Definitions
- TIA: Transient Ischemic Attack – “mini-strokes” – an episode of ischemia where blood flow is quickly restored, and symptoms resolve within 24 hours
- Glascow coma scale: it is the summation of scores for eye, verbal, and motor responses – the minimum score is a 3 which indicates deep coma or a brain-dead state – the maximum is 15 which indicates a fully awake patient
- Aphasia: the loss of ability to understand or express speech, caused by brain damage
- FEEST: Flexible Endoscopic Evaluation of Swallowing with Sensory Testing – a two-part test used to directly examine motor and sensory functions of swallowing in order to determine the dietary and behavioral management for patients with swallowing problems to decrease the probability of aspiration – the first part of the test assesses sensation in the larynx in order to illicit an airway protective reflex – the second part of the test involves giving food to the patient and watching/ tracking where the food travels in the throat region
- Modified barium swallow: radiological examination performed while the person swallows barium-coated substances, done to assess the quality of the swallowing mechanisms of the mouth, pharynx, and esophagus
- Aspiration: inspiration of foreign matter into the lung
Pathophysiology
For each of the following, describe the etiology, clinical symptoms and nutritional management.
| Disease | Etiology | Clinical Symptoms | Nutritional Management |
| Multiple sclerosis (MS) | Exact cause is unknown; family history is the strongest known risk factor; environmental risk factors include geographic latitude (relationship between increased sunlight exposure and lower MS risk), dietary intake of vitamin D from food and supplements (increased intake corresponds to lower risk of MS), and smoking increases the risk | Symptoms vary because any nerve can be affected – progression also varies – some progress rapidly, others have periods of remission and relapse
Numbness, paresthesia, ataxia, and weakness are common
Visual problems such as double vision, blurred vision, or blindness
Slurred speech, fatigue, dizziness, and problems with bowel and bladder function |
Supplementation with omega-3 fatty acids and restriction of saturated fat – anti-inflammatory effect of omega-3s could be beneficial
Supplementation with antioxidants – beta-carotene, vitamin C, vitamin E, and selenium. A
Supplementation with vitamin D and calcium in patients at increased risk of osteoporosis because of long-term steroid use
Monitor for dramatic changes in weight – gain or loss – encourage regular exercise to improve weight status and decrease the symptoms of fatigue and weakness
Monitor for inadequate nutritional intake – interventions should address the specific problem |
| Parkinson’s disease | Unclear, may be related to genetics, environmental toxins, oxidative stress, imbalance of neurotransmitters, loss of ability to reproduce dopamine-producing cells | Tremor of the hand when it is relaxed, slowed movement, rigid muscles, impaired posture and balance, loss of automatic movements, speech changes (speak softly, quickly, slur or hesitate before talking; speech may become more monotone), and writing changes (may become hard to write, and writing may appear small) | Adequate caloric intake and close monitoring of weight status – decreased intake and unintentional weight loss are common
Assisted feeding and extended mealtimes – tremors and fatigue can decrease intake; cognitive decline, confusion and agitation can lead to feeding difficulties
Adjust meal time to periods in which the individual is well rested
Dysphagia diet and/or tube feeding |
| Huntington’s disease | A rare single-gene disorder in which nerve cells in the brain break down over time | Movement symptoms – involuntary jerking, muscle rigidity or contracture, slow or abnormal eye movements, impaired gait, posture and balance, and difficulty speaking or swallowing
Cognitive impairments – lack of awareness, lack of impulse control that can result in outbursts, difficulty learning new information
Psychiatric symptoms – irritability, social withdrawal, insomnia, fatigue and loss of energy, frequent thoughts of death, dying or suicide |
Increased caloric needs
Follow a general healthful diet with an emphasis on fruits, vegetables, whole grains, and healthy fats, especially omega-3s
Special utensils, plates, and seats can make eating easier and improve oral intake and thus nutritional status
Enteral nutrition may be considered if the person can no longer meet their nutritional needs with an oral diet
Tube feedings to supplement oral diet may be considered if the person has difficulty swallowing |
| Alzheimer’s disease | A progressive disease that destroys memory and other important mental functions, characterized by the formation of amyloid plaques in the brain and neurofibrillary tangles within neurons
Exact cause is unknown – believed to be caused by a combination of genetic, lifestyle and environmental factors that affect the brain over time |
Memory loss, confusion, difficulty concentrating and thinking, difficulty multitasking, changes in personality and behavior, difficulty planning and performing familiar tasks, difficulty making judgements and decisions | Adequate caloric intake and close monitoring of weight status – decreased intake and unintentional weight loss are common
Assisted feeding and extended mealtimes – tremors and fatigue can decrease intake; cognitive decline, confusion and agitation can lead to feeding difficulties
Adjust meal time to periods in which the individual is well rested
Dysphagia diet and/or tube feeding |
| ALS (Amyotrophic lateral sclerosis) | A progressive neurological disease that affects the motor neurons of the nervous system
Exact cause is unknown, unless it is familial ALS (genetic) – non-familial ALS is thought to be caused by multiple factors, including genetic, biological, and environmental factors |
Main symptom is muscle weakness
Muscular symptoms – problems with coordination, stiff muscles, loss of muscle, muscle spasms, or overactive reflexes
Speech symptoms – difficulty speaking, vocal cord spasm, or impaired voice
Other symptoms – fatigue or feeling faint, difficulty swallowing, drooling, lack of restraint, mild cognitive impairment, severe constipation, severe unintentional weight loss, shortness of breath, or difficulty raising the foot |
Increased caloric needs
Follow a general healthful diet with an emphasis on fruits, vegetables, whole grains, dairy, healthy fats and oils, and lean meats |
Nutritional Management
How does the pathological state of swallowing (dysphagia) differ from the normal swallowing function? What conditions commonly lead to dysphagia? What are the signs and symptoms of dysphagia? What are some of the nutritional problems associated with dysphagia? Describe the optimal eating conditions for the patient with dysphagia.
Dysphagia is the difficulty swallowing, caused by a medical condition which causes an impairment in the person’s ability to complete either the oral phase, pharyngeal phase, or esophageal phase of swallowing. The normal swallowing function consists of four phases: (1) the oral preparatory phase – anticipating eating, and then putting the food or liquid in your mouth, (2) the oral phase (voluntary) – the bolus is formed and the tongue moves it to the back of the throat , (3) the pharyngeal phase (involuntary stage – controlled by the parasympathetic nervous system) – breathing is inhibited when the muscles of the pharynx contract and the upper esophageal sphincter relaxes, allowing the bolus to pass into the esophagus, and (4) the esophageal phase (involuntary stage – controlled by local and central nervous system reflexes) – peristalsis moves the food through the esophagus, and the lower esophageal sphincter relaxes allowing the food to pass into the stomach. The difference between normal swallowing and swallowing in dysphagia depends on which phase is impaired, but it will be either a voluntary impairment (difficulty chewing food and forming a bolus) or an involuntary impairment (disruption of the neural networks coordinating the swallowing mechanism – difficulty swallowing foods and liquids, problem closing the vocal cords which can result in aspiration, dysfunction of peristalsis, and reflux).
Certain medications can cause dry mouth, making it hard to swallow. Damage to the brain or nerves (e.g. stroke, brain injury, spinal cord injury, Parkinson’s disease, multiple sclerosis, ALS, muscular dystrophy, cerebral palsy, and Alzheimer’s disease) can also lead to dysphagia. Additionally, problems with your head or neck (e.g. cancer in the mouth, throat or esophagus, head or neck injuries, mouth or neck surgery, and bad or missing teeth or dentures that don’t fit well) can lead to dysphagia.
Signs of oral stage dysphagia include extra effort needed to chew/swallow, inability to eat specific food types, loss of food or liquids from the mouth, and food sitting in the mouth long after a meal. Common signs of pharyngeal phase dysphagia include coughing, choking or gagging during or right after a meal, “wet” or “gurgled” voice and/or breath sounds after eating or drinking, and a sensation of food “sticking” in the throat (pharyngeal phase dysphagia may not present with any signs or symptoms). Signs of esophageal phase dysphagia include frequent episodes of regurgitation, reflux or spitting up after a meal, difficulty managing solid food, a sensation of food sticking in the throat or chest area, and complaints of dysphagia without overt coughing or choking
Malnutrition, weight loss, and dehydration are common nutritional problems associated with dysphagia. Dietary management of dysphagia includes modifying the consistency of foods and liquids so that they are easier to chew and/or swallow. The National Dysphagia Diet has three different categories for diet texture modification – (1) Dysphagia Level 1 – Pureed Diet, (2) Dysphagia Level 2 – Mechanically Altered Diet, and (3) Dysphagia Advanced – Level 3 Diet – and which one is prescribed depends on the what phase of the swallowing function is impaired and how severe the impairment is.
The optimal eating conditions for a patient with dysphagia include a quiet and relaxed atmosphere, sitting upright when eating and drinking, keeping foods soft and moist if needed, chewing well, swallowing before taking another bite or sip, chewing and swallowing food before talking, and wearing dentures that fit well (if they have them). If a patient needs to be fed, they should let the person feeding them know if they’re going too fast, giving too much at once, and/or not putting the food in their mouth correctly. After eating, have the patient sit upright for at least an hour to allow food to be digested, check their mouth with their tongue or finger to make sure there’s no food leftover, and brush their teeth.
When would a tube feeding be the selected method of nutrition support for a patient with a neurological deficit? What ethical issues may be involved?
Tube feeding may be the selected method of nutrition support if the patient is malnourished or at risk of becoming malnourished and adequate oral intake cannot be safely maintained. Ethical issues revolve around the patient’s ability to make a decision about their care – if they cannot understand the options or communicate what they want, and they have left no directives about what they would want in that situation, the decision may fall to their family. This may result in a course of treatment they would not have wanted were they able to make the decision themselves.
