CNS MNT Psychiatric and Cognitive Disorders

The medical therapies available for AD are currently limited to what kinds of drugs?

1). acetylcholinesterase inhibitors such as donepezil (Aricept), aimed at maintaining levels of acetylcholine in the brain 2) memantine (Nemanda), an N-methyl-D- aspartate (NMDA) receptor antagonist aimed at reducing glutamate activity, which is excitatory and destructive of brain tissue. S

Associated Disorders with dementia

-Alzheimer's disease -Chronic oral inflammation -Sarcopenia - contributes to dementia -Insulin resistance, toxicity, inactivity, obesity, oxidative stress -Postural or orthostatic hypotension (decrease in systolic BP of 20 mmHg or a decrease in diastolic BP of -10 mmHg within three minutes of rising from sitting or supine position) -Irregular sleep-wake patterns in those in institutional care -Adrenoleukodystrophy - rare congenital enzyme deficiency that affects metabolism of very-long-chain fatty acids and leads to accumulation in the brain and adrenal glands

Explain beta amyloid in AD

Amyloid general term for protein fragments the body produces normally Beta-amyloid is a fragment snipped from amyloid precursor protein (APP) Beta-amyloid is a fragment snipped from amyloid precursor protein (APP). In AD beta-amyloid protein fragments accumulate into hard plaques between neurons - block transmission of messages and lead to death of brain cells, neurofibrillary tangles and dementia

Genetics in AD

Amyloid precursor gene on chromosome 21 Presenilin genes on 14 and 1 ----Mutations on 21, 14, and 1 - rare and associated with symptoms before age 50 Apolipoprotein E gene (APOE) on 19 The most significant genetic finding APOE of e4 type is linked to much greater risk ---One copy - 3.4 times increased odds ---Two copies - 12.9 times increased odds ****APOE2 is protective

______may play a role in regulating the production of dopamine in the brain. Mechanisms of action by which it reduces depressive symptoms include (1) decreasing dopamine reuptake (by binding to the dopamine receptor), (2) increasing the conversion of the thyroid hormone T4 to T3, and (3) the promotion of excitatory neurotransmitter function.

Zinc

Schizophrenia what is it what is the risk factor how much of it is genetic?

a heterogeneous disorder generated by a combination of biochemical, genetic, structural, nutritional, and environmental factors, including infections and toxins - 83% inheritable - high sugar increases risk - high copper, low Mn and Fe associated - 3x increase visceral fat

With aging, there is accumulation of _____________-containing molecules in the brain, particularly in Alzheimer and Parkinson diseases, perhaps caused by enhanced generation of reactive oxygen species (ROS) and higher neuronal vulnerability.

iron Iron accumulation also occurs in other neurologic diseases, such as congenital aceruloplasminemia. Exam Edge

_____ deficiency results in poor brain myelination and impaired monoamine metabolism. Glutamate and g-aminobutyric acid homeostasis is modified by changes in brain (same thing) status. Such changes not only produce deficits in memory, learning capacity, and motor skills but also result in emotional and psychologic problems

iron Iron plays a critical role in dopaminergic signaling.

Omega-3 supplements containing ______ oil have the added advantage of containing phosphatidylcholine and the phyto- nutrient astaxanthin, a natural antioxidant that gives krill oil its red color

krill

MNT for biopolar:

- consider low sugar and caffeine - screen for iron excess - evaluate mineral and trace deficiencies - screen celiac and gluten sens - Fish oil: high doses of 9.3 g a day of omega-3 oils have been helpful - NAC (N-acetylcysteine): 1000 mg twice per day. This significantly improved symptoms relative to placebo in 24 weeks - Magnesium: 300 to 600 mg a day. Magnesium has effects that are similar to lithium, but without the toxicity

Psychiatric Disorders etiology:

Genetic predisposition Poor nutritional intake External triggers such as marijuana or other drug use, stress Imbalance of om3 and om6 FAs

_________ are found in the peripheral nervous system. They produce myelin sheaths around the PNS.

Schwann cells Exam Edge

What amino acid can help with panic attacks?

glycine Studyforxyz CLINICAL INTERVENTION AND MONITORING

Hor- monal imbalances, including __3___ can also trigger anxiety

high or low thyroid, low progesterone, and high or low testosterone levels

Nutrition diagnoses for neuro patient include:

increased energy expenditure, inadequate access to food or fluid, elimination problems, chewing difficulty Studyforxyz CLINICAL INTERVENTION AND MONITORING

Different forms of anxiety include

(GAD), panic disorder, obsessive compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and social anxiety disorder

MNT fibro and CFS:

- Assess B12, iron, TIBC, ferritin - RBC Mg, and Zn - high PRO, Low-CHO -Avoid sugar, excess caffeine, and alcohol - may need to increase salt and water intake

MNT for Depression:

- Fish oil 60% EPA and 40% DHA. -200 to 2200 mg/day of EPA were effective - Curcumin (BCM 95 or CuraMed 500 mg 23/day) was effective for treating major depression after 8 weeks of use. Research has also shown this special, highly absorbed BCM 95 form of curcumin to be as effective as Prozac - 0.8 mg of folic acid/ day or 0.4 mg of vitamin B12/day - 5HTP - St. Johns wort interacts w/ SSRI, SNRIs or tramadol ->serotonin sydnrome - MTHFR support

MNT for Alzheimer's

- adequate amounts of B vitamins, vD, vE (mixed tocopherols), antioxidants, polyunsaturated fatty acids, phytonutrients, and nitrites and nitric oxide - Hb A1c levels in the range of 4.3% to 6.5% - lower fructose - probiotic/ prebiotic - low AGEs - A multivitamin, preferably with higher than RDA doses of vitamin B1 and 400 to 1000 mcg/day of folate, is recommended. -B12 injections if < 300 mcg - natural therapies: huperzine, acetylcholine, and alpha-lipoic acid all of which are natural agonists of acetylcholine receptors

MNT for anxiety:

-Assess for vitamin D, magnesium, and B vitamin status (see Chapter 7). -Reduce caffeine intake. Eliminating caffeine for 3 to 4 weeks is recommended to see if anxiety decreases. Warn the person about withdrawal for 7 to 10 days, including headaches. Cutting intake in half every 4 to 7 days may avoid this. Switching from coffee to green tea can also be helpful as it has less caffeine and contains theanine, a calming amino acid. Anxiety may be triggered by even low doses of caffeine (the amounts in decaffeinated coffee); a switch to caffeine-free teas may be necessary. - Reduce intake of sucrose and other forms of sugar. - Add a multivitamin containing high doses of B vitamins and minerals including copper, chromium, zinc, and selenium plus 200 mg per day of magnesium. - Increase high-quality protein intake throughout the day.

Protective factors for PD

-Coffee and cigarettes are associated with a lower risk of Parkinson's disease (for reasons that are, as yet, unknown) -Increased intake of Omega-3 fatty acids

Early symptoms of PD

-Decrease in arm swing or stride length on one side can lead to pain in the extremities, low back and hip -Decrease in fine motor coordination - leading to difficulties doing up buttons and clasps -Handwriting may become smaller and more difficult to read Intermittent tremors with stress

Risk factors of AD

-Genetic factors play a major role -Risk predictability relationship to the polymorphisms in angiotensin-converting enzyme (ACE) SNPs -Lifestyle: diet - excess saturated or trans fatty acids may predispose neurons to aluminum (Al)-induced toxicity -traumatic head injury -long term exposure to aluminum, silicon, environmental neurotoxins, and free radicals increased oxidative damage -Homocysteine -Type 2 diabetes -Aluminum - concentrated in neurofibrillary tangles and significantly contributes to AD -Inadequate levels of vitamin B12 can affect the risk for cognitive decline, AD, and dementia. -Vitamin E deficiency - poor transmission of nerve impulses and nerve damage -High cholesterol in the periphery may be associated with AD

Risk factors for dementia

-Homocysteine -Drug toxicity -Metabolic and nutritional disorder- Hypoglycemia, thyroid, vitamin B12, folate, thiamine -Hyperhomocysteinemia -Vitamin B3/niacin deficiency -Chronic proton-pump inhibitor use -Clostridium difficile -Low levels of vitamin K -Regular use of Benadryl (diphenhydramine) -Insulin resistance -Downregulation of the activated form of B6 -Continuous activation of the HPA-axis from -inflammatory cytokines -Low levels of DHA -Inadequate levels of vitamin B12 can affect the risk for cognitive decline, AD, and dementia.

Medical Nutrition Therapy (Dietary & Lifestyle) for AD

-MIND diet -Limit red meats, cheeses, and fried foods -Nutritional support and attention to adequate hydration -Measures to improve glycemic control -Mediterranean-type diet slows cognitive decline -Reduces risk of progression from mild cognitive impairment (MCI) to AD Dietary components may work directly on reducing beta-amyloid formation or deposition -Polyphenols - prevent beta-amyloid formation and promote tau disassembly Absorbed in the brain after oral administration -Celery consumption - may offer protection Reduced total cerebral beta-amyloid plaque deposition and lowered brain beta-amyloid levels -Avoid all known sources of aluminum - antacids, antiperspirants, Al-containing baking powder, cookware, foil food wrap, canned beverages, non dairy creamers, table salt additives -Citric acid and calcium citrate increase absorption of aluminum from water and food -Al absorption is decreased by Mg - recommend a Mg rich diet: unprocessed whole foods (avoid milk and dairy), vegetables, whole grains, nuts, and seeds -Nutrient deficiencies are directly related to cognition in the elderly -Antioxidants - oxidative damage = major role in AD Vitamins C, E, and beta-carotene -Fruits and vegetables with their array of antioxidants Majority of antioxidant activity from phytochemicals - flavonoids, phenols, other carotenoids -Increase whole foods - wild small ocean fish, cereals, vegetables, and monounsaturated fats -Decrease total calories and unhealthy fats -Use morning light therapy -Possible use of the ketogenic diet/increasing the levels of ketones in the brain Key nutrients being investigated for involvement in AD pathogenesis: -B-vitamins - folate, B12, B6; choline, iron, potassium, vitamins A, E, D, omega-3 fatty acids, saturated fat, and cholesterol -Flavanols, polyphenols, caffeine/coffee, and curcumin -Folate - important nutrient for prevention and treatment of AD -High folate with low B12 worsens enzymatic functions of B12 - leads to hyperhomocysteinemia and elevated MMA - both associated with cognitive impairment and decline -Adequate intake of dietary fiber, fermented foods, and plant-based foods to support a healthy gut microbiome should be encouraged

MNT for dementia

-Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) Diet Mediterranean-type diet slows cognitive decline -Lowers predementia syndromes and their progression to over dementia -Mediterranean-DASH (MIND) intervention for neurodegenerative delay - may help slow cognitive decline and reduce risk of developing AD -Ketogenic diet has shown some promise in dementia -Increased intake of omega-3 fat or fish oil intake - likely to be helpful in those with mild cognitive defects (more so than those with AD)

Nutrition for ADHD

-Omega 3-fatty acids -Amino Acids (carnitine may help improve attention and behavior in children and adults with ADHD -Minerals such as iron, magnesium, and zinc -Vitamins such as the B vitamins -Water. Dehydration may impair attention and mood Melatonin. Melatonin does not improve daytime symptoms, but it can help with sleep. 0.3 to 5 mg taken 1 hour before bedtime. Calming herbs. Again, good for sleep but not really helpful for daytime symptoms. Chamomile Hops Kava Lavender Lemon balm Passion flower Valerian

Medical Nutrition Therapy (Dietary & Lifestyle) for PD

-Primary focus is to optimize dietary intake, particularly to maintain muscle mass for strength and mobility -Remove exacerbating factors -Cease all medications that can induce parkinsonism (neuroleptics (haloperidol, risperidone (Risperdal), perphenazine, metoclopramide, prochlorperazine. Lithium, valproate, amlodipine and amiodarone may lead to parkinsonism -Reduce exposure to pesticides, industrial solvents and dry cleaning -If on well water, have tested annually for pesticides and heavy metals -Manage drug-nutrient interactions -Diet high in vegetables, fruits, nuts, fish, and olive oil -High fiber diet to minimize constipation -Low protein (40 g/d for women, 50 g/d for men) diet for those on levodopa may minimize dyskinesia (abnormality or impairment of voluntary movement); -lower levels of protein at morning and mid-day meals; take levodopa with high carbohydrate meal (amino acids in the diet delays or lessens the absorption of levodopa) -Ensure manganese and iron do not exceed recommended levels (DRI) -Consider evaluating for iron overload as begin working with a PD patient/client (measure serum ferritin, serum iron and iron-binding capacity) -Detoxification and Anti-inflammatory diets appropriate in many cases -Ketogenic diet may be helpful -Diet rich in Omega-3 fatty acids -Plenty of nuts (nut consumption reduces the risk of developing Parkinson's disease according to some studies) -Include turmeric in cooking (antioxidant and anti-inflammatory which can reduce cell death in dopaminergic neurons) -Green tea: 3 cups per day (can decrease the risk of developing Parkinson's disease by 28% and has antioxidant actions) -Limit aspartame (competes with absorption sites for levodopa) Later stages of disease may present difficulties coordinating eating and dysphagia Tai Chi: for reducing stress and improving balance Regular aerobic exercise Acupuncture: May help with both the nonmotor and pain symptoms

Medical nutrition therapy

-Special attention must be given to B vitamins, magnesium, and amino acid deficiencies -When gastritis or other intestinal problems are evident, these must be treated to allow for adequate digestion and absorption of nutrients. -Providing adequate levels of amino acids, B vitamins, minerals, and omega-3 fatty acids generally stabilizes function in a patient dealing with addiction of any kind. -As seen with many psychiatric disorders, magnesium and NAC are also very helpful in addiction recovery. -Finally, educating addicts about brain function and nutrition enhances their ability to participate successfully in a recovery program, and empowers them to make healthy choices while also understanding the mechanism of addiction

MNT for addictions:

-Special attention must be given to B vitamins, magnesium, omega 3's, and amino acid deficiencies - treat gastritis - test for deficiencies - Mg and NAC are helpful - address neurotransmitter imbalance - digestive enzymes if needed - educate about brain function and nutrients

Risk Factors & Causes for ADHD

-acetaminophen during pregnancy was a contributing factor to ADHD in the children at the age of 7 (Krause, 14th ed.) -Alcohol, drug, or tobacco use during pregnancy -Premature delivery or low birth weight -Environment, exposure at a young age; lead, pesticides, institutional care -Brain injury (Krause, 15th ed. p. 2261)

Dopamine is a NT synthesized in the brain via the following pathway:

-phenylalanine hydroxylase converts phenylalanine to tyrosine -tyrosine hydroxylase converts tyrosine to L-DOPA -L-DOPA is converted to dopamine by aromatic amino acid decarboxylase -dopamine then can be converted to epinephrine or norepinephrine used throughout the body Studyforxyz CLINICAL INTERVENTION AND MONITORING

In his 2019 seminal paper, Dr Komaroff (Harvard) highlighted emerging components of CFS/ME pathophysiology:

. Brain & Nervous System Energy metabolism Immune system: Switch to "hunkering-down

MNT therapy for psychiatric disorders requires a nutritional assessment, which takes into account the following:

1. Increase or decrease in appetite 2. Increase or decrease in activity level and therefore calorie requirements 3. Use of medications which cause dry mouth, thirst, and constipation 4. Decrease in ability to concentrate, understand, and follow directions 5. Altered nutritional needs due to use of alcohol, drugs, or tobacco 6. Possible decrease in ability for self-care such as adequate income, shopping, meal preparation 7. History of food choices or comorbid conditions that result in suboptimal or deficient nutritional intake, or supplement use while restoring healthy eating habits 8. Use of food or nutrition supplements as the "Magic Answer" in therapy

The recommended amount of artificial food dyes for children has been set at 12 mg per day; however high usage of beverages, colored cereals, and candies can result in _________ mg per day.

100

________ to ________ μg/day of B12, administered orally, was as effective as intramuscular B12 in achieving hematologic and neurologic responses

1000 to 2000

Supplements for Fibro and CFS: Acetyl L-carnitine (ALCAR)

1500 to 2000 mg daily for 4 months - Supplementation to replace the deficits routinely present in CFS/FMS is limited to 4 months because of some concern about elevated carnitine levels being associated with increased risk of myocardial infarction

A study of seventh graders showed that____________ mg a day of supplemental zinc improved school performance with improved memory and attention span.

20

Supplements for Fibro and CFS: A high-potency multivitamin should include:

40 mg of each of the B vitamins 400 mcg folate (with at least 200 mcg as the MTHF form) 500 mcg of B12 1000 IU of vitamin D 200 mg of magnesium glycinate 15 mg of zinc

______% of population of AD older than 65 have severe dementia

5 Only 50% of dementia patients have AD In brain biopsies done on those with AD - only half showed AD, the others had other causes of dementia that were missed

Supplements for Fibro and CFS: D-Ribose Dose? what is it?

5g 3/D for 3 weeks, then BID D-Ribose is natural sugar produced by the body in the pentose phosphate shunt to produce ATP, NADH, FADH, DNA, and RNA, and is a potentially critical rate-limiting nutrient in the production of energy

__________% of individuals with PD are disabled after 10 years

80 Studyforxyz CLINICAL INTERVENTION AND MONITORING

Lewy body dementia

A form of dementia characterized by an increase in Lewy body cells in the brain. Symptoms include visual hallucinations, momentary loss of attention, falling, and fainting. Not PD.

Fatty Acid Vectorization

A new process called "vectorization" yields a source of omega-3 fatty acids, in which the fatty acid is positioned in the center position of a glycerol (sn2) instead of position three (sn3). The COOH end of the fatty acid is phosphorylated, creating a phospholipid.

7. Which food is a good source of vitamin D? a. Butter b. Flax seed c. Egg yolk d. Steel cut oat

ANS: C The best sources of vitamin D are exposure of a large amount of skin to sunlight or foods such as oily fish, egg yolks, and vitamin D fortified foods such as cow's milk and soy milk. Cereals are only a good source if they are fortified. REF: p. 846

16. Chronic fatigue syndrome and fibromyalgia are associated with dysfunction of the a. pituitary gland. b. cerebral cortex. c. hypothalamus. d. glucose metabolism.

ANS: C The hypothalamus controls sleep, temperature regulation, and autonomic systems. It has high energy needs for its size. Dysfunction has been associated with chronic fatigue syndrome and fibromyalgia. REF: p. 858

9. Folic acid supplementation in the methylated form is useful in some psychiatric disorders because of its role in a. production of serotonin and dopamine. b. macrocytic anemia. c. histamine metabolism. d. preventing neural tube defects.

ANS: A Clients with some genetically linked psychiatric disorders have been shown to improve when given the methylated form of folate. This is because of folate's role in the production and function of dopamine and serotonin. REF: p. 846

1. The brain is _________% fat. a. 80 b. 50 c. 100 d. 20

ANS: A The brain is approximately 80% fat. REF: p. 839

8. Which of the following groups is at high risk for deficiency of DHA? a. Formula-fed infants b. Pregnant women c. Weight lifters d. Adolescent girls

ANS: B Experts have recently suggested that a daily intake of 900 mg of DHA during pregnancy may be necessary to support both infant and maternal needs. Starting in 2002, DHA has been supplemented to infant formulas to ensure adequate fatty acid for brain development. The risk of deficiency of omega-3 fatty acids has not been identified in weight lifters or adolescent females. REF: p. 842

11. What is the recommendation of the International Society for the Study of Fatty Acids and Lipids (ISSFAL) for the daily intake of DHA and EPA? a. 220 mg of each daily b. 500 mg combined daily c. Total of 1100 mg daily d. Total of 1600 mg daily

ANS: B The ISSFAL makes a general recommendation for a daily minimum intake of 500 mg combined of EPA and DHA. However, this recommendation does not clarify whether this is for populations with significant or limited fish intake. A total intake of 500 mg of alpha linoleic acid is the AI for infants. A total intake of 1100 mg of alpha linoleic acid is the RDA for women, and a total intake of 1600 mg is the RDA for men. REF: p. 842

Which of the following dietary interventions should be used in treating children with attention-deficit hyperactivity disorder? a. Eliminate table and added sugars from the child's diet. b. Serve meals at regular eating times and provide small servings. c. Prevent the child from consuming foods with caffeine. d. Provide large doses of vitamin supplements to the child.

ANS: B Serve meals at regular eating times and provide small servings Children with attention-deficit hyperactivity disorder (ADHD) have no nutrient needs or exclusions additional to those of otherwise healthy children. These children do run the risk of not getting enough to eat because of behaviors associated with the disorder. To promote adequate intake, parents should establish regular meal times and provide initial small portions in a distraction-free environment. Children with ADHD may eat a little and then walk away from the table, expecting to graze later. Some recommend removing the food and returning it only once after explaining to the child what behaviors are desired in relation to eating. Various dietary manipulations in the past have attempted to treat children with ADHD by eliminating sugars, eliminating artificial food colors, eliminating caffeine, and using megavitamin therapy. Research has not substantiated the effectiveness of any of these. (Krause 14th ed, CH 44)

5. Which of the following are sources of alpha linoleic acid? a. Cod b. Spinach c. Walnuts d. Oysters

ANS: C ALA is found in the oil of seeds and some nuts. Walnuts are the best source. REF: p. 842

14. An excess of which nutrient has been associated with bipolar disorder? a. Chromium b. Magnesium c. Iron d. Vitamin C

ANS: C Iron excess is associated with increased risk of bipolar disorder, so screening some ferritin is warranted. Magnesium is a potentially useful supplement for bipolar disorder. Chromium and vitamin C excess have not been associated with bipolar disorder. REF: p. 853

3. MTFHR mutations are associated with what psychiatric disorder? a. Alzheimer disease b. Anxiety disorder c. Schizophrenia d. Chronic fatigue syndrome

ANS: C MTHFR and COMT polymorphisms may increase the predilection for schizophrenia. MTHFR defects and elevated plasma homocysteine concentration have been suggested as risk factors for schizophrenia, but epidemiologic studies have been inconsistent. REF: p. 861

10. Which of the following conditions may be improved by supplementation of long-chain fatty acids? a. Anxiety disorder b. Eating disorders c. Depression d. Attention-deficit hyperactivity disorder

ANS: C Supplementation with long-chain fatty acids (LCFAs) improves depression. Other mental conditions that benefit from use of LCFA supplementation include bipolar disorder, postpartum depression, schizophrenia, dementia, alcoholism, and tardive dyskinesia. Anxiety disorder, eating disorders, and attention-deficit hyperactivity disorder benefit from the use of fish oils. REF: p. 857

12. What is the most efficient way to improve the omega-6:omega-3 ratio in the diet? a. Supplement the diet with fish oil supplements. b. Decrease the intake of meat and poultry. c. Increase the intake of fish and seafood. d. Increase the intake of vegetables.

ANS: C To bring the omega-6:omega-3 ratio closer to the recommendation of 2:1, increasing the intake of fish and seafood will increase the intake of omega-3 fatty acids while still providing omega-6 fatty acids. Simply supplementing the diet with fish oil supplements does not bring the omega-6 fatty acid level down. Instead, it requires higher intakes of fish oil supplements to bring down the ratio. Part of the problem with the omega-6:omega-3 ratio that is consumed now is the decrease in saturated fat intake and increased vegetable intake. This trend in dietary intake increases the omega-6 intake while not providing omega-3 fatty acids. REF: p. 839

6. Vitamin D deficiency has been associated with a. bipolar disorder. b. delusional disorder. c. active mood disorder. d. generalized anxiety.

ANS: C Vitamin D affects hundreds of genes in the human body and is recognized as an important nutrient in brain health. Clinical research has associated vitamin D deficiency with the presence of mood disorders and with an increased risk of depression in older adults. REF: p. 846

2. Wernicke encephalopathy can be treated with what nutrient(s)? a. EPA and DHA b. Vitamin C c. Thiamin d. Zinc

ANS: C Wernicke encephalopathy is a potentially reversible, yet serious disorder caused by thiamin deficiency. It is commonly associated with heavy alcohol consumption. It can also be seen after bariatric surgery. Although EPA and DHA are important to brain health, they are not used to treat this disorder. REF: p. 845

Wernicke encephalopathy can be treated with what nutrient(s)? a. EPA and DHA b. Vitamin C c. Thiamin d. Zinc

ANS: C Thiamin Wernicke encephalopathy is a potentially reversible, yet serious disorder caused by thiamin deficiency. It is commonly associated with heavy alcohol consumption. It can also be seen after bariatric surgery. Although EPA and DHA are important to brain health, they are not used to treat this disorder. REF: Krause, 14th ed. p. 845

15. The most proven risk factor for Alzheimer disease is a. protein-energy malnutrition. b. folic acid deficiency. c. insulin resistance. d. advanced age.

ANS: D Advanced age is the most proven risk factor for Alzheimer disease. Folic acid deficiency and insulin resistance have been identified as possible risk factors. Protein-energy malnutrition is a result of the disease rather than a cause. REF: p. 853

13. Flavonoid-rich foods include a. peaches, apricots, and sweet potatoes. b. fish and seafood. c. kale, broccoli, and spinach. d. apples, oranges, berries, and chocolate.

ANS: D Evidence indicates that plant-based foods, especially foods with flavonoids, have nutritional and possibly pharmacologic effects in the brain. These foods include apples, berries, chocolate, citrus fruits, grapes, and tea. REF: p. 851

4. Fluctuations in blood glucose can amplify which condition/disease? a. Depression b. Schizophrenia c. Anxiety d. All of the above

ANS: D Excessive sugar intake can cause wide fluctuations in blood glucose that can amplify aberrant moods and behavior. Both high and low blood glucose have been found to have a strong association with a myriad of psychiatric conditions including anxiety, depression, and schizophrenia. REF: p. 841

Earlier Diagnostic Criteria/Pre SEID

All of these 1. Fatigue 2. Post-Exertional Fatigue and Malaise 3. Sleep Dysfunction 4. Pain 5. Cognitive Dysfunction At least one symptom from the following 1. Automatic Nervous System Dysfunction 2. Neuroendocrine Dysfunction 3. Immune Dysfunction 4. Illness length is chronic: Adults 6 months; Children 3 months

plaque formation, amyloid deposition, neurofibrillary tangles, granulovacuolar degeneration, massive loss of telencephalic neurons,

Alzheimer's Disease Particularly evident in the cerebral cortex and hippocampal formation Clinical features believed to arise from cholinergic dysfunction by reduced activity of the enzyme choline acetyltransferase (Synthesizes acetylcholine), and neuronal transfer of choline

Drinking city water associated with progression of ____________

Alzheimer's disease Studyforxyz CLINICAL INTERVENTION AND MONITORING

The 4 As of Alzheimer's Dementia

Amnesia - inability to use or retain memory, including short-term & long-term Aphasia - inability to use or understand language Apraxia - inability to use or coordinate purposeful muscle movement or coordination Agnosia - inability to recognize people or use common objects

Selenium is an important antioxidant and has been linked to adverse mood states. However, supplementation may have a moderate interaction with some medications. These include

Anticoagulants, aspirin, clopidogrel (Plavix), warfarin (Coumadin), and cholesterol-lowering drugs atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), and pravastatin (Pravachol). Selenium may decrease the clear- ance and excretion time of barbiturates. It may also interact with niacin, vitamins C and E, and beta-carotene

Some Conditions for Which EPA* and DHA Have Benefit

Anxiety Attention-deficit/ hyperactivity disorder (ADHD) Autism Bipolar disorder Depression Dyspraxia Eating disorders Postpartum depression Schizophrenia Suicidal ideation

pernicious anemia, stroke, ALS have neurological pathologies True or False

True Studyforxyz CLINICAL INTERVENTION AND MONITORING

Form of curcumin that was helpful for depression as well as pain in fibro:

BCM 95

The _______ questionnaire has been commonly been as a screening and evaluation tool for alcoholism

CAGE Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

MNT for CFS

CDC view is that a balanced diet is essential and will benefit a person both with and without a chronic illness. In terms of supplements for CFS/ME, medical professionals "might" run tests to identify nutritional deficiencies to guide supplementation recommendations They note that patients may lack energy to shop and prepare food, and even to chew and swallow. If patients cannot chew, soup/stews, mashed/pureed or smoothie type foods are indicated. Other supportive services may be indicated. Ideally patients should avoid refined sugars, caffeine, alcohol and deep fried foods. Eating small meals and snacks is considered to help patients to maintain energy levels. Patients may have GI symptoms (irritable bowel, reflux, nausea, slow gastric emptying and poor bowel peristalsis). For those with IBS, use of the Low FODMAP (Fermentable Oligo-Di-Monosaccharides and Polyols) diet may be helpful For those with food sensitivities, reducing and avoiding sensitive foods which worsen symptoms is helpful. Ideally, patients could rotate their foods every 4-5 days so they avoid developing more food sensitivities. If intestinal dysbiosis is present, use of L-glutamine or butyrate or by using evidence based probiotics may be indicated

It is important to evaluate all patients with longstanding mood disorders, especially those with a family history of mood disorders, for a genetic methylation mutation of either ____________ or ___________________

COMT (catechol-O-methyl transferase) or MTHFR (methylenetetrahydrofolate reductase) -These mutations are involved in inactivation of catecholamine neurotransmitters and are implicated in schizophrenia, OCD, ADHD, and depression as well as vascular disease, thrombotic stroke, homocystinuria, and homocysteinemia

Inositol for anxiety:

Can be helpful in treating anxiety and panic disorders, and is very safe. In high doses may be valuable in controlling several other mental health disorders, including panic disorder, obsessive compulsive disorder, agoraphobia, and depression.

Associated Disorders of PD

Cardiovascular disease Skin cancer GI issues Genitourinary dysfunction Musculoskeletal conditions Type 2 diabetes Vit D deficiency Pseudobulbar affect (sudden/uncontrollable outburst of crying or laughing)

Microglia, Schwann cells and Ependymal cells are found in the ________

Central nervous system Exam Edge

Pharmacologic Treatment(s) for dementia

Cholinesterase inhibitors - increase the amount of brain acetylcholine Side effects - nausea, fatigue, diarrhea Includes: Donepezil (Aricept), Rivastigmine (Excelon), Galantamin (Razadyne) Memantine (Namenda) - regulates glutamate - involved in information storage and retrieval of the brain Side effects - headache, constipation, confusion, dizziness Vascular dementia - eliminate further vascular insults to the brain - aspirin, cholesterol and BP lowering agents, medically manage heart disease when present

Lewy bodies

Clumps of proteins observed in the surviving dopaminergic neurons of Parkinson's patients

Supplements for Fibro and CFS: CoQ10

CoQ10 at 200 mg/day for 3 to 6 months, because blood levels of CoQ10 are often low in CFS/FMS

Herbs/Supplements:

Coenzyme Q10 (CoQ10): 400 mg t.i.d (reduced in the mitochondria of those with early Parkinson disease. Supplementation increases levels in the brain mitochondria) Creatinine: 5g b.i.d. (protects neurons from oxidative damage and death) N-Acetylcysteine: 600 mg b.i.d. (to increase glutathione levels in the brain) Vitamin D3: to keep serum levels between 30-80 ng/mL (deficiency is more common in those with PD and vit D deficiency may lead to a greater risk of developing PD; there is also some evidence to suggest that it is neuroprotective) CDP-choline: 500 to 1200 mg q.d. (requires reduction of carbidopa/levodopa dose by 30-50% - discuss with the client/patient's physician/healthcare provider; intermediate in the synthesis of phospholipids; neuroprotective and may enhance dopaminergic therapy in PD) Vitamin B6 (Pyridoxine): can increase the conversion of the dopamine agonists to dopamine and thus should be avoided (or limited to 5 mg per day in supplement form) in those taking carbidopa and levodopa (dopamine agonists) Glutathione (not to be given to those with sulfite sensitivity) Gingko biloba: 240 mg q.d. for 12 weeks or more to adequately assess efficacy; antioxidant, inhibits lipid peroxidation, prevents apoptosis and may help decrease levodopa toxicity Mucuna pruriens: 7.5 g in water 3-6 times per day; antiparkinson effect

A 39-year-old man presents to the clinic for follow up. He has a history of fatigue, body aches, and sleep disturbances. He has had these symptoms for the past six months. He also complains of occasional abdominal cramps and diarrhea. He tires easily and prefers to stay at home. He has trouble falling asleep and feels tired, even if he gets enough sleep. He denies tobacco, alcohol, or illicit drug use. He has not had a stable job for the past two years due to his fatigue and ended up getting fired twice for taking too many sick days. He also reports a 10-pound weight loss in the last two months. Physical examination is unremarkable except for a BMI of 17 kg/m2. Complete blood count is significant for a platelet count of 45000/microL. Further labs, including renal function, liver function, hepatitis panel, antinuclear antibody, anti-Ro, anti-La, and anti-CCP, are negative. Which of the following is the next best step in the management of this patient? a. Sertraline. b. Graded exercise program. c. Bone marrow biopsyg d. HIV screening

D- HIV screening This question illustrates the importance of ruling out syndromes that mimic chronic fatigue syndrome. This patient's prodromal symptoms are commonly seen in both chronic fatigue syndrome (CFS) and late-stage acquired immune deficiency syndrome (AIDS). Since CFS is essentially a diagnosis of exclusion, it is imperative to rule out an HIV infection. Not all HIV patients have known risk factors, while others may refuse to admit injection drug use or promiscuous behavior. Another hint for an HIV infection in this patient is the low platelet count. Thrombocytopenia is a common finding in patients with HIV. While depression still has not been ruled out in this patient, it is not confirmed either. Hence, treating the patient with an antidepressant is not appropriate. The same goes for CFS, as it has not been confirmed either. Bone marrow biopsies are not routinely carried out in patients with thrombocytopenia. The patient has a more likely cause of thrombocytopenia, i.e., an HIV infection. HIV screening is a relatively less invasive test.

Theanine for anxiety:

Derived from green tea—doses of 200 mg 1 to 43 per day are helpful. l-theanine is involved in the formation of the calming neurotransmitter, gamma amino butyric acid (GABA), and also stimulates the release of serotonin and dopamine.

Medications that may cause B1 deficiency:

Digoxin Diuretics Phenytoin

Passion flower extract for anxiety:

Doses of 100 to 500 mg 1 to 43 per day can be helpful.

hemianopsia; hemianopia

Defective vision or blindness in one half of the visual field, usually referring to bilateral defects resulting from a single lesion, often as the result of a cerebrovascular accident (CVA). The individual is unable to perceive objects to the side of the visual midline. Visual loss is contralateral; that is, it is on the side opposite the brain lesion. Studyforxyz CLINICAL INTERVENTION AND MONITORING

GABA:

Deficiency of the neurotransmitter GABA is associated with anxiety, with GABA being a primary counterbalance for the excitatory neurotransmitter glutamate

Nutrient deficiencies can exacerbate these negative consequences of chronic alcohol consumption:

Deficiency of vitamin B1 can trigger confusion and psychosis (called Wernicke encephalopathy; see Chapter 28) Magnesium deficiency may aggravate withdrawal symptoms such as delirium tremens (DTs) and cardiac arrhythmias. Red blood cell (RBC) magnesium levels are more useful in assessment than serum magnesium levels, which may remain normal even with severe magnesium deficiency. Because magnesium deficiency is so common in alcoholics, deficiency should be presumed to be present. Malnutrition, malabsorption, gastritis, and chronic diarrhea (see Chapters 26 and 27) Hepatitis and cirrhosis (see Chapter 28) Cardiomyopathy (see Chapter 32) Bone marrow disorders Neuropathy, which is also associated with B12 deficiency, and dementias

Loss of cognitive function, usually because of damaged brain cells Includes memory loss and at least one of the following: Difficulty with language Impaired movement Inability to plan and initiate appropriate behaviors socially or at work

Dementia

3 stages of dementia

Early preclinical asymptomatic stage - amyloid buildup and other nerve cell changes -may have olfactory and taste dysfunction that may reduce appetite Mild Cognitive Impairment (MCI) - memory or other thinking problems unusual for a person's age and education that do not interfere with independent living -manage nutrition in the context of behavioral changes -Monitor for weight loss and signs of dysphagia Dementia (severe stage)- memory loss, difficulty finding words, visual/spatial problems that interfere with independent living -provide appropriate therapy for dysphagia as needed Correct weight loss Monitor for signs of pulmonary aspiration risk Consider finger foods and high calorie drinks when intake at meals decreases Complications of immobility, swallowing disorders, and accompanying risk of malnutrition

Those with _____________, a genetic condition involving a defect in collagen, seem to more vulnerable to with rates as high as 30-40% vs 1% in general population

Ehlers Danlos Syndrome (EDS)

In regards to psychiatric disorders, vitamin E has a crucial role in proliferation, differentiation, neurotrophism, neuroprotection, neurotransmission, and neuroplasticity of cells. True False

False, its Vitamin D

Medical Nutrition Therapy (Dietary & Lifestyle) for ADHD

Feingold diet Foods containing synthetic food colors and naturally occurring salicylates be removed from the diet because of their neurologic effect. Recently there has been renewed interest in the role of artificial food colorings (previously identified by Feingold) as exacerbating hyperactivity in some children. Eight dyes are included: FD&C Blue 1 and 2 FD&C green 3 Orange B FD&C Red 3 Red 40 FD&C Yellow 5 and 6 (see Table 44-6). Elimination diet- common allergens include milk, egg, wheat, soy, peanuts, tree nuts, fish/shellfish. FODMAPs GFCF diet Other recommendations The elimination of sugar The elimination of caffeine Or the addition of large doses of vitamins (megavitamin therapy). Fish oil supplementation

Associated disorders with CFS

Fibromyalgia is quite frequently associated with and/or confused with CFS/ME; indeed, the two often co-occur.

Nutrients correlated with alcohol consumption

Folate: absorption, storage, transport, and release by liver; < hepatic uptake and renal conservation; changes in microvilli Methionine: changes, promotes liver injury Thiamin: Severe: Wernicke-Korsakoff due to alcohol dependence. Damage to the CNS and PNS B6: Low B6 levels in 50% of alcoholics even without abnormal liver enzymes tests. Niacin: although not depleted, is a source of tryptophan, so often given with B6 Vitamin C: Deficient in alcoholics with and w/o liver disease Vitamin D: often deficient from poor intake or malabsorption Vitamin K: May be present if also fat malabsorption (also think vitamin A, D, E) Look at > in prothrombin time to determine. Vitamin A and zinc: < due to intake, absorption, < liver storage capacity. Night blindness Iron: Deficiency or excess Calcium: Altered calcium homeostasis: < bone density Potassium: Hypokalemia due to poor intake, vomiting, and diarrhea

Ehlers-Danlos Syndrome (EDS)

Genetic defect in collagen and connective-tissue synthesis and structure

is a strong, independent risk factor for dementia and AD

Homocysteine

Supplements for Fibro and CFS: B12

If serum < 540 pg/ml, then start 10 weekly B12 injections, or prescribe 5 mg sublingual B12 daily.

Supplements for Fibro and CFS: Iron.

If the iron percent saturation is under 22%, or serum ferritin is under 60 mcg/l (ng/ml), iron supplementation is recommended. -It should not be taken within 6 hours of thyroid hormone, because iron blocks thyroid absorption. - Treatment should be continued until the ferritin level is over 60 mcg/l (ng/ml)

Clinical findings of psychiatric disorders:

Increase or decreased serum cholesterol Elevated serum triglycerides Increase C-reactive protein Blood pressure changes Low HDL-cholesterol Metabolic syndrome? Serum glucose (high or low)

______________ in the brain - third hallmark of AD after tau tangles and amyloid plaques

Iron accumulation -Released in breakdown and repair of myelin sheaths - the more myelin sheath breakdown the greater the accumulation of iron -Involved in several molecular steps leading to protein deposits, beta-amyloid plaques, and tau

______________ is associated with apathy, depression, and fatigue

Iron deficiency Iron deficiency anemia in children is associated with a significantly increased risk of psychiatric disorders, including mood disorders, autism spectrum disorder, ADHD, and developmental disorders

Diagnosis of ADHD

It usually is diagnosed first in childhood and often lasts into adulthood

___________ are intraneuronal inclusions that result from the death of dopaminergic neurons in the brainstem; they are abnormal aggregates and inclusions of protein that develop inside nerve cells in people with PD (aggregations usually consist of insoluble fibrillary aggregates containing misfolded proteins)

Lewy bodies

Pharmacologic Treatment for CFS

Low Dose Naltrexone (LDN): LDN is thought to disrupt the inflammatory process and restore the impaired cation channel functioning associated with chronic fatigue. Several papers in reference section. Pain Medications: Nonsteroidal medications, including COX-2 inhibitors, are used due to their action in relieving pain and associated inflammation. Opioid medications are addictive and hence only used for very severe cases for the shortest possible duration. Krause notes, NSAIDs not helpful and contribute to bleeding ulcers, heart issues, stroke. Krause also notes that chronic use of acetaminophen can deplete glutathione. Tricyclic Antidepressants: Multiple tricyclic antidepressants have shown varying degrees of success in improving sleep, pain levels, as well as the severity of fatigue. Selective Serotonin Reuptake Inhibitors (SSRI) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRI) : Many SSRIs like fluoxetine, sertraline, paroxetine have been used for treating depression and anxiety, which either accompany the disease process or occur as a consequence of it. Antiviral Therapy: The hypothesis regarding viral etiologies, including Epstein Barr virus, for chronic fatigue syndrome, several antiviral medications have been tried in these patients, but most of these studies have been inconclusive. Immunoglobulin: A systemic review conducted by Whiting et al. in 2001 evaluated the effect of the five RCT's on the use of immunoglobulins in patients of chronic fatigue syndrome, and four RCTs showed positive results. Unfortunately, other studies did not report any benefit and, in fact, concluded the potential dangers of the immunoglobulins. Corticosteroids: One systemic review conducted (2015) showed weak benefit from low dose hydrocortisone, but effect was only short-lived and was associated with adverse effects.

Magnolia for anxiety:

Magnolia bark has a long history of use in traditional Chinese formulas that relieve both anxiety and depression without the feeling sedation

Herbs for CFS

Melatonin: A melatonin/zinc combination is currently being tested in a NIH Clinical Trial. A number of papers mention it as potentially helpful while also noting that larger, randomized double-blind trials of supplementation are needed. Krause (citing a Teitelbaum) mentions it in the section on fibromyalgia/CFS. They note that lower does (0.5 mg) may be more helpful than higher doses; this seems counterintuitive to most people- so worth noting. Other sleep support (Teitelbaum): Valerian: 200-800 mg/day; Passionflower: 90-360 mg/day; L-Theanine: 50-200 mg/day; Hops: 30-120 mg/day; Lemon Balm: 20-80 mg/day; Lavender spray on pillow at bed (capsules also) NADH (Campagnolo et 2017): Possibly helpful to fatigue High polyphenol cocoa (Campagnolo et 2017): Possibly helpful for fatigue COQ10 + NADH combination: Significant reduction in max HR during a cycle ergometer test. Perception of fatigue improved but no benefits in terms of pain and sleep

Pharmacological treatment for ADHD and drug nutrient interactions

Methylphenidate (Ritalin, Concerta) Avoid St. John's Wort Adderall- high dose vitamin C and acidifying foods may decrease absorption

serontonin syndrome

Mild symptoms may consist of increased heart rate, anxiety, and sweating, along with dilated pupils, tremor or twitching, and hyperresponsive reflexes. Symptoms of moderate elevation include hyperactive bowel sounds, high blood pressure, and fever. Severe symptoms include increases in heart rate and blood pressure that may lead to shock.

Pharmacologic Treatment(s) for PD

Monoamine Oxidase (MAO) Inhibitors and Dopamine agonist or Amantadine MAO Inhibitor: Rasagiline -Interact with tyramine-containing foods (consuming foods with tyramine with MAOI may trigger a hypertensive crisis; cause sensitivity (with vasoconstriction, tachycardia, chest pains, headache, intracranial hemorrhage, cardiac arrhythmias, cardiac failure) to dietary tyramine (found in cheese, smoked or pickled fish, chianti, banana peels, yeast, dry sausage, sauerkraut, beers and ales) -Increase appetite and carbohydrate craving -Inhibit the actions of enzymes requiring vitamin B6 Dopamine agonist: Carbidopa, Levodopa, Ropinirole, Pramipexole -May deplete vit B6, vit B3 -Vit C may support effectiveness -Iron reduces effectiveness -Food, especially foods high in protein, compete with levodopa for absorption; however, levodopa may be taken with food to avoid stomach upset -It is important to take levodopa at the same time every day, always with or always without food -AVOID iron and 5- HTP or St. John's wort supplements -Iron supplements taken with carbidopa interfere with the action of the drug -People taking carbidopa should not supplement iron without consulting the prescribing physician -Several cases of scleroderma-like illness have been reported in patients using carbidopa and 5-HTP -People taking carbidopa should not supplement 5-HTP (or the herb St. John's wort, which elevates 5-HTP levels) without consulting the prescribing physician

Cardinal symptoms of PD

Motor Symptoms: Resting tremor Rigidity Bradykinesia (slowness of movement) Akinesia (lack of movement) Postural instability Flexed posture Freezing episodes Nonmotor symptoms: Psychiatric: depression, anxiety, apathy, dementia, hallucinations, impulse control disorders Autonomic: constipation, orthostasis (lightheaded on standing), excessive sweating, urinary incontinence Sleep-related: insomnia, restless legs syndrome, fatigue, excessive daytime sleepiness, REM sleep behavior disorder Sensory: impaired sense of smell and taste, blurred vision, numbness, tingling and pain

Diagnosis of impairments of dementia

Multiple cognitive deficits, which include memory impairment, and at least one of the following: aphasia (inability to comprehend or formulate language), apraxia (acquired oral motor speech disorder), agnosia (inability to process sensory information), or disturbance in executive functioning.

Chronic use of acetaminophen depletes glutathione, a key antioxidant. The glutathione depletion from acetaminophen may be prevented by supplementing with

NAC 500-1000 mg/d

Preclinical symptoms of PD

Nonspecific signs and symptoms such as constipation, a decreased sense of smell and taste (asomnia and hyposomnia) (hypogeusia and ageusia), restless legs syndrome and REM (rapid eye movement) sleep behavior disorder predate motor symptoms by many years -There has also been reported to be a decrease in the range of facial expressions, a flattening of the voice, more passivity of the personality and late-onset depression may be present in the very early stages of the disease Also, "unilateral sense loss of smell is a very early indication"

_______________ is a complex progressive neurodegenerative disorder characterized by involuntary tremor, a shuffling gait and a masked facial expression

Parkinson's disease

Progression of ______________ is associated with drinking city water, agricultural chemicals, drug use

Parkinson's disease Studyforxyz CLINICAL INTERVENTION AND MONITORING

Diagnosis for CFS

Per the CDC, a very thorough medical exam is the first step. Use of a validated clinical questionnaire like the DePaul Symptom Questionnaire (DSQ) or the CDC CFS Symptom Inventory is recommended

Herbs/Supplements for dementia

Phosphatidylcholine - can increase brain acetylcholine in normal patients L-Acetylcarnitine (LAC) - thought to be much more active than other forms of carnitine in brain disorders 1500mg q.d. Beneficial for non-AD mild mental deterioration in elderly Smelling lavender - may be effective in terms of alleviating agitation associated with dementia Curcumin - antioxidant and anti-inflammatory High-dose studies suggest therapeutic role - improve glucose homeostasis, lipid metabolism, endothelial function, insulin immunosuppressant, and inhibition amyloid plaque aggregation Bioavailability is improved 2000 times in the presence of piperine (naturally found in black pepper)

____________ have been shown to be a superior carrier of DHA and EPA, enhancing the absorption of the omega-3 fatty acids up to 50-fold over fish oil

Phospholipids

SHINE protocol for CFS and FIbro

Sleep support Hormonal support Infection treatment Nutritional support Exercise as able

Specific nutrients for CFS

Specific nutrient considerations (Bested & Marshall, 2015) 1. Vit D 2. Vitamin B12 and B complex 3. EFA 4. Zinc 5. Coq10 Other considerations (in addition to above) - Teitelbaum 2004 (republished in 2012) 6. MVM/mineral 7. acetyl L carnitine

Describe the reason why eating sugar when your stressed is phyisioligcally sensible?

The habit of eating sweets during stress may be physiologically rewarding, as it results in an increased movement of tryptophan into the brain. This occurs as insulin selectively drives other competing amino acids into muscles, leaving more tryptophan to enter the brain. This raises the level of serotonin, causing a soothing effect, the result being people learn to reach for sugar during stress. Over time the increased sugar consumption combined with low fiber intake will cause increasing insulin resistance, paradoxically worsening the symptoms

lavender for anxiety:

The smell of lavender is calming, so keeping a vase full of lavender flowers (even dried) around or using a lavender oil spray can be helpful. In addition, taking a lavender capsule can be calming and reduce the need for tranquilizers

Labs for CFS

The standard laboratory tests include urinalysis, complete blood count with differential, blood chemistries, thyroid function tests, muscle enzymes like creatine kinases, and C- reactive protein.

2015 IOM Diagnostic Criteria for CFS/SEID

The three (3) primary symptoms present (a) For more than six (6) months; (b) Be moderate or severe in intensity at least 50% of the time. 1. Fatigue 2. Post exertional malaise 3. Unrefreshing sleep Plus one of these 1. cognitive impairment 2. orthostatic intolerance

Risk Factors & Causes for PD

The underlying cause of Parkinson's disease is unclear, but the following are risk factors associated with the condition Genetic factors Environmental toxins/exposures -Pesticides (Rotenone, Trichloroethylene) -Solvent exposure (petroleum, plastic, rubber) -Manganese exposure (manganese miners) -Welding (welders experience symptoms ~15 years earlier than average) -Heavy metal exposure -Well water Glutathione depletion - may contribute to increased damage from exposure to toxins Mitochondrial hypothesis Dysfunction of the mitochondria (damage to mitochondrial complex I) seen in Parkinson's disease). This dysfunction may lead to impaired energy metabolism in the mitochondria of dopaminergic neurons - and possibly leading to the production of reactive oxygen species and oxidative damage to the cell (proteins, lipids and DNA), and ultimately may lead to cell death. Defective protein clearance mechanisms Neuroinflammation Sleep problems (may affect dopamine levels) Other: possible past microtrauma, microcirculatory problem, viral or prion infection

Which hormonal issues is common in fibro and CFS?

Thyroid hormone T4 In two studies by Dr. G.R. Skinner and his associates in the United Kingdom, patients thought to have hypo- thyroidism had technically normal thyroid blood tests. Yet, when treated with thyroid hormone, the large majority of patients with symptoms of low thyroid and yet normal testing, improved when given thyroid hormone (levothyroxine—T4) at an average dosage of 100 to 120 mcg/day.

Schizophrenia MNT

Treat lifestyle and metabolic disorders (CVD, met syn) - restore FA imbalance w/ supps (ie, fish oil) - screen for COMT and MTHFR - GF and casein free diet trial is recommended - screen for IgA and IgG transglutaminase Abs

True or False Fingerprint patterns - abnormal in AD - increased number of ulnar loops on fingertips with concomitant decrease in whorls, radial loops and arches

True

True or False Television, parenting styles, sugar, and/or family dysfunction do not cause ADHD although they can exacerbate symptoms

True

True or False Women are impacted by CFS at 2x the rate of men, with middle aged females comprising 70% of patients.

True

A patient with neuro disease may not be able to eat independently due to apraxia, hemianopsia, limb weakness but not xerostomia (dryness of mouth) True or False

True Studyforxyz CLINICAL INTERVENTION AND MONITORING

An ____ (vegetarian) source of DHA is also available for vegetarians and vegans

algal

T/F Most vitamin E supplements can increase risk of vitamin E deficiency

True. Vitamin E may help slow progression, but only if a mixed natural tocopherol containing gamma tocopherol is used. Most vitamin E supplements are synthetic alpha tocopherols, which not only increase risk of vitamin E deficiency, but do not help AD. The high levels of alpha tocopherol (more than 100 IUs/day) can induce a relative deficiency of the other to- copherols. Because of this, supplementation with vitamin E at doses more than 100 IU is not recommended, unless a natural mixed tocopherol is used

natural remedies for sleep:

Valerian (200-800 mg/day) Passion flower (90-360 mg) l-Theanine (50-200 mg) Hops (30-120 mg) Wild lettuce (18-64 mg) Lemon Balm Extract (20-80 mg) Melatonin: 0.5-5 mg at bedtime

Risk factors for CFS

Various injuries, illnesses, deficiencies or infections Infection Age and gender (or not):-Being female and middle aged seems to be the most common risk factor for developing. It can, however, occur in younger people, although it is more common in adolescents (both genders) than in children Genetic factors

__________ - caused by poor circulation to the brain and multiple ministrokes (transient ischemic attacks/TIAs)

Vascular dementia 2nd leading cause of dementia Can result from -Atherosclerotic vascular disease -Embolism usually from the heart due to vascular or arrhythmic disease -Poorly controlled hypertension -Increased tendency to clotting for reasons either inherited or acquired

Causes of dementia:

Vascular disease (blockage of a blood vessel to the brain) Traumatic brain injury Parkinson, Huntington, Creutzfeldt-Jakob, and other diseases Brain tumor Vitamin B deficiencies Drug or alcohol abuse, medications, or exposure to toxic substances A history of severe hypoglycemic episodes among people with type 2 diabetes Delirium Stroke

Key nutrients and recommended doses to improve bone density

Vitamin D inhibits strontium absorption, so it must be taken at a different time of day (Reginster et al, 2012). Strontium: 340 to 680 mg/day Vitamin D: 1000 to 2000 IU Magnesium: 200 mg Vitamin K: 150 mcg Boron: 3 mg Calcium is best obtained from food sources, such as dairy foods, sardines, dark green vegetables, and seeds. (Krause 14thed p.850).

Orthostatic intolerance

Worsening of symptoms upon assuming and maintaining an upright posture. Symptoms are improved, although not necessarily abolished, by lying back down or elevating the feet. Tricylic antidepressants can worsen it

In AD, excess saturated or trans fatty acids may predispose neurons to _______________

aluminum (Al)-induced toxicity

A proposed mechanism of addiction for all substances of abuse involves the sudden release of a neurotransmitter that is believed to cause a sense of euphoria and pleasure that is at the root of drug abuse. Which neurotransmitter is most responsible for this "reward pathway?" a. Dopamine b. Epinephrine c. Norepinephrine d. Acetylcholine

a. Dopamine Dopamine is thought to play a significant role in all addictions. It is also responsible, in part, for the small pleasure released when someone receives a text or an e-mail. (Rakel, CH 83)

The 4 As of Alzheimers

amnesia, aphasia (The inability to use or understand language), apraxia (The inability to use or coordinate purposeful muscle movement or coordination), agnosia (The inability to recognize people, or use common objects).

Hallmark of AD

cumulation of beta-amyloid and the formation of neurofibrillary tangles

The best behavioral approach to ADHD is: a. Focus on strengths, goals, and SMART strategies including healthy habits in a healthy habitat to achieve goals b. Remedial classrooms with developmentally delayed students c. Frequently pointing out errors so they have an opportunity to correct them d. A ratio of 3 corrections for each statement of praise

a.Focus on strengths, goals, and SMART strategies including healthy habits in a healthy habitat Encourage positive family communication, focusing on goals rather than problems. Help families view overall long-term goals in terms of short-term achievable objectives. Help families learn to make specific, measurable, achievable, relevant, time-specific (SMART) plans, including ways to celebrate success. Consider referring families for additional support for parenting, strengths-based communication, and discipline skills, in addition to time management and organizational skill development. (Rakel, CH 7)

Thiamin diphosphate (TDP) an essential coenzyme in glucose metabolism and the biosynthesis of neurotransmitters, including

acetylcholine, g-aminobutyrate, glutamate, aspartate, and serotonin Low TDP concentrations and impaired thiamin-dependent enzy- matic activities have been detected in the brains of patients with Alzheimer's disease (AD), Parkinson's dementia (PD), and other neurodegenerative diseases

Which pharmaceutical treatment can assist in preventing alcohol relapse by reducing the anxiety and sleep disturbances associated with alcohol craving? a. Disulfiram b. Acamprosate c. Naloxone d. Clonidine e. Gabapentin

b. Acamprosate Topiramate, like acamprosate, also helps by reducing cravings. Disulfiram creates a negative feedback for avoidance by stimulating nausea, and naloxone and topiramate reduce the high associated with a substance. Clonidine works on reducing symptoms of withdrawal. Gabapentin can help reduce pain and improve sleep if given at bedtime, but there are no data to show it helps reduce relapse. (Rakel, ch 83)

2. A 36-year-old man presents to the clinic for follow up. He has a history of fatigue, joint pains, and sleep disturbances. He has been extensively worked up in the past, but no definite causes were found. His symptoms have been present for the last eight months. He tires easily and is not able to continue any of the physical activities he used to engage in about a year ago. He often takes sick days or early leave due to fatigue. His symptoms worsen with standing and sitting for long periods of time. Which of the following interventions is most likely to be helpful for this patient? a. Prednisolone b. Graded exercise therapy c. Infliximab d. Hydroxychloroquine

b. Graded exercise therapy The clinical vignette is most indicative of a patient with a diagnosis of chronic fatigue syndrome. Chronic fatigue syndrome (CFS) is considered a diagnosis of exclusion. To diagnose CFS, criteria include: significantly lowered ability to participate in previously routine physical activities (persisting more than six months), physical or mental activity causing worsening symptoms (post-exertional malaise (PEM), and sleep problems. Moreover, there should be either memory difficulties, or worsening symptoms with standing or sitting. Although there is no cure for CFS, there are many strategies employed to manage symptoms. These include graded exercise therapy, cognitive behavioral therapy, pacing, and a well-balanced diet. There is no proven benefit of corticosteroids, infliximab or hydroxychloroquine.

Which dietary supplements are most likely to be helpful for children with ADHD? a. Vitamin A, zinc, and choline b. Omega-3 fatty acids, iron, magnesium c. B vitamins and calcium d. Glutamine, N-acetylcysteine, and vitamin C

b. Omega-3 fatty acids, iron, magnesium Low levels of omega-3 fatty acids are linked to ADHD and behavioral problems in both adults and children. Supplementation with fish oils (which are rich sources of omega-3 fatty acids) can alleviate ADHD symptoms and decrease depression, anger, anxiety, impulsivity, and aggression. Fish oils may also improve academic achievement. Although flaxseed, walnuts, and green leafy vegetables contain the omega-3 fatty acid, linolenic acid, humans convert only 5% to 10% of linolenic acid to useful eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Encourage patients to eat either sardines, salmon, or mackerel twice weekly, consume 1 to 2 tablespoons of flaxseeds daily, or consider a supplement containing between 500 and 2000 mg of combined EPA and DHA. Iron deficiency interferes with memory, concentration, behavior, and both physical and mental performance. Accordingly, correcting iron deficiencies (indicated by low ferritin levels) may improve attention and restlessness. Magnesium supplements may have benefit in children with ADHD who are excitable, easily stressed, or worriers, as well as those who also suffer from constipation. (Rakel CH 7)

he pathologic changes in Parkinson's disease

begin in the brainstem and then spread up into the brain, involving the dopaminergic neurons of the substantia nigra pars compacta (contains 95% of the dopaminergic neurons in the brain), later in the course of the disease (determined by the German pathologist, Hideo Braak) As the severity of PD increases, the depletion of dopamine leads to further changes in the basal ganglia pathways, including altered function of other basal ganglia neurotransmitters such as glutamate, GABA, and serotonin

The optimal amount of exercise for someone with ADHD is a. 5-10 minutes before school b. 10-20 minutes after school c. 30-60 minutes daily d. At least 2 hours daily

c. A minimum of 30 to 60 minutes of aerobic activity daily is required for general physical and mental health. A 2009 study in children with developmental coordination disorder found that regularly playing table tennis was improved coordination and ability to sustain focus. Exercise outdoors in nature is considered preferable to exercise in a gym or urban setting. Exercise increases brain-derived neurotrophic factor levels and enhances neurogenesis, thus promoting overall cognitive function including attention and memory, which are both required for academic achievement.

5. A 42-year-old woman presents to the clinic for follow up. She has a history of fatigue, irritability, and sleep disturbances. She has been extensively worked up in the past, but no definite causes were found. She also complains of occasional abdominal cramps and diarrhea. Her symptoms have been present for the last four months. She tires easily and prefers to stay at home. She reports spending a lot of time in her bed, and yet she feels tired out of bed. She smokes half a pack of cigarettes a day and drinks on the weekends but denies illicit drug use. She lives alone and has not kept a stable job for the past two years. She also reports a 10-pound weight loss in the last two months, and when if it is intentional, she replies, "I don't know." Which of the following is the next best step in the management of this patient? a. Prednisolone b. Graded exercise therapy c. Inquire about her mood d. Fluoxetine

c. Inquire about her mood The patient's symptoms are most consistent with a diagnosis of chronic fatigue syndrome. However, chronic fatigue syndrome (CFS) is considered a diagnosis of exclusion. It is imperative to rule out psychiatric illnesses in a patient with chronic fatigue syndrome as depression, and CFS have a lot of symptoms in common. This patient has weight loss, sleep disturbances, gastrointestinal symptoms, and irritability. She also does not seem to be that concerned about her weight loss. Inquiring about the patient's mood is the most appropriate step before diagnosing or treating the patient with anything else. While graded exercise therapy has been shown to be beneficial for patients with CFS, this patient's diagnosis has not been confirmed yet. Prescribing an antidepressant without inquiring about the patient's mood is inappropriate.

9. In the context of CFS/ME Teitelbaum's SHINE protocol a. Refers to the importance of getting enough sunshine to support vitamin D production b. Refers to the importance of getting outdoors to improve mood c. Is an acronym for Sleep support, Hormonal treatment, Infection treatment, Nutrition Support, Exercise as able d. None of the above

c. Is an acronym for Sleep support, Hormonal treatment, Infection treatment, Nutrition Support, Exercise as able

Which of the following is a traditional Chinese herb and has been used as an "antiinebriation" treatment for hundreds of years? a. St. John's Wort b. Mugwort c. Kudzu d. Valerian

c. Kudzu

Iron accumulation also occurs in other neurologic diseases, such as

congenital aceruloplasminemia. Exam Edge

10. Per Krause, the hypothalamus controls sleep, the hormonal and autonomic systems and temperature regulation. In addition: a. It has a high energy need for its size, so it malfunctions early in a shortage of energy b. Can become dysfunctional in conditions like CFS/ME c. a & b d. Hypothalamic dysfunction is not implicated in the CFS/ME paradigm

c. a & b

New information relates bipolar disorder to mitochondrial dysfunction, which opens the door to treating bipolar disease with mitochondrial modulators such as

coenzyme Q10, n-acetyl- cysteine (NAC), acetyl-l-carnitine (ALCAR), SAMe, alpha lipoic acid, creatine monohydrate, and melatonin

Which of the following modes of therapy has been found to be most effective in sustaining abstinence in alcoholism? a. Pharmaceuticals b. Botanicals c. Acupuncture d. Spiritual, 12-step programs e. Physical exercise

d. Connecting to spiritual meaning with the guidance of a 12-step process has been found to be the most effective therapy for alcoholism and requires the most active treatment by the individual. It works much better than passive treatments such as pharmaceuticals, botanicals, or acupuncture. However, a synergistic approach of spiritual meaning in conjunction with these other therapies can add to their effectiveness. (Rakel, CH 83)

3. A 54-year-old woman presents to the clinic with fatigue and irritability. She has had these symptoms for the past eight months. An extensive workup for rheumatologic and medical causes has not revealed any positive findings. She finds it difficult to sit or stand for long periods of time and is considering early retirement. She finds it difficult to concentrate on her work. She finds it difficult to fall asleep at night and feels tired even if she gets adequate sleep. Which of the following infections is most often implicated with the patient's symptoms? a. Acute HIV infection b. Coxsackievirus infection c. Chronic hepatitis C d. Infectious mononucleosis

d. Infectious mononucleosis The clinical vignette is most indicative of a patient with a diagnosis of chronic fatigue syndrome. Chronic fatigue syndrome (CFS) is considered a diagnosis of exclusion. To diagnose CFS, three criteria are used: significantly lowered ability to participate in previously routine physical activities (persisting more than six months), physical or mental activity causing worsening symptoms (post-exertional malaise (PEM), and sleep problems. Moreover, there should be either memory difficulties, or worsening symptoms with standing or sitting. About 60% of cases of CFS are known to occur after a viral illness, such as mononucleosis or gastroenteritis.

8. Melatonin is a. Not likely to benefit those with CFS/ME b. Higher doses (3-4.5 mg) tend to improve sleep more c. Lower dose (0.5 mg) tend to help with GERD more d. Lower doses (0.5 mg) tend to help with sleep more

d. Lower doses (0.5 mg) tend to help with sleep more

The best way to diagnose ADHD is by: a. Experienced clinical intuition b. Experienced teacher intuition c. fMRI and serum choline levels d. Vanderbilt parent and teacher rating scales

d. Vanderbilt parent and teacher rating scales The majority of clinicians use behavioral checklists, such as the Vanderbilt Parent and Teacher Rating Scales, to inform the diagnosis of ADHD and monitor progress. No laboratory or imaging studies are able to confirm the diagnosis, although clinicians often use laboratory or neuropsychological tests to rule out contributory problems, such as hearing or vision problems, anemia, hypothyroidism, absence seizures, reading or math learning disabilities, and short-term memory impairment. (Rakel CH 7)

6. Salt restriction is a. Important in those with CFS/ME as they retain fluids and are susceptible to edema b. Generally not advised since CFS/ME patients may be susceptible to adrenal dysfunction, low blood pressure and orthostatic intolerance c. Something that should be evaluated on a patient by patient basis. d. b & c

d. b & c

7. Acetaminophen a. Is the only medication used in pain management for CFS/ME b. Is a compound that can deplete glutathione if used chronically b. Is sometimes combined with NAC to reduce side effects, such as depleting glutathone d. b & c

d. b & c

The master pleasure molecule, which links and involves most forms of addiction, is ______________

dopamine. The production of dopamine is triggered by use of heroin, amphetamines, marijuana, alcohol, nicotine, cocaine, and caffeine or the activities of gambling or sex.

PD is associated with loss of ______________ neurons of the substantia nigra pars compacta, with the pathological hallmark being intracellular aggregates of α-synuclein, in the form of Lewy bodies and Lewy neurites

dopaminergic

Tyrosine rich foods include:

duck, chicken, ricotta cheese, dark chocolate, and seaweed

Apraxia

impaired ability to carry out motor activities despite intact motor function Studyforxyz CLINICAL INTERVENTION AND MONITORING

4. A 59-year-old woman presents to the clinic with sleeping difficulties, fatigue, and irritability. She has had these symptoms for the past seven months. She finds it difficult to sit or stand for long periods of time. She finds it difficult to concentrate on her work and cannot hold long conversations without losing focus. She used to enjoy yoga about a year ago but has not been able to perform it due to fatigue for the past six months. Extensive workup for rheumatologic and medical causes has not revealed any positive findings. Which of the following is most likely to be discovered on a sleep study in this patient? a. Decreased slow wave sleepb. Decreased sleep efficiency c. Increased sleep latency d. Normal sleeping pattern e. a, b, c

e. a, b, c The clinical vignette is most indicative of a patient with a diagnosis of chronic fatigue syndrome. Chronic fatigue syndrome (CFS) is considered a diagnosis of exclusion. The hallmark symptom is the post-exertional fatigue associated with numerous neurological, cardiovascular, respiratory, as well as gastrointestinal complaints.The fatigue described by patients is not exertional in nature, worsened by low upright posture, not relieved by rest, and no medical reason can be found for it. CFS is associated with multiple sleeping disturbances, including decreased slow wave sleep, decreased sleep efficiency, and increased sleep latency.

A patient with neurological disease may not be able to__________________because of hemianopsia, limb weakness, and apraxia.

eat independently Studyforxyz CLINICAL INTERVENTION AND MONITORING

Rapid and abrupt increases in blood sugar (glucose) can trigger rapid and excessive release of insulin. This is followed by a rapid drop in blood sugar as insulin drives glucose into the cells. The body compensates by raising levels of the compounds _______ and _______, both of which can trigger marked emotional changes and erratic behavior.

epinephrine and cortisol

High ____________ levels in the presence of low vitamin B12 status worsens the enzymatic functions of vitamin B12, which can lead to hyperhomocysteinemia and elevated methylmalonic acid (MMA), and both are associated with cognitive impairment and decline

folate

Riboflavin is involved in determining circulating concentrations of homocysteine and may exert some of its effects by reducing the metabolism of other B vita- mins, notably ______ and _______, of particular interest in psychiatric disorders

folate and vitamin B6

The metabolic consequences of a high ______ intake and a deficiency of omega-3 fatty acids on cognitive abilities was associated with insulin action, signaling mediators, and lower cognitive scores. Insulin is a vasodilator. This vasodilator function is blunted in insulin-resistant individuals, and decreases cerebral circulation

fructose

Higher incidence of PD has been reported in _____________ miners

manganese Studyforxyz CLINICAL INTERVENTION AND MONITORING

Preclinical or early dementia -

may have olfactory and taste dysfunction that may reduce appetite

Tau

microtubule-associated protein - major constituent of neurofibrillary tangles Produced in soluble hyperphosphorylated form when beta-amyloid levels become toxic

In those with frequent (condition), supplementing with 400 mg of riboflavin a day decreased frequency by 50% to 69% after 6 weeks of use

migraines

Per Krause, what is the pathophysiology for CFS?

mitochondrial and/or hypothalamus dysfunction are "common denominators" in the syndrome, noting issues with hormonal, sleep, autonomic control (hypothalamic related) and energy production. A detailed paper by Bested & Marshall (2015) color CFS/ME as "a complex condition that affects every organ system in the body" involving inflammation at cellular and biochemical levels, including the muscles, brain and spinal cord.

Primary tool to screen for alcoholism

ne such tool is the Alcohol Use Disorders Identification Test (AUDIT) developed by the WHO and available at their website. The CAGE questionnaire was commonly used as a screening and evaluation tool for alcoholism (Box 40.3) but has been largely replaced by the AUDIT screening instrument due to its improved sensitivity and specificity

Nutritional considerations for spinal trauma-

provide a high fiber diet, maintain weight, provide enteral or parenteral nutritional support, minimize constipation Studyforxyz CLINICAL INTERVENTION AND MONITORING

The key energy molecules ATP, FADH, and NADH are predominantly _____(carbohydrate) plus B vitamins and phosphate

ribose

Children with attention-deficit hyperactivity disorder had lower blood levels of ____________ than children without ADHD, but had normal copper levels

zinc, ferritin, and magnesium

Nutrition Management for psych disorders:

• DASH or anti-inflammatory diet pattern • Increase ω-3 rich foods and/or supplement • High fruit and vegetable intake for phytochemicals and antioxidants • Weight reduction if needed

Nutrition Assessment for psych disorders:

• Fatty acids • Antioxidants and phytochemicals • Excessive processed foods • Excessive refined carbohydrates Assess for weight changes

Changes in neurotransmitters in psych disorders:

• Production of fewer neurotransmitters • Altered neurotransmitter levels • Changes in neurotransmitter receptor density