KNH 413 Neurological System Nervous System Central nervous

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KNH 413 Neurological System

KNH 413 Neurological System

Nervous System Central nervous system (CNS) ◦ Processing of sensory information followed by responsive

Nervous System Central nervous system (CNS) ◦ Processing of sensory information followed by responsive motor signal Peripheral nervous system (PNS) ◦ Transmission of impulses between CNS and peripheral organs ◦ Somatic division - to and from CNS ◦ Autonomic division – involuntary Sympathetic Parasympathetic

Nervous System Cellular level - functional cells ◦ Neurons – cell to cell transmission

Nervous System Cellular level - functional cells ◦ Neurons – cell to cell transmission Soma Dendrites Axon terminals ◦ Glial cells - surround neurons ◦ Neurological disorders result from dysfunction of these cells or their communication

Nervous System Cellular level - functional cells ◦ Neuron to neuron communication is through

Nervous System Cellular level - functional cells ◦ Neuron to neuron communication is through release of neurotransmitters into synapses Neurotransmitters specific to synapses See Table 22. 1 – neurotransmitters ◦ Endorphins and neuromodulators, nitric oxide, and CO 2 act like neurotransmitters

Central Nervous System Brain ◦ Corpus callosum – communication between hemispheres ◦ Distinct areas

Central Nervous System Brain ◦ Corpus callosum – communication between hemispheres ◦ Distinct areas responsible for specific functions Frontal lobe - thinking, planning, emotion Parietal lobe – pain, touch, taste, temp. , pressure Temporal lobe – hearing, memory, emotions Occipital lobe - visual Limbic lobe – emotional, sexual ◦ Spinal cord – messages to rest of body

Neurological Disorders Epilepsy and seizure disorders – spontaneous, uncontrolled electrical activity among cerebral neurons

Neurological Disorders Epilepsy and seizure disorders – spontaneous, uncontrolled electrical activity among cerebral neurons ◦ Epilepsy – more than 2 unprovoked seizures ◦ Partial or generalized; simple or complex ◦ Signs and symptoms depend on type and location of focal point in brain

Neurological Disorders Epilepsy and Seizure Disorders ◦ Tonic-clonic most common Loss of consciousness, stiffening

Neurological Disorders Epilepsy and Seizure Disorders ◦ Tonic-clonic most common Loss of consciousness, stiffening of limbs ◦ EEG used for diagnosis ◦ Treatment: epilepsy medications Significant drug-nutrient interactions esp. phenytoin and folate ◦ Ketogenic diet High fat (70 -90% of kcal) Maintains state of ketosis which may change neuron metabolism

Neurological Disorders Epilepsy and seizure disorders – nutrition implications ◦ Inadequate nutrient intake Ensure

Neurological Disorders Epilepsy and seizure disorders – nutrition implications ◦ Inadequate nutrient intake Ensure adequate energy ◦ Limited food choices ◦ Drug-nutrient interactions Potential weight gain or loss ◦ ketogenic diet

Neurological Disorders Stroke – disruption of brain function d/t blockage or interruption of blood

Neurological Disorders Stroke – disruption of brain function d/t blockage or interruption of blood flow ◦ Ischemic stroke ◦ Hemorrhagic stroke ◦ TIA ◦ Aneurysm

Neurological Disorders Stroke ◦ Non-modifiable risk factors Age, gender, ethnicity, genetics ◦ Modifiable risk

Neurological Disorders Stroke ◦ Non-modifiable risk factors Age, gender, ethnicity, genetics ◦ Modifiable risk factors Htn. , CVD, DM, hyperlipidemia, carotid stenosis, cigarette smoking, alcohol use, illicit drug use, diet, oral contraceptive use, exercise

Neurological Disorders Stroke ◦ Signs/symptoms Loss of vision or speech, paralysis, muscle weakness, change

Neurological Disorders Stroke ◦ Signs/symptoms Loss of vision or speech, paralysis, muscle weakness, change in mental status ◦ Diagnosis National Institutes of Health Stroke Scale CT, MRI, PET imaging

Neurological Disorders Stroke ◦ Treatment Medical support, thrombolysis, anticoagulants, neuroprotection Aspirin Rehabilitation

Neurological Disorders Stroke ◦ Treatment Medical support, thrombolysis, anticoagulants, neuroprotection Aspirin Rehabilitation

Neurological Disorders Stroke - Nutrition Implications/Interventions ◦ Impairment of ability to chew, swallow, selffeed

Neurological Disorders Stroke - Nutrition Implications/Interventions ◦ Impairment of ability to chew, swallow, selffeed ◦ Dysphagia ◦ Individualize nutrition support ◦ Modify consistency of food or liquids, positioning of patient, swallow exercises ◦ Manage modifiable risk factors

Progressive Neurological Disorders Neurodegenerative disorders ◦ Nutrition needs and status affected by progression of

Progressive Neurological Disorders Neurodegenerative disorders ◦ Nutrition needs and status affected by progression of disease ◦ Ethical decisions regarding nutrition support ◦ Nutrition therapy similar among progressive disorders

Progressive Neurological Disorders Parkinson’s disease - neuromuscular, neurodegenerative disease caused by loss of dopamine-producing

Progressive Neurological Disorders Parkinson’s disease - neuromuscular, neurodegenerative disease caused by loss of dopamine-producing cells ◦ Progressive loss of dopamine; imbalance between excitatory and inhibitory communication ◦ Resting tremor, rigidity, bradykinesia, stooped posture, shuffling gait, cognitive dysfunction

Progressive Neurological Disorders Parkinson’s disease ◦ Primarily treated with L-dopa, other medications, surgery ◦

Progressive Neurological Disorders Parkinson’s disease ◦ Primarily treated with L-dopa, other medications, surgery ◦ Drug-nutrient interactions important concern ◦ Limit supplement levels of B 6 to 15 mg ◦ Closely monitor weight status ◦ Manage GI symptoms; gastroparesis

Progressive Neurological Disorders Parkinson’s disease ◦ High protein may interfere with L-dopa levels Limit

Progressive Neurological Disorders Parkinson’s disease ◦ High protein may interfere with L-dopa levels Limit overall protein to. 5 -1 g/kg with even distribution throughout all meals Limit protein during waking hours with increased amounts at evening meal and before bed High CHO-low protein ratio

Progressive Neurological Disorders Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s disease; affects motor neurons ◦

Progressive Neurological Disorders Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s disease; affects motor neurons ◦ Destruction of neurons involved in controlling stimulation of muscles ◦ Dead neurons replaced with non-functional fibrous cells ◦ Muscle atrophy ◦ Bulbar and spinal forms

Progressive Neurological Disorders ALS – clinical manifestations ◦ Asymmetric muscle weakness and atrophy, hyperflexia,

Progressive Neurological Disorders ALS – clinical manifestations ◦ Asymmetric muscle weakness and atrophy, hyperflexia, fasciculations, leading to paralysis and vent and nutrition support ◦ Treatment – Riluzole and control of symptoms ◦ Address specific nutritional needs Texture, nutrient density, nutrition support

Progressive Neurological Disorders Guillain-Barré - acute peripheral nervous system disease characterized by progressive paralysis

Progressive Neurological Disorders Guillain-Barré - acute peripheral nervous system disease characterized by progressive paralysis ◦ Autoimmune response to infectious trigger ◦ Damage to myelin sheath, axons, sensory nerves, roots ◦ Rapidly progressive paralysis involving all limbs, dysphagia, respiratory failure

Progressive Neurological Disorders Guillain-Barré ◦ Treatment – high-dose IV immunoglobin, plasmapheresis ◦ Full recovery

Progressive Neurological Disorders Guillain-Barré ◦ Treatment – high-dose IV immunoglobin, plasmapheresis ◦ Full recovery can occur within several months ◦ Modifications may be needed related to mechanical ventilation, difficulty swallowing, chewing

Progressive Neurological Disorders Myasthenia Gravis – progressive neuromuscular disorder affecting skeletal muscles ◦ Autoimmune

Progressive Neurological Disorders Myasthenia Gravis – progressive neuromuscular disorder affecting skeletal muscles ◦ Autoimmune reaction destroys cellular receptors for acetylcholine ◦ Muscles tire easily, muscle weakness with physical activity ◦ May affect face, eyes, arms, legs ◦ Periods of remission and exacerbation

Progressive Neurological Disorders Myasthenia Gravis ◦ No cure ◦ Immunosuppressants, other medications, stem cell

Progressive Neurological Disorders Myasthenia Gravis ◦ No cure ◦ Immunosuppressants, other medications, stem cell transplant, removal of gland, plasmapheresis ◦ Assess oral intake, meal preparation ability Increase nutrient density, modifications in timing of meals Texture, consistency

Progressive Neurological Disorders Multiple Sclerosis – demyelination within cells within the CNS, inflammation, development

Progressive Neurological Disorders Multiple Sclerosis – demyelination within cells within the CNS, inflammation, development of scar tissue; RRMS, SPMS, PPMS ◦ Genetic, autoimmune, infectious ◦ Anecdotally linked to high fat and animal protein with low B 12

MRI results showing sclerotic plaques in MS © 2007 Thomson - Wadsworth

MRI results showing sclerotic plaques in MS © 2007 Thomson - Wadsworth

Progressive Neurological Disorders Multiple Sclerosis ◦ Symptoms vary depending on nerve affected ◦ Numbness,

Progressive Neurological Disorders Multiple Sclerosis ◦ Symptoms vary depending on nerve affected ◦ Numbness, tingling, ataxia, weakness, visual problems, dysphagia, constipation, bladder dysfunction… ◦ Immunosuppressive therapy, corticosteroids, other meds

Progressive Neurological Disorders Multiple Sclerosis ◦ Assess drug-nutrient interactions ◦ Supplement with omega-3 fatty

Progressive Neurological Disorders Multiple Sclerosis ◦ Assess drug-nutrient interactions ◦ Supplement with omega-3 fatty acids (? ) ◦ Restrict saturated fat (? ) ◦ Supplement antioxidants ◦ Vitamin D, calcium ◦ Weight management ◦ Regular exercise

Progressive Neurological Disorders Dementia – loss of memory, impairment in language, judgment, calculation, problem

Progressive Neurological Disorders Dementia – loss of memory, impairment in language, judgment, calculation, problem solving; Alzheimer’s disease ◦ Early-onset, late-onset, familial (type 1) ◦ Types 1, 2, 3, 4 Apolipoprotein E (type 2) Beta amyloid (3, 4)

Progressive Neurological Disorders Dementia - pathophysiology ◦ Beta amyloid plaques develop ◦ Plaques clump

Progressive Neurological Disorders Dementia - pathophysiology ◦ Beta amyloid plaques develop ◦ Plaques clump together and prevent neurons from functioning normally ◦ Protein tau forms neurofibrillary tangles within neurons

Progressive Neurological Disorders Dementia – clinical manifestations ◦ Affect memory, reasoning, language ◦ Cause

Progressive Neurological Disorders Dementia – clinical manifestations ◦ Affect memory, reasoning, language ◦ Cause disorientation, abstract thinking, personality disorders, loss of purposeful action ◦ Treated with medications ◦ Vitamin E for prevention and plaque formation ◦ Prevent malnutrition

Progressive Neurological Disorders Dementia intake ◦ Aphasia ◦ Apraxia ◦ Agnosia ◦ Amnesia ◦

Progressive Neurological Disorders Dementia intake ◦ Aphasia ◦ Apraxia ◦ Agnosia ◦ Amnesia ◦ Anorexia – problems affecting food

Neurotrauma and Spinal Cord Injury Traumatic brain injuries (TBI) ◦ d/t accidents, falls, violence,

Neurotrauma and Spinal Cord Injury Traumatic brain injuries (TBI) ◦ d/t accidents, falls, violence, firearms, sports ◦ Lacerations, crushing of brain tissue, cerebral edema, hemorrhage, hematoma, infection ◦ Swelling, bleeding, seizure, stroke, coma ◦ Glasgow Coma Scale

Neurotrauma and Spinal Cord Injury Traumatic brain injuries (TBI) ◦ Focus on stabilization ◦

Neurotrauma and Spinal Cord Injury Traumatic brain injuries (TBI) ◦ Focus on stabilization ◦ Prevent further complications ◦ Promote rehabilitation ◦ Nutrition therapy integral part of team

Neurotrauma and Spinal Cord Injury Traumatic brain injuries (TBI) ◦ Hypermetabolism ◦ Hyperglycemia ◦

Neurotrauma and Spinal Cord Injury Traumatic brain injuries (TBI) ◦ Hypermetabolism ◦ Hyperglycemia ◦ Insulin resistance ◦ Increased gluconeogenesis ◦ Lipolysis ◦ Catabolism as evidenced by nitrogen excretion

Neurotrauma and Spinal Cord Injury Traumatic brain injuries (TBI) ◦ Requires aggressive nutrition support

Neurotrauma and Spinal Cord Injury Traumatic brain injuries (TBI) ◦ Requires aggressive nutrition support See Table 22. 9 ◦ Energy at 140% of REE – non-paralyzed, 100% - paralyzed ◦ Infants, children higher ◦ Protein 15 -20% of energy, kcal: nitrogen ratio of 125 -150: 1

© 2007 Thomson - Wadsworth

© 2007 Thomson - Wadsworth

Neurotrauma and Spinal Cord Injury (SCI) ◦ Paraplegia ◦ Quadriplegia ◦ Level of injury

Neurotrauma and Spinal Cord Injury (SCI) ◦ Paraplegia ◦ Quadriplegia ◦ Level of injury determines signs and symptoms ◦ Nutrition therapy for complications such as bowel dysfunction, UT problems, pressure sores, weight control

Neurotrauma and Spinal Cord Injury (SCI) ◦ Nutritional needs similar to TBI ◦ Inflammatory

Neurotrauma and Spinal Cord Injury (SCI) ◦ Nutritional needs similar to TBI ◦ Inflammatory and metabolic stress ◦ Increased energy needs, gluconeogenesis, lipolysis, hyperglycemia, insulin resistance ◦ Rehabilitation ◦ Prevent excessive weight gain ◦ Skin care and decubitus ulcer prevention

Neurotrauma and Spinal Cord Injury (SCI) ◦ Protein requirements elevated - negative nitrogen balance

Neurotrauma and Spinal Cord Injury (SCI) ◦ Protein requirements elevated - negative nitrogen balance persisting up to 7 weeks post-injury Provide 1. 5 -2 g/kg protein ◦ Energy requirement 30 -35 kcal/kg; progress to: 22. 7 kcal/g – quadriplegia 27. 9 kcal/g - paraplegia

Neurotrauma and Spinal Cord Injury (SCI) ◦ Adequate hydration and fiber ◦ Vitamin &

Neurotrauma and Spinal Cord Injury (SCI) ◦ Adequate hydration and fiber ◦ Vitamin & mineral supplementation