Download PARKINSON`S DISEASE: AN OVERVIEW

PARKINSON’S DISEASE:
AN OVERVIEW
Living with Parkinson’s Disease
Deborah Orloff, MPH, RN
Chief Executive Officer
Michigan Parkinson Foundation
Background and Definitions
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Parkinson’s 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.
Pathology
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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.
Pathology
Normal
Courtesy of Kapil D. Sethi, MD
Courtesy of Kapil D. Sethi, MD
PD
Histology of PD Showing Lewy
Body
Disease Onset
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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
Motor Symptoms of PD
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Resting Tremor
Rigidity (Cogwheel)
Bradykinesia (slow movement) or
Akinesia (absence of movement)
Postural Instability (balance and
coordination)
Tremor
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First Sign in 75% of patients
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Occurs at rest
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Does not need to be present to make a
diagnosis
Typically on ones side of body and involves a
distal extremity (hand, leg)
Rigidity
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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
Akinesia/Bradykinesia
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“Absence of Movement”
Describes the difficulty Parkinson’s 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).
Postural Instability
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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.
Non-Motor Symptoms
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Dysautonomias (problems in functioning of the
autonomic nervous system)
*constipation
*impotence
*urinary problems
*orthostatic hypotension
*regulation of heat
*sensory disturbances
*problems swallowing
*pain
Non-Motor Symptoms, con’t
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Speech problems
Behavioral problems, including:
depression
anxiety
panic attacks agitation
Sleep Disorders
Non-Motor Symptoms, cont.
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Loss of smell
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Constipation
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Cognitive (thinking) problems, including
dementia
Fatigue
PARKINSON’S SYMPTOMS
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VARIABLE—from person to person
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VARIABLE—from day to day
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VARIABLE—response to treatment
Parkinsonism
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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)
Clinical Features That May
Suggest a Diagnosis Other Than
PD
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Early onset of postural instability
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Axial more than appendicular rigidity
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Poor response to adequate dosages of
levodopa
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Early dementia
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Supranuclear gaze palsy
Treatment and Intervention
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Non-pharmacologic
Exercise
Education
Nutrition
Group Support
Treatment and Intervention
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Pharmacologic Intervention Considerations:
*Degree of functional impairment
*cognitive impairment
*Age (potential side effects)
*Cost
Treatment and Intervention
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Newer agents are being introduced at
greater ages with success.
Research into an effective agent for
neuroprotection is ongoing.
Neuroprotection remains controversial.
How is P.D. Treated?
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First Line
*rest and relaxation
*exercise
*stress management
*nutrition
*rehab therapy–ot, pt, speech
*mental health counseling
*education
*support (e.g. support groups)
Medication
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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.
Medication, con’t
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Newly diagnosed: may hold off until
symptoms interfere
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May start with low levels and work upwards.
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May use multiple medications.
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PD meds may interact with others.
Types of Medications
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Anticholinergics
Levodopa (Sinemet CR, Atamet)
Amantadine
MAO Inhibitors (NO DEMEROL OR
ANTIDEPRESSANTS)
Dopamine Receptor Agonists
Catechol-O-Methyl Transferase (COMT)
Selegeline
Frequent Side Effects of Meds
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Orthostatic hypotension
Memory loss or confusion
Agitation
Depression
Hallucinations and psychosis
Sleep disturbances/daytime sleepiness
Nausea
Motor Fluctuations
Challenges of Medications
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Timing
Monitor and adjust
Side effects
Complications
Drug interactions
Cost
Frustration
Incorporating med regimen into setting
Surgery
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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
Surgical Treatments
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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
Current Research
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Cause of PD
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Restoration
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Neuro-protection
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New Pharmacologic Agents
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Different Modes of Administrating Drugs
Management
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Physical Therapy
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Occupational Therapy
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Speech and Language Therapy
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Mental Health Counseling
Treatment Goals
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Reduce incidence and severity of
symptoms
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Maintain independence
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Work together as a team
IMPLICATIONS FOR CARE
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Provide information
Medication Management
Skin Care
Elimination (bowel,
bladder)
Comfort
Rest
Cognition
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Mental health
Safety
Cognition
Sleep
Communication
General Health
Family
education/support
Community Resources
Role:
Medication Management
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Correct dose and time
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Properly administer
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Track behavior
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Drug interactions
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Swallowing difficulties
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Report problems
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Document, communicate
Provide Expert Care :
COMMUNICATION
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Speech production
Facial expression
Slowed thinking
Slowed responses
Information
processing, including
memory,
concentration,
confusion
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Stress increases
problems
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Depression
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Dementia
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Handwriting
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Family talks for PWP
Communication, continued
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Management
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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
Communication, continued
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Identify problems
Document
Communicate to other team members
Develop plan that works for PWP and
family
Evaluate
Safety Management
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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
Safety Management:
Ambulation
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Ambulation
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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
ADL’S: MANAGEMENT
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Symptoms vary/abilities vary
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Frustration = PATIENCE
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Perform tasks at times of optimum functioning
Give medications so optimal time for tasks is at
peak medication time
Person with PD/Caregiver
Referrals: Occupational Therapy
Assistive Devices
Sleep Problems
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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
Sleep Problems: Management
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Sleep hygiene
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Medications
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Alter PD medications
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Treat depression
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Physical aids, e.g. satin sheets
Special Issues in LTC Settings
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Connecting with health professional
knowledgeable about management of
Parkinson’s disease.
Medication management.
Complexity of care and course.
Hospitalization.
Communication/cognition issues.
Maintaining in mainstream of life.
Family interactions.
End of Life issues.
Objectives in Long Term Care
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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.
Where to get help
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Michigan Parkinson Foundation
 30400 Telegraph, Suite 150
 Bingham Farms, MI 48025
 800-852-9781;
[email protected]
 www.parkinsonsmi.org