Parkinson’s Disease

1. Parkinson’s Disease Case Study: Muhammad Ali Adult Med-Surg II 04/05/10 Allen, S., Daniels, M., Masih, L., Nirala, K., Swartz, E.

2. Case Study: Muhammad Ali Patient: Muhammad Ali(born Cassius M. Clay) • Male, 68 y/o, retired American boxer • Admission: 03/27/2010 • Hx: Parkinson’s Disease (PD) (1992). • Falls, tremors, mild dementia, and dysphagia secondary to PD. (http://en.wikipedia.org/wiki/Muhammad_Ali)

3. What is Parkinson’s Disease (“PD”) • A slowly progressing neurologic movement disorder that leads to disability. • Degenerative or idiopathic form is the most common. • Secondary form usually linked to a known or suspected cause. Muhammed Ali Parkinson’s Center Movement Disorders Clinic., Parkinson’s disease.http://maprc.com.

4. Incidence Fourth most common neurologic disorder. • 1% of persons age 65 and older • 2% of persons age 85 and older • Affects men more frequently than women. • Usually first appears in fifth decade of life. • Can occur as early as 30 years of age. (Smeltzer, S.C., Barle, B.G., Hinkle, J.L, & Cheever, K.H. ,2008)

5. Diagnosis Criteria for diagnosis of PD Group A: Features characteristics of PD: • Resting tremor • Bradykinesia • Rigidity • Asymmetric onset Gelb (1999), Advisory Council of the National Institute of Neurological Disorders and Stroke, US National Institutes of Health.

6. Diagnosis Criteria for diagnosis of PD • Group B: Features suggestive of alternative diagnoses • Features unusual early in the clinical course • Prominent postural instability in the first 3 years after symptom onset • Freezing phenomena in the first 3 years • Hallucinations unrelated to medications in the first 3 years • Dementia preceding motor symptoms or in the first year

7. Diagnosis GROUP B (cont.): • Supranuclear gaze palsy (other than restriction of upward gaze) or slowing of vertical saccades • Severe, symptomatic dysautonomia unrelated to medications • Documentation of a condition known to produce Parkinsonism and plausibly connected to the patient’s symptoms.

8. Diagnosis Criteria for POSSIBLE diagnosis of Parkinson’s disease • At least 2 of the 4 features in Group A are present; at least 1 of these is tremor or bradykinesia And either: • none of the features in Group B is present • or symptoms have been present for less than 3 years, and none of the features in Group B is present to date And either: • substantial and sustained response to levodopa or a dopamine agonist has been documented • or patient has not had an adequate trial of levodopa or dopamine agonist

9. Diagnosis Criteria for probablediagnosis of Parkinson’s disease • At least 3 of the 4 features in Group A are present • And none of the features in Group B is present (note: symptom duration of at least 3 years is needed to meet this requirement) • And substantial and sustained response to levodopa or a dopamine agonist has been documented

10. Diagnosis Criteria for definitediagnosis of PD: • All criteria for possiblePD are met, and • Histopathological confirmation (autopsy): • Substantial nerve cell depletion with gliosis in substantianigra • At least one Lewy body in substantianigra or in locus coeruleus. • No pathological evidence for other diseases that produce Parkinsonism (eg progressive supranuclear palsy, multiple system atrophy, cortical–basal ganglionic degeneration).

11. Diagnosis Basal Ganglia

12. Diagnosis The basal ganglia includes the caudate nucleus, putamen, globuspallidus, subthalamic nucleus, and substantianigra.

13. Diagnosis Gliosis: A process leading to scars in the central nervous system(CNS) that involves CNS production of a dense fibrous network of neuroglia (supporting cells) in areas of damage. Gliosis is a prominent feature of many diseases

14. Lewy Bodies Lewybodies: Abnormal aggregates of protein that develop inside the nerve cells in PD.

15. Pathophysiology • Associated with loss of dopamine nerve cells in the substantianigra in the basal ganglia of the brain. • Loss of dopamine causes imbalance of neurotransmitters, which affects voluntary movement. • Clinical symptoms do not appear until 60% of dopamine neurons are lost and dopamine level is decreased by 80%. • Cellular degeneration impairs control of semiautomatic functions and coordinated movements.

17. Causes Cause is unknown, may be linked to: • Genetics • Atherosclerosis • Excessive oxygen free radicals • Viral infections • Head trauma • Chronic use of antipsychotic medications • Environmental exposures.

18. Causes • Head trauma • Considered a risk factor for PD since past episodes are reported more frequently by individuals with PD than by others in the population. • Recent studies suggest no true relationship between severe head injury and PD.

19. Causes • Genetics • Someone with PD is more likely to have relatives who also have PD. • Inheritance of PD is usually complex and not due to a single gene defect.

20. Pharmacological Therapy • Antiparkinsonian medications • Anticholinergics • Antiviral therapy • Dopamine Agonists • Monoamine oxidase inhibitors • Catechol-O-methyltransferase (COMT) inhibitors • Antidepressants • Antihistamines Smeltzer, et al (2008)

21. Pharmacologic Therapy Antiparkinsonian medications: • Increase striataldopaminergic activity • Reduce excessive influence of excitatory cholinergic neurons • Restore balance between dopaminergic and cholinergic activities Or • Act on neurotransmitter pathways other than the dopaminergic pathway.

22. Antiparkinsonian Medications Larodopa (Levodopa) • Most effective treatment • Converted to dopamine in basal ganglia, producing symptom relief. • Benefits wane over several years • Adverse effects with long-term use - confusion, hallucinations, depression, sleep alterations • Protein, Vitamin B6 may decrease effectiveness Deglin, J. and Vallerand, A. (2009)

23. Antiparkinsonian Medications Sinemet (carbidopa) • Usually administered with levodopa • Prevents breakdown of levodopa; reduces adverse effects of levodopa • Long-term use can cause: • Dyskinesia • On-off syndrome (acute episodes of near- immobility followed by sudden return of mobility) • Neuroleptic malignant syndrome (medical emergency) Deglin (2009)

24. Anticholinergics Cogentin • Control tremor – may be used in combination with levodopa. • Counteracts action of acetylcholine. • Side effects poorly tolerated in the elderly (blurred vision, flushing, rash, constipation, urinary retention, acute confusion) • Monitor for urinary retention in patients with enlarged prostate • Contraindicated in patients with narrow-angle glaucoma Deglin (2009)

25. Dopamine Agonists Parlodel and Permax • May postpone the need for carbidopa or levodopa therapy. • May be used after carbidopa or levodopa lose effectiveness. • Monitor for adverse reactions: • N/V, diarrhea • Lightheadedness, hypotension • Impotence • Psychiatric effects Smeltzer, et al (2008)

26. Other Pharmacological Therapy Monoamine Oxidase Inhibitors • Eldepry - inhibits dopamine breakdown • Selegiline - Used with dopamine agonist to delay carbidopa or levodopa therapy Catechol-O-methyltransferase (COMT) Inhibitors Comtan and Tasmar • Increase duration of action of carbidopa or levodopa • Reduce motor fluctuations in patients with Parkinson’s Smeltzer, et al (2008)

27. Other Pharmacological Therapy Antiviral Therapy • Symmetrel • Used in early stages of disease • Reduces rigidity, tremor, bradykinesia, postural changes • Low incidence of side effects Antihistamines • Benadryl, Banflex, Neo-Synephrine • Mild central anticholinergic and sedative effects • May reduce tremors. Smeltzer, et al (2008)

28. Assessment • Clinical diagnosis based on: • Patient’s history • Presence of two of the four cardinal manifestations: • Tremors; pill-rolling tremor of the hands • Muscle rigidity • Bradykinesia (abnormal slow movement) • Stooping, forward posture Smeltzer, et al (2008)

29. Assessment • Observe the degree of disability and functional changes that occur throughout the day, such as response to medication. • Assess nutritional status. • Assess for mood swings, depression, and cognitive impairments.

30. Assessment Ask patient if they ever experience: • Leg or arm stiffness • Irregular jerking of your arms or legs • Feeling “frozen” to a spot and unable to move • Excessive saliva production or drooling • Grimacing, facial contortions, or chewing movements • Difficulty performing specific activities

31. Assessment Observe patient for: • Dysphonia - soft, slurred, low-pitched, and quiet speech • Dysphagia- swallowing deficits • Drooling, poor head control, coughing • Bradykinesia (slowness of movement) • Tremors (pill-rolling movements) • Weakness • Stooping, forward posture • Muscle rigidity • Loss of facial expression (“flat” effect) • Autonomic symptoms (orthostatic hypotension, flushing, and diaphoresis).

32. Assessment Assess for medication-related S/S: • Adverse reactions • Side effects • Food-drug interactions • Drug-drug interactions • Effectiveness of medications Deglin (2009)

33. Nursing Diagnoses • Risk for aspiration r/t swallowing deficits. • Risk for falls r/t impaired balance and tremors. • Constipation r/t medication and reduced activity. • Impaired mobility r/t muscle rigidity and weakness. • Imbalanced nutrition - less than body requirements, r/t chewing and swallowing deficits. • Self-care deficits r/t tremor and motor disturbance. • Impaired verbal communication r/t dysphonia • Ineffective coping r/t depression, secondary to disease progression. Ackley, B. J. & Ladwig, G. B., (2006).

34. Planning • Improve functional mobility • Implement an exercise program that will increase muscle strength, improve coordination and dexterity, reduce muscular rigidity, and prevent contractures that occur when muscles are not used. • Examples: walking with care, riding a stationary bike, swimming • PT/OT referral Ackley (2006)

35. Planning • Achieve adequate bowel elimination • Encourage increase fluid intake • Follow a regular time pattern • Stool softener (avoid laxatives b/c they may cause bowel obstruction) • Eat balanced diet with plenty of fruits, vegetables, and whole grains b/c of their high fiber content

36. Planning • Attain and maintain acceptable nutritional status • Supplemental feedings to increase caloric intake • Consult dietician • In later stage of disease, a nasogastric tube or percutaneous endoscopic gastroscopy may be needed to maintain adequate nutrition

37. Planning • Achieve effective communication • Speech therapy referral • Use of electronic amplifier if difficulty hearing patient • Other referrals/consults • Case manager • Home health • Social worker

38. Interventions Enhance Swallowing • Ensure patient is in upright position during mealtime. • Provide semisolid diet with thick liquids; avoid thin liquids. • Teach patient to think through the swallowing sequence with eat bite. • Teach patient to chew first on one side of the mouth and then the other. • Teach patient to hold head upright and make conscious effort to swallow to control saliva buildup. Smeltzer et al (2008)

39. Interventions Improve Bowel Elimination • Encourage moderate fiber intake. • Provide adequate fluids. • Encourage and assist with regular, daily exercise. • Provide raised toilet seat. • Allow pt sufficient time for toileting. • Avoid psyllium (can cause bowel obstruction).

40. Interventions Improve Mobility • Encourage and assist with daily exercise • Improves muscle strength, coordination and dexterity; can delay progression of the disease. • Reduces muscular rigidity; prevents contractures. • Walking, riding stationary bicycle, swimming, and gardening can help maintain joint mobility.

41. Interventions Improve Mobility • Stretching (stretch–hold–relax) and range-of-motion exercises promote joint flexibility. • Postural exercises - counter the tendency of the head and neck to be drawn forward and down. • Special walking techniques - compensate for balance issues caused by arm rigidity.

42. Interventions Improve Nutrition • Monitor daily weight during inpatient stay. • Request swallowing and nutrition consults. • Identify patient’s food likes and dislikes- provide food the patient enjoys. • Provide supplemental feedings. • Encourage daily exercise to stimulate appetite. • Provide adaptive equipment for meals (non-tip cup, raised utensils, warming tray).

43. Interventions Promote Self-Care Activities • Encourage, teach, and support the patient during ADLs. • Overbed frame with a trapeze can provide assistance in pulling up without help. • Allow sufficient time to self-dress, eat, and perform personal hygiene. • Encourage pt to wear clothing without buttons, zippers, or snaps; slip-on, non-skid shoes. • Encourage use of assistive devices. Wissman (2007)

44. Interventions Improve Communication • Teach the patient to: • Face the listener • Exaggerate enunciation of words • Speak in short sentences • Take a few deep breaths before speaking. • Provide a sign board/marker board • Request speech therapy consult

45. Interventions Support Coping Abilities • Visit with patient daily to reduce social isolation/ • Refer to support groups, community resources and Internet resources:

46. Discharge Planning • Ensures that the patient leaves the hospital in a timely manner with the necessary resources. • Begins at admission. • Nurse provides information about to the patient and caregivers r/t the disease and self-care. Potter, P.A. & Perry, A., (2008).

47. Discharge Planning Nurse provides information about: • Medication instructions; potential food-drug interactions • Activity restrictions • Rehabilitation techniques/adaptation • Access to available community resources • Guidance on when and how to obtain follow-up care • Patient/family responsibilities in patient’s care

48. Discharge Planning Multidisciplinary process that may involve: • Speech-Language Therapy (SLT)- Swallowing and speech needs. • PT consult – Walking/balance issues; assistive equipment needs • OT – ADL teaching/adaptive equipment needs • Case Manager – Coordination of discharge planning • Social Worker – Financial, caregiver, and home environment needs. • Dietitian - Nutritional/dietary education • Home Health – In-home care

49. Evaluation Strives toward improved mobility • Range-of-motion exercise to all joints three times daily • Massage and stretch muscles to reduce stiffness • Walks with wide base of support; exaggerates arm swinging when walking • Avoid staying in one position for prolonged periods • Rest without a pillow and lie prone frequently to deter flexed posture • Ackley (2007)

50. Evaluation Progresses toward self-care • Allows time for self-care activities • Explore the use of assistive devices