the brain evidence for practice - university of sydney...≥400kcal (1.5 sustagen or 1 can of...
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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?