Motor neuron disease (MND) is a motor system disease characterized by progressive, asymmetrical muscle weakness and wasting, with eventual paralysis. Atrophy may begin anywhere in the skeletal musculature and typically progresses to involve all of the striated muscles except extraocular and cardiac muscles. Three main clinical variants are usually identified: progressive muscular atrophy, progressive bulbar palsy (PBP) and amyotrophic lateral sclerosis (ALS).
Swallowing problems are associated with PBP and ALS. There is progressive loss of oral manipulation of food, associated with increasing weakness and atrophy of the tongue, masseter muscles and soft palate. All phases of swallowing become progressively compromised. Lingual sweeping may be ineffective and food is retained in the mouth after swallowing. Lip seal may also be ineffective during eating, causing oral loss of food. Nasal regurgitation may occur, in association with incompetent velopharyngeal closure. Many patients experience difficulty clearing secretions from the mouth; drooling is a common problem. Swallowing may be further compromised by the presence of thick mucous or a dry mouth. Esophageal abnormalities also occur with weak or absent peristaltic waves, simultaneous peristaltic waves and diffuse esophageal spasm. Cricopharyngeal spasm results in pooling in the pyriform sinuses.
Oral feeding becomes increasingly slow and difficult and may eventually become a high-risk activity due to inability to meet nutritional requirements and the risk of aspiration.
In recent years, percutaneous endoscopic gastrostomy (PEG) has become the intervention of choice when oral food intake becomes unsafe or inadequate. PEGs are not, however, the choice of all patients. A small but important group of patients choose to continue oral feeding.
We have observed that those patients who refuse PEG feeding are likely to be older (60+ years of age), live at home, have good family support, and/or have co-existing conditions (e.g., cancer, cardiac disease, mental illness). Reasons given for refusing PEG feeding include an unwillingness to give up the pleasure associated with eating (a "live to eat" personality), denial of swallowing problems, a desire to avoid invasive procedures, acceptance of impending death, and fear of the procedure (despite information and reassurance provided).
Patients with MND require continuous management plans designed to minimize risk of aspiration, malnutrition and dehydration, while supporting continued enjoyment of food. An interdisciplinary approach with input from Nutrition, Speech Pathology and Occupational Therapy is most beneficial.
Identification and avoidance of problem foods
Modification of food texture to facilitate oral management of food - soft/moist, cut-up, diced, minced, pureed
Modification of liquid consistency to minimize aspiration risk
Teach Heimlich manoeuver to caregivers) and self-Heimlich to patient
Use of nutritional supplements to ensure adequate energy and nutrient intake
Use of alternative fluid sources to ensure adequate hydration JELL-OS applesauce, ice cream
Snacking as an important contribution to nutritional intake
Head position for airway protection
Chin tuck manoeuver to maximize airway protection and minimize aspiration risk
Double swallow to clear residue in the valleculae or pyriform sinuses Supraglottic swallow to facilitate
full laryngeal excursion and airway protection Thermal stimulation of oral cavity prior to eating
Thorough oral hygiene after meals and snacks to prevent aspiration of food residue
Smaller, more frequent meals to minimize fatigue of eating
Maintenance of consistent food temperature - hot or cold foods are easier to chew and swallow than tepid food
Introduction or elimination of highly seasoned foods
Leave last half inch of liquid in a cup to avoid chin tilt Reduce bite size
Reduce distractions while eating Adapted Tools
Adapted utensils for eating scoop plate, non-slip mat, raised plate, handle extensions, built-up handles, mobile arm support
Adapted drinking tools - "nosey" cup, lidded cup Summary Nutritional support in ALS/MND may involve use of a PEG, or patients may choose to continue oral feeding. Health care professionals are responsible for providing persons with ALS/MND information on available strategies for nutritional support; helping patients to understand treatment choices and their consequences; supporting a person Is decision, and developing an appropriate management plan responsive to changing needs. At the core of any management plan is the concept that food should remain a pleasure as well as a source of nutrition.
This information was originally presented as a poster at the 10`" International Symposium on ALS/MND, Vancouver (11/99).
Elaine Cawadias RD Susan Carroll-Thomas, SLP(C) ALS Clinic, The Rehabilitation Centre Ottawa, ON firstname.lastname@example.org 613-737-7350 (5528)
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