ESPEN Guideline Clinical Nutrition in Neurology

Clinical Nutrition

Burgos, R., Bretón, I., et al. (2017).

Clinical Nutrition, 37(1), 354-396.

This guideline offers recommendations for the medical management of nutrition in stroke, Parkinson's disease, multiple sclerosis (MS), and amyotrophic lateral sclerosis (ALS). Although several recommendations address medical management, several address management of oropharyngeal dysphagia.

European Society for Clinical Nutrition and Metabolism (ESPEN)

<p>This guideline was reviewed with the following supplemental document:</p> <ul> <li>Bischoff, S. C., Singer, P., et al. (2015) Standard Operating Procedures for ESPEN Guidelines and Consensus Papers. <i>Clinical Nutrition, 34</i>(2015), 1043-1051.</li> </ul>

As part of a comprehensive clinical and neurological evaluation, both at diagnosis and follow up, individuals with ALS should receive a dysphagia screen. Frequency of clinical dysphagia assessment at follow-up "should depend on the presence and the progression of clinical signs. In general, a 3 months frequency can be recommended" (Good Practice Point; p. 360).

"Videofluoroscopy study can detect early signs of dysphagia in ALS patients, and should be recommended in the clinical evaluation of dysphagia in these patients at diagnosis of the disease" (Good Practice Point; p. 361).

"Nasogastric tube feeding does not worsen dysphagia and is therefore no obstacle to dysphagia rehabilitation. Dysphagia therapy should therefore start as early as possible in all stroke patients" (Grade B Recommendation; p. 381).

Thin liquids, in addition to thickened liquids, may be an option for individuals diagnosed with thin liquid aspiration post-stroke (as opposed to thickened liquids only). Those with diagnosed risk of thin liquid aspiration "may be allowed unthickened water in addition to thin liquids on an individual decision with regular follow-up" (Good Practice Point; p. 379).

For individuals with MS, early detection and treatment of malnutrition by a multidisciplinary team is recommended (Good Practice Point). The multidisciplinary team is defined as "a neurologist, a nutritionist/dietitian, a speech and language therapist for the evaluation of swallowing ability, physiotherapist for the evaluation of eating posture, occupational therapist to evaluate the need of specific cutlery, and a nurse" (p. 374).

There is insufficient evidence to make a recommendation on behavioral dysphagia treatments for individuals with MS. "Therefore, general recommendations for dysphagic patients should be followed" (Good Practice Point; p. 376).

Individuals should receive a swallowing assessment, either clinical or preferably instrumental (e.g. videofluoroscopic swallowing study, flexible endoscopic evaluation of swallowing), before beginning behavioral swallowing intervention. Treatment effects should be reassessed on a regular basis (Good Practice Point).

Evidence suggests expiratory muscle strength training (EMST) improves swallowing in oropharyngeal dysphagia of varying etiologies. EMST is recommended for individuals "with motor-neuron disorders and Parkinson's disease (Good Practice Point; p. 384).

"Modified textures and thickened liquids should be used in persons with chronic dysphagia to enhance nutritional status" (Grade B Recommendation; p. 838).

All individuals with stroke should receive a formalized swallowing screen as soon as possible and before oral intake. Those who fail the screen, or demonstrate risk factors or symptoms of dysphagia, "should be evaluated with a more thorough assessment of swallowing function as early as possible" (Grade B Recommendation; p. 377).

"Systematic and sufficiently frequent swallowing therapy making individualized use of the different exercises available is recommended in patients suffering from [oropharyngeal dysphagia]" (Grade B Recommendation; p. 385).

Dysphagia screening is recommended for every individual with ALS, given high prevalence, impact on nutritional status, and risk for respiratory complication (Grade B Recommendation).

"The chin-down maneuver is recommended in patients with premature spillage and predeglutitive aspiration" (Grade B Recommendation; p. 384).

"There is evidence that neuromuscular electrical stimulation (NMES) improves swallowing function in patients with [oropharyngeal dysphagia] of different etiologies. NMES applied together with behavioral swallowing treatment is superior to behavioral swallowing treatment alone, in particular in post-stroke [oropharyngeal dysphagia]. NMES may be used alone, or preferentially, as adjunct to behavioral swallowing treatment in patients with [oropharyngeal dysphagia]" (Grade B Recommendation; p. 386).

Individualized rehabilitation treatment (e.g., postural maneuvers, exercises, adapting bolus characteristics) should be advised for individuals with Parkinson's disease and dysphagia after comprehensive swallowing assessment. There is not enough evidence to make a recommendation regarding repetitive transcranial magnetic stimulation, video-assisted swallowing therapy, or surface electric stimulation (Good Practice Point).

"Carbonated liquids may reduced pharyngeal residue when compared to thickened liquids. The use of carbonated liquids may be an option for stroke patients diagnosed with pharyngeal residue" (Good Practice Point; p. 379).

Given strong evidence suggesting the Shaker head lift improves strength of the suprahyoid muscles and upper esophageal sphincter opening, the Shaker head lift is recommended for upper esophageal sphincter dysfunction (Grade A Recommendation; p. 384).

Postural maneuvers such as the chin tuck should be recommended for individuals with ALS and moderate dysphagia, in order to facilitate airway protection during swallowing (Good Practice Point).

Individuals with MS, particularly those with cerebellar dysfunction, should receive a dysphagia screen early in the disease. Screens should be repeated at regular intervals depending on the clinical situation. There is currently insufficient evidence to definitively recommend timing of screens over the course of the disease, but individuals at highest risk are those with long disease duration, severe disabilities, and cerebellar dysfunction. There is also insufficient evidence to recommend any screening method over another (Good Practice Point).

Individuals should receive a clinical or, preferably, instrumental swallowing assessment before beginning any stimulation intervention for oropharyngeal dysphagia, and again following intervention. Preferably, "due to the limited number of evidence, all stimulation treatments should preferentially be carried out within clinical trials" (Good Practice Point; p. 386).

Regarding modification of liquids or solids in adults with oropharyngeal dysphagia: <div> <ul> <li>Strong evidence suggests thickening liquids can reduce aspiration risk, but may increase post-swallow oral and pharyngeal residue risk.&nbsp;</li> <li>Modified liquids or solids should only be prescribed after clinical and/or instrumental (e.g., videofluoroscopic swallow study, fiberoptic endoscopic evaluation of swallowing) dysphagia assessment.&nbsp;</li> <li>Different types of thickeners should be offered for patient choice and to increase compliance (Good Practice Point)</li> </ul> </div>

Modified foods and liquids are recommended, according to the individualized needs of the individual with MS and dysphagia, to ensure safe swallowing (Good Practice Point).

"All patients with Parkinson's disease with a Hoehn &amp; Yahr stage above II or weight loss, low body mass index, drooling, dementia, or signs of dysphagia should be screened for dysphagia during an ON-phase" (Grade B Recommendation; p. 366). A questionnaire specific to Parkinson's disease, or "a water swallow test with the measurement of the average volume per swallow" (p. 366), is recommended (Grade B Recommendation).

"In ALS patients with moderate dysphagia, dietetic counseling should be advised to adapt the texture of solid and liquids to facilitate swallowing and avoid aspiration. Instrumental study of swallowing function (videoflouroscopy, flexible endoscopic evaluation of swallowing, or videofluoromanometry), if available, can guide the security and efficacy of the texture-modified diet" (Good Practice Point; p. 362).

"Instrumental exploration of dysphagia should be performed in MS patients with high risk for dysphagia (severe disabilities, cerebellar dysfunction and long disease duration), or dysphagia symptoms. We have not sufficient evidence to recommend one specific method for diagnosis" (Good Practice Point; p. 375).

Although modified solids and thickened liquids may reduce incidence of aspiration pneumonia in dysphagia after stroke, there is insufficient evidence on the effect on mortality. Modified solids and thickened liquids should only be ordered after "an assessment of swallowing function including assessment of risk of aspiration according to a standardized protocol (clinical and, if feasibly, instrumental) by professionals trained and experienced in the assessment and treatment of dysphagia" (p. 379). Until normal swallowing function is regained, assessment should be repeated at regular intervals (Good Practice Point).

<p>As no specific methods exist for screening and assessment of dysphagia in individuals with ALS, general methods for neurological disorders can be used. Options include:</p> <ul> <li>structured questionnaires;</li> <li>water swallow tests;</li> <li>volume-viscosity swallow test (V-VST); and</li> <li>instrumental techniques (e.g., videofluoroscopy, flexible endoscopic evaluation of swallowing, videofluoromanometry) particularly for detecting early signs of dysphagia (Grade B Recommendation).</li> </ul>

"All patients with Parkinson's disease who were screened positive for dysphagia or demonstrate rapid deterioration of the disease, pneumonia or other signs of dysphagia should undergo an instrumental dysphagia assessment" (Good Practice Point; p. 367). Fiberoptic endoscopic evaluation of swallowing is preferred; if unavailable, videofluoroscopy is recommended. Clinical assessment should be used if instrumental assessments are not available (Good Practice Point).