Parkinson’s Disease Nutritional Issues

Parkinson’s Disease

Parkinson’s Disease is a progressive neurogenerative disease first described in 1817¹. It is a collection of symptoms which include bradykinesia which is the slowness of movement, rigidity which is having stiff muscles, and tremor of body parts when the patient is at rest¹. These motor features are three of the most common symptoms seen in patients with Parkinson’s Disease¹. Other symptoms of Parkinson’s include postural instability, dysarthria which is difficulty with speech due to muscle weakness, and dystonia which is repetitive muscle contraction in parts or sometimes the entire body¹. The disease is difficult to diagnose so the patient must be seen by a specialist that will rule out other motor disorders and get an understanding of the patient’s medical history¹. The Unified Parkinson’s Disease Rating Scale (UPDRS) is a tool for physicians to use to determine if the patient has the disease². It is an extensive form that rates the patient’s symptoms on two different scales to determine the likelihood of disease. Multiple sections for dates are allotted to test periodically and symptoms are revealed over time. The cause of the disease is still unknown but is thought to be associated with the combination of many factors, some being genetics, the environment, and loss of dopamine cells produced (which is associated with aging) ². Age is one of the most common factors seen with the disorder, with an average age of 60-year-old at diagnosis². Because there is no cure for the disease, a large focus for care providers is prevention and managing symptoms. Patients with Parkinson’s Disease are at risk for problems associated with nutrition which allows for the management of the disease to be a multidisciplinary approach- involving dietitians, speech-language pathologists, mental health professionals, neurologists, occupational therapists, physical therapists, and social workers³. Parkinson’s is one of the most common neurological disorders¹. This progressive disease can be many things to a patient: painful, embarrassing, frustrating, upsetting, emotional, etc. The disease impacts motor and nonmotor functions that alter normal functioning. Depending on the severity and rate of progression, the disease can also be extremely upsetting for the patient’s family and friends offering their support.

Parkinson’s disease has been shown to begin with symptoms that are nonmotor- making it especially difficult for care providers to diagnose if the distinctive motor features that make the disease more detectable are not present¹. These include depression, sleeping problems, anxiety, impairment of the senses, pain, and cognitive impairment ranging from memory issues to the struggle of completing tasks that are more advanced. These non-motor symptoms are typically in seen the early stages of the disease which lasts about four to six years¹. Research has shown that the loss of cells that produce dopamine in the brain is what causes the known symptoms of the disease². Dopamine is produced by the substantia nigra². The substantia nigra is a portion of the structures in the extrapyramidal system that controls involuntary movement². Dopamine is the excitatory neurotransmitter and GABA is the inhibitory neurotransmitter that when in balance, will control movement that is coordinated, control posture, and muscle tone². As more neurons responsible for relaying dopamine signals are destroyed, the balance of excitatory and inhibitory will be disrupted, and patients will experience disruption of movement and the motor symptoms of the disease¹. Lewy bodies are abnormal clumps of protein that are deposited into cells⁴. These deposits will interfere with normal functioning and communication of the brain⁴. The clumps formed will cause neurons to not work as well and they will eventually die off⁴. Lewy bodies can disrupt normal thoughts, behavior, movement, and mood⁴. The brain regions responsible include the cerebral cortex, the limbic system including the hippocampus, the midbrain, the basal ganglia, and the brain stem⁴. Damage of neurons in the cerebral cortex can cause disruption to multiple lobes in the brain of higher functioning like thinking, processing, understanding, memory, cognition, posture, movement, and more⁵. The limbic system is where emotions, learning, and memory are processed⁵. The midbrain and basal ganglia are where motor movements are processed⁵. The brainstem is important for autonomic functions⁵. The rate destruction of neurons that are responsible for these functions determines when the symptoms of the disease will present themselves. With symptoms of Parkinson’s comes major nutritional risk and intervention for care providers.

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Parkinson’s Disease can put those who are affected at risk for nutritional problems including weight loss and malnutrition². As the severity of symptoms increase, the risk for malnutrition will increase as well. The symptoms that are presented in the disease that cause the patient to be at high risk for poor nutrition include a decrease in ability to self-feed, decreased appetite, chewing and swallowing problems, inadequate fluid and oral intake, and drug-nutrient interactions². Resting tremor is a motor symptom of Parkinson’s disease that can cause patients trouble with self-feeding². Tremor can cause patients to exert more effort at meal times, causing fatigue and poor intake². Adaptive equipment for Parkinson’s can help patients keep their independence when experiencing such symptoms⁶. Weighted utensils, travel cups with lids or straws attached, and scoop plates are all assisted devices that can help to increase intake and decrease patient frustration and loss of independence⁶. Patients can also benefit from help from caregivers during mealtimes, as well as allowing patients with Parkinson’s to have more time to eat their meal². If problems still persist, mechanical alterations can be made to food to make mealtimes easier². Dry mouth- or xerostomia in Parkinson’s is a nutritional problem caused by the action of excessive swallowing or from the side effect of some medications². If dry mouth is not treated, it can be hard for patients to speak and eat, causing a downward spiral of problems including decreased intake and also dysphagia². Foods can be moistened to help with chewing and swallowing difficulties. The lack of saliva and also impairment of motor muscles in the throat can cause a decreased intake and pose a risk for choking². Patients can be assessed by a speech-language pathologist to determine what level of dysphagia the patient is at². Some diets may need to be altered in order to match a consistency that will allow the patient to consume food safely and in appropriate amounts for their needs². If the patient is still not consuming enough through the oral route, they can benefit from nutrition support². With altered GI function, patients may experience gastroparesis². The initial recommendation for this problem is to encourage small, more frequent, low fat and low fiber meals to increase the likelihood of digestion². Delayed emptying of the stomach can attribute to patient feelings of fullness, nausea, and loss of appetite². To prevent malnutrition, patients with gastroparesis may benefit from enteral feeding passing the stomach and letting nutrients enter through the duodenum². Dehydration is another nutritional risk for patients with Parkinson’s disease and can be hard to resolve if patients are depressed, fatigued, or if they are having trouble with swallowing². Dehydration can result in constipation². Small and frequent sips of water should be encouraged and alternate routes for hydration should be implemented if needed². If patients are losing weight unintentionally, the dietitian can work with the patient to brainstorm ways the patient can increase their intake by increasing nutrient dense foods, providing the patient with supplements, and extending meal times². Enteral feeding is a way that the health care team can monitor the patient’s specific nutritional needs and meet them through a formula². If patients choose enteral support, they should be receiving bolus feedings in order for medications to be administered in between feedings to ensure optimal levels are available for absorption². Long term nutrition support is also an option for patients who are continuously at high risk for malnutrition and may need more assistance². The choice of nutrition support poses a quality of life decision that is made between the patient, the patient’s medical team, and the patient’s family/caregivers. Research has shown that patients that have a say in the outcome of their medical plan have a better quality of life. Drug-nutrient interactions must be taken into account when working with patients with Parkinson’s disease². Patients will need to be educated on how to take their medications and what foods to avoid in order to prevent disruption of absorption from either medications or nutrients which are both extremely important in the management of the disease².

References

1. DeMaagd G, Philip A. Parkinson’s Disease and Its Management: Part 1: Disease Entity, Risk Factors, Pathophysiology, Clinical Presentation, and Diagnosis. P T. 2015;40(8):504-32.

2. Nelms, Marcia; Sucher, Kathryn P.. Nutrition Therapy and Pathophysiology. Cengage Learning. Kindle Edition. Published 2011. Accessed January 21, 2019.

3. Downward E. Choosing Your Healthcare Team: Who Needs to be Involved? ParkinsonsDisease.net https://parkinsondisease.net/diagnosis/assembling-healthcare-team/. Published March 2017. Accessed January 21, 2019.

4. What Is Lewy Body Dementia? National Institute on Aging. https://www.nia.nih.gov/health/what-lewy-body-dementia. Accessed January 25, 2019.

5. Anatomy of the Brain. Brain Anatomy, Anatomy of the Human Brain. https://mayfieldclinic.com/pe-anatbrain.htm. Accessed January 25, 2019. 

6. Downward E. Useful Assistive Devices for Parkinson’s Disease. ParkinsonsDisease.net. https://parkinsonsdisease.net/living-with-pd/assistive-devices/. Published March 2017. Accessed January 25, 2019.