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Eight years of nutrition intervention for a young person with an acquired brain injury.

Article Excerpt
Abstract

This case is about a 38-year-old man with an acquired brain injury (ABI). It is a qualitative analysis of eight years of nutrition intervention by a private dietetic practitioner in a nursing home setting. For the eight years of nutrition intervention, enteral formula met all his nutrition requirements. Optimal goal weight was reached and stable eight years after the initial injury. In the early postacute period, energy requirements were 16 MJ/day for a goal weight of 70 kg. Today, energy requirements are less than 7 MJ/day to maintain weight at or below 80 kg. Over the eight years, the dietitian reviewed the client 40 times and adjusted the regimen 12 times. Each review was one hour long; monthly reviews for the first four years, then bimonthly. Weight was the main clinical outcome directing nutrition decisions. No gross nutrient deficiencies were incurred. No pressure sores developed. Reflux resolved with changes to medication, enteral formula and regimen. One episode of aspiration pneumonia was recorded. Based on this case study, we recommend nutrition planning for postacute care include a two-hour initial assessment, then one-hour monthly review for the first 12-24 months. Weight should be recorded monthly, and routine biochemistry bimonthly with six-monthly nutrition-specific measures of trace elements, micronutrients, blood glucose, serum lipids, iron studies and protein markers. Long-term nutrition intervention for ABI is a mostly unexplored, challenging and growing area of dietetics. This case study provides preliminary information for developing long-term enteral nutrition services to people with an ABI.

Key words: benchmarking, brain injury, dietitian, enteral nutrition, long term.

INTRODUCTION

Acquired brain injury (ABI) is a major public health problem in Australia affecting 160 000 people, mostly men. (1) People with an ABI are among the most marginalised population in society because they have limited methods of communicating and interacting in society, (2) and only a small number of ABI cases receive ongoing funding. (3)

There are about 80-100 young people with an ABI in nursing homes across Victoria. (2) The number of young ABI cases needing a place in a nursing home is expected to increase with advances in medical care. A nursing home is the only accommodation for young people with an ABI who need 24-hour high-level care. Being placed in a nursing home may slow rehabilitation, because nursing homes are not suited to the intensive treatment people with an ABI need. For this reason, alternative accommodation is actively being sought in Victoria. (4)

There is evidence that a comprehensive and intensive multidisciplinary team is more effective compared with a 'natural recovery' for people with an ABI. (5) Natural recovery means treatment is aimed at convalescence and maintenance, and not treatment directed towards rehabilitation and improvement. Nutrition can affect clinical outcome in the early postacute6 and rehabilitation periods. (5) For this reason, nutrition goals will change over time, consistent with a move towards rehabilitation and improvement.

There is very little published evidence for nutrition intervention and clinical outcomes for long-term enterally fed ABI cases. Current literature for nutrition and ABI focuses on the acute and early postacute period (up to two years post injury). In this early postinjury period, gastrointestinal problems, and a high metabolic rate with high protein and energy requirements (100-160% of basal energy requirements), are well described. (6) Despite this evidence, there is no consensus, or nutrition guidelines, for the acute treatment period. (6,7)

This case study was one of the first in Victoria to obtain funding on the Victorian Government's Acquired Brain Injury: Slow to Recover program. It is one of the longest-running ABI cases in Victoria, where funding has been provided for nutrition services for eight years. This case...

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