Brittany Shannon
NUTR 490
Veteran Living with Parkinson’s Disease, Paranoid Schizophrenia
and Dysphagia
Abstract:
E.M. is a 59-year-old male Veteran who is a resident in the Community Living
Center at Bay Pines VA Medical Center. He has been diagnosed with Parkinson’s
disease and paranoid schizophrenia, which lead to dysphagia. Therefore, the
Veteran is currently on a special diet order that places him on a mechanical nectar
consistency dysphagia diet. The patient’s neurological diseases have affected his
ability to perform his activities of daily living. I was intrigued by this Veteran’s
condition because I was able to have the opportunity to correlate his neurological
disorders to his dysphagia and understand the importance of following a dysphagia
diet to ensure the safety of the patient.
My case study patient will be referred to as E.M. He was admitted in
November of 2012 to the Emergency Room at Bay Pines VA Medical Center for a
urinary tract infection. The patient received rehabilitation in the hospital after
experiencing many falls and his medical staff noted that his coordination skills were
diminishing. He also had wounds on the posterior side of his body and peripheral
edema. E.M. was transferred to the Community Living Center at Bay Pines VA
Medical Center in April of 2013 when his condition worsened and he needed around
the clock care to help him perform all of the activities of daily living. He currently
has no discharge date as his health is predicted to gradually decline over the next
few years. He has been primarily diagnosed with Parkinson’s disease and paranoid
schizophrenia. A clinical dietitian at Bay Pines selected this patient for me because
the patient also has dysphagia. Therefore, it was a great learning experience to be
able to dissect the two neurological disorders he has been diagnosed with and relate
them to the development of dysphagia and how it has an important impact on his
nutritional care.
E.M. is a 59-year-old white male who is a Veteran that served in the Vietnam
War. Before he became a resident at the Community Living Center, he lived in an
Adult Living Facility in the Tampa area. His relevant family members include his
father and his stepmother whom living in Florida as well. The resident completed
two years of college and entered the Navy during the Vietnam War for three years.
While E.M. was in the war he was a Senior Air Traffic Controller. The Veteran is
unable to work and receives a service-connected pension from the government each
month, which serves as his source of income. Also, E.M. has never been married and
has no children or other dependents.
The patient’s current weight is 219.5 lbs and he usually weighs about 234 lbs.
However, his ideal body weight is about 190 lbs. He is 74 inches tall and has a BMI of
28.24, which shows that the patient is overweight. Also, the patient’s blood pressure
is 105/66. His previous illnesses include Parkinson’s disease, paranoid
schizophrenia, dementia, psoriasis, hyperlipidemia, knee pain, colon polyps, COPD,
HTN, and peripheral neuropathy. The patient has been hospitalized due to reasons
including deconditioning, urinary incontinence and sacral wounds. Also, the patient
is currently on 33 active medications to help combat his abundant list of active
medical conditions.
I was able to look through the patient’s past and most current nutrition
assessment and progression notes and observe his nutritional problems. His most
recent nutrition problem was diagnosed as unintentional weight gain, but this
problem has been resolved as noted by the RD and can be observed in the patient’s
weight history that will be addressed as follows. Previous nutrition goals that were
set for the patient include: weight maintenance of within 5 lbs during admission;
consume greater than 75% of meals and snacks during admission; and hydration
requirement met during admission. His must current nutrition-focused physical
findings show that the Veteran denies any problems that might interfere with per
oral intake on current diet. Also, E.M. prefers to have a variety in the consistency of
foods that are provided, but he verbalized an understanding of the explanation of
his current diet and how it was ordered for his safety. The patient’s appetite is very
good as he eats 100% of his meals and he denies any gastrointestinal distress. Also,
the resident is pleased with his current weight loss.
The patient was first diagnosed with Parkinson’s disease in August of 2009.
His signs and symptoms include tremors, slowed movements, slurred speech, rigid
muscles leading to the inability to walk, and impaired posture. E.M. was diagnosed
with paranoid schizophrenia in April of 2008. His signs and symptoms include
hallucinations, behavioral outbursts, delusions, argumentative behavior, and
anxiety. The patient’s medical records indicate that a cause of Parkinson’s disease
may be from the ingestion of Prolixin, which was prescribed for the patient’s
paranoid schizophrenia. However, the only treatment plans available for the
Veteran are the use of medications to help suppress the symptoms of each
condition. Unfortunately, the patient’s Parkinson’s disease is worsening
progressively and the RD foresees that his diet will be switched to NPO by next year.
Also, schizophrenia is a chronic condition and the patient will battle this disease for
the rest of his life. Both of these diseases are neurological disorders and have a
direct impact on the patient’s dysphagia condition and current diet order.
Parkinson’s disease is a disorder that affects the nervous system
(MayoClinic). The most common side effect of this disease is tremors, but it also
causes stiffness, slowness in movement, rigid muscles, and slurred speech. E.M. has
each of these main symptoms of Parkinson’s disease. The treatment plan for this
disease includes a medication called Cardidopa-levodopa, which is a natural
chemical that enters the brain and is converted into dopamine. This is an active
medication that the patient is taking. Also, someone with Parkinson’s disease may
have trouble completing daily living activities, such as eating, which is a side effect
that E.M. has and must be placed on a dysphagia diet to help combat this disease.
Paranoid schizophrenia is a chronic mental illness that forces people to lose
sight of reality (MayoClinic). The most common symptoms of this disorder include
delusions and hearing things that are not real, both of which are symptoms that the
patient experiences day-to-day. One treatment option is the use of a prescription
medication called Prolixin, which is taken by the patient and is used to help diminish
the episodes of hallucinations, delusions, and altered behavior (MedlinePlus).
Both of these diseases may first be noticed because of another condition,
dysphagia. The weakness of nerves and muscles caused by Parkinson’s disease can
also weaken the throat muscles, which makes it difficult to move food from the
mouth to the throat and esophagus (NIDCD). This sensation causes people to gag,
choke, or cough, which are all symptoms that E.M. has and must be put on special
diet orders to protect his safety.
I had the opportunity to ask the patient about his usual dietary intake. For
breakfast, he told me that he has scrambled eggs with cheese, hash browns,
applesauce, and nectar thickened iced-tea. He usually has vanilla or chocolate ice
cream or a candy bar, such as a 3 Musketeers, that he buys with his pocket change
from the vending machine. The RD is very concerned when she hears about the
resident eating candy bars, but it is difficult because she cannot keep an eye on him
twenty-four hours a day and seven days a week. Around noon he has beef or
chicken, potatoes, chunky carrots, and nectar thickened iced-tea. He also has a
mechanical dinner consisting of salmon, chicken, or beef and vegetables. His
desserts consist of vanilla or chocolate ice cream. Overall, the resident is consuming
a good diet especially because he has lost weight and is maintaining a normal body
weight due to the patient’s present conditions. E.M. is unable to walk and participate
in exercise and his medical care team must monitor his current diet to make sure it
does not affect his weight and cause him to become obese. In fact, the patient is
currently within the 75th percentile dependent on his weight and age for males
(Halls, MD).
The patient does not have any lab values that are of major concern. For
example, he has an average cholesterol level of 120, an average triglyceride level of
120, white blood cell count of 5.0, hemoglobin A1C count of 6.2, and a potassium
reading of 4.0. The only pertinent lab values that were below the normal range were
his albumin levels of 3.2 and 3.1. However, albumin levels alone are not used at Bay
Pines VA Medical Center to determine if a patient is nutritionally at risk.
On April 9th, the patient was ordered the Bay Pines Healthy Diet with Nectar
thick liquids. The Veteran was given Nectar thick liquids because he did display
indicators of penetration and aspiration with thin liquids, which was observed by
the medical care team. The dietitian gave the resident and nursing staff feeding
guidelines and safe swallowing precautions that include: he must be as upright as
possible to eat and drink, medication should be taken with nectar or pudding, and
encourage small bites and sips as he consumes his meals. Then on April 15th, the
patient’s diet got changed to a Dysphagia/Advanced Nectar diet because it promotes
ease of chewing with poor dentition and ensures airway protection and the Veteran
was given the same guidelines as above with the addition of not using straws. Then
just a few days later, his diet was downgraded to a Dyshagia/Mechanical Nectar diet.
The Veteran continued to cough after eating too big of bites so this diet helped to
ensure that he would take smaller bites because it has a higher moisture content.
However, at this point it appears the resident is not able to comply with small bites
and eating slowly to the degree necessary for a diet upgrade. He needs reminders to
take small bites before every bite of food and may even need a staff member to
physically reduce the amount of food on his fork or spoon. This type of supervision
may be unrealistic at times and if the resident is not willing to comply with the
feeding guidelines, then he may need to be downgraded again to a Dysphagia/Puree
Nectar diet. Unfortunately, the prognosis for this resident is considered poor due to
his behavior and cognitive issues, as well as the progressive nature of Parkinson’s
disease.
Summary:
In conclusion, I was able to study the relationship between neurological
disorders and how the symptoms of Parkinson’s disease and paranoid
schizophrenia can cause dysphagia. Also, I was able to understand how the
development of dysphagia can influence Parkinson’s disease symptoms. I had the
opportunity to follow this resident over the course of four weeks at the Community
Living Center at Bay Pines VA Medical Center and interact with him on many
occasions. I was able to see first hand the medical attention that the Veteran
receives and how dependent he is on his medical care team to help him with his
daily activities of living. I was very thankful to have the opportunity to get to know
E.M. and hear his story about his time during the Vietnam War. I am grateful to have
followed the clinical dietitian that worked with this resident and watch her care for
him by monitoring his nutrition status and counseling him on his dysphagia diets.
References:
Dysphagia. National Institute on Deafness and Other Communication Disorders
(NIDCD). October 1, 2010. Available at
http://www.nidcd.nih.gov/health/voice/pages/dysph.aspx. Accessed August
8, 2013
Fluphenazine: MedlinePlus Drug Information. MedlinePlus. May 16, 2011. Available
at http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682172.html.
Accessed August 8, 2013
Hall S. Men's Weight Chart. Halls, MD. May 26, 2008. Available at
http://www.halls.md/chart/men-weight-w.htm. Accessed August 8, 2013
Paranoid schizophrenia: Symptoms- MayoClinic. MayoClinic. December 16, 2010.
Available at http://www.mayoclinic.com/health/paranoidschizophrenia/DS00862/DSECTION=symptoms. Accessed August 8, 2013
Parkinson's disease- MayoClinic. MayoClinic. May 11, 2012. Available at
http://www.mayoclinic.com/health/parkinsons-disease/DS00295. Accessed
August 8, 2013