Patho: Acute Chronic EXAM 3

Onset age for Parkinson’s disease

>= 50

Who does Parkinson’s disease affect more? Men or women?

Men

Etiology of Parkinson’s Disease

• Unknown

• Genetic and environmental influences

In Parkinson’s, what is the imbalance between?

Dopamine and acetylcholine levels (ACh)

What is Parkinson’s disease?

Chronic, progressive neurodegenerative disease

What is Parkinson’s characterized by?

TRAP:

Tremors

Rigidity

Akinesia/Bradycardia

Postural disturbance

What are other non-motor symptoms

• Depression

• Psychosis

• Dementia

• Sleep disturbances

• Autonomic dysfunction

Medications for Mild symptoms (Parkinson’s Disease):

• MAO-B inhibitors

• Anticholinergics

Medications for Mild-to-Moderate symptoms (Parkinson’s):

• Dopamine releaser

• Dopamine agonists

Medications for severe symptoms (Parkinson’s):

• Levodopa/carbidopa

  • Adjunct medication: COMT inhibitors

• Dopamine agonists, dopamine releaser

Levodopa-Carbidopa side effects

• Nausea and vomiting

• Dyskinesia

• Change in behavior, personality, psychosis

• Postural hypotension and dysthymias

• Hypertensive crisis and non-selective MAO inhibitor

Dyskinesia vs. Dystonia

Dyskinesia: involuntary movements

Dystonia: Painful muscle contractures, abnormal postures, involuntary twisting

What is the On-Off phenomena:

On period: Levodopa-carbidopa working well, symptoms controlled

Off-period: Acute loss of levodopa-carbidopa effects

On-off phenomena are possibly due to:

Issues with absorption/distribution or adaptive mechanisms of brain

When does Levodopa wear off?

May occur near end of dosing interval or randomly

What do you do when Levodopa wears off?

• Increase dose

• Decrease dosing interval

• Administer COMT inhibitor to prolong levodopa ½ life

Surgical Treatment for Parkinson’s Disease":

• Thalamotomy and pallidotomy

• Deep brain stimulator

What is Multiple Sclerosis?

Chronic autoimmune disease affecting the myelin sheath and conduction pathway of the CNS (brain, optic nerve, spinal cord)

What happens during Multiple Sclerosis?

Demyelination: Immune mediated inflammatory response that destroys the myelin sheath

What is MS characterized by?

Periods of remission and exacerbation

What age range is MS the leading cause of neurologic disability?

20-30

Who does MS effect the most? Men or women?

Women

What triggers the inflammatory response for MS?

Genetic predisposition and environmental factor trigger an autoimmune inflammatory response

What happens when there’s a loss of myelin in CNS (loss of oligodendrocytes)?

Plaques form causing axonal scarring which disrupts nerve conduction

Disease course for: Relapsing remitting, Secondary and Primary progressive, Progressive relapsing

• Relapsing remitting: 85-90%

  • Secondary progressive: 40%

• Primary progressive: 10%

• Progressive relapsing: 5%

MS Manifestations: General

• Fatigue

• Pain

• “Brain Fog”

MS Manifestations: Eyes

• Diplopia (Double vision)

• Blurry vision

• Visual clouding

• Partial loss of visual field (scotoma)

• Nystagmus (involuntary, rapid, repetitive movement of one or both eyes

• Orbital pain

MS Manifestations: Ears

• Tinnitus (ringing in ears)

• Vertigo (feeling of spinning)

• Hearing loss

MS Manifestations: Mouth

• Dysphagia

• Changes in speech

MS Manifestations: Motor

• Fatigue/Stiffness of extremities

• Unsteady gait

• Weakness

• Flexor spasms at night

• Hyperactive, deep tendon reflexes

MS Manifestations: Cerebellar

• Loss of balance, poor coordination

• Intention tremor

• Clumsy motor movement

MS Manifestations: Sensory changes

• Paresthesia: Numbness, tingling, burning of face or involved extremities

  • Lhermitte sign

• Decreased temperature perception

• Bowel/Bladder dysfunction

• Alterations in sexuality

What is the goal of MS treatment?

• Delay disease course, treat exacerbations

• Symptom: Management only, no cure exists

Modalities of MS treatment:

• Corticosteroids — flares

• Immunomodulators — first line treatment

• Immunosuppressants: Used when interferon-beta fails to suppress symptoms/disease progression

• Antispasmodic drugs: Reduce spasms, contractures

Mechanism of Action for Corticosteroids

• Anti-inflammatory

• Suppress immune system

Absorption methods of Corticosteroids

• Rapid orally

• IM

• IV

Side effects of Corticosteroids

• Hyperglycemia

• Hypokalemia

• Adrenal insufficiency

• Osteoporosis

• Infection

• Peptic ulcer disease

• Cataracts and glaucoma

Nursing considerations for Corticosteroids

• Monitor serum electrolytes

• Close monitoring for infection

• Assess muscle strength

• Monitor skin integrity

• Monitor for dyspepsia, melena

• Assess visual acuity

• Safety precautions

• Assess for psychosocial manifestations

What is Amyotrophic Lateral Sclerosis (ALS) also known as?

Lou Gehrig disease: a progressive and degenerative disease that involves the motor system

Early symptoms of Amyotrophic Lateral Sclerosis

• Fatigue while talking

• Tongue atrophy

• Dysphagia

• Weakness of hands and arms

Amyotrophic Lateral Sclerosis pathophysiology

• Loss of upper motor neurons —> Spasticity

• Loss of lower motor neurons —> Muscle weakness, atrophy paralysis, and death

Amyotrophic Lateral Sclerosis clinical manifestations

• Extremity weakness

• Dysphagia (aspirations)

• Fatigue while talking

• Respiratory muscle weakness —> respiratory failure —> death

• Intellect, eye movements and sensory system are spared

Amyotrophic Lateral Sclerosis treatment

No cure, supportive care only

What is Guillain-Barre Syndrome?

Acute, life-threatening disorder: Auto-immune attack of peripheral nerve myelin causing rapid demyelination, slowing conduction

What does the Guillain-Barre Syndrome follow?

A viral GI or respiratory infection

• EBV

• CMV

• Mycoplasma pneumoniae

Guillain-Barre Syndrome Manifestations

• Hyporeflexia —> Paresis —> Quadriplegia

• Respiratory compromise (30%)

• Autonomic dysfunction

  • Postural hypotension

  • Arrhythmias

  • Facial flushing

  • Decreased sweating/salivation

  • Urinary retention

GBS stages

• Acute/Initial period

  • 1-4 weeks

• Plateau Period

  • Days to weeks

• Recovery phase

  • 4-6 months up to 2 years

  • Remyelination and axonal regeneration

GBS Treatment

High-dose IVIG therapy, Plasmapheresis

• Neutralizes and removes antibodies causing myelin destruction

What is Myasthenia gravis?

Autoimmune disorder affecting acetylcholine receptors at the neuromuscular junction

What percentage of patients have thymus dysfunction (thymoma)?

75%

Myasthenia Gravis is characterized by:

Weakness primarily in muscles innervated by cranial nerves, and in skeletal and respiratory muscles

Myasthenia Gravis: Clinical Manifestations

• Ocular signs

  • Ptosis (eyelid droop)

  • Diplopia (Double vision)

  • Respiratory compromise, SOB

  • Rapid onset fatigue

  • Muscle weakness

  • Facial weakness

  • Dysphagia

  • Dysarthria

  • Unstable, wadding gait

Myasthenia Gravis Pharmacotherapy

• Acetylcholinesterase inhibitor drugs

• Corticosteroids, Immunosuppressant medications

  • Use if poor response

Emergency Crisis of Myasthenia Gravis

• Myasthenic Crisis

• Cholinergic Crisis

Myasthenic Crisis

An exacerbation of the myasthenic symptoms caused by stressors, undermedication, or spontaneous occurrence

Cholinergic Crisis

An acute exacerbation of muscle weakness caused by overmedication with cholinergic (anticholinesterase) drugs

What test is used to distinguish between Myasthenic and Cholinergic Crisis?

Tensilon test

Myasthenic Crisis symptoms

• Increased pulse, RR, BP

• Bowel and bladder incontinence

• Extreme muscle weakness can result in death

Nursing Management of Myasthenic Crisis

• Priority is to maintain respiratory function

  • Ventilator support

• Administer neostigmine, immunosuppressants

Cholinergic Crisis symptoms

• Acute exacerbation of muscle weakness/paralysis

• Muscarinic stimulation

  • SLUDGE” — Salivation, Lacrimation, Urination, Defecation, Gastrointestinal Distress and Emesis

What is withheld in Cholinergic Crisis?

Anticholinesterases drugs are withheld while client is maintained on a ventilator

What medication can be given for Cholinergic Crisis?

Atropine may be given and repeated if necessary

• Displaces acetylcholine, decreases SLUDE symptoms

What is the antidote for Tensilon complications?

Atropine sulfate