PARKINSON

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PARKINSONS DISEASE AN OVERVIEW

• Living with Parkinsons Disease
• Deborah Orloff, MPH, RN
• Chief Executive Officer
• Michigan Parkinson Foundation

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Background and Definitions

• Parkinsons disease was first described by Dr.
  James Parkinson in his paper An Essay on the
  Shaking Palsy in 1817.
• Slowly progressive neurodegenerative disorder
  with no identifiable cause.
• The fourth most common neurodegenerative disease
  of the elderly
• Affects about 1 of the population over 55 years
  of age.

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Pathology

• Massive loss of the pigmented neurons and
  gliosis, most prominently in the substantia nigra
  with presence of Lewy bodies.
• Loss of approximately 80 of these neurons
  results in the presence of clinical symptoms.

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Pathology
Courtesy of Kapil D. Sethi, MD
Courtesy of Kapil D. Sethi, MD
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Histology of PD Showing Lewy Body
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Disease Onset

• Average age of onset 50-60 years
• Approximately 5 of cases occur before age 40
  (young onset)
• Slowly progressive over 10-20 years
• Early symptoms may be constipation, REM sleep
  disorder, loss of sense of smell, depression
• non-specific symptoms easy fatigability,
  incoordination, change in writing, pain/tension
  in one shoulder, depression

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Motor Symptoms of PD

• Resting Tremor
• Rigidity (Cogwheel)
• Bradykinesia (slow movement) or Akinesia (absence
  of movement)
• Postural Instability (balance and coordination)

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Tremor

• First Sign in 75 of patients
• Occurs at rest
• Does not need to be present to make a diagnosis
• Typically on ones side of body and involves a
  distal extremity (hand, leg)

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Rigidity

• Stiffness caused by an involuntary increase in
  muscle tone
• Can affect all muscle groups
• Often presents as back, neck or shoulder
  discomfort
• Often dismissed as arthritis referrals to
  orthopedists initially

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Akinesia/Bradykinesia

• Absence of Movement
• Describes the difficulty Parkinsons patients
  have in initiating and executing a motor plan.
• Early signs include microphagia (small writing)
  and loss of dexterity.
• Facial Drooling, hypomimia (masked face).
• Vocal hypophonia (soft voice).

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Postural Instability

• Usually the last motor sign to appear.
• Often the most disabling and least treatable
  problem.
• No single factor alone is responsible.
• Freezing is a form of akinesia which is most
  problematic during ambulation and often leads to
  falls.

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Non-Motor Symptoms

• Dysautonomias (problems in functioning of the
  autonomic nervous system)
• constipation
• impotence
• urinary problems
• orthostatic hypotension
• regulation of heat
• sensory disturbances
• problems swallowing
• pain

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Non-Motor Symptoms, cont

• Speech problems
• Behavioral problems, including depression
  anxiety
• panic attacks agitation
• Sleep Disorders

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Non-Motor Symptoms, cont.

• Loss of smell
• Constipation
• Cognitive (thinking) problems, including dementia
• Fatigue

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PARKINSONS SYMPTOMS

• VARIABLEfrom person to person
• VARIABLEfrom day to day
• VARIABLEresponse to treatment

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Parkinsonism

• A clinical syndrome characterized by specific
  motor deficits including tremor, akinesia,
  bradykinesia, rigidity and postural
  changes/instability.
• An underlying cause is usually identified
  chemicals (drugs), structural NPH, or possibly a
  neurodegenerative disorder (PSP, MSA)

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Clinical Features That May Suggest a Diagnosis
Other Than PD

• Early onset of postural instability
• Axial more than appendicular rigidity
• Poor response to adequate dosages of levodopa
• Early dementia
• Supranuclear gaze palsy

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Treatment and Intervention

• Non-pharmacologic
• Exercise
• Education
• Nutrition
• Group Support

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Treatment and Intervention

• Pharmacologic Intervention Considerations
• Degree of functional impairment
• cognitive impairment
• Age (potential side effects)
• Cost

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Treatment and Intervention

• Newer agents are being introduced at greater ages
  with success.
• Research into an effective agent for
  neuroprotection is ongoing.
• Neuroprotection remains controversial.

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How is P.D. Treated?

• First Line
• rest and relaxation
• exercise
• stress management
• nutrition
• rehab therapyot, pt, speech
• mental health counseling
• education
• support (e.g. support groups)

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Medication

• Complex Know action, dosage, side effects, how
  respond.
• Used to treat symptoms, not cure.
• No two people respond the same.
• Own responses vary.
• Need to monitor and change medication regime over
  time.

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Medication, cont

• Newly diagnosed may hold off until symptoms
  interfere
• May start with low levels and work upwards.
• May use multiple medications.
• PD meds may interact with others.

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Types of Medications

• Anticholinergics
• Levodopa (Sinemet CR, Atamet)
• Amantadine
• MAO Inhibitors (NO DEMEROL OR ANTIDEPRESSANTS)
• Dopamine Receptor Agonists
• Catechol-O-Methyl Transferase (COMT)
• Selegeline

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Frequent Side Effects of Meds

• Orthostatic hypotension
• Memory loss or confusion
• Agitation
• Depression
• Hallucinations and psychosis
• Sleep disturbances/daytime sleepiness
• Nausea
• Motor Fluctuations

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Challenges of Medications

• Timing
• Monitor and adjust
• Side effects
• Complications
• Drug interactions
• Cost
• Frustration
• Incorporating med regimen into setting

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Surgery

• Surgery does not cure or stop the progression.
• Destruction of cells
• Deep brain stimulation
• Pallidotomy
• Thalamomtomy
• Gene transfer (beginning stages)
• Fetal and adrenal grafting (stem cells)
  EXPERIMENTAL

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Surgical Treatments

• Deep Brain Stimulation Surgery
• Insertion of an electrode into the brain to
  deliver electrical stimulation which dampens
  tremor, rigidity, dyskinesia.
• Reversible
• Sites vary depending on diagnoses

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Current Research

• Cause of PD
• Restoration
• Neuro-protection
• New Pharmacologic Agents
• Different Modes of Administrating Drugs

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Management

• Physical Therapy
• Occupational Therapy
• Speech and Language Therapy
• Mental Health Counseling

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Treatment Goals

• Reduce incidence and severity of symptoms
• Maintain independence
• Work together as a team

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IMPLICATIONS FOR CARE

• Provide information
• Medication Management
• Skin Care
• Elimination (bowel, bladder)
• Comfort
• Rest
• Cognition

• Mental health
• Safety
• Cognition
• Sleep
• Communication
• General Health
• Family education/support
• Community Resources

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Role Medication Management

• Correct dose and time
• Properly administer
• Track behavior
• Drug interactions
• Swallowing difficulties
• Report problems
• Document, communicate

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Provide Expert Care COMMUNICATION

• Speech production
• Facial expression
• Slowed thinking
• Slowed responses
• Information processing, including memory,
  concentration, confusion

• Stress increases problems
• Depression
• Dementia
• Handwriting
• Family talks for PWP

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Communication, continued

• Management
• Assess for hearing problems, also
• Allow time - patience
• Quiet environment
• Positive communicative atmosphere
• Structure conversations, use familiar words
• Adult topics and routine
• Encourage communication
• Referrals Speech and Language Pathology
• Assistive devices

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Communication, continued

• Identify problems
• Document
• Communicate to other team members
• Develop plan that works for PWP and family
• Evaluate

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Safety Management

• Assess for risks
• Identify probable causes
• Review previous incidents
• Develop plan
• Monitor outcomes, revise as necessary
• Referrals Physical Therapy, Occupational
  Therapy, Speech and Language Pathology, Dietitian

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Safety ManagementAmbulation

• Ambulation
• Avoid rubber or crepe soled shoes
• Visual, auditory cues
• Identify problem areas, e.g. narrow hallways,
  doors
• Remove hazards, e.g. area rugs
• Concentrate on one task at a time
• Ambulatory aids
• Avoid pivot turns

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ADLS MANAGEMENT

• Symptoms vary/abilities vary
• Perform tasks at times of optimum functioning
• Give medications so optimal time for tasks is at
  peak medication time
• Frustration PATIENCE
• Person with PD/Caregiver
• Referrals Occupational Therapy
• Assistive Devices

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Sleep Problems

• Different sleep problems
• Assess when person is having difficulty falling
  asleep, awakening during the night, early
  awakening, napping during the day, etc.
• Difficulty normally moving in bed
• Other problems lead to interrupted sleep,
  including other medical problems, depression,
  anxiety, pain, RLS
• May be related to medications

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Sleep Problems Management

• Sleep hygiene
• Medications
• Alter PD medications
• Treat depression
• Physical aids, e.g. satin sheets

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Special Issues in LTC Settings

• Connecting with health professional knowledgeable
  about management of Parkinsons disease.
• Medication management.
• Complexity of care and course.
• Hospitalization.
• Communication/cognition issues.
• Maintaining in mainstream of life.
• Family interactions.
• End of Life issues.

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Objectives in Long Term Care

• Assist individual and family to obtain optimal
  functioning physically, emotionally,
  spiritually.
• Provide highest quality of care to assist
  individual to achieve a state of wellness
  consistent with the quality of life desired by
  the patient.
• Assist individual and family to achieve a
  satisfactory end of life experience.

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Where to get help

• Michigan Parkinson Foundation
• 30400 Telegraph, Suite 150
• Bingham Farms, MI 48025
• 800-852-9781 info_at_parkinsonsmi.org
• www.parkinsonsmi.org