Parkinsons

Disease
Kelly Bigley
Giovannia Garcia
Elina Luskina
Andrea Meneses
Elizabeth Neahring

Parkinsons Disease
One of the most common neurological disorders
1% of citizens > 70y/o in US and Canada
Incidence increases with Age
More commonly diagnosed in men
Less common:Asian and African American
populations.

Patient: R.M.
69 y/o Female
Diagnosis: Parkinsons Disease
CC
Every time I eat, something get stuck in my throat. I cough and
feel like I'm choking

HPI
Respiratory symptoms and fever. Increasing difficulty eating,
including coughing and choking during meals. Continued
progression of Parkinson's disease.

R.M.
SH:
Alcohol use: Socially
Tobacco use
Quit over 30 years ago
Medications:
Sinemet,citalopram,esomeprazole,omega-3 fatty acids
Living conditions:
Retired hairdresser, widowed, lives with son(45) and
his wife(42)

Physical Exam
Temp:101.5

BP:135/85

Weight: 90lbs

Height: 60 UBW:110 (6 months previous)

HEENT: Head-Normocephalic; dry, dull hair; sunken cheeks; evidence of temporal

wasting. Throat: Slightly dry mucous membranes without exudates or lesions.
Neurologic: Alert and oriented x 3; decreased blink reflex; positive palmomental;
diminished postural reflexes.
UPDRS: Stage 3: Mild to moderate bilateral disease; some postural instability; physically
independent.
Extremities: Reduced strength, evidence of muscle loss in quadriceps and gastrocnemius;
koilonychias, bilateral tremor
Skin: Warm, dry, poor turgor, angular stomatitis and cheilosis noted on lips.
Chest/lungs: Respirations rapid; crackles, rhonchi noted.
Skin condition: ecchymosis

Abnormal Values
-

Low calcium 8.9 mg/dL

Low albumin 3.2 g/dL
Low cholesterol 109 mg/dL
High WBC 11.9
Low Hgb 11.5
Low mean cell volume 74
Low mean cell Hgb content 28
Low ferritin 11 mg/mL

- Low protein 5.8 g/dL

- Low prealbumin 15 mg/dL
- Low HDL 42 mg/dL
- Low RBC 3.9
- Low Hct 35
- Low mean cell Hgb 23
- High transferrin 392 mg/dL

Pathophysiology

Abnormalities of cells within the substantia nigra

Area of production of the dopamine.
A balance of excitatory(dopamine) and inhibitory
(GABA) neurotransmitters normally maintains
slow, coordinated movement, muscle tone, and
posture.
Progressive loss of dopamine, which causes an
imbalance between excitatory and inhibitory
communication.
Resulting imbalance of neurotransmitters appear

Common Diagnostics Test

No definitive diagnostic test
Evaluation of symptoms and response to treatment allows a
diagnosis to be made.
Presence of tremor, rigidity, and bradykinesia, loss of postural
reflexes, response to treatment with L-dopa.
Staging of Parkinsons disease
Hoehn and Yahr Staging Process
Unified Parkinsons Disease Rating Scale (UPDRS)-assesses
more detail for cognition, behavior, mood, activities of daily
living, and motor skills.

Common Procedures
1. FEES (Fiberoptic Endoscopic Evaluation of Swallowing)
a. Optic laryngoscope is passed transnasally to the hypopharynx.
b. Pts fed varying food consistencies while a monitor shows the
swallowing process on a screen.
2. MBS test (Modified Barium Swallow)
a. X-ray test that evaluates swallowing abilities.
b. Pt consumes food containing barium and the x-ray captures the
food as it moves through the esophagus.
c. Pinpoint the area of weakness in the stages of swallowing.

Dysphagia Severity Scale

Level

Assessment

Level 6-7

Full PO, normal diet

Level 3-5

Full PO, some modifications

Level 2-

Non-oral nutrition necessary

Level 1-

NPO

National Dysphagia Diet

Level Description

Diet

Pureed

Pureed and thickened, lump free, little

or no chewing is required

Mechanically Altered

Moist, soft-textured, easily chewed

Advanced

Excludes hard, dry, sticky, or crunchy

foods, most regular foods

No Restrictions

Regular diet

Dysphagia Diet: Liquid

Texture

Description

Thin

Clear liquids

Nectar-like

Vegetable juices,handmade milkshakes

Honey-Like Consistency of honey at room temperature,

thickeners used
Spoon-thick High viscosity liquid too thick for a straw,
thickeners used

Common Drugs
Carbidopa-levodopa- L Dopa
Sinemet, Parcopa, Stalevo
Dopamine agonists- Mimics effects
of dopamine
Parlodel, Neuprom, Mirapex,
Requip
MAO-B inhibitors- prevents
breakdown of dopamine
Eldepryl, Carbex, Zelapar,Azilect

Common Drugs, cont

Catechol O-methyltransferase (COMT) inhibitorsblocks enzyme that breaks down dopamine
Comtan, Tasmar
Anticholinergics- Controls tremors
Cogentin, Artane
Amantadine- Short-term relief of mild, early-stage
PD.
Symmetrel, Exelon

Surgical Treatments
Few surgical treatments
Deep Brain Stimulation
Generator implanted in pts chest near the collarbone.
Electrical impulses sent to the brain.
Settings are adjustable according to patient needs and are
completed by a surgeon.
Usually initiated in the later stages of PD, especially in
those with an unstable response to levodopa.

R.M.
Pts symptoms in line with progression of disease
Stage 3 on the Unified Parkinsons Disease
Rating Scale (UPDRS)
Expected issues with food consistencies
o Evaluation for dysphagia
o MBS, FEES

Nutrition Assessment:
PMH:
Meds at home:
Sinemet:50mg carbidopa/200mg levadopa 2x/daily
citalopram 20 mg daily
esomeprazole 20 mg daily
omega 3 fatty acids 1000 mg daily
Onset of disease: Diagnosed initially 10 years ago
Medical History: Parkinsons disease
Surgical history: Bilateral salpingo-oophorectomy- reason unknown
(surgical removal of both ovaries and both fallopian tubes.)

Lab Values:
Levels indicating malnutrition: Levels indicating possible anemia
Calcium- 8.9 ml/dL
High Transferrin- 392 mg/dL
Cholesterol- 109 mg/dL
Ferritin- 11mg/mL
Low Hgb-11.5
Low Mean Cell Hgb- 28
Low protein- 5.8 g/dL
Low Mean Cell Volume- 74
Low prealbumin-15 mg/dL Temperature of 101.5 is
Low RBC-3.9
significant
Low Hct-35
Pt is fighting infection
Wt loss of 20lbs in 6 months.
Pt has heightened WBC count
Pt has signs/symptoms of dysphagia and is afraid to eat

Anthropometrics:
Age: 69 y/o WF Ht: 60 152.4 cm Current Wt: 90 lbs(40.9 kg)
BMI: Current 17.6; underweight
UBW: 110 (50 kg.) (currently 82% of her UBW)
IBW: 100 (45 kg.) (currently 90% of her IBW)
Weight loss: 20 lbs. in 6 months (18% = severe weight loss)
EER: (using UBW) 30 kcal/kg=1500 kcal/day
Protein: 1g/kg= 50 g/day
Temp: 101.5 Pulse: 80 Resp rate: 22 BP: 135/85

EER & EPR

Estimated Energy Requirement is 30 kcal/kg*50=1500 kcal
Suggested protein amount is 1 g/kg=50 g protein= 200 kcal
Provide education as to when to take protein and levodopa
medication in order to avoid food/drug interaction.
Protein should not be reduced due to muscle wasting in
older adults.

Diet History
Breakfast- scrambled egg,
slice toast or English muffin (135 kcal),
1 tsp jelly,
coffee with 2% milk and artificial sweetener
Lunch- ham or turkey sandwich, 6-7 chips,
iced tea with artificial sweetener
Dinner- cup spaghetti with c meat sauce,
2-3 tbsp green peas or other vegetable,
fruit cocktail, 1/2 slice bread with 1 tsp butter,
iced tea with artificial sweetener

Calories- 692
Protein-32g, 18%
This is significantly
lower than her ideal of
1500 kcal/day.
Her protein intake is
low 32 g/day, but
should be at 50g/day.

Nutrition Diagnosis
PES#1 Inadequate fluid intake related to dehydration as
evidenced by poor skin turgor and cloudy/amber urine
appearance.
PES#2 Swallowing difficulty related to diagnosis of Parkinson's
disease as evidenced by coughing and choking as reported by
patient.
PES#3 Unintended weight loss related to inadequate energy
intake as evidence by severe weight loss (18%) in 6 months.

Nutrition Intervention
1. Increase fluids to 1500 ml/day
through oral intake and enteral
support.
2. Refer to SPL for swallowing
evaluation in order to determine
appropriate thickened liquids
and pureed foods. Give patient
education handout to take home
on appropriate foods and
textures to eat. Patient agrees to
keep a daily food journal in
order to determine oral intake.

3. Patient will gain 1-3 lbs. a week to reach UBW

within 2 months. Patient will be educated about
protein/drug (Sinemet) interaction and will not have
protein within 2 hours of taking medications.
Collaborate with SPL and gastroenterologist to
recommend and determine if PEG is necessary.
Patient will receive half of daily calories (750 kcal)
from enteral nutrition; bolus feedings, 3 times a day
in addition to 750 kcal of oral intake. Educate and
give handouts to inform about PEG and enteral
formulas.
Check patients understanding of interventions.

Monitoring & Evaluation

1. Follow up appointment in 1 week.
2. Evaluate urine sample to determine level of dehydration and
check for improved skin turgor.
3. Review food journal, discuss changes (improvements and
difficulties) in swallowing. If necessary educate client how to
blenderize food to adjust to food consistencies.
4. Evaluate patients current weight.

TIP
SHEET

Fun Time
Which neurotransmitter is affected by
Parkinson's?
A. Dopamine
B. Acetylcholine
C. Epinephrine
D. Glutamate

A. DOPAMINE

Question 2
What is an MBS?
a.
b.
c.
d.

Modified Barium Swallow

Melbourne Business School
Mortgage Backed Security
Mono-bilateral Syndrome

A. MODIFIED BARIUM
SWALLOW

Question 3
What nutrient affects the uptake of Levodopa?
a. Carbohydrates
b. Protein
c. Fat
d. Water

B. PROTEIN

Question 4
What is a common symptom of Parkinson's?
A. Increased appetite
B. Frequent urination
C. Dysphagia
D. Angina

A. DYSPHAGIA