NEUROLOGY/REHABILITATION MODULE

Objectives
Satisfactory Not

Completion Applicable
Review
1.The student will discuss with the rotation
coordinator the role of nutrition for neurological
disorders including trauma, stroke, degenerative
disorders and dysphagia. nclude in the discussion,
but not limited to, all the following that are
applicable!
a. etiology and treatment
b. pathophysiology
c. metabolic"nutritional alterations
d. current medical treatments"trends

#. $iscuss the dietitian%s role as part of the health
care team
Assess
&. 'sing height"weight"labs and other pertinent
information the student will assess the
appropriateness of!
a. the ($%s order
b. diet
c. energy"protein"nutrient re)uirements
*. The student will obtain diet histories.
+,,,,,,, -.oal of & or more/
0. The student will complete nutrition care plans.
+,,,,,, -.oal of & or more/
1
Educate
1.The student will utili2e the diet history and care
plan as well as any other pertinent educational
material to instruct patients and"or family member
on his"her speci3c dietary regimen.
+ ,,,,,, -.oal of & or more/
Document
4. 'sing the format appropriate for the site, the
student will document all pertinent information in
the medical record.
+,,,,,,,,-.oal of & or more/
Observe
5. 6bserve a swallow study -788S/.
9. (eet with 6T to observe adaptive feeding
e)uipment.
4"1&
2
NEUROLOGY/REHABILITATION WORKSHEET
1. Defe t!e "#$$#%i& 'bb(evi'ti#s)
I*H) ntracerebral hemorrhage
SIADH) Syndrome of inappropriate antidiuretic hormone
GBS) .roup : Strep.
.illian;:arr< syndrome
*+A! Cerebrovascular accident
,ERRLA) pupils e)ual, round, reactive to light and accommodation
SAH) Subarachnoid hemorrhage
ALS! Amyotrophic lateral sclerosis
S*I) Spinal cord in=ury
G*S) .lasgow Coma Scale
*NS) Central Nervous System
I*,) ntracranial pressure
MS) (edical student -(S>1, (S>#, (S>&, (S>*/
mental status
mitral stenosis
multiple sclerosis
*HI! Closed head in=ury
I+H! ntra>ventricular hemorrhage
BKA) :elow>the>knee amputation
AKA) Above>the>knee amputation
Also known as
All known allergies
M+*) (otor ?ehicle Crash
ADL) Activities of daily living
UE) 'pper e@tremity
LE) Aower e@tremity
Aupus erythematosus
ROM) Bange of motion
OA) osteoarthritis
6vereaters anonymous
THR) Total hip replacement
MG! (yasthenia gravis

-. I.eti"/ t!e 0e'i& #" t!e "#$$#%i& te(0s!
A1!'si') Aoss of speech or e@pression.
A1('2i') nability to perform purposeful movements although no sensory or motor impairment
e@ists.
3$'cci.) -of part of the body/ Soft and hanging loosely or limply, not 3rm or stiC.
Sc#$i#sis) A lateral curvature of the spine.
G'it) The manner or style of walking.
He0i1'(esis) Deakness aCecting only one side of the body.
He0i1$e&i') Earalysis on one side of the body.
,'('1$e&i') Earalysis of the lower part of the body, including the legs.
45'.(i1$e&i') Earalysis of all four limbs.
,(#st!esis) An arti3cial substitute for a missing body part, such as an arm, leg, eye, or toothF
used for functional or cosmetic reasons or both.
S1'sticit/) A feature of altered skeletal muscle performance in muscle
tone involving hypertoniaF it is also referred to as an unusual GtightnessG, stiCness, or GpullG of
musclesF resistance to stretch.
3
T('s"e(s) 6#57 A condition in which learning in one situation inHuences learning in
another situation. t may be positive, as when learning one behavior facilitates
the learning of something else, or negative, as when one habit interferes with
the ac)uisition of a later one.
6ve(b7 The moving of a patient from one surface to another. Eatients can be
taught to transfer safely either independently or with minimal assistance if
they can balance in a sitting position.
H/1#t#ic) 1. Iaving less than the normal tone, as a muscle.
#. $esignating a solution of lower osmotic pressure than another.
H/1e(t#ic) 1. Iaving e@treme muscular or arterial tension.
#. Iaving the higher osmotic pressure of two solutions.
At!et#sis) A symptom characteri2ed by slow, involuntary, convoluted, writhing movements of
the 3ngers, hands, toes, and feet and in some cases, arms, legs, neck and tongue.
*#t('ct5(es) Chronic loss of =oint motion due to structural changes in non>bony tissue. These
tissues include muscles, ligaments, and tendons.
Ae5(/s0) A locali2ed, blood>3lled balloon>like bulge of a portion of an artery, due to weakness in the
wall of a blood vessel.
De0eti') A serious loss of global cognitive ability in a previously unimpaired person, beyond what
might be e@pected from normal aging. t may be static, the result of a uni)ue global brain in=ury, or
progressive, resulting in long>term decline due to damage or disease in the body.
8. Desc(ibe t!e #(0'$ st'&es #" s%'$$#%i& '. !#% t!e/ '(e '9ecte. i ' 1'tiet
%it! ./s1!'&i':
Beceiving food in the mouth, preparing it, and moving it from the mouth to the stomach is a
comple@ process that occurs in & stages. The 3rst stage, or oral phase, occurs when the tongue
collects the food or li)uid and prepares it to be swallowed. The tongue and =aw move food
around in the mouth during the chewing process. Chewing makes the food a manageable si2e,
and as it mi@es with saliva, becomes softer and smoother thus, easier to swallow. The second
stage, or the pharyngeal phase, begins when the tongue pushes the food or li)uid to the back of
the mouth. The swallowing response that occurs ne@t is involuntary. The laryn@ closes tightly
and breathing stops to prevent food or li)uid from entering the trachea, and lungs. The third
stage, or esophageal phase, begins when food or li)uid enters the esophagus. The passage
through usually occurs in about three seconds, depending on the te@ture or consistency of the
food, but can take slightly longer in some cases, such as when swallowing a pill.
$ysphagia occurs when there is a problem with the neural control or the structures involved in
any of the phases in the swallowing process. A weak =aw, or tongue can make moving food
around in the mouth diJcult. $ental problems may prevent the grinding of the food into
manageable portions and salivary glands aCected by disease may not produce enough li)uid to
moisten food making swallowing diJcult and dangerous. A stroke or other neurological disorder
may make it diJcult to start the swallowing response, causing food to lodge in the back of the
throat and cause choking or gagging. Deak throat muscles, such as after cancer surgery, cannot
move all of the food toward the stomach. $ysphagia may also result from disorders of the
esophagus.
1
;. Desc(ibe t!e 'ti#'$ D/s1!'&i' Diet
-
.
Eatients e@periencing dysphagia may have!
6ral leaking"drooling
Choking"gagging
4
Eocketing food in cheeks
Taking K1L seconds to swallow
Deakness and poor motivation
Eoor chewing ability leading to choking
The National $ysphagia $iet -N$$/ is the national standard for dietary treatment of dysphagia
and accounts for modi3cations in food te@tures, as well as li)uids.
#
:ased on evaluation, a
customi2ed dysphagia diet recommendation contains two speci3cations! one for food te@ture
-dysphagia pureed, dysphagia mechanically, dysphagia advanced, and regular/, and a second
one for li)uids -thin, nectar like, honey>like and spoon>thick/. Therefore the dysphagia diet may
be speci3ed as! N$$ Aevel & or $ysphagia Advanced with thin li)uids, or N$$ Aevel 1 or
$ysphagia pureed with honey>like li)uids. See chart below for te@ture and li)uid level
recommendations. Dhen clients have swallowing problems, the speech pathologist may
encourage special positioning and other suggestions to help ease swallowing during meals. t is
important to remember that li)uids are harder to swallow than solid foods and should be
thickened according to need. n general, positioning residents as close to a 9L>degree angle as
possible makes swallowing easier and safer. f clients are in bed, their heads, backs, necks and
sides need to be supported.
NDD 3##. Te2t5(e Leve$s
-
)
NDD Leve$ 1 M $ysphagia Eureed
Smooth pureed, pudding>like foods that re)uire very little chewing ability.
.eneral .uidelines!
1. :read should be pre>gelled through the entire thickness, pureed, or pureed into other foods in
accordance with recipes.
#. 7ruits and vegetables should be pureed with no pulp, seeds, or chunks.
&. (ashed potatoes should be served with gravy, sauce, butter, or margarine to moisten.
*. Soups should be pureed smooth.
0. Avoid scrambled, fried, or hard>boiled eggs. SouN<s are allowed.
1. Avoid fruited yogurt, peanut butter, and any food with lumps, including soups and hot cereal.
NDD Leve$ - M $ysphagia (echanically>Altered
Cohesive, moist, semisolid foods that re)uire some chewing ability. ncluded in this level are
fruits and vegetables that can be easily mashed with a fork. 8@cluded are most bread products,
crackers, and other dry foods.
.eneral .uidelines!
1. :read should be pre>gelled through the entire thickness or pureed according to recipe.
#. 7ruits should be soft, canned, or cooked. Soft, ripe bananas are allowed. Avoid canned
pineapple.
&. ?egetables should be soft, well cooked, easily mashed with a fork, and in pieces smaller than
O inch.
*. (eat should be tender and moist, ground, or cubed smaller than P inch. (oisten with gravy.
0. Avoid dry whole grain cereal with nuts, seeds and coconut.
1. Avoid items that are diJcult to chew, including large chunks or nuts.
NDD Leve$ 8 M $ysphagia Advanced
Soft>solid foods which re)uire more chewing ability. This level is close to the regular te@ture of
food. ncluded are easy>to>cut whole meats, fruits, and vegetables. 8@cluded are hard, crunchy
fruits and vegetables, sticky foods, and very dry foods.
.eneral .uidelines!
1. :reads and cereals should be well moistened.
#. 7ruits such as bananas or soft, peeled fruits such as peaches, berries, nectarines, kiwi or
melon without seeds may be tolerated.
&. Avoid potato skins, corn, and raw vegetables.
*. (eat must be very tender, small pieces, or ground, and well moistened.
5
0. Avoid items that are diJcult to chew! nuts, seeds, popcorn, potato chips, coconut, etc.
NDD Leve$ ; M Begular
Any solid food te@ture.
NDD Li<5i. Leve$s
-
)
T!i
Thin li)uids include clear li)uids, milk, commercial nutritional supplements, water, tea, coCee,
soda, beer, wine, broth, and clear =uice. ndividuals tolerating thin li)uids will also be able to
tolerate foods containing thin li)uids, such as watermelon, grapefruit or oranges. 7oods like ice
cream, fro2en yogurt, or plain gelatin which turn to li)uid in the mouth are also considered thin
li)uids.
Nect'(:$i=e
(edium thickness li)uids include nectars, vegetable =uices, and handmade milkshakes. Thin
li)uids can be thickened with commercial thickeners or purchased pre>thickened to nectar>like
thickness.
H#e/:$i=e
Ioney>like is thicker than the nectar>like level and resembles the consistency of honey at room
temperature. Commercial thickeners can be added using package instructions to bring any
li)uids to this level of thickness or purchased commercially pre>thickened to honey>like
thickness.
S1##:t!ic=
This includes high viscosity li)uids too thick for a straw. Commercial thickeners can be added to
any beverage to obtain this level of thickness or purchased commercially pre>thickened to
spoon>thick.
>. I.eti"/ 8 1(#.5cts t!'t '(e 'v'i$'b$e c#00e(ci'$$/ "#( 1'tiets # ' ./s1!'&i' #(
t!ic=ee. $i<5i. .iet.
1. Commercial thickeners
#. Commercial stabili2ers
&. Commercial shaping"enhancing products
1. ,'t!#1!/si#$#&/ #" *+A? A$@!ei0e(? ALS? ,'(=is#As .ise'se? TBI. N5t(iti#'$
1(#b$e0s '. (ec#00e.'ti#s 'ss#ci'te. %it! e'c! c#.iti#
8
)
Dise'se ,'t!#1!/si#$#&/ N5t(iti#'$ ,(#b$e0/Rec#00e.'ti#
*+A:
st(#=e
$amage to a portion of the
brain resulting from loss of
blood supply due to a blood
vessel spasm, clot, or
rupture. (ost have a
genetic, polygenic
component. TAs are brief
episodes of blood loss to the
brain from a clot or an
embolismF 1LQ of patients
will have a ma=or C?A w"in a
year. Some recover
7eeding"swallowing problems> Aeft C?A aCects sight and hearing
-can%t see where food is placed on a plate/. Bight C?A, brainstem
or bilateral C?As> problems with feeding and swallowing. Nerve
damage> sensory problems, motor de3cits with muscular
weakness of tongue and lips, =udgment problems with not
knowing how much food to eat, or what to do with food when it
reaches the mouth. Eromote self>help, self>esteem, and
independence. Te@ture modi3cation, small amounts of easy>to>
chew foods. (oisten foods with small amounts of li)uid. Ielp
patient simplify meal preparation.
Aack of nutritional knowledge> those with coronary heart disease
6
completely, others are
disabled or may die.
can reduce stroke mortality and morbidity with nutritional
counseling. ntake of folate, vitamins :1 and :1# should be
maintained in high>risk groups. The amount of sat fat and trans
fatty acids in the planned diet should be R1LQ of total calories,
and cholesterol R&LL mg"d. Beduce animal fats and salt added
to foods in cooking and at the table. Beplace sat fat with
monounsat fats. Add nuts for healthy fat and vitamin 8. Elant
stanols and sterols. (ilk fat is negatively correlated with certain
C$ risk factors. ncrease potassium.
Deight problems> overweight stroke victims should be counseled
on weight reduction strategies to lower :E, T.s, and lessen work
on cardiovascular system.
A$@!ei0e( (ost common dementia.
Erogressive deterioration of
intellect, memory,
personality and self>care.
Characteri2ed by deposition
of peptide containing
pla)ues in cerebral cortical
regions and the presence of
intracellular neuro3brillary
tangles in cerebral
pyramidal neurons.
$eclining body mass> 8nsure healthy diet, increased protein and
calories for se@"age"activity. (ay need &0 kcal"kg or more.
ncrease potassium from fruits and vegetables favors
preservation of muscle mass. Ai)uid supplementation for e@tra
calories or protein can be used.
Nutritional decline> Nutrient dense foods high in antio@idants.
6ily 3shS omega>& 7A, vegetable oilsS omega>1 7A
7olic acid may lessen decline of cognitive function.
(editerranean of $ASI diet. Avoid e@cess :1# from dairy"red
meat. Cut back on saturated fats which increase brain beta>
amyloid levels. Add foods high in copper, choline.
Constipation> Eroper scheduling of meals high in 3ber such as
fresh fruits and vegetables
$ehydration> oCer regular drinks of water, =uice, milk and other
Huids.
Eressure ulcers> maintain activity to preserve function. Ereserve
muscle mass by ade)uate protein and caloric intake.
$ysphagia> (ake food small and visible, give one at a time and
wait till each bite is swallowed before oCering more. Beduce
distractions at meal times. Serve soft food to make food easier
to chew"swallow. Tube feed or use te@ture altered foods with
thickened li)uids
,'(=is#
As
Age>related
neurodegenerative disorder
aCecting 1>#Q of persons
1LT. $iminished levels of
dopamine at the basal
ganglia of the brain, causing
tremor of hands, arms, legs,
=aw and face, rigidity of
limbs and trunk, slow gait,
'nintentional weight loss> due to increased 8 e@penditure from
tremor, dyskinesia and rigidity. 1>1.0 g"kg protein daily plus e@tra
energy may be needed. f using levodopa a high intake of protein
can decrease drug eCectiveness, use L.0 g"kg of body weight.
Timing of levodopa should be monitored to avoid conHicting
responses to protein at mealtimes.
Beduced 8 intake> due to olfactory dysfunction, cognitive
impairment, depression, dysphagia, disability, medication related
7
coordination diJculty,
dysphagia, speech problems.
Eathophysiology are poorly
understood. 6@idative
stress contributes to apoptic
death of dopamine neurons.
Aong>term e@posure to
manganese, herbicides,
pesticides or high intake of
7e with high manganese
may promote symptoms.
side eCects including! dry mouth, N"?, appetite loss, anore@ia,
insomnia, fatigue and an@iety.
$ysphagia> swallowing evaluation. Cut, mince, or soften foods as
re)uired. 'se small, fre)uent meals if needed.
$yskinesia>Iigher :1# levels are associated with lower
dyskinesia risk. Ade)uate :>comple@ intake and measurement of
serum levels of :1# may be important.
6@idative stress> Eromotes degeneration of neurons. Antio@idant
therapy may be protective. Besveratrol in red wine and grape
=uice, and )uencetin in green tea are polyphenols that have
preventative )ualities in E$. *>0 cups of coCee daily and foods
rich in vit 8 and $& may also be protective. (ultivitamin>mineral
supplement can be used.
$iJculty eating> place all foods within easy reach of the patient.
:races may help control tremors at mealtimes. Teach patient
how to blenderi2e food. Small fre)uent meals. Ereserve
functioningF delay disability as long as possible.
Tyramine>restricted diet if using (A6s> to prevent severe
headaches, blurred vision, diJculty thinking, sei2ures, chest pain,
or symptoms of a stroke. Avoid aged and fermented meats,
cheeses, vegetables -sauerkraut/, red wine, tap beers, broad
bean pods, soybean products like soy sauce and tofu.
TBI Traumatic brain in=ury results
from head in=ury after (?As,
falls, 3ghts, e@plosions, and
gunshot wounds.
Classi3cation is by location,
eCect and severity. :rain
trauma is accompanied by
regional alterations of brain
metabolism, overall
reduction in metabolic rates,
and persistent metabolic
crisis.
(alnutrition, cache@ia, over feeding> ndirect calorimetry to
determine the respiratory )uotient and B88 should be
determined twice weekly. 7ull nutritional replacement is
desirable by day 4 to prevent negative>nitrogen balance.
8@cessive weight gain> if brain in=ury aCected the hypothalamus,
the patient may forget that they have eaten and state their
constant hunger. (onitor 8 intake carefully.
Iyperglycemia> prevent or maintain by regulating glucose and
insulin intake.
7eeding and swallowing problems> Teach self>feeding, breathing,
and swallowing techni)ues. $ysphagia diet may be needed.
ALS Erogressive motor neuron
disease of adult life that
destroys nerve cells from the
spinal cord to muscle cells.
Symptoms include! muscle
wasting and atrophy,
drooling, loss of reHe@es,
respiratory infections or
failure, spastic gait, and
weakness. Bespiratory
failure due to bulbar,
cervical and thoracic loss of
motor neurons. AAS usually
occurs after age *L.
(alnutrition> aggravated by elevated metabolic needs and
swallowing dysfunction. 'se a soft diet in initial stages. 7laky
3sh, ground meats, foods moistened with sauces and gravies.
8nhance energy intake by oCering 0>1 small meals a day. Beduce
fears of aspiration by feeding slowly and testing swallowing
reHe@es with water. Antio@idants! vitamins C, 8, selenium, 2inc,
mg, U, folate, lycopene, E, 6mega>& 7As. E8. or E8V is well
tolerated with dysphagia.
Negative nitrogen balance> ncrease protein prevent negative N
balance and to decrease muscle wasting.
Constipation and 'T> ade)uate 3ber and 3ber supplementation
-:ene3ber, phsyllium/ if 3brous foods are not tolerated. #>& A of
8
water a day. Thickened with commercial thickeners if needed.
4. N5t(iti#'$ ee.s #" t!e i00#bi$i@e. 1'tiet 1'(tic5$'( e01!'sis # t!e 1(eveti# #"
c#sti1'ti#? 1(ess5(e 5$ce(s '. (e'$ c'$c5$i.
Erevention of constipation
*
> Constipation occurs when fecal mass remains in the colon longer than
#*>4# hours after eating. Constipation is a comorbidity of many disease states. t can be
e@acerbated by medications, poor diet, dehydration, and lack of physical activity. Spastic
constipation is often the result of immobility and physical activity should be encouraged if possible.
Nutrition ntervention in the prevention of constipation!
> ncorporate more Huids into meals. Try prune =uice or caCeinated beverages.
Communication with nursing and family is important in Huid tracking. 5>1L glasses of water
a day, warm water may be bene3cial.
> $iscuss with patient and family the role of 3ber, Huid and EA in maintaining normal bowel
movements.
> $iscuss how to increase 3ber in meals by including more fruits, vegetables, and adding 3ber
supplements if needed.
> ncrease 3ber slowly, decrease if pain is present and then increase when pain has subsided.
> :owel retraining programs include e@ercise -if possible/, drinking more Huids, setting regular
toilet times and increasing 3ber intake.
Erevention of pressure ulcers
0
> an immobili2ed person is susceptible to pressure ulcers if careful
attention is not paid to their healthcare needs. mmobili2ation can result in ulcerations on the skin,
as bony protuberances create pressure, and thus friction on the skin. Aack of o@ygen and poor
nutrition are also associated with pressure ulcer development. Eressure ulcers are staged based on
their appearance and severity on a scale of 1>*. 'nintentional weight loss, incontinence,
immobility, poor circulation, infection, prolonged pressure, multiple medications, serum albumin
R&.* g"dA, reduced functional ability, poor oral intake, chewing and swallowing problems and chol
levels below 11L mg"dA, are risk factors that should be assessed fre)uently. The (NA is a useful
tool for assessing risk.
Nutrition ntervention in the prevention of pressure ulcers includes!
> Eroviding a high>)uality protein diet. 1.L>1.0 g protein"kg body weight daily. $eep or
multiple ulcers e@ist patient may re)uire 1.0>#.L g"kg daily. Adding protein to beverages,
casseroles, tube feedings and li)uid supplementation can help meet protein needs.
> Ade)uate caloric intake> #0>&0 kcal"kg body weight. Aower end for obese patients and
higher end for underweight patients. Tube feed if necessary.
> Erovide small fre)uent meals
> .eneral multivitamin
> (onitor drugs for possible side eCects including depletion of serum proteins or blood>
forming nutrients. $rugs that aCect skin. Appetite stimulant if needed.
> $iscuss the importance of maintaining healthy, intact skin. Skin should be kept clean and
dry. Erovide information about high>protein diets, appropriate calorie and Huid intake.
> mprove ambulation and circulation to tissues. EA can increase appetite.
> $iscuss nutrition%s role in ulcer prevention. Erotein, 2inc, vitamin C for collagen and
3broblast formation and vitamins A, U, : comple@ for healthy nerves and muscle.
> $etermine degree of assistance needed at mealtime and instruct accordingly.
Erevention of kidney stones
1
> $iminished water intake during illness can predispose one to the
formation of kidney stones. An immobili2ed patient will rely on the diligence of family or healthcare
providers to provide ade)uate hydration.
Nutrition ntervention in the prevention of kidney stones!
9
> The composition of stones vary and should be determined in order to provide accurate
dietary recommendations to prevent their reoccurrence.
> Normali2ing :(, ade)uate EA -if possible/, balanced nutrition, and suJcient daily Huid
intake can prevent recurrence.
> Eromote a heart healthy diet like $ASI. 7ruits and vegetables increase potassium intake
and reduce sodium intake.
> Colorless urine is desired and Huid intake should be increased. Aimit the consumption of
apple or grapefruit =uices, however. Eatient should produce # )uarts of urine every #* hours.
'rinalysis can determine the chemical make>up of stones that have been passed and are
useful to determine speci3c dietary advice to prevent their recurrence.
5. List t!e 5t(iti#'$ e9ects #" t!e "#$$#%i& .(5&s 5se. b/ 0'/ 1'tiets %it!
e5(#$#&ic'$ c#.iti#s)
The 14
th
edition of 7ood and (edication nteractions was referenced for the following
medications.
4
Ste(#i.s)
: (ay cause stomach irritation if taken without food.
: $iet> decrease sodium, increase calcium, vitamin $, protein. (ay need increased vitamins
A, C. ncrease potassium, phosphorus. Supplementation may be necessary.
: Calcium, vitamin $ supplementation recommended with AT use.
: Chromium de3ciency may increase risk for steroid induced diabetes
o Chromium sources! broccoli, grape =uice, 8nglish muJn, potato, beef, orange =uice,
turkey, whole wheat bread, brewer%s yeast, onions, liver, Bomaine lettuce, tomatoes
: Steroids may also cause a dramatic increase in appetite.
: Aong term use of K1 g for 1 mo> osteoporosis, necrosis, fractures, muscle wasting, W#LQ
,!e/t#i 6Di$'ti7)
: Take consistently with or without food. (ay cause . irritation if taken without food or milk.
: (ay cause 7olate, Calcium, ?itamin $ and"or Thiamin de3ciencies. Therefore, current
recommendations include a 1 mg 7olate supplement daily, as well as Calcium, ?itamin $
and"or Thiamin supplements as needed.
: 7olate intake of W1 mg"day increases drug metabolism and decreases serum folate levels in
10>0LQ of patients. Iowever, since drug can also decrease folate levels, drug level should
be closely monitored if supplementing folate.
: Calcium or magnesium supplements or antacids may decrease absorption of drug, take
separately by # hours. Separate suspension by W# hours from oral enteral supplementation
as enteral feedings decrease bioavailability of drug.
: Avoid St. Vohn%s Dort.
: $rug increases metabolism of vitamin $, and U, especially in children, which could result in
rickets or osteomalacia respectively.
: .um hyperplasia, altered taste, dysphagia, nausea, vomiting, constipation
: Avoid alcohol
: $o not breastfeed, use while pregnant could decrease vitamin U in fetus, supplement
1Lmg"day for last month of pregnancy
: $iabetics should use with caution because of possible glucose increase
+'$1(#ic 'ci.)
: (ay cause . irritation if taken without food.
: $o not mi@ syrup form of drug with carbonated beverages> will liberate drug and may cause
mouth"throat irritation or unpleasant taste.
10
: ncrease Calcium"?itamin $ intake or supplement. Eossibly take a carnitine supplement with
a poor diet.
: (ay cause high appetite and weight gain W0Q
: Nausea"vomiting W#LQ, dyspepsia, cramps, gastroenteritis, diarrhea, constipation, fecal
incontinence, Hatulence
: Avoid alcohol
: $o not take if breastfeeding
Atic#v5$s'ts/ Atie1i$e1tic)
: (ay increase appetiteF may induce hepatic en2ymes and increase the metabolism of
vitamins $, U and 7olateF supplements of these vitamins are often prescribed with these
drugs.
: Aimit caCeine to R*LL>0LL mg"day
: Caution with grapefruit"related citrus with cloba2am, dia2epam, tria2olam, or mida2olam
: Caution with sedative herbal products or stimulant products
: Avoid St. Vohn%s Dort with alpra2olam, cloba2am, dia2epam or mida2olam
: Anore@ia, decreased weight
: ncreased appetite and weight gain with alpra2olam or chlordia2epo@ide
: ncreased thirst, dry mouth, increased salivation, N"?, constipation, diarrhea
: Avoid alcohol, do not use while breastfeeding
: Caution with soy or egg allergy with parenteral
*'(b'0'@e1ie 6'tie1i$e1tic7)
: (ay cause . distress if taken without food.
: XCaution! with grapefruit"related citrus, pomegranate =uice and star fruit> may increase drug
levels"lead to to@icity.
: Aimit or avoid )uinine> may increase drug level.
: Dith Carbama2epine use K 1 months > Calcium"?itamin $ supplement may be needed.
: (ay cause anore@ia
: $ecreased biotin, 7olate, ?itamin $ and Calcium.
: (ay cause dry mouth, stomatitis, glossitis, N"?, abdominal pain, constipation and diarrhea.
: Avoid alcohol, do not use while breastfeeding
Ati1'(=is#)
Lev#.#1')
: (ay cause dry mouth, taste loss, e@cessive salivation, dark saliva, bitter taste, teeth
grinding, dysphagia, N"? -5LQ/, epigastric distress, constipation, diarrhea, Hatulence, XBare!
. ulcers"bleeds.
: (ust take at least O hour before meals to increase absorptionF may take with low protein
food or =uice if . distress occurs. $o not take directly with high protein food, amino acids,
or protein hydolysaes
: Erotein re>distribution diet of 0!1 to 4!1 CI6 to protein with ma=ority of protein in the
evening, may stabili2e drug eCects
: Concerning levodopa content> must limit Eyrido@ine -:1/ to R0 mg"day -may decrease drug
eCect/F Take 7e supplement or (? with minerals separately -7e decreases absorption of
drug/
: XCaution! 7ava beans contain signi3cant levodopa. Also, aromatic amino acids compete with
levodopa for absorption both in the intestine and at the blood"brain barrier.
: The levodopa content of the drug may cause anore@ia.
Sie0et 6c'(bi.#1'/$ev#.#1':c#0bi'ti#7
: ncreases availability of levodopa to the brain, lower doses of levodopa are needed
: Aower dose of levodopa decreases the incidence of N"? -10Q/, anore@ia, constipation
: Carbidopa usually prevents negative Eyr eCect with less than 1L>#0 mg Eyr"day. Iigher
doses of Eyr may re)uire e@tra carbidopa
11
Di1(iv' 6,(#1#"#$7 Aest!esi'? se.'tive)
: -Earenteral 6nly"?/ Erovides 1.1 kcal"mA, therefore use K 4# hr> low fat diet, low fat enteral
feeding or low fat TEN -must subtract drug fat kcal from TEN fat re)uirements> fat free TEN
often used/.
: ? infusion rate of &L mA"hr -&LL mg"hr/ provides 49L kcal fat"day
: Avoid alcohol
: $o not use with an egg or soy allergyF may increase triglyceride and cholesterol levels.
: 'rine may become green in color and high in Yinc content.
: Caution with hyperlipidemia, acute pancreatitis, lipid nephrosis, diabetes, cardiac disease,
I?"A$S, decreased kidney and"or liver function, sei2ures, geriatric or anemia
B. Desc(ibe !#% t!e .ietiti'? s1eec! t!e('1ist '. #cc51'ti#'$ t!e('1ist %#(=
t#&et!e( i t!e 'c5te c'(e '. (e!'b setti&.
(edical doctors and speech language pathologists evaluate swallowing disorders using 7iber
optic endoscopic evaluation of swallowing -788S/, or ?ideoHuorographic swallowing study
-?7SS/. After evaluation speech>language pathologists e@plore changes that can be made to
oCer a patient a safe strategy when swallowing. Changes such as! food and li)uid te@ture as
recommended by the N$$, si2e of food"li)uid portion consumed, head"neck posture and
behavioral maneuvers can provide a patient with dysphagia safe, ade)uate nutrition. f orally
consuming food is no longer an option, tube feeding is necessary. Amount of calories, food
te@ture or thickness of li)uid can be determined by a dietitian and physical postures or e@ercises
are managed by an occupational therapist.
1
Beferences for Neurology"Behabilitation
1. 'S $epartment of Iealth and Iuman Services. National nstitute on $eafness and other
Communication $isorders. $ysphagia.
http!""www.nidcd.nih.gov"health"voice"pages"dysph.asp@. Eublished 6ctober, #L1L. 'pdated
April #0, #L1*. Accessed Vune #1, #L1*.
#. 'nderstanding and mplementing $ysphagia $iets. Dietary Manager. (arch #LL*! 15>#L.
http!""www.anfponline.org"Eublications"articles"#LL*,L&,LL5$ysphagia.pdf. Accessed Vune
#1, #L1*.
12
&. 8scott>Stump S. Neuro>psychiatric Conditions. n! 8scott>Stump S, ed. Nutrition and
Diagnosis-Related Care. 4
th
ed. :altimore, ($! Aippincott Dilliams and DilkinsF #L1#!##L>
#9L.
*. 8scott>Stump S. .astrointestinal $isorders. Constipation. n! 8scott>Stump S, ed. Nutrition
and Diagnosis-Related Care. 4
th
ed. :altimore, ($! Aippincott Dilliams and DilkinsF
#L1#!*15>*#L.
0. 8scott>Stump S. Nutrition Eractices, 7ood Safety, Allergies, Skin and (iscellaneous
Conditions. Eressure 'lcers. n! 8scott>Stump S, ed. Nutrition and Diagnosis-Related Care. 4
th
ed. :altimore, ($! Aippincott Dilliams and DilkinsF #L1#!11*>115.
1. 8scott>Stump S. Benal $isorders. Uidney Stones. n! 8scott>Stump S, ed. Nutrition and
Diagnosis-Related Care. 4
th
ed. :altimore, ($! Aippincott Dilliams and DilkinsF #L1#!55#>
550.
4. Eronsky Y(, Crowe VE. Food and Medication Interactions. 14 ed. :irchrunville, EA! 7ood>
(edication nteractions Eublishing CoF #L1#.

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