Referred for: nutrition assessment related to difficulty swallowing

Transcription

1 Sage Nutrition Science Department - NCP Form Case 24: Progressive Neurologic Disease: Parkinson s Disease Kristen Perrella Patient: R.M. NUTRITION ASSESSMENT Referred for: nutrition assessment related to difficulty swallowing Food and Nutrition Related History: PT states that everything she eats, something gets stuck in her throat. She coughs and feels like she s choking and is afraid to eat. PT s diet based on 24 hour recall indicates inadequate energy consumption (currently consuming ~820kcal) and inadequate protein (35g). PT is not meeting target vitamin and mineral needs with the exception of selenium and sodium with are in the appropriate ranges. PT is consuming inadequate fruit, vegetables, dairy, protein, and grains. Anthropometric Measurements Age: 69 Gender: F Ht: 60 Wt: 90lb/2.2kg/lb= 40.9kg Wt Hx:usually 110lbs (6 months ago) % Wt change: 18% BMI: 17.7 (underweight) Biomedical Data, Medical Tests & Procedures Labs/Date Albumin Glucose HbA1C BUN Creat Na+ K+ Hgb Hct MCV Other 2/ N/A Calcium 8.9 total protein 5.8 prealbumin 15 cholesterol 109 HDL-C 42 WBC 11.9 RBC=3.9 Mean cell Hgb 23 Transferrin 392 Ferritin 11 Mean cell Hgb content Medical Diagnosis/PMH/Relevant Conditions: Parkinson s Disease x 10 years. Presents w/fever and increased WBC count. Dysphagia. Surgical history: bilateral salpingo-oophorectomy. Family history of Alzheimer s disease (mother). Quit smoking over 30 years ago. Pertinent Medications At home: carbidopa/levodopa (antiparkinson), 50/200 mg controlled-release tablet BID; citalopram (antidepressant) 20 mg daily; esomeprazole (proton pump inhibitor/antiulcer) 20 mg daily; omega-3 fatty acid (antihyperlipidemic, anticoagulant, antiarrhythmic, antidepressant recommended for PD patients) 1000 mg daily In hospital: azithromycin (antibiotic) 500mg IV once daily Skin status: x Intact Pressure Ulcer/Non-healing wound; Comments: ecchymosis, poor turgor, pale, Braden score=15 (high risk) Physical Assessment: sunken cheeks, temporal wasting, dull hair Estimated Nutritional Needs Based on Comparative Standards: Using IBW of 45.5 Calories Mifflin-St. Jeor Protein 1g/kg=~46g [10 (wt.) (ht) 5 (age) + 5]*PA = kcal/day Fluid 1mL/kcal=1781mL [10 (45.5 kg) (152.4 cm) 5 (69 years) + 5]*1.2 = kcal/day (for weight gain at 1lb/week) = 1781 kcal/day Diet Order NPO Feeding Ability Independent Limited Assistance Extensive/Total Assistance x N/A Oral Problems Chewing Problem x Swallowing Problem: PT s family states that PT often coughs and appears to choke during Intake Good (> 75%) Fair (approx. 50%) Poor (<50%) Minimal (<25%)

2 No Nutritional Diagnosis at this time NUTRITION DIAGNOSIS P (problem) Inadequate oral intake related to: P (problem) related to: INTERVENTION meals Mouth Pain None of the Above x Proceed to Nutrition Diagnosis Below E (Etiology) dysphagia associated with Parkinson s Disease as evidenced by: E (Etiology) as evidenced by: x NPO S (Signs & Symptoms) patient currently being NPO. S (Signs & Symptoms) Nutrition Prescription: National Dysphagia Diet, Level TBD based on SLP s swallow evaluation; 1781kcal/day to gain weight at 1lb/week, 46g protein, 1781mL fluid. Rx addition of omega 3 fatty acid supplement 1000mg daily based on PD condition and taking the omega 3 at home Food or Nutrient Delivery: Meals and snacks texture-modified diet Supplement omega 3 fatty acid Nutrition Counseling: N/A Goal(s): Dysphagia diet initiated within 24 hours Pt meeting >/=75% of est needs within 4 days of initiating oral diet Maintain or gain weight while in hospital MONITORING & EVALUATION Indicators: Total energy intake Total protein intake Total fluid intake Weight Nutrition education: When patient is ready for discharge, educate patient, son, and daughter-in-law on NDD prescription; how to thicken liquids/how to soften/puree foods to desired consistency. Discuss commercial thickeners available for use. Coordination of Care (refer to): follow up w/ SLP post-swallow eval. Criteria: kcal/day ~46g/day ~1780mL 90lb+ >or=1lb/week *I chose to use her ideal body weight as opposed to R.M. s current weight because her current weight put her at an underweight BMI classification. I chose to add 500kcal to that number so that she would ideally gain weight or maintain weight if she was unable to consume all that was given to her. *The dysphagia diet was not classified because the results of the evaluation from the SLP had yet to be determined.

3 1. Describe our current understanding of the pathophysiology of Parkinson s Disease. Our current understanding involves a combination of genetic etiology and environmental triggers. There is a substantial loss of both dopaminergic neurons in the substantia nigra and tyrosine hydroxylase, the ratelimiting enzyme for dopamine. Genetically, over 10 genes have been identified as causing familial Parkinson s Disease (PD). Endogenous toxins from cellular oxidative reactions are also believed to play a role in the loss of dopaminecontaining neurons and increase in monoamine oxidase. Toxins are produced when the monoamine oxidase is metabolized, causing endogenous toxins which cause the peroxidation of membrane lipids as well as cell death. Environmentally, neuroleptics or metoclopramide has side effects which may cause PD. Folate, elevated plasma homocysteine levels, fiber, and caloric deficits are currently being researched as having an association with PD. Vitamin B6 may reduce one s risk of PD. Exposure to chemicals and toxins, as in farming communities with pesticides, is also associated with PD incidence, although specific chemicals and toxins have yet to be identified. 2. How does this pathophysiology translate into the cardinal signs and symptoms of Parkinson s? Which may contribute to nutritional risk? Which of these are noted in Mrs. McCormicks history and physical? The cardinal signs and symptoms of PD include slow and decreased movement, muscular rigidity, resting tremor, postural instability, and decreased dopamine transmission to the basal ganglia. The decreased dopamine transmission is a result of the loss of the domapinergic neurons in the substantia nigra and the rate-limiting enzyme for dopamine, tyrosine hydroxylase. The other symptoms are likely to be a result of the peroxidation of membrane lipids and the cell death caused by the metabolism of monoamine oxidase, a toxin. The resting tremor may increase an individual with PD s resting energy expenditure; however the slow and decreased movement could cancel that out or call for a decrease in maintenance calories. Muscular rigidity may contribute to nutritional risk but that could make it more difficult to perform self-feeding as it interferes with the ability to control the position of the head and trunk. Additionally, this causes one to eat very slowly, so meals can take up a lot of time. Dysphagia is a late complication, but it can cause nutritional risk because one may be unable to swallow and consume adequate calories and there is a risk of aspiration. RM s history and physical states that according to her BMI, she is underweight, which could again be the result of the resting tremor. 3. Identify and describe the primary medical interventions that are used for the treatment of Parkinson s Disease. L-dopa, a precursor to dopamine, controls sympoms. Exelon, a cholisterase inhibitor, was recently approved by the FDA (in 2006) for those with PD who exhibit mild to moderate dementia. Pharmacoheapy agents, surgical interventions, and physical therapy are the best aiding therapies. 6. Define dysphagia. What medical and nutritional complications may be associated with dysphagia? Dysphagia is difficulty swallowing. Symptoms may include drooling, choking, coughing during or following meals, inability to suck rom a straw, a gurgly voice quality, holding pockets of food in the buccal recesses absent gag reflex, and chronic upper respiratory infections. A medical complication associated with

4 dysphagia is aspiration, and nutritional complications include not consuming adequate energy/protein. Patients with MS ALS, dementia, and intermediate or late-stage PD are likely to have dysphagia. 8. What is an MBS? What information will this test provide? An MBS, or a modified barium swallow test, is where barium coats the tongue, throat, mouth, and esophagus so that they will show up in x-rays. The test will provide information as to where the difficult swallowing occurs, or if aspiration is taking place which part of the throat is lacking coordination. Source: After examining Mrs. McCormick s 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? Signs that alert to a nutrient deficiency include being underweight, losing 18% of bodyweight over 6 months, her dull air, sunken cheeks, temporal wasting, dysphagia, as well as her low lab values including calcium, protein, albumin prealbumin, cholesterol, HDL, RBC, hemoglobin, hematocrit, mean cell volume, mean cell Hgb, mean cell Hgb content and ferritin (see question 14). The anorexia is likely due to her PD medication (carbidopa/levodopa). To assess her risk for malnutrition, I can utilize the malnutrition universal screening tool (MUST). Some assessments include whether she exhibits muscle wasting, bowel irregularity, limited or low income, GI complications, immobility, visual impairments, to name a few. The swallow test will help to further assess Mrs. McCormick s risk once her phase/dysphagia diet is established. I could also ask about what liquids she is currently drinking besides the iced tea. 14. Evaluate Mrs. McCormick s laboratory values. List all abnormal values and explain the likely cause for each abnormal value. Transferrin increased due to depleted iron stores RBC=3.9 --nutritional deficits; cell death associated with PD WBC likely due to due to infection (her fever), and stress HDL-C 42 --low, likely due to inadequate overall diet cholesterol likely due to protein-calorie malnutrition prealbumin 15 --likely due to inflammatory stress; can also be due to a zinc deficiency as zinc is required for hepatic synthesis of prealbumin total protein 5.8 Calcium likely due to vitamin D deficiency and/or magnesium deficiency Ferritin 11 --due to low iron stores Albumin due to acute inflammatory disease Hgb low because of nutritional deficits; also because of PD and the associated cell death Hct 35 --low because of nutritional deficits; also low because of PD and the associated cell death MCV 74 --likely microcytic/decreased because if an iron deficiency Mean cell Hgb 23 --same as mean cell volume; due to an iron deficiency Mean cell Hgb content decreased in those with iron deficiency

5 16. Assess Mrs. McCormick s diet prior to having difficulty swallowing. Compare her energy and protein intakes to her estimated nutrient needs. Overall, her diet is lacking in most areas including calories, protein, fat, as well as fruit, vegetable, grain, and dairy intake. She is currently consuming 823kcal/day while her needs are estimated to be ~1280kcal or ~1780kcal to gain weight. She is currently consuming 35g of protein, though she needs ~46g protein. Nutrients Target Average Eaten Status Total Calories 2000 Calories 823 Calories Under Protein (g)*** 46 g 35 g Under Protein (% Calories)*** 10-35% Calories 17% Calories OK Carbohydrate (g)*** 130 g 114 g Under Carbohydrate (% Calories)*** 45-65% Calories 55% Calories OK Dietary Fiber 25 g 10 g Under Total Fat 20-35% Calories 28% Calories OK Saturated Fat < 10% Calories 9% Calories OK Monounsaturated Fat No Daily Target or Limit8% Calories No Daily Target or Limit Polyunsaturated Fat No Daily Target or Limit8% Calories No Daily Target or Limit Linoleic Acid (g)*** 12 g 7 g Under Linoleic Acid (% Calories)*** 5-10% Calories 7% Calories OK α-linolenic Acid (g)*** 1.1 g 0.4 g Under α-linolenic Acid (% Calories)*** % Calories 0.4% Calories Under Omega 3 - EPA No Daily Target or Limit1 mg No Daily Target or Limit Omega 3 - DHA No Daily Target or Limit27 mg No Daily Target or Limit Cholesterol < 300 mg 168 mg OK Minerals Target Average Eaten Status Calcium 1000 mg 211 mg Under Potassium 4700 mg 1365 mg Under Sodium** < 2300 mg 1542 mg OK Copper 900 µg 766 µg Under Iron 18 mg 7 mg Under Magnesium 310 mg 120 mg Under Phosphorus 700 mg 421 mg Under Selenium 55 µg 67 µg OK Zinc 8 mg 5 mg Under

6 Vitamins Target Average Eaten Status Vitamin A 700 µg RAE 180 µg RAE Under Vitamin B6 1.3 mg 0.8 mg Under Vitamin B µg 0.9 µg Under Vitamin C 75 mg 11 mg Under Vitamin D 15 µg 1 µg Under Vitamin E 15 mg AT 5 mg AT Under Vitamin K 90 µg 44 µg Under Folate 400 µg DFE 298 µg DFE Under Thiamin 1.1 mg 0.7 mg Under Riboflavin 1.1 mg 1.0 mg Under Niacin 14 mg 13 mg Under Choline 425 mg 159 mg Under 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 modification. 3 solid levels 1. Level 1: dysphagia: pureed diet consists of pureed, homogenous and cohesive foods. Food should be puddinglike. No coarse textures, raw fruits or vegetables, nuts, etc. allowed. Any foods that require bolus formation, controlled manipulation, or mastication are excluded. 2. Level 2: dysphagia: mechanically altered characteristics consists of foods that are moist, soft-textured, and easily formed into a bolus. Meats are ground or are minced no larger than ¼ inch pieces; they are still moist, with some cohesion. All foods from NDD Level 1 are also acceptable. 3. Level 3: dysphagia: transition to regular diet consists of food of nearly regular textures with the exception of very hard, sticky, or crunchy foods. Foods still need to be moist and should be in bite-size pieces at the oral phase of the swallow. 4 liquid levels (in order of least to most viscous) 1. Thin (unthickened) centipoise (cp) e.g. water, tea, soda, ice cream, frozen yogurt, gelatin 2. Nectar-like cp e.g. nectars, vegetable juices, milk shakes, 3. Honey-like 351-1,750 cp e.g. the texture of honey at room temperature, or achieved via commercial thickeners or premade drinks for dysphagia 4. Spoon-thick - >1,750 cp e.g. pudding or liquids too thick for a straw; can be achieved via commercial thickeners or premade drinks for dysphagia Source: