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Case Study #6 (23)
Jody Gill
Submitted on April 8, 2009
Parkinson’s Disease with Dysphagia
1.
Describe Parkinson’s disease.
Parkinson’s disease is a disorder that affects nerve cells, or neurons, in a part of the brain that
controls muscle movement. It occurs when certain cells (neurons) in a part of the brain called the
substantia nigra die or become impaired. Normally, these cells produce a vital chemical known as
dopamine. Dopamine allows smooth, coordinated function of the body’s muscles and movement.
When approximately 80% of the dopamine-producing cells are damaged, the symptoms of
Parkinson’s disease appear.
2.
What is the current thought regarding the etiology of Parkinson’s Disease?
Although the etiology of Parkinson’s disease is not completely understood, the condition probably
results from a confluence of several factors. The first is an age-related attrition and death of the
approximately 450,000 dopamine-producing neurons in the pars compacta of the substantia nigra.
For every decade of life there is estimated to be a 9% to 13% loss of these dopamine-producing
neurons. If carried to its logical extreme, those patients achieving very great age are destined to
lost approximately 70-80% of these critical neurons.
Another possibility is associated with a potent neurotoxin, a by-product of illicit drug synthesis.
After the initial discovery, a number of other environmental neurotoxins have been described that
have led to the parkinsonian state. These discoveries have led to the suggestion that Parkinson’s
disease may arise as a combined consequence of the ongoing aging process coupled with
environmental exposure that accelerate the process of nigral cell death.
The third component of the puzzle is the possibility that some individuals may have a
predetermined genetic susceptibility to these environmental insults.
3.
How does the etiology translate into signs and symptoms of Parkinson’s?
When substantia nigra projections to the putamen have been impaired, the globus pallidus interna and
subthalamic nucleus begin to function abnormally. The result is that the brain is no longer able to
sufficiently control motor function.
4.
5.
6.
What specific signs and symptoms are noted with the patient’s exam and history that are
consistent with her diagnosis?

Complains of coughing and choking on food

Feeling as though something is stuck in her throat

Weight Loss

Son and daughter in-law observances of a lesser food intake

Parkinson’s Disease

Diminished postural reflexes (Not related to Dysphagia but PD)
Which symptoms may place individuals at nutritional risk?

Dysphagia

Fear of eating

Weight loss

Diminished postural reflexes
Define Dysphagia.
Difficulty swallowing. It can develop at any point in the swallowing process from the mouth to the
pharynx, esophagus or stomach. In some cases, Dysphagia is marked by choking or coughing that
occurs when a person is eating. In other cases, the person may not be able to swallow at all.
7.
Could Mrs. Leaming’s difficulty eating be linked to Parkinson’s disease? If so, how?
Yes, the neurological damage can weaken the throat muscles, making it difficult to move food
from the mouth to the throat and esophagus. Nerve damage can also inhibit swallowing by
reducing sensation in the mouth and throat. The swallow reflex is a complex neurologic event
involving participation of high cortical centers, brain stem centers such as the tract of the nucleus
solitarius and nucleus ambiguous, and cranial nerves V, VII, IX, X, and XII. Neurologic deficits
in any of these areas can result in dysphagia.
8.
9.
What problems/complications are associated with Dysphagia?

Malnutrition

Anorexia

Weight loss

Dehydration

Aspiration pneumonia
Describe the four phases of swallowing:
Phase
Oral preparation
Oral transit
Pharyngeal
Esophageal
Description
Conversion of food from the solid to the semisolid
state. This phase requires intact dentition and is
negatively affected by poor salivary gland function
(lubrication), surgical defects, and neurologic
disorders.
A formed bolus is positioned in the middle of the
tongue, neurological disability or surgical defects
result in a weak tongue, cheeks or lips. These
deficits can lead to leakage into the airway
Shortest, but most complex phase. The soft palate
elevates closing off the nasopharynx and preventing
nasopharyngeal regurgitation. The superior
constrictor muscle contracts, beginning pharyngeal
peristalsis while the tongue base drives the bolus
posteriorly. Respiration ceases during expiration-the
larynx elevates and the epiglottis retroflexes,
driving the bolus around the opening of the larynx.
The arytenoids adduct and are approximated to the
base of the epiglottis. Bolus propulsion is enhanced
by passive and active dilatation of the upper
esophageal sphincter (of which the cricopharyngeus
is a part). The cricopharyngeal and inferior
constrictor muscles then relax, allowing food to pass
into the upper esophagus
The bolus is propelled about 25 cm from the
cricopharyngeus through the thoracic esophagus via
peristaltic contractions. The lower esophageal
sphincter relaxes and the bolus moves into the
gastric cardia
10. Give an example of one problem or condition related to each phase.
Phase
Oral preparation
Problem
Not able to chew,
difficulties positioning
tongue not able hold
food, decreased salvia
Signs and Symptoms
Unable to clear
Oral transit
Delayed swallow/absent
of swallow
Aspiration, jaw
movement
Pharyngeal
Epiglottis doesn’t close,
food into the lungs
Aspiration
Esophageal
Originate in the
esophagus, foods or
liquids “stick” in the
chest or throat and
sometimes come back
up
Food Reflux
Dietary Considerations
Cold foods (awareness
of sensation), textured
foods, gravy-add
moisture to food,
artificial salvia
Very cold food,
carbonated beverages,
thickening foods will
give patient more time
to get foods down
Slow down the
movement with
textured, cohesive foods
that form more of a
bolus that stick together,
thicken liquids
Moistened foods, chop
or diced foods for easier
voluntary movement
through the esophagus
11. Describe a bedside swallowing assessment.
Assessment most likely completed by a speech pathologist to provide data for use in diagnosis and
treatment planning. The clinical exam can be divided into 2 parts:

Preparatory exam with no actual swallows

Initial swallowing exam when actual swallowing is attempted and physiology is
observed.
The bedside examination will provide information regarding

Location of patient’s dysphagia

Patient’s readiness for a radiographic study

Ability to accept food into the mouth

Oral reaction to placement of various tastes, temperatures, and textures in oral cavity

Presence of any oral apraxia, abnormal oral reflexes such as otnic bite

Postural and behavioral needs of the patient that must be addressed during the
radiographic study

Laryngeal function as it may affect airway protection and aspiration during the swallow

Coughing status

Best position of food in mouth

Best food consistency

Selection of optimum swallowing instructions
Signs and Symptoms of Dysphagia

Pocketing of food in the sulci or collection of food on the hard palate

Excessive secretions

Expectoration or regurgitation

Reduced pharyngeal or laryngeal function on bedside assessment

Repeated pneumonia

Weight loss of unknown etiology

Gurgly voice quality, especially after eating

Suspected delay in triggering the pharyngeal swallow or reduced laryngeal elevation observed
on bedside assessment

Delayed or absent elevation of hyoid bone and thyroid cartilage

Obvious difficulty eating or slow eating in presence of functional tongue motion

Coughing during or after swallowing
12. Describe a modified barium swallow or fiberoptic endoscopic evaluation of swallowing.
A modified barium swallow is a radiographic examination of the esophagus during or after the
introduction of a contrast medium consisting of barium sulfate. Structural abnormalities of the
esophagus may be diagnosed through use of this technique.
A fiberoptic endoscopic evaluation of swallowing assesses swallowing, without x-rays. It involves
passing a small, flexible, custom-designed scope, attached to a camera, through the nose and into
the middle of the throat, recording pictures of the throat and voice box as the patient swallow
liquid and foods.
13. For this patient, compare the values of labs that are significantly different from admission
and day 2 of hospitalization. Which values are more accurate? Why?
Lab
Albumin
Total protein
Prealbumin
Transferrin
Sodium
WBC
Urine specific gravity
PO4
Magnesium
Osmolality
Glucose
Hct
RBC
Admit Value
5.1
7.9
35
250
150
10
1.030
3.5
2.6
350
135
48
5.5
Day 2 Value
2.8
6.4
11
148
135
4.0
1.002
3.6
1.5
297
118
38
4.3
The lab values of Day 2 are more accurate. The admitting values are not accurate due to possible
dehydration and the fact that the patient was not eating of drinking much prior to admittance. This
affected almost all of the lab values including albumin, total protein, prealbumin, transferrin, sodium,
WBC, Mg, Osmolality, Glucose, HCt and RBC.
14. Mrs. Leaming’s usual body weight is approximately 100 lb. On admission, she was found to
weigh 90lb. Calculate her percent usual body weight (%UBW).
Mrs. Leaming is at 90% UBW.
15. How would you interpret her %UBW?
Mrs. Leaming’s % UBW is indicative of significant weight loss and possible malnutrition.
16. She reportedly lost 10lb in the past 6 months. Calculate her percent weight change.
Mrs. Leaming has had 10% weight loss in the past 6 months.
17. How would you interpret her percent weight loss?
Mrs. Leaming’s weight loss is significant and on the verge of moving into a severe state. Pt.
should be ideal body weight is that of her usual body weight (dependent on frame size) of 100 lbs.
Mrs. Leaming is weight is significantly affected by her dysphagia which could additional be
causing nutritional deficiencies.
18. Are signs and symptoms documented in the physical examination that may indicate a poor
nutritional status? Of so, which ones? What type of nutritional deficiency may they indicate?
Dry, dull hair: Protein, zinc, or linoleic acid deficiency
Sunken cheeks: Protein, calorie deficiency
Bilateral redness, fissured eyelid corners: Riboflavin, Niacin deficiency
Reduced strength in extremities: Possibly due to protein, calorie deficiency or PD
Poor skin turgor: fluid losses
Angular stomatitis and cheilosis noted on lips: Riboflavin, Niacin, pyridoxine deficiencies
Hypoactive bowel sounds: influences nutrition
19. Which of Mrs. Leaming’s lab values may reflect her nutritional status?
Low albumin (protein-energy deficiency; often associated with other deficiencies i.e. zinc, iron,
and vitamin A), low prealbumin (protein-energy deficiency), low transferrin (protein-energy
deficiency), low magnesium (decreased magnesium body stores, affects neuromuscular function),
high osmolality (dehydration), low total cholesterol (increased risk, correlates with decreased
albumin, prealbumin, iron, zinc, and vitamins A and E), and low WBC (possible vitamin
deficiency).
20. Albumin, prealbumin, and transferring lab values are often used to evaluate visceral protein
stores. Compare Mrs. Leaming’s values to the norms, and indicate whether these reflect
mild, moderate, or severe deficits of her visceral protein stores.
Lab
Norms
Pt Values
Albumin
Prealbumin
3.6-5.0
19-43
2.8
11
Transferrin
200-400
148
Mild/Moderate/Severe
Deficit
Mild
Mild/Moderate
borderline
Moderate
21. By evaluating Mrs. Leaming’s anthropometric data, biochemical data, clinical data, and
what you know about her recent dietary intake, what would you conclude regarding her
nutritional status?
I would conclude that Mrs. Learning is deficient in energy, protein, riboflavin, thiamin, niacin and
fluid. She is most likely deficient in other micronutrients, in addition to the aforementioned
nutrients.
22. Estimate Mrs. Leaming’s energy needs using the Harris-Benedict equation.
Harris-Benedict Equation:
Women: kcal/day = 655 + 4.3(100) + 4.7 (60) – 6.8 (77)
430 + 282 – 523.6
X 1.2 (SF)
1012 kcal/day
23. Calculate her protein needs. What standards would you use? Why?
30-40 gm/day
I would use the standards of 0.8 g/kg body weight/day. Due to competition of absorption of
protein with levodopa (Pt. taking 50/200 mg pid of Sinemet) in the S.I., the timing of meals and
medications must be carefully planned out. I would limit dietary protein at breakfast and lunch and
add more to the evening meal.
24. Estimate Mrs. Leaming’s fluid needs using the following methods; weight, age and weight,
energy needs.
Weight: 30 – 35 ml per weight in kilograms
1227 – 1431 ml/day
Age and Weight: > 75 years = 25ml/kg
1022 ml/day
Energy needs: 1 ml fluid per calorie consumed
If followed estimated needs = 1012 ml/day
25. Which of the preceding methods for estimating fluid needs is the easiest to calculate? Which
method appears most reasonable for this patient? Explain.
Estimating fluid needs based on energy needs is the easiest to calculate because as RDs we would
already have that information available. I also believe it is the most reasonable for this patient
because the estimated energy requirements (HBE) already factors in age, height and weight in the
calculation.
26. To maintain or attain normal nutritional status while reducing danger of aspiration and
choking, texture (of foods) and/or viscosity (of fluids) are personalized for a patient with
Dysphagia. In the following table, define each term used to describe characteristics of foods
and give an example.
Term
Consistency
Texture
Viscosity
Definition
Degree of density firmness,
viscosity; condition of cohering
or holding together and retaining
form; solidity or firmness
The visual and tactile quality of
food surface
Glutinous nature or consistency;
sticky; thick; adhesive
Example
The liquid has the consistency of
cream.
The avocado had a smooth
texture.
The soup’s viscosity was
extremely thick making it a very
filling meal.
27. Diets for Dysphagia are described in four stages. In the following table, describe each diet
stage and give examples of five foods that could be included in each diet.
Diet
Phase I: Pureed diet
Phase 2: Ground/minced diet
Description
This diet consists of pureed,
homogenous, and cohesive foods.
Food should be “puddinglike.”
No course textures, raw fruits or
vegetables, nuts, and so forth are
allowed. Any foods that require
bolus formation, controlled
manipulation, or mastication are
excluded.
This level consists of foods that
are moist, soft-textured, and
easily formed into a bolus. Meats
are ground or are minced no
larger than one quarter-inch
pieces; they are still moist, with
some cohesion. All foods from
Phase I are accepted.
Phase 3: Soft/easy-to-chew diet
This level 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 bitesize pieces at the oral phase of
swallow.
Phase 4: Modified general diet
This level consists of food that is
normally eaten just sticking to
soft, moist, regularly textured
foods.
Examples of Foods
Pureed bread mixes, pureed fruits
or well-mashed bananas, fruit
juices without pulp, seeds or
chunks (may need to be thickened
to appropriate consistency if thin
liquids are restricted).
All beverages with minimum
amounts of texture, pulp, etc., any
texture should be suspended in
the liquid and should not
precipitate out; may need to be
thickened depending on liquid
consistency recommended,
moistened ground or cooked
meat, poultry, or fish may be
served with gravy, casseroles
without rice, soft pancakes
moistened with syrup, etc.
Any beverages, depending on
liquid consistency, all well
moistened breads, etc. with the
exception of dry bread, toast or
crackers, no coarse or dry cereals,
no fruit leather, yogurt with nuts
or coconut thin sliced meat is
okay along with well-moistened
fish, etc.
Any beverages, any breads,
cereal, meats as long as it has
been moistened.
28. It is determined that Mrs. Leaming’s Dysphagia is centered in the esophageal transit phase
and she has reduced esophageal peristalsis. Which diet is appropriate to try with Mrs.
Leaming?
I would try starting Mrs. Leaming on Phase 2 the ground/minced diet. Her chewing ability is still
intact and the textures at this level are appropriate for her type of dysphagia. She will need to be
assessed for tolerance to mixed textures.
29. What products or substance can be added to thicken liquids?

Baby Cereal

Banana flakes

Bread Crumbs

Cornstarch

Cooked cereals (cream of wheat or rice)

Custard mix

Graham cracker crumbs

Gravy

Instant potato flakes

Mashed potatoes

Plain unflavored gelatin powder

Plain sauces (white, cheese, tomato)

Pureed fruits/meats/vegetables (baby food)

Saltine cracker crumbs
30. Using her usual dietary intake, make suggestions for food substitutions to Mrs. Leaming and
her family.
Orange Juice
Cream of Wheat
Raisin bran
2% milk
Banana
Coffee
Sweetener
Chicken tortellini soup
Saltine crackers
Canned pears
Iced tea
Baked chicken
Baked potato
Steamed broccoli
Margarine
Canned peaches
Popcorn
Coca-Cola
Pulp added
Added milk
Slightly moistened dry cereal with little texture and
no dried fruit, i.e. corn flakes or Wheaties
Use to thicken cereal
Mashed, or make sure it is soft/ripe
Continue as long as thin liquids continue o be
allowed
Continue to consume
Add Saltine crackers to thicken, avoid corn, peas
and rice in soup, must be small easy-to-chew, easyto-swallow chunks of meat
Use to thicken soup
Continue to consume
Continue as long as thin liquids continue o be
allowed
Grind and moisten with gravy or sauce
Avoid skin, well-cook and moisten with gravy or
sauce
Avoid, substitute with soft well-cooked vegetable
(carrots, softened)
Continue to consume
Continue to consume
Avoid
Continue as long as thin liquids continue o be
allowed
Ice cream
Avoid, replace with cookies dunked in milk, canned
fruit (excluding pineapple), soft fruit pies with
bottom crust only or pudding
31. Because her foods will be ground or chopped and few raw fruits and vegetables are
tolerated/allowed, how can Mrs. Leaming get adequate amounts of fiber in her diet? (What
are some high-fiber foods that could be included?)
Pregelled whole grain breads, whole grain pancakes moistened with syrup, slightly moistened high
fiber cereals with little texture, fortified pudding/yogurt, pear juice, moistened beans and dietary
supplement.
32. What is the current treatment for Parkinson’s? How do Mrs.Leaming’s current medications
fit into this picture?
The current treatment for Parkinson’s include choices of several medications, surgical treatment,
and physical and occupational therapy. Mrs. Leaming is already taking the most powerful weapon
against Parkinson’s, which is the Levodopa. It effect is to replace the dopamine that is no longer
being produced by degenerating brain cells. The other medications available are Selegilne, COMT
inhibitors, Dopamine agonists, Anticholinergic drugs, Amantadine and Apomorphine. Surgical
treatment includes Pallidotomy, brain tissue transplants and deep brain stimulation. Exercise may
help to relieve stiffness and muscle wasting. Mrs. Leaming could include additional medications
to help treat her Parkinson’s but she is currently taking the most powerful drug available for
treatment.
References
1.
2.
3.
4.
5.
6.
7.
National Parkinson Foundation. About Parkinson’s Disease. Available at:
http://www.parkinson.org/Page.aspx?pid=225. Accessed on: April 1, 2009.
Cleveland Clinic. Parkinson’s Disease. 2008. Available at:
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/parkinsonsdisease/. Accessed on: April 1, 2009.
http://www.learningcommons.umn.edu/neuro/mod4/posture2.html
Jeff and Bonnie story. Parkinson’s Disease. Available at:
http://www.pjstory.com/Parkinsons.htm. Accessed on April 7, 2009.
Ask.com. Dictionary.com. Available at: www.dictionary.com Accessed on April 7, 2009.
Florida Institute for Nuerologic Rehabilitation, INC. Glossary of Terms. Available at:
http://www.finr.net/resources/glossary.htm. Accessed on April 2, 2009.
Mahan, L.K., & Escott-Stump, S. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis,
Mo:Saunders Elsevier Inc.;2008.