Guidelines & References
2015 ESPEN guidelines on nutrition in dementia: provides possible support based on stage of disease |
Best practice guidelines for aged care |
NICE Parkinson’s Disease in Adults Guidelines |
What is it?
Dementia |
Parkinsons |
It’s a cognitive impairment with a decline in memory AND at least one other cognitive domain such as language, object recognition, motor skills, abstract thought, visuospatial or executive function. There are two major changes believed to interrupt normal processes of the brain: formation of amyloid plaques and formation of neurofibrillary tangles. |
Neurological condition where the brain cells in the brain stem are destroyed. These cells usually produce the neurotransmitter, dopamine, which is needed for control of movement and coordination. This results in a range of S/S that predominantly affects movement. |
Cause
unclear - Likely genetic & environmental factors |
Risk factors
Dementia |
Parkinsons |
Age |
Age |
CVD |
Sex (males more common) |
Genetics |
Ethnicity (less common in Asian/African Americans) |
Dementia & malnutrition
Affects food purchasing, preparation & intake – smell and taste changes, loss of eating skills, loose the ability to recognise foods, disturbed eating patterns, refusal to eat, forgetting how to chew or swallow |
Dry mouth: mouth rinses & gels. Adding gravies or sauce to meals. |
Update preferences regularly |
Stages & NIS
Stage |
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NIS |
Early |
memory loss & disorientation |
Difficulty shopping, preparing and storing food. Forgetting to eat. Food preferences change or unusual choice. |
Mild-mod |
loss of function in ADLs |
Food not chewed or swallowed properly. Poor concentration. Impaired reasoning and judgement – ability to recognised hunger/thirst/satiety. Agnosisa – cannot recognise objects or food Malnutrition and dehydration risk. |
Severe |
communication difficulties and reliance on others for ADLs. May be bed-bound at this advanced stage and lack ability to communicate |
Food refusal. Aphasia – inability to understand or produce speech. Dysphasia |
Parkinsons S/S
Non-motor: depression/anxiety, memory problems, anosmia (loss of smell), Hypersalivation (drooling), dysphagia, slowed gastric motility (gastroparesis), Sleep disturbances, pain |
Motor: Bradykinesia (slowness of movement), Akinesia (loss or impairment of the power of voluntary movement), Resting tremor, shuffling gait, mucle rigidity, postural instability |
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Assessment
Nut concerns: Vit D, B12, Iron |
Chewing & swallowing: dentures, dry mouth, dysphagia |
Dehydration: urine colour, thirst sensation |
Constipation: linked w/ inadequate fluid/food. Physical activity? |
Altered taste & ↓ smell (hyposmia) |
Appetite: when is it strongest? |
Favourite flavours – changes likely |
Parkinsons Medication
Levodopa |
S/E [short term]: nausea, vomiting, loss of appetite, fatigue – usually subsides after continued use |
S/E [long term]: delayed/absent response resulting in motor and non-motor fluctuations (‘off periods’) and Dyskinesia (involuntary movements) |
Take 30-45min gap between dosage and consumption of meal – since meals can slow down absorption due to slowed gastric motility |
Parkinsons Management
IF pt taking levodopa AND experiencing motor fluctuations – redistribute protein to end of the day – majority in the evening - to maximise effectiveness of medication during the day |
Avoid a reduction in total daily protein consumption |
Vitamin D supplement – medical team |
Do not offer creatine supplements |
Don’t take over-the-counter dietary supplements without consulting pharmacist or other HCP |
Nut Reqs
Increase EER: restlessness, constant pacing up and down, tremors |
Decrease EER: immobility, apathy (emotional indifference or lack of motivation), somnolence (drowsiness) |
ESPEN: no indications that nut reqs are generally different in persons with dementia (*very low evidence) |
Acute elderly: 100-125kg/day, 1-1.5g P/day (NEMO) |
Repletion: 125-145kJ/day, 1.2-1.5g P/day (NEMO) |
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Strategies
Difficulty with ADLs |
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Easy, basic recipes |
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Frozen meals/snacks |
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Having someone with them at meal times |
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Adaptive utensils |
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Mealtime socialisation |
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Flavour enhancers – herbs, spices, citrus, soy sauce, garlic/onion, oils |
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Pleasant eating environment |
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Help with grocery shopping – support worker – home care package |
Forgetting to eat/drink - Reduced oral intake Fatigue |
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*Malnut screen |
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Supervision during meals |
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Verbal prompting |
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Pouring fluids in front of them - acts as a prompt |
Recognizing food and ability to eat independently |
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Feeding assistance |
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↑ time with nurses spent feeding |
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Identify flavour preferences |
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Offer one meal at a time or food – avoid having condiments out to choose from |
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ONS |
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Educating – eating even when you don’t want to |
Swallowing issues |
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Malnut screen |
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Texture-modification & swallowing assessment – speechies |
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Oral care |
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Dental treatment |
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Soft, moist food. Avoid: tough, crunchy, sticky, dry foods |
Xerostomia (Dry mouth) |
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Check medication |
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Adequate fluid intake |
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Mouth rinse and gel |
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Offering drinks |
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Moist foods – gravies, dressings, mayonnaise, sauce, custard, butters |
Inadequate fluid intake |
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Assess med S/E that could interfere with adequate fluid intake |
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Edu: what fluid is |
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Schedule small frequent amounts of fluids (esp. surrounding meals) |
Nausea |
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Small frequent meals |
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Cold foods |
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Sipping ONS/HPHE through straw |
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Limit fatty and fried foods |
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Ginger products |
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Levodopa may need to be taken with food if ‘on/off’ periods are stable |
Loss of smell and taste |
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Flavour enhancers – herbs, spices, citrus, chilli, garlic, onion |
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Enhance food is presented nicely – variety/colour |
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Identify specific issue – bitter? Metallic? |
Constipation (and overflow diarrrhea, urinary incontinence, abdo pain) |
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↑ fluid, adequate fluid |
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Physical exercise |
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Fibre supps – Metamucil |
Example PESS
Inadequate oral intake |
Inadequate protein-energy intake |
Self-feeding difficulty, related to diagnosis of Parkinson’s Diseases with increasing tremor and fatigue, as evidenced by observation at mealtime, calorie count and recent 5% weight loss. |
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