Assessment and Diagnosis
Figure 2. Algorithm for Nutrition Management
Diagnosis: ALS
Nutritional education
including PEG
b
Nutritionist or
speech therapist
referral
Monitor
respiratory status
▶ Anesthesia evaluation
▶ Experienced
gastroenterologist
▶ Respiratory support during
PEG if needed
FVC <30%
a
Bulbar questions in the Amyotrophic Lateral Sclerosis Functional Rating Scale or other instrument.
b
Percutaneous endoscopic gastrostomy: rule out contraindications.
c
Prolonged mealtime, ending meal prematurely because of fatigue, accelerated weight loss due to poor
caloric intake, family concern about feeding difficulties.
PEG accepted
▶ Oral intake as tolerated
▶ Enteral nutrition via
PEG as needed
PEG declined
▶ Oral intake as tolerated
▶ Palliative IV hydration
▶ Palliative NG feeding
Low risk for PEG
High risk
Moderate risk
Symptom progression
c
or continued weight loss
Clinic visits every 3 months
Clinic visits every 3 months
Early dysphagia detected
Monitor body
weight;
Dysphagia
assessment
instrument
a
Assessment and Diagnosis
Î Screening for cognitive and behavioral impairment should be considered (B).
Screening tests of executive function may be considered to detect cognitive
impairment prior to confirmation with formal neuropsychological evaluation (C).
However, there are insufficient data to support or refute treatment to optimize
communication, treatment of cognitive or behavioral impairment, or the impact of
cognitive or behavioral impairment on management of ALS (U).
Î There is insufficient evidence to support or refute any specific method of
disclosing the diagnosis (U).
Text in bold = evidence-based
Text in italics = consensus-based
PEG, percutaneous endoscopic
gastrostomy
Discuss PEG to stabilize weight
and possibly prolong survival
FVC >50%
FVC 30-50%
