FN 418/618: Medical Nutrition Therapy II Spring 2017

Progressive Neurological Disease: Parkinsons Disease

Dakota Cossairt

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give more information with the 24-hour recall vs just stating how many kcals she is eating

PES statement: why is she have difficulty consuming sufficient kcals? this is what your etiology should be

you will need to wait and see what the speech therapist recommends for a diet before providing education

your nutrition prescription is different than the amount of kcals you recommended above in the assessment
how many kcals do you recommend for her

when will you see her again?

A Rita McCormick is a 69 yo female with Parkinsons disease. She lives with

her son and his wife. Family states she has had increasing difficulty eating.
She stated that every time she eats, something gets stuck in her throat. She
often coughs and appears to choke during meals and is scared to eat. She
previously ate solid foods, but is now NPO due to difficulty swallowing. She
has lost 20# within the past 6 months.

Physical findings include dry, dull hair; sunken cheeks; evidence of temporal
wasting; reduced strength; evidence of muscle loss.

Medications include Sinemet, esomeprazole, and a daily omega-3-fatty acid.

Family medical history includes mother with Alzheimers and father with
CAD.

Lab values indicate increased levels of transferrin and WBC, and decreased
levels of RBC, Hgb, Hct, calcium, total protein, albumin, cholesterol, HDL-C,
and ferritin.
Nutritional intake from 24-hr recall = 850 kcals

Ht. = 60 Wt. = 90# UBW= 110# %UBW = 81.8% BMI = 17.6

BP = 135/85

Recommended kcals = 1230-1430 kcal/day

Recommended protein = 40-50 grams/day

Recommended fluid intake = 1700 mL/day

D Inadequate oral intake R/T decreased ability to consume sufficient

calories AEB low total protein and albumin levels, involuntary weight loss,
difficulty swallowing food and consumption of a liquid diet.

I Recommend patient to get 1600-1825 kcals/day with 50% carbohydrates,

30% protein, and 20% fat. RD recommends patient to focus on weight
gain/maintenance and to prevent further weight loss. RD will educate and
counsel on calorie-dense food items including eating smaller, more frequent
meals and snacks.

ME Schedule f/u. Will monitor pertinent lab values and have patient keep a
food diary. Will also monitor weight.
1-Day Meal Plan
Breakfast
2 slices of WW bread w/ peanut butter & jelly
1 poached egg
1 piece of fruit
8 oz. fruit juice
Lunch
Turkey Salad
1 cups chopped turkey breast (w/o skin)
1 cup diced celery
3 cups raw red apples w/ skin
cup chopped pecans
3 tbsp. mayonnaise
1 tbsp. cranberry French dressing
Snack
2 cups popcorn (no added salt or butter)
8 oz. fruit juice
Dinner
1 cup pasta noodles
cup meat sauce (marinara)
2 tbsp. parmesan cheese
1 cup cooked broccoli and carrots
8 oz. fruit juice
Questions
1. Describe our current standing understanding the
pathophysiology of Parkinsons disease.
a. Parkinsons is a progressive, disabling, neurogenerative disease.
There is a gradual loss of dopaminergic neurons in the substantia
nigra portion of the midbrain. There is also a loss of the rate-
limiting enzyme for dopamine. There is no exact cause for the
loss of these cells. It is possible that it could be due to genetics
and/or environmental factors.

2.
a. How does this pathophysiology translate into the cardinal
signs and symptoms of Parkinsons?
i. The signs and symptoms of Parkinsons include decreased
transmission of dopamine to the basal ganglia, muscular
stiffness, decreased movement/muscle function, postural
instability and resting tremors.

b. Which may contribute to nutritional risk?

i. All the signs and symptoms of Parkinsons may contribute
to nutritional risk, because they make eating difficult and
dangerous.

c. Which of these are noted in Mrs. McCormicks history and

physical?
i. Decreased movement/muscle function
1. Trouble swallowing
 2. Often choking on foods
ii. Resting tremors
1. Bilateral tremor
iii. Postural instability
1. Diminished postural reflexes

4. Identify and describe the primary medical interventions that

are used for treatment of Parkinsons disease.
a. Medications that increase dopamine or replace it can be used to
help improve the symptoms of Parkinsons. The main medication
for this is Carbidopa/Levodopa (Sinemet). Also, some surgical
interventions and physical therapy can be used as interventions
to treat the disease.

5. One of the major medications used to treat Parkinsons is

levodopa. How does diet potentially play a role in this
medications efficacy? Identify all drug-nutrient interactions
for Mrs. McCormicks prescribed medications.
a. Levodopa nausea, vomiting, loss of appetite, change in sense
of taste, fatigue, abdominal pain, and dryness of mouth, nose or
throat.

6. Define dysphagia. What medical and nutritional complications

may be associated with dysphagia?
a. Dysphagia is defined as difficulty or discomfort in swallowing.
b. With having difficulty or discomfort swallowing, it puts the
patient at high risk for choking or aspiration.
c. Patients with dysphagia are also at a high risk for malnutrition, as
dysphagia is often accompanied by inadequate intake.

10. Mrs. McCormicks MD discusses the potential for the

placement of a PEG tube for this patient. Provide any
justification for nutrition support using the appropriate
criteria.
a. Inability to consume adequate nutrition orally due to problems
swallowing
b. Decreased motor ability with history of progressive Parkinsons
disease
c. Increased nutritional needs as evidenced by a 20# weight loss.

11. There are a number of supplements that have been

studied as components of Parkinsons treatment. Discuss the
use of coenzyme Q, omega-3-fatty acids, and creatine and their
potential efficacy for patients with Parkinsons.
a. Coenzyme Q
 i. It slows the progressive deterioration of function in
Parkinsons and improves respiratory chain activity.
b. Omega-3-fatty acids
i. Omega-3s play a crucial role in the maintenance of normal
neurological function. People with Parkinsons are often
deficient in omega-3.
c. Creatine
i. Effective in preventing or slowing the progression of
Parkinsons because of its pro-mitochondrial effect. It is
critical in maintaining cellular energy homeostasis and has
proven to be neuroprotective.

12. Evaluate Mrs. McCormicks weight by calculating her BMI

and %UBW.

90#/2.2kg = 40.9 kg
60*2.54cm = 152.4 cm / 100m = 1.524m*1.524m = 2.32m2

BMI 40.9/2.32 = 17.6

%UBW (90#/110#) * 100 = 81.8%

13. 13. After examining Mrs. McCormicks history and

physical, identify any clinical signs and symptoms that may
alert you to a nutrient deficiency. What further assessments
can you make to assess her risk for malnutrition?
a. Avoidance of solid foods
b. Difficulty swallowing coughing & choking during meals
c. 20# weight loss in last 6 months
d. NPO
e. Altered lab values
f. Dry, dull hair
g. Sunken cheeks
h. Evidence of temporal wasting
i. Reduced strength
j. Evidence of muscle loss.
k. For further assessment, I would consult a speech pathologist for
swallow evaluation, and assess/monitor drug-nutrient
interactions.

14. 14. Evaluate Mrs. McCormicks lab values. List all

abnormal values and explain the likely cause for each
abnormal value.
a. Increased levels of
i. Transferrin
 1. Iron deficiency
ii. WBC
1. Inflammation and stress
b. Decreased levels of
i. RBC
1. Due to her overall state of malnutrition
ii. Hgb
1. Decreased RBC
iii. Hematocrit
1. Malnutrition
2. Iron deficiency
iv. Calcium
1. Probably due to deficiency in her diet
v. Total protein & Albumin
1. Likely due to decreased protein intake
2. Inflammation and stress
vi. Cholesterol & HDL-C
1. Decreased intake of fruits, vegetables, and whole
grains
vii. Ferritin
1. Iron deficiency

15. Determine Mrs. McCormicks energy and protein

requirements. Explain the rationale for the method you used to
calculate these requirements.

Energy Requirements = 30-35 kcals/kg BW

Protein Requirements = 1.0-1.2 grams/kg BW

40.9*30 = 1,227
40.9*35 = 1,432
Recommended kcals = 1230-1430 kcal/day

40.9*1.0 = 40.9
40.9*1.2 = 49.08
Recommended protein = 40-50 grams/day

16. Assess Mrs. McCormicks diet prior to having difficulty

swallowing. Compare her energy and protein intakes to her
estimated nutrient needs.
a. According to Mrs. McCormicks prior intake, she was receiving
about 850 kcals and about 35g of protein. Her estimated nutrient
needs are 1500-1600 kcals/day and 45-50g of protein/day. She
was also lacking in fat, fruit, vegetables, grain and dairy intake.
 b. Under in calcium, potassium, copper, iron, magnesium,
phosphorus, zinc, vitamin A, B6, B12, C, D, E, K, folate, thiamin
riboflavin, niacin, and choline.

17. Identify at least two pertinent nutrition problems and the

corresponding nutrition diagnosis.
a. Malnutrition
i. Related to Parkinsons disease and dysphagia
ii. Evidenced by unintentional weight loss, inadequate energy
intake, patient being scared to eat, decreased muscle, and
decreased total protein, albumin levels
b. Unintended weight loss
i. Related to inability to consume foods
ii. Evidenced by unintentional weight loss, muscle loss, and
temporal wasting.
c. Inadequate energy intake
i. Related to inability to consume sufficient energy
ii. Evidenced by unintentional weight loss, NPO diet, and
difficulty wallowing

18. Write your PES statement for each nutrition problem.

a. Malnutrition R/T difficulty swallowing AEB decreased muscle
mass, unintentional weight loss, and decreased total protein &
albumin levels.
b. Inadequate oral intake R/T decreased ability to consume
sufficient calories AEB low total protein and albumin levels,
involuntary weight loss, difficulty swallowing food and
consumption of a liquid diet.

19. The National Dysphagia Diet defines three levels of solid

foods and four levels of fluid consistency to be used when
planning a diet for someone with dysphagia. Describe each of
these levels of diet modifications.
a. Level 1 Pureed Diet
i. Moderate to severe dysphagia
ii. Foods are smooth, homogenous, very cohesive, pudding-
like, and require very little chewing
b. Level 2 Mechanically Altered Diet
i. People with some chewing ability
ii. Foods are moist and include bite sized cooked vegetables
and soft meats
iii. Requires some chewing
c. Level 3 Advanced Diet
i. Patients in transition to a regular diet
ii. Most liberal
 iii. Foods consist of regular textures except hard, sticky, or
crunchy foods
iv. Bite-sized pieces
d. Liquid Consistency
i. Thin normal consistency unthickenend liquids
ii. Nectar-like slightly thicker than thin applesauce
iii. Honey-like consistency of honey medium thickness
iv. Spoon-like pudding thickest consistency

20. The Dysphagia Outcome and Severity Scale (DOSS) is

used to determine the nutrition prescription for a patient.
Discuss this scale and how it corresponds to the level of
dysphagia diet that is recommended.
a. The DOSS scale is a 7-point scale that rates the functional
severity of dysphagia. It is based on objective assessment and
includes recommendations for diet level and diet modifications,
independence level, and type of nutrition.
i. Level 1 severe: NPO: unable to tolerate any P.O. safely
ii. Level 2 moderately severe: maximum assistance and
maximum use of strategies for partial oral intake
iii. Level 3 moderate: total assist with modified texture of
food; 2 or more diet consistencies restricted
iv. Level 4 mild to moderate: intermittent supervision or
cueing with 1-2 diet consistencies restricted
v. Level 5 mild: distant supervision and may need 1 diet
consistency restricted
vi. Level 6 within functional limits: modified independence
with a normal oral diet; functional swallow
vii. Level 7 normal diet in all situations

21.
22. The FEES and MBS indicate the following: patient
demonstrates difficulty initiating the swallow and bolus was
held in the mouth for an excessive amount of time. Spillage
into the larynx is noted with some aspiration. Identify the diet
you would recommend at this time.
a. I would rate this patient as a level 1 on the DOSS scale. The diet I
would recommend at this time would be a liquid consistency diet.

23. Using the data collected during your nutrition

assessment, what vitamin and mineral supplements would you
recommend?
 a. Under in calcium, potassium, copper, iron, magnesium,
phosphorus, zinc, vitamin A, B6, B12, C, D, E, K, folate, thiamin
riboflavin, niacin, and choline.
b. Thiamin, niacin, and B12

24. Identify factors that you will need to monitor to ensure

adequacy of her nutrition intervention.
a. Weight and nutritional intake
b. Pertinent lab values