagia Bowel function Weight loss Nausea & vomiting Decreased independence Decreased motor function Patient goals

Any questions?