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Parkinson’s Disease Kelly Bigley Giovannia Garcia Elina Luskina Andrea Meneses Elizabeth Neahring

Parkinson’s

Disease

Kelly Bigley Giovannia Garcia Elina Luskina Andrea Meneses Elizabeth Neahring

Parkinson’s 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.

Patient: R.M. ● 69 y/o Female ● Diagnosis: Parkinson’s Disease ● CC ○ “Every time I

● 69 y/o Female

● Diagnosis: Parkinson’s 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 protein 5.8 g/dL

 

-

Low albumin 3.2 g/dL

- Low prealbumin 15 mg/dL

-

Low cholesterol 109 mg/dL

 

- Low HDL 42 mg/dL

 

-

High WBC 11.9

 

- Low RBC 3.9

 

-

Low Hgb 11.5

 

- Low Hct 35

 

-

Low mean cell volume 74

 

- Low mean cell Hgb 23 - High transferrin 392 mg/dL

-

Low mean cell Hgb content 28

-

Low ferritin 11 mg/mL

 

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 Parkinson’s disease

○ Hoehn and Yahr Staging Process

○ Unified Parkinson’s 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

1

Pureed

Pureed and thickened, lump free, little or no chewing is required

2

Mechanically Altered

Moist, soft-textured, easily chewed

3

Advanced

Excludes hard, dry, sticky, or crunchy foods, most regular foods

4

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

Neuprom, Mirapex, Requip ● MAO-B inhibitors- prevents breakdown of dopamine ○ Eldepryl, Carbex, Zelapar,Azilect

○ Eldepryl, Carbex, Zelapar,Azilect

Common Drugs, cont

Catechol O-methyltransferase (COMT) inhibitors- blocks 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 pt’s 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.

Pt’s symptoms in line with progression of disease

● Stage 3 on the Unified Parkinson’s 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: Parkinson’s disease Surgical history: Bilateral salpingo-oophorectomy- reason unknown (surgical removal of both ovaries and both fallopian tubes.)

Lab Values:

● Levels indicating malnutrition:

○ Calcium- 8.9 ml/dL

○ Cholesterol- 109 mg/dL

○ Low Hgb-11.5

○ Low protein- 5.8 g/dL

○ Low prealbumin-15 mg/dL

○ Low RBC-3.9

○ Low Hct-35

● Wt loss of 20lbs in 6 months.

● Levels indicating possible anemia

○ High Transferrin- 392 mg/dL

○ Ferritin- 11mg/mL

○ Low Mean Cell Hgb- 28

○ Low Mean Cell Volume- 74

● Temperature of 101.5 is significant

○ Pt is fighting infection

○ Pt has heightened WBC count

○ Pt has signs/symptoms of dysphagia and is afraid to eat

Anthropometrics:

Age: 69 y/o WF

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

Ht: 60” 152.4 cm Current Wt: 90 lbs(40.9 kg)

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- ½ scrambled egg, ½ slice toast or English muffin (135 kcal), 1 tsp jelly, coffee with 2% milk and artificial sweetener Lunch- ½ ham or turkey sandwich, 6-7 chips, iced tea with artificial sweetener Dinner- ¾ cup spaghetti with ½ 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 ½ 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 patient’s 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 patient’s current weight.

TIP

SHEET

TIP SHEET
TIP SHEET

Fun Time

Which neurotransmitter is affected by Parkinson's?

B. Acetylcholine

C. Epinephrine

A. Dopamine

D. Glutamate

A. DOPAMINE

A. DOPAMINE

Question 2

What is an MBS?

a. Modified Barium Swallow

b. Melbourne Business School

c. Mortgage Backed Security

d. Mono-bilateral Syndrome

A. MODIFIED BARIUM SWALLOW

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