Parkinson’s disease

is a progressive neurologic disorder that primarily affects movement à characterized initially by unilateral hand tremor that progresses to include bilateral tremor, rigidity, bradykinesia, and postural instability

Decrease patient’s quality of life and increase dependence 

Parkinson disease (PD)

Dopamine is a brain neurotransmitter that regulates voluntary movement, reward-seeking behavior, memory/learning, attention, sleep, affect, and many other functions

Dopamine and acetylcholine must be  balanced to produce smooth movement à when dopamine neurons are degenerated, acetylcholine signaling is increased, causing an imbalance that contributes to the clinical manifestations of PD

Pathophysiology

Unknown heredity or combination of genetics and environmental toxins, and/or sporadic

Etiology

Increased age

Gender

Environmental factors

Heredity/genetic mutation

Risk Factors

No definitive way to prevent 

suggested prevention techniques: Reduce caffeine, healthy diet

Prevention

Symptoms of PD are mild at beginning; gradually worsen over time

Motor symptoms include 4 “classic symptoms” à tremor, rigidity, bradykinesia, and postural instability

Nonmotor symptoms include cognitive deficits, emotional changes, and sleep problems

Clinical Manifestations

5-10% of individuals with PD have “early-onset” (or “young-onset”) PD in which onset begins before the age of 40

Women with early onset may need referral

Lifespan Considerations

Motor symptoms begin unilaterally progresses bilaterally 

Tremor early sign of PD

Most prominent at rest

“pill-rolling” motion à thumb and fingers gently rub together

Tremors of hands, arms, legs, jaw, and face can occur with disease progression

Tremors may worsen with stress or excitement

Motor Symptoms

Rigidity (resistance to movement) involuntary contraction of muscles. Muscles remain contracted instead of relaxing which prevents movement. Leads to muscle aches or weakness

Muscle stiffness of trunk and limbs, Limits ROM, causes pain, Passive ROM causes short jerky movements (Cogwheel)

Bradykinesia (slowed movement)

Voluntary - ADLs, bathing, dressing

Automatic: Arms may not swing, Blink rate, Stand from seat position, Steps become shorter, Difficulty with speech/swallowing/chewing, Hypophonia

Motor Symptoms Rigidity and Bradykinesia

Postural instability: stooped posture that leads to balance problems and falls. Retropulsion-topple backward

Parkinsonian gait: small, shuffling steps; steps may be characterized by bradykinesia, or steps may be rapid as if the patient is trying to run (festination). When walking, the whole foot typically strikes the ground simultaneously (or the toes strike first)

Freezing → individual with PD feels as though feet are stuck to the floor; can increase risk of falling forward

Parkinsonism

Festination - patient is not going anywhere but it looks like they are trying to go fast

Motor Symptoms Parkinsonism

Sleep problems - Insomnia, Daytime sleep attacks, Restless leg syndrome, Parasomnias

Non-motor symptoms

No cure for PD, chronic progressive disease

Treatment requires a multidisciplinary approach:

Nursing

Primary Care Provider

Neurologist

Physical Therapy

Occupational Therapy

Collaboration

Physical examination

Neurological examinations

Medical history

Sign and Symptoms

Dopamine Transporter Scan(Da T scan)

Rule out - CT scan, MRI, Blood tests

Diagnostic Tests

injection of radioactive iodine binds to dopamine transporters  in the brain; allows visualization of dopaminergic neurons à patients with degeneration of dopamine neurons will show less uptake of radioactive iodine; results are evaluated by trained neurologist

DaT scan

Advanced disease

Deep brain stimulation (DBS) is most common surgical procedure à neurostimulator and electrodes are implanted into patient to send electrical signals to one of three brain regions: Subthalamic nucleus, Globus pallidus, Thalamus 

Pallidotomy or Thalamotomy may also be used

Surgery

Allows patients to decrease dosage of levodopa medication à decrease side effects such as dyskinesia

Complications of surgical procedure: hemorrhage, infection, stroke

Complications of DBS: misplacement/dislodging of leads, component failure, and stimulation-related side effect

Deep Brain Stimulation

No pharmacologic cure is available for PD à reducing severity of symptoms

Goals of pharmacologic treatment are to: Improve the quality of life, Reduce disability, Maintain ability to work

Medications: Levadopa/Carbidopa (increases dopamine, reduces tremors. Effectiveness decreases over time and can cause diskinesia), Dopamine Agonists, MAO-B Inhibitors (can be given early, enhance Levadopa), COMT Inhibitors (slow breakdown of Levadopa in brain, increase availability), Anticholinergics- benztropine (Cogentin) (reduce tremor and rigidity, brings cdocolin back down, side effects: dry mouth, confusion)

Pharmacologic Therapy

Exercise is most important, especially combination of walking and strength training. Exercises that promote flexibility, balance, and posture (i.e., yoga, t’ai chi)

Physical Therapy (helps with grooming/cooking), Occupational Therapy (helps with cooking), Speech Therapy (swallowing/talking)

Nonpharmacologic Therapy

It is essential for nurses to:

Evaluate progression of patient’s PD 

Monitor ability of ADLs and ambulate independently. Patient teaching and emotional support

Nursing Process

Observation, patient interview, physical exam

Affect, mood, and speech pattern, presence and degree of tremor, note movement and characteristics of posture and gait

Past medical history and current complaints/symptoms, ADLs, assistive devices, effectiveness of medication regimen, sleeping habits, and memory issues

Noticing/Assessment

Actual or potential problems may include:

Impaired mobility, impaired swallowing, impaired verbal communication, impaired sleep pattern, risk for injury/falls

Goals for patients with PD may include:

Maximize functioning and mobility, remain free from injury/falls, participate in speech therapy to improve speech pattern and swallowing function

Identifying problems and planning care

Optimize Mobility

Best strategy for mobility is encouraging patient to walk daily and participate in an exercise program

Aerobic exercises and strength training increase muscle strength, balance, and coordination

ROM exercises increase joint mobility and function, and help prevent contractures

For patients who cannot ambulate independently nurse or caregiver should help patient walk several times daily

Participation in Physical and Occupational Therapy is vital for helping patients with PD maintain mobility as long as possible

Nurses should: Providing ongoing emotional support and encouragement is essential à as disease progresses, patients can experience fear, anxiety, and depression

Promote independence

Deficits in performing ADLs is a major burden for patients with PD, as well as their caregivers

Use of assistive devices is key to helping patients maintain independence in performing ADLs (i.e., shower seat, eating utensils with large handles, electric toothbrush, reachers/grippers)

Vocal training may be provided by Speech Therapy for patients with voice changes

Nursing Interventions

Routine assessments using the UPDRS to determine patient’s level of disability significant changes in the UPDRS score may indicate need for modification of pharmacologic, nonpharmacologic, or surgical therapy

Individuals with PD who have been taking levodopa for a long time may notice changes in effectiveness of the medication, or may experience intensified side effects as dosage is increased routinely assess patient’s understanding of medication regimen, potential side effects, and efficacy of drugs

As disease advances and symptoms intensify, patients may experience hopelessness and depression routinely evaluate patient’s emotional status and make referrals as necessary

Assess patient’s support system and resources at each stage of disease progression and make appropriate referrals

Evaluation