Download Nursing - The Movement Disorder Society

10/20/2014
Disclosures for Susan Heath
• Paid Consultant and educator for Medtronic
• Consultant for AbbVie
ALLIED TEAM
TRAINING FOR
PARKINSON
ROLE OF THE NURSE IN MIDDLE STAGE
PARKINSON’S DISEASE PRACTICE
Susan Heath, MSN, RN Slides complements of JOAN M GARDNER, RN BSN
Learner Objectives
Middle Stage PD-Hoehn and Yahr Staging
• Describe the symptoms of Middle Stage PD
• Describe appropriate nursing interventions with
middle stage PD
• Identify educational needs of patient/caregiver in
middle stage PD
• Describe at least two tools used for assessment of
depression in Parkinson disease
• Discuss the potential benefits of a structured
caregiver assessment in Parkinson disease
Stage I:
Unilateral involvement
Stage II:
Bilateral or Axial involvement without
balance impairment
Bilateral involvement
Mild postural imbalance
Patient leads independent life
Bilateral involvement
Postural instability
Patient requires help with activities of
daily living
Fully developed disease
Patient restricted to bed or chair
Stage III:
Stage IV:
Stage V:
3
4
Middle Stage PD
Parkinson’s Disease Progression
• Greater impact of symptoms
– More bothersome
– Interfere with day to day tasks
– Require more assistance, less independence
0%---
Advanced P.D.
Moderate P.D.
Early P.D.
Palliative Care (Relief of Suffering)
|
1.0
|
1.5
|
2.0
Diagnosis
of
Parkinson’s
Disease
|
2.5
|
3.0
|
4.0
Hoehn & Yahr Score
Bereavement Care for Family
Treatment of PD (Prolongation of Life)
Hospice
Schwab & England ADL Score
100%---
• Medication schedules become more complex
– May have multiple medications 4-6x/day
• Referral to the team members is essential, as
medications will not help all symptoms
• Family involvement
|
5.0
– Becomes necessary for family to attend medical
appointments to understand plan
Death
– Sometimes family must be educated in Parkinson’s if
they have not attended appointments
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(Bunting-Perry, 2007)
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Multiple area/issues for team members
Additional concerns –
• Non-motor sx’s worsen
• Motor fluctuations
– Sleep issues, mood issues, bladder issues, pain, cognitive
• Autonomic complications
• Motor sx’s worsen
–
–
–
–
• Sleep disturbances
Ability to turn in bed, get in or out of a chair, bed or car
Freezing and /or gait changes
Balance impairment (near falls) or falls
Swallowing/choking fears
• Sensory problems (pain, numbness, tingling)
• Cognitive impairments
• Medication schedule complicated
• Anxiety
– Reliable organiziation system for pills
– Medication complications (dyskinesias)
• Depression
• Caregiver/family issues
• Apathy
– Increased dependence, communication challenges (“one
person is deaf and the other mumbles”)
– Coping strategies, support, resources
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• Hallucinations
•8 Increased carepartner burden
Lang AE, PD
andMedication
Lozano AM.
ParkinsonsSome
Disease.
Second
of two
Treatment:
Potential
Flows
Monotherapy-MILD
parts.
(Review) N Eng
JN of Medicine 1998;
339; 1130-1143
MODERATE
SEVERE
MILD/MODERATE
Narrowing of the Therapeutic Window
MAO-B
Levodopa
Dopamine Agonist
(decrease
Levodopa)
COMT
Progresses in advanced PD
COMT
The Levodopa Therapeutic Window Narrows
with Disease Progression – less time with ‘perfect’ benefit
Levodopa
Plasma levodopa concentrations
Anti
cholergernic
Amantadine
Older patients
MAO-B
Dopamine
Agonist (2x)
Levodopa
COMT
Levodopa
Anti
cholergernic
Amantadine
Younger patients
Levodopa
Dopamine
Agonist
MAO-B
COMT
MAO BRasagiline
Dopamine Agonist
Levodopa
Anti
cholergernic
Schematic depicting the narrowing of the levodopa therapeutic window over time
Dyskinesia
threshold
Early
disease
*
Time
Dyskinesia incidence
increases with levodopa use
Obeso et al 2000
Lang AE, and Lozano AM. Parkinsons Disease. Second of two parts. (Review) N Eng JN of Medicine 1998; 339; 1130-1143
Motor Complications = Fluctuations
Dyskinesia
Obeso et al 2000
Teach the Parkinson’s Symptom “Lingo”
The patient/carepartner should learn terms:
“wearing off”, “on/off”, “dyskinesia”
-Choreiform
movements
-Usually peakdose
“Are you looking
Or waiting
for your next
dose of meds?”
“ON” without
dyskinesia
“OFF”
Advanced
disease
Efficacy
Efficacy
threshold
Therapeutic
window
Amantadine
After 5 years of treatment with Levodopa Use- Dyskinesia and
Motor Fluxuations develop in ~50% of patients. * Lang (1998)
Moderate
disease
“OFF”
Fluctuations/Wearing off
-L-dopa effect duration shortens
-more frequent doses, or adjunct
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Presentation
Dyskinesia
Implications
•Able to ambulate
Peak “on”
•Self care for ADLS’s
•Often clearer thinking
Dyskinesia = uncontrolled writhing movement of the
body or limb
• Dyskinesia needs to be assessed (when it
occurs in the treatment cycle)
–Peak dose (usual)
–End of dose (wearing off, D-I-D)
• Tool: Dyskinesia Rating Scale
•Understand what each patient
“on” state looks like
•Increase dose
Wearing off
•Return of PD motor symptoms
•Increase frequency
•Anxiety, mood changes
•Add another medication
•Adjunct therapy (PT, OT, ST)
•Med adjustment
Freezing
Dystonia
Dyskinesia
Akinesia with step initiation,
turning, changed environment
Sustained posturing of a limb
that is painful and disabling
Early morning foot dystonia is
common (curling of toes)
•Involuntary movement of UE,
LE, trunk, head, (varies)
•Different from tremor
•Physical therapy for Physical
cuing (rocking, singing, etc)
•Med adjustment
• Botox, pain meds
Management strategies:
• May give less levodopa more frequently
• May add dopamine agonist and decrease levodopa
• May add amantadine; may try newer med options
•Physical, occupational therapy
•Levodopa adjustment
•Add amantadine
•OT- fatigue management
•Dietician
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Dyskinesia Video
Dyskinesia Video
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Dyskinesia Video
Motor Fluctuations
• Once “unpredictable” motor fluctuations occur
they can be difficult to treat
– Common in advancing PD
– Sudden onset, often associated with freezing of
gait (“FOG”)
– Cognition and mood may also be affected
• Apomorphine, an injectable dopamine agonist
for treating sudden or unpredictable “offs”
• Pt may be DBS candidate if meds improve motor
function by minimum of 30% (off versus on) and
cognitively ok (does not have to be perfect.)
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Off/On Video
Patient Med Diary
Off/on video
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Complex Symptoms
Importance of Pills on Time
Case Study
• Pt Diagnosed with Parkinson’s disease 2008
• Current medications
– Carb/levodopa 25/100 1.5 tablets every 3 hours
– Pramipexole ER 1.5 mg
– Clonazepam 0.5 mg hs and prn bid
A visual chart outlining schedule is helpful to many
6 8
1
10
1.5
12
Carb/levodopa
25/100
1.5
1
Comtan
1
1
1
1
2
1.5
4
1
6
1.5
8
1
10
1.5
noc
1
• Motor symptoms
– Tremor-right sided despite meds
– Rigidity bilat in off state, wakes up slow and stiff
– Bradykinesia in off state
– FOG (freezing of gait - in med off state)
1
Carb/levodopa
CR 50/200
1
• Non-motor symptoms and secondary symptoms
– Anxiety, Depression
– Painful ankle dystonia – wants to see Orthopedist
– Dyskinesia and spouse reports ICD behavior
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amantadine
21
Schedules and Timing of Medications
Protein and Levodopa
• For best absorption of levodopa
avoid high protein foods within
30-60 minutes before and after
The need for Pills on Time
Exact timing should be obtained from the
ordering clinician
• Typical bid. tid, qid usually does not apply
• Should follow the same schedule daily
• Pill boxes, timers, referral to OT
• Teach patient / family self monitoring- to
relate symptoms to timing of medications
• A frustration for all who are hospitalized
or move to a residential living setting
• Some studies state 15% are negatively
affected by protein
• Requirements are 56 grams/day for men and 46
grams/day for women
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Protein and Levodopa
Protein and Levodopa
If protein appears to be interfering with levodopa absorption,
and/or the patient experiences motor fluctuations, a trial
of charting the timing of c/l before or after meals for 2
weeks may be helpful.
If protein sensitive:
• Consider portion size of protein containing food
• Experiment with plant vs. animal protein sources
• Eat the majority of protein in the evening
– Protein redistribution diets (PRD) are at first
followed but not long term
• Eat small frequent meals throughout the day
• Eat a low fat diet-fat further delays emptying
Encourage use of a diary to monitor effectiveness
Scheduling mealtime away from pills is challenging if requiring
frequent doses/day
Taking carb/levo with a carbonated beverage may result in
faster absorption
Some chew tablets for a faster effect (parcopa – quick
dissolving)
Should not chew or crush CR medications
**Cereda E, et al, Low-protein and protein-redistribution diets for Parkinson’s
disease patients with motor fluctuations: a systemic review.; Mov Disorders
2010 Oct 15;25(13):2021-34.
Deep Brain Stimulation (DBS)
STN
Before and After STN DBS
STN
• An option for some when medications no longer
provide sufficient quality of life
• Risk factors are low in experienced centers, not
experimental
• The stimulator requires adjustment over time to
maximize benefit to the patient.
• Batteries need surgical replacement. Average Q
27 3yrs
Deep Brain Stimulation (DBS)
•
•
•
•
Nursing has a key role in patient/family education Many nurses in some centers programs the DBS
Group classes regarding DBS pre‐op teaching/candidacy
Goal oriented individual teaching
– What are your top 3 goals for DBS surgery?
– What are your concerns regarding DBS surgery?
• Programming after surgery
• Required post‐DBS follow‐up Okun, M. n engl j med 367;16 nejm.1530 org october
18, 2012
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5
– Programming and battery assessment
– Med adjustments
– Objective assessments / triage for rehab/support
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Hospitalization and Parkinson’s
Hospitalization and Parkinson’s
• Pills “on time” is a big problem for hospitalized PD patients ‐3 out of 4 people with Parkinson’s disease do not receive medications on time in the hospital1
• 61% of patients who did not get their medications on time had serious complications ‐ falls, pain, dysphagia, cognitive and mood changes, urinary sx’s
• Most schools of Nursing do not teach undergraduate students about Parkinson’s • People with Parkinson’s are hospitalized 50%
more than their non-PD peers1
– As a group, PD patients have more inpatient days
over their lifetime (following the diagnosis of PD)
when compared to the general population 4
• Length of hospitalization is 2-14 days longer
than non-PD patients
• Usually admitted for other medical conditions
Gerlach OH et all, Clinical problems in the hospitalized Parkinson’s disease patient:
systematic review, Movement Disorders 2011 Jan 31
National Parkinson Foundation working group on hospitalization in Parkinson’s Disease,
Parkinsonism and Related Disorders 2011 Mar;17(3):139-145.
KN Magdalinou, et al. Prescribing medications in Parkinson's
disease (PD) patients during acute admissions to a District
General Hospital. Parkinsonism and Related Disorders. 2007
Dec;13(8):539-40.
What to do if Hospitalized
Resources
Upon admission to hospital it is Important for
patient/family to advocate for their usual PD meds and
dosing schedule
National Parkinson Foundation
 AWARE in CARE kit
• With the patient/family, verify exact dosages and
formulations (immediate release, controlled release,
etc.) Hospital medication schedules (qid) are not same
as home qid. Need to specify individual’s PD med times
with hospital providers and nursing staff.
www.awareincare.org
or
call 1-800-4PD-INFO (473-4636)
• Patient may need a dose of PD meds before meds are
received from the pharmacy.
Story: Bill who forgot his hospital kit…..
What’s in the Kit?
What’s in the Kit?
1.
Aware in Care Bag—Pack your bag with your Parkinson’s medication and
your Aware in Care materials
2.
Hospital Action Plan—Read about how to prepare
for your next hospital visit—whether it is
planned or an emergency
3.
Parkinson’s Disease ID Bracelet—Wear your bracelet at all times in case
you are in an emergency situation and cannot communicate
7. I Have Parkinson’s Reminder Slips—
Share vital information about Parkinson’s
disease with every member of your care team in the hospital
4.
Medical Alert Card—Fill in your card with emergency
contact information and place in your wallet
8. Thank You Card—Present this card to a staff
member who provides high quality care
5.
Medication Form—Complete this form and
keep copies
9. Magnet—Use this magnet to display a copy of your Medication
Form in your hospital
6. Parkinson’s Disease Fact Sheet— Share the facts about
Parkinson’s with hospital staff and ask that a copy be placed in
your chart
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Considerations for inpatient stays
Considerations for Care During Hospitalization
• Plan nursing care/activities after medications have ‘kicked
in.’
– Instead of NPO after midnight, give PD pills with
a small sip of water right up to time of procedure
• If medications have to be crushed and administered through
a tube, give them at least one hour prior to meals
– Crushed CR will convert to immediate release levodopa
– Restart PD pills as soon as able to swallow
following a procedure
• Anticipate delirium if general anesthesia is used
– Avoid Haldol (dopamine depleting) instead use seroquel for agitation.
– Dissolvable form of carbidopa/levodopa
(Parcopa®) may be useful in some patients after a
procedure or if swallowing difficulties
• Narcotics, muscle relaxants, bladder, sleep and pain
medications can increase the risk of confusion,
hallucinations or delirium
• If patient becomes confused, consider urinary or lung
infection as possible cause
– Story: Neurologist from small hospital called
about unresponsive pt in their ICU.
Care Transitions from the hospital
Contraindicated Medications for PD
Medical Purpose
Safe Medications
Medications to Avoid
Antipsychotics
quetiapine (Seroquel®), clozapine (Clozaril®). These drugs minimally affect Parkinson symptoms. avoid all other typical and atypical anti‐
psychotics, such as haloperidol (Haldol®)
Pain Medication most are safe to use, but narcotic medications may cause confusion/ psychosis and constipation if patient is taking MAOB inhibitor such as selegiline or rasagiline (Azilect®), avoid meperidine (Demerol®) domperidone (Motilium®), trimethobenzamide (Tigan®), ondansetron (Zofran®), dolasetron (Anzemet®), granisetron (Kytril®) prochlormethazine (Compazine®), metoclopramide (Reglan®), promethazine (Phenergan®), droperidol (Inapsine®), as they can worsen Parkinson symptoms
Nausea/ GI Drugs Discharge to home or rehab facility.
•Be sure patient/family understands reviews
usual med dosing and schedule with Rehab center
team.
•Often errors occur when changes in usual
medications schedules or dosages occurred
during hospitalization (good or otherwise) then
transferred (incorrectly) to rehab setting.
•If medications or schedules were changed during
hospitalization a follow-up with the Neurologist is
recommended.
Importance of PD care by Neurologist
Recommendations from the NPF Work Group
National Parkinson Foundation working
group on hospitalization in Parkinson’s Disease,
Parkinsonism and Related Disorders 2011 Mar;17(3):139-145.
Hospitalization issue‐prevention
Management consideration
PD patient admitted to the hospital
Obtain early neurological consult
Early ascertainment of a medicine list
Obtain early information on prescription medications as well as the length of time taking over‐the‐counter medication which could impact cognition and motor symptoms (e.g. diphenhydramine).
Rehabilitation and aspiration prevention
Mobilize the patient as much as possible
Understand dosing intervals
Pay as much attention to the dosing interval as to actual doses of both prescription and over‐the‐counter medications
Determine if patients can self‐medicate
If the hospital allows patients to take their own medications, it may be required that the medication doses and times match the medicine bottle (this may not be the case for many PD cases)
Willis et at, Neurologist-associated reduction in PD-related
hospitalizations and health care expenditures, Neurology.
2012 Oct 23;79(17):1774-80
• 24,929 cases - 13489 had neurologist care
• 9112 PD-related hospitalizations
Hospitalization occurred and recurred less often among
neurologist-treated patients.
Neurology treated patients had lower adjusted odds of both
initial and repeat hospitalization for psychosis, UTI and
traumatic injury
Pa
Mental status change
Consider temporarily simplifying the medication regimen if a mental status change is present (e.g. carbidopa/levodopa only)
Patients who cannot take meds P.O.
Consider nasogastric tubes, apomorphine, and dopamine patches when patients can’t take medicines by mouth
Drugs that may worsen PD
Avoid dopamine‐blocking drugs (including metoclopramide and many common anti‐nausea drugs such as prochlorperazine) with the exceptions of quetiapine and clozapine which are useful forr psychosis
Patient/family pre‐education
Educate patients and families prior to elective procedures and hospitalization
This may reflect an improved ability of neurologists to
prevent, recognize, or treat PD complication
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Changes in Sleep
RBD = REM Sleep Behavioral Disorder
Difficulty with sleep maintenance
The violent acting out of dreams = RBD.
When non PD persons dream their brainstem paralyses the body. But in PD this does not happen and during REM sleep the body still can move allowing acting out of dreams. Saftey issues for bed partner due to pt’s unconscious aggressive behavior – may hit the partner, jump out of bed, fall, yell, etc., can be a safety risk to patient and partner. (Attorney story) First advise bed partner to sleep in different bed. May need sleep study to check for OSA
• Fragmented sleep. Numerous nighttime awakenings may
progress with increase in motor symptoms
Causes
• Physical symptoms of Parkinson’s
• Wearing off in middle of night
• Nocturia
• Obstructive Sleep Apnea (OSA)
• Emotional-mood disturbances
• Depression or anxiety
• Other
• Naps during day
• Presence of dreaming / REM Sleep Behavioral Disorder
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Sleep Treatment Strategies
Parkinson’s Disease Sleep Scale
• RBD medications
– 0.5-1mg clonazepam qhs
– 6mg Melatonin
– Sleep study with possible need
for cpap (OSA?)
• Sleep maintenance:
•Subjective report
•Validated for PD
•Will help determine best
treatment options
•Medications
•Referral to team
•Referral for sleep
study
•Need permission to use
– Treat for depression as indicated
– Sleep medications
• Sleep hygiene measures
– Limit daytime naps
– Create a restful night-time environment and practice
relaxation strategies
Story: Former military special forces & what he did to wife during sleep.
PDSS-2: self-rating questionnaire. PDSS-2 VC is protected by
international copyright, with all rights reserved to Claudia
Trenkwalder and Ray Chaudhuri
Autonomic Changes
Orthostatic hypotension
• Drop in BP with position change of 20 mm hg or more upon
standing
• Occurs in 20-50%
Potential ANS Conditions
•
•
•
•
•
Orthostatic or postural hypotension
GI dysfunction
Urinary urgency and frequency
Changes in Skin
Sexual dysfunction – -not all are symptomatic of BP drop
• Causes
• ANS dysregulation related to PD
• PD medication may magnify problem
– Results in PD med dosing limitations
• Symptoms
– Lightheadedness, dizziness, unsteadiness, vision changes,
impaired thinking (cognitive slowness) , lethargy,
fatigue, weakness, headache, neck tightness
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Orthostatic hypotension management
GI Dysfunction
Medication evaluation/change
Avoid rapid changes of position or straining
Initiate ambulation slowly
Increase fluids (work toward 8 cups/day)
Increase salt intake, unless contraindicated
Small frequent meals
Raise head of the bed 30-40 degrees
Compression stockings
Medications to compensate
(fludrocortisone, midodrine)
• Mestinon may help to prevent supine highs *
•
•
•
•
•
•
•
•
•
•
•
•
•
Excess saliva
Dysphagia
Nausea / gastroparesis
Bowel dysfunction
• Decreased frequency
• Difficult bowel movements
Low PA, Singer W, Management of neurogenic orthostatic hypotension: an update,
Lancet Neurology 2009 May;7(5):451-8.
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Drooling
Drooling Management
Treatments options include:
• Botulinum (Botox®) injections into the parotid
and submandibular glands (effect lasts several
months)
• Saltropine or other anticholinergic medication
• Cautious use of atropine® eye drops under the
tongue (not to exceed 1-2 drops daily- can cause
confusion)
• Papaya tablets
• Meat tenderizer contains papaya as a main
ingredient… small amount on a q-tip under
the tongue
• Gum or hard candy may facilitate swallow
• Lemon juice and soda water
Importance of good oral care
Noted in 70-78% in persons with PD
• Saliva production unchanged
• Loss of automatic swallow reflex
• Accentuated by:
• Stooped posture
• Open mouth
• Socially isolating
Merello M, Sialorrhoea and drooling in patients with Parkinson’s disease: epidemiology and management,
Drugs Aging, 2008:25(12):1007-19.
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Gastroparesis
Constipation
Impaired or slowed stomach emptying
• Fewer than 3 bowel movements per week
Cause:
•
•
•
•
PD
PD medication side effect
Decrease in activity
Decrease in fluid intake
• Experienced by 29% of persons with PD
• Due to slowed passage through the colon
• Normal colon transit time about 24 hours
Symptoms may include:
•
•
•
•
Early satiety
Sense of bloating
Nausea and vomiting
Weight loss
• Colon transit time ay be prolonged to 44
hours in PD
• Has not been extensively studied
May
hamper levodopa effectiveness
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Constipation Management
Cognitive Decline
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Changes in thought, behavior and judgment. These
changes can cause some of the most troubling and
disabling symptoms in PD
Attention
• Difficulty maintaining attention, easily distracted
Speed of information processing
• Slow sluggish thinking with a delay in verbal
response
Working Memory
• Delayed retrieval of information and word finding
Executive function
• Difficulty with organizing, generating, shifting and
blending different types of information “I can no
longer multi-taks”
Visuospacial changes
• Difficulty processing information
about their environment
Changes in Judgment
Screening Tool for Cognitive Impairment
»Increase fiber and fluids
»Prunes, prune juice, yogurt
»Increase physical activity
»Regular use of miralax®, stool softeners,
senna
»Avoid bulk laxatives if decreased fluid
intake
Montreal Cognitive Assessment (MoCA)
Hot Topics
• 1 page, 30 point test, Assesses 5 domains: visuospacial,
language, executive function, attention concentration and
working memory, and orientation
• Normal is 26/30
• Available in multiple languages on-line
• Driving
• Being left alone
• Kitchen safety
• Using appliances
• Using power tools
•
–
–
May be difficult for families to
acknowledge and accept
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Can be normal and still have cognitive deficits.
“People with PD and normal MMSE have broad range
of cognitive performance.” (Burdict et al. 2014
Movement Disorders)
58
Cognitive Decline Treatment
•
www.mocatest.org
• Mini-Mental Status Exam (MMSE) – no longer
recommended
Evaluating Cognition
Acetyl cholinesterase inhibitors
– Aricept®, Exelon®, Namenda®
• May need referral to Neuropsychologist to evaluate
•
Cognitive stimulation
“Use it or lose it”
• Consider if patient’s medications are at end of dose.
Thinking is often better when medication is at peak
dose.
•
Cognitive retraining/memory
strategies
• Think about the fatigue factor
•
Focus on strengths
• Give time to respond
•
Provide more direction
• Make only one request at a time
• Reduce distractions in the environment.
• Don’t shift quickly between tasks or requests
• Assure safety
Will need to engage the carepartner
and family into accepting more care
and
59 responsibility
• Referral to ST and OT
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Complexities of Management
Fatigue in Parkinson’s
• Associated with increasing Hoehn and Yahr stages
• Fatigue should be considered as a separate PD
entity
• May be related to neuroinflammatory mechanisms
• 16 item Parkinson’s Fatigue Scale strongly
correlated to the Fatigue Severity Scale **
• Consider methylphenadate (Ritalin®, Concerta®)
• Consider amantadine or eldepryl
• Referral to OT for energy conservation techniques
Motor vs. Non motor symptoms
• Non-motor symptoms include changes in mood, cognition,
autonomic nervous system dysfunction, sleep, pain-they are
often poorly recognized and inadequately treated (in
contrast to motor symptoms)
• Non-motor symptoms often more bothersome to patient and
family
• Non-motor symptoms can be improved with currently
available treatments
– Further research into more effective drug therapies are needed
• In 2010, the American Academy of Neurology (AAN) published
Parkinson disease quality measures for standardization of
treatment (Cheng, EM, et al, Quality improvement in neurology: AAN Parkinson disease quality Neurology. 2010
Hagell P, , Brundin L, Towards an Understanding of Fatigue in Parkinson’s Disease.
Journal of Neurology, Neurosurgery and Psychiatry, 2009 May;80(5):489-92.
Nov 30;75(22):2021-7).
Chaudhuri KR, Odin p,The challenge of non-motor symptoms' in Parkinson’s disease,
Progressive Brain Research 2010;184:325-41.
Chaudhuri KR, Healy DG, Non-motor symptoms of Parkinson’s disease: diagnosis and
management, Lancet Neurology, 2006 Mar;5(3):235-45.
** Grace J, Mendelsohn A, Friedman JH, A Comparison of Fatigue Measures
In Parkinson’s Disease, Parkinsonism and Related Disorders,2007 Oct;13(7):443-5.
•6
Specific AAN Guidelines
Hallucinations and Delusions
Hallucinations – a phenomenon in which a person
• Erectile dysfunction--Sidenafil citrae
(Viagra®) (but Cialis is better as it helps
urinary urgency)
• Excessive daytime sleepiness—modafinil
(Provigil®)
• Constipation– polyethylene glycol (Miralax®)
• Periodic limb movements of sleep
(carbidopa/levodopa)
• Fatigue– methylphenadate (Ritalin®,
Concerta®)
Insufficient evidence for treatment of:
• Orthostatic hypotension
• Urinary incontinence
• REM sleep disorder
• Anxiety
perceives that they see, hear, or feel something that
is not physically present
• Visual hallucinations are most common
• Occurs in 50% *
• Specifically ask the patient and carepartner if they
experience hallucinations
• VH with insight vs without insight. Most common
reason for placement in SNF
Delusions – persistent, illogical beliefs or perception
– often paranoid in nature
• May be treatment related
• May be seen later in the disease process,
thought to be a part of the disease pathology
Hely MA, Morris JG: Movement Disorders 2005;20:190-199
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Hallucinations and Delusions Treatment
Caring for the Caregiver
Transitions in Mid-Stage PD
In Mid-stage the care partner may begin to feel
more like a caregiver
• Multiple aspects of care giving
• Physically more difficulties
• Emotionally difficult
• Reduced daily skills such as driving, paying bills
• Affects health and quality of life of the care giver
• Person with PD may be a different person since
becoming ill
• Verify care partner referred to a support group
• Discontinue agonist or amantadine
• If unable to decrease the levodopa dose, it may be
add an atypical antipsychotic
medication such as quetiapine
• Clozapine is most effective but requires blood
monitoring- danger of agranulocytosis (lowering of
the white blood count)
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10/20/2014
Evaluating Caregiver Strain
Role of the Nurse in Middle Stage PD
• Multidimensional Caregiver Strain Index (MCSI)
• Validated measure of caregiver burden and strain
(Stull 1996)
• Modified for use in PD (Carter et al 1998)
• Identifies whether the external criteria, some of
– which could be considered causes of caregiver
strain
– others consequences of strain are differentially
– related to dimensions of caregiver strain.
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Nursing Interventions
PATIENT EDUCATION
• Provide National Parkinson Foundation (NPF)
brochures and booklets and other appropriate
reading materials to patients and caregivers
www.parkinson.org
• Discuss support groups opportunities with patient
and caregivers, and encourage participation if they
have not yet tried attending one
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