Cognitive impairment

♦ Cognitive impairment is estimated to affect about 19% of patients.

♦ Another 27% may suffer from dementia.

♦ All degrees of cognitive impairment can affect eating habits.

♦ Mild forgetfulness can affect: O Ability to drive.

O Shopping for food. O Preparation of food. O Taking medications on time. O Symptoms thus are not well managed, and decreased control of symptoms may affect manual dexterity and other physical abilities.

Dementia may:

O Influence the desire to eat. O Require increasing assistance from carer. Malnutrition itself may be a causative or contributing factor to cognitive impairment and dementia.

O Older adults are less likely to produce the stomach acid and intrinsic factor needed to metabolize vitamin B12. Changes in sensory functions and/or appetite may alter the kind or amount of foods eaten, resulting in nutrient deficiencies. O B vitamin deficiencies may produce confusion, cognitive impairment, behaviour change, even an Alzheimer-type dementia. O B12 deficiency may result in macrocytic megaloblastic anaemia; paresthesias, peripheral neuropathy; psychiatric disorders, including impaired memory, irritability, depression, and dementia.

Parkinson's disease

Impaired mental and emotional health

Cognitive impairment

Ability to shop for/ prepare food and take medications on time

PD symptoms not managed; no desire to eat; weight loss

Impaired mental and emotional health

13 1 Mental and emotional health. Involvement of mental and emotional health and its impact on nutritional status in PD.

Disinterest in food; weight loss

Malnutrition

Deepened depression; anorexia

Downward spiral to further malnutrition, cognitive impairment

Fatigue

Ability to shop for/prepare/consume food

Drop in blood sugar, nutrient deficiencies, anaemia, further fatigue

Cognitive impairment

Disinterest in food; weight loss

Fatigue

Malnutrition

♦ Management. Assess status of B1 (thiamine), B2 (riboflavin), B3 (niacin), B6 (pyridoxine), B12, and folate, all of which are implicated in cognitive impairment, memory loss, confusion, and dementias. Assess dietary intake, and provide advice where needed. Consider use of fortified foods or vitamin/mineral supplements. The carer will be of primary importance in helping to guard against malnutrition, and careful instruction and education of the carer are required.

Depression

♦ Affects about 40% of patients.

♦ May be endogenous or exogenous.

♦ May range from sadness to major depression.

♦ May predate diagnosis of PD by several years.

♦ Depression can impact on nutritional health: O Significantly affects functional ability.

O May adversely affect the appetite and desire to eat.

O Results in narrowed range of food choices, diminished food intake, unplanned weight loss.

O Ensuing nutritional deficiencies can exacerbate existing depression, anorexia, and unwillingness to eat. O Creates a downward spiral to malnutrition.

♦ Anxiety or panic attacks may accompany, or be independent of, depression.

♦ Management. It will be important to determine both the form and degree of depression, and whether it will be best treated by therapeutic counselling, dietary measures, or medication. Addition of antidepressants, particularly in older adults, and more particularly those already using two or more medications, may produce adverse side-effects.

O Consider referral to a registered dietician for assessment of dietary intake, particularly if unplanned weight change has occurred. If diet is inadequate, fortified foods or a multivitamin/mineral supplement may be helpful. Additionally, provision of omega-3 fatty acids, via fish oil capsules, may be helpful. O Also consider referral to a qualified therapist who can provide counselling and prescribe an antidepressant if needed.

O If anxiety or panic attacks are reported, determine whether these occur regularly, particularly if before meals, or at the same time of day. If so, hypoglycemia should be ruled out as a causative factor.

Fatigue

♦ Complaints of exhaustion and sleepiness are common among patients. This may alter the ability to shop for, prepare, and eat food.

♦ May be a side-effect of medications, with additive effects from multiple medications.

O Decreased food intake can result in drop in blood glucose, with attendant fatigue. O Prolonged reduction in caloric intake may result in deficiencies of B vitamins and iron, and fatigue.

O The various anaemias can result in fatigue, shortness of breath, dizziness, confusion.

♦ Management. Rule out dietary causes. Reports of recent weight loss along with fatigue are an indication of nutrition-related etiology.

O Determine if energy intake is adequate (particularly if unplanned weight loss has occurred).

O Rule out deficiencies of folate, B6, B12, iron. O Rule out hypoglycemia. O Test for anaemia (iron-deficiency, macrocytic megaloblastic). O If insomnia is present, discuss avoidance of caffeine and alcohol after late afternoon; regular practice of meditation, or yoga; a light snack before bedtime, such as a cracker with a teaspoonful of peanut butter, or half a banana. A calcium-magnesium supplement at bedtime may help with relaxation: 100-200 mg calcium, 50 mg magnesium.

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