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A 91-year-old ectomorphic male with a 25-year history of Parkinson's disease (PD) was transported by ambulance to the emergency department with complaints of confusion and weakness. The patient lives with his 70-year-old daughter who reported finding her father confused, disoriented, and unable to get out of bed that morning. She denied any change in his medication schedule, but was concerned that her father might have become dehydrated from being outside in the heat the previous day. Approximately 3 years ago, the patient had been active in the community and was independent in activities of daily living (ADLs) and mobility. Over the past 2 years, the patient's cognitive and physical status declined significantly. He needed to use a walker for ambulation and he also lost 20 lb. The patient had been receiving outpatient physical therapy intervention until 3 months ago when he developed a severe urinary tract infection requiring a 3-day hospitalization. According to the patient's daughter, his energy level declined considerably. At this point, the patient moved into his daughter's home, and appointed her as his power of attorney. Over the last month, the patient's ambulation declined to the point of short household distances with minimal assist. He also experienced two choking episodes during meals in the past week. Home health physical therapy had just been initiated to address functional decline. The patient has several comorbidities including: hypertension, hyperlipidemia, osteoporosis, and a cardiac pacemaker placement 3 years ago due to bradycardia. His home medications included alendronate, Aricept, carbidopa/levidopa, Celebrex, citalopram, Cozaar, Namenda, aspirin, and calcium. The patient was admitted to the hospital for further testing and follow-up. Chest x-ray revealed increased basilar opacities and vascular congestion with small left effusion, consistent with pneumonia. A computed tomography (CT) scan of the head was unchanged from 3 years prior, and normal except for atrophy and chronic small vessel ischemic change. Over a 2-week inpatient hospital stay, the patient experienced multisystem failure. He continued to demonstrate moderate confusion and orientation deficits and was agitated at times. On several occasions, he reported seeing “strange objects” in his room. Wheezing and upper respiratory expiratory noises were pronounced after meals; diagnosis of aspiration pneumonia was confirmed and swallowing precautions were initiated. The option of placing a percutaneous endoscopic gastrostomy tube into the jejunum (J-PEG) was considered, but the patient and his daughter decided against this measure. He continued to exhibit decreased appetite, resulting in a 7-lb weight loss. Inpatient physical therapy assessment noted impairments of rigidity, akinesia/bradykinesia, and loss of trunk, pelvic girdle, and lower extremity extension that contributed to loss of functional mobility. Ten physical therapy interventions were provided over 30-minute sessions. The emphasis was on optimizing range of motion of trunk and extremities, strengthening, and activities to promote functional mobility. The patient made minimal progress due to general malaise, weakness, and severe rigidity. At times, he appeared restless and in pain. His bed mobility varied from maximal to moderate assist and he required maximal assistance for standing pivot transfers. He could ...

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