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NURS 640 > Neuro chapter 11 Parkinson's Disease > Flashcards

Neuro chapter 11 Parkinson's Disease Flashcards

1
Q

Parkinson’s Disease Description

A

Idiopathic, progressive, chronic, incurable neurodegenerative movement disorder characterized by bradykinesia in combination with rest tremor or rigidity

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2
Q

The diagnosis of Parkinson’s disease is supported by…

A

therapeutic response to dopaminergic therapy or presence of levodopa-induced dyskinesia.

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3
Q

Etiology

A

gradual loss of neurons in the substantia nigra pars compacta and basal ganglia that results in decreased dopamine production. This decline adversely affects movement and balance.

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4
Q

Incidence

A

men > women
1/% age over 65. 2.5% older than 80
expected to double by 2030
childhood or adolescence onset is rare

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5
Q

Risk factors family history

A

not considered genetic

15% of patients with PD have positive family history

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6
Q

Risk factors environmental

A

weak

- well water, pesticides, herbicides, industrial chemicals, wood pulp mills, farming, rural

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7
Q

Risk factors toxins

A

ingestion of certain medications or toxins may produce secondary PD

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8
Q

Benign essential tremor is relieved by…

A

alcohol ingestion and usually associated with a positive family history.

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9
Q

Primary motor symptoms

A
  • bradykinesia
  • rigidity or stiffness in limbs and trunks (sometimes cogwheeling).
  • resting tremor
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10
Q

bradykinesia

A

slowness of movement AND decrease in speed

  • evaluated by hand movements, pronation-supination movements, toe tapping, foot tapping
  • interferes with ability to perform fine motor tasks
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11
Q

resting tremor

A
  • appears in hands and arms, legs, jaw and face: disappears with intention movement; may be unilateral (early stages)
    = described as “pill-rolling”; presenting sign in 50-80% of patients (30% do not present with tremor)
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12
Q

Secondary motor symptoms

A

Caused by rigidity and bradykinesia

  • dysarthria
  • hypophonia
  • dysphagia
  • sialorrhea
  • gait freezing
  • micrographia
  • mask-like expression
  • tachyphemia
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13
Q

Nonmotor symptoms

A 
May precede motor symptoms by several years
-autonomic dysfunction
= orthostatic hypotension
= sweating dysfunction
= sphincter dysfunction
= erectile dysfunction
= urinary bladder distention/infections
= constipation
- cognitive/neurobehavioral disorders
= depression
= anxiety
= hallucinations
= apathy
= lewy body dementia
= OCD
= impulse disorders
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14
Q

Parkinson’s disease should be suspected in….

A

a patient who presents with tremor at rest, rigidity, and bradykinesia.

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15
Q

Differential diagnosis

A 
essential tremors
vascular Parkinsonism
Drug-induced Parkinsonism (from neuroleptic medications)
Dementia
Other movement disorders
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16
Q

Clinical diagnosis rated on…

A
  • Movement Disorder Society-Unified Parkinson’s Disease Rating Scale, with attention to absolute exclusion criteria, supportive criteria, and red flags.
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17
Q

Diagnosis - at least two supportive criteria…

A
  • clear and dramatic response to dopaminergic therapy
  • presence of levodopa-induced dyskinesia
  • rest tremor of a limb
  • positive results from at least one ancillary diagnosis test (olfactory loss, metaiodobenzyguanidine)
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18
Q

diagnosis - absence of absolute exclusion criteria…

A
  • unequivocal cerebellar abnormalities on exam
  • downward vertical supranuclear gaze palsy
  • probable behavioral variant frontotemporal dementia or primary progressive aphasia diagnosis within 5 years
  • PD features restricted to lower limbs for > 3 years
  • dopaminergic-induced Parkinsonism
  • absence of observable response to high-dose levodopa
  • unequivocal corticol sensory loss or progressive aphasia
  • norrmal functioning neuroimaging of presynaptic dopaminergic system
  • documentation of an alternate condition known to produce PD
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19
Q

diagnosis - no red flags

A
  • rapid progression of gait impairment requiring wheelchair within 5 years of onset
  • absence of progression of motor symptoms or signs > 5 years unless stability is related to treatment
  • early bulbar dysfunction
  • inspiratory respiratory dysfunction
  • severe autonomic failure in the first 5 years
  • recurrent falls from impaired balance within 3 years of onset
  • presence of disproportionate anterocollis or contractures within first 10 years
  • absence of common nonmotor features of the disease
  • otherwise unexplained pyramidal tract signs
20
Q

Diagnosis cont.

A

bilateral symmetric Parkinsonism throughout disease course

21
Q

Treatment goals

A
  • improve motor function
  • maximize functional level
  • manage neuropsychiatric complications
22
Q

Nonpharmacologic management

A
  • palliative care with disease trajectory, education and training, emotional support at diagnosis, discussion of goals of care
  • physical, occupational, and speech therapy
  • adjustments in home environment to accomodate physical limitations.
  • screening for depression
23
Q

Pharmacologic treatment

A
  • Dopaminergic agents
  • Dopamine agonists
  • NMDA Receptor Inhibitor
  • MAO-B inhibitors
  • Anticholinergics
24
Q

Dopaminergic Agents

Carbidopa/levodopa

A
  • most effective for symptomatic treatment of PD and drug of choice for many symptoms, including bradykinesia and akinesia.
    Levodopa - more improvement in motor symptoms and ADLs with more motor complications as in long-term use associated with dyskinesia
25
Q

Carbidopa / levodopa

Comments

A
  • must discontinue levodopa at least 12 hours before starting carbidopa/levodopa.
  • may cause dyskinesias, mental disturbances, hypotension, nausea
  • note dose ratios
  • avoid abrupt cessation - Parkinsonism-hyperpyrexia syndrome
  • adverse effects include: dyskinesia, somnolence, confusion, dystonia.
26
Q

Dopamine agonists

general comments

A
  • may be ineffective in patient with no response to levodopa
  • associaated with fewer motor fluctuations than levodopa
  • do not abruptly stop, may cause dopamine agonist withdrawal
  • less improvement in motor symptoms and in ADLs, yet fewer motor complications
27
Q

D.A

Bromocriptine

A
  • adverse effects include: dizziness, fatigue, headache, constipation, weakness, nausea
28
Q

D.A

Pramipexole

A
  • may cause sudden drowsiness and falling asleep, even while engaging in ADLs
  • may cause orthostatic hypotension
  • adjust dose in impaired renal function
  • do not crush or chew ER tablets
  • avoid ER formulations with impaired renal function patients
  • can switch between immediate release and extended release on a mg-for-mg basis
29
Q

D.A

Ropinirole

A
  • may be taken without regard to meals
  • may cause sudden drowsiness and falling asleep, even while engaged in ADLs
  • may cause hypotension, dyskinesia
  • see package inserts for conversion from immediate release to extended release
30
Q

D.A

Rotigotine transdermal

A
  • remove patch before procedures such as cardioversion or MRI; backing layer contains aluminum
  • caution if hypersensitive to sulfites
  • may cause psychosis, syncope, hallucinations
31
Q

NMDA Receptor Inhibitor

comments

A

Mechanism is uncertain but may interfere with excessive glutamate neurotransmission in the basal ganglia

32
Q

NMDA

Amantadine

A
  • reduce dose in patients with chronic heart failure, edema, hypotension, or impaired renal function, impaired hepatic function
  • increases risk of melanoma
  • may cause blurry vision
  • may impair mental activity
  • avoid alcohol
33
Q

MAO-B Inhibiitor

general comments

A

Less improvement in motor symptoms and in ADLs, yet fewer motor complications.

34
Q

MAO-B

Selegiline

A
  • used as adjuncty therapy with levodopa/carbidopa
  • may reduce dose of levodopa/carbidopa as tolerated
  • may cause dry mouth, blurred vision, hypotension, insomnia
35
Q

MAO-B

Rasagiline

A
  • perform dermatologic exams
  • signs and symptoms of orthostatic hypotension
  • may cause hypertensive crisis, sudden sleep episodes, dyskinesia
36
Q

MAO-B

Safinamide

A
  • newest MAO0B inhibitor

- adverse reactions include dyskinesia, hypertension, falls, nausea, increased liver enzymes

37
Q

Anticholinergics

A
  • useful in treatment of tremors in cognitively functioning patients < 70 years with disturbing tremor and no significant bradykinesia or gait disturbance
38
Q

Benztropine

A
  • may divide BID-QID
  • Contraindicated/caution: glaucoma, angle-closure, tardive dyskinesia, ileus, BPH
  • May cause: tachycardia, psychosis, heat stroke
39
Q

Trihexyphenidyl

A
  • give with food
  • doses > 10mg/day divide QID
  • caution in renal and hepatic impairment
40
Q

A sudden worsening in status may indicate…

A

depression or nonadherence to medication.

41
Q

Consultation / Referral

A
  • consult a neurologist for Parkinson’s disease
  • allied health: physical, occupational, nutrition, language, and speech therapy
  • support groups
42
Q

Follow-up

A
  • communicate and educate
  • lifelong neurology follow-up and medication adjustment q 6-12 months
  • educate to never abruptly withdraw antiparkinsonian medicines due to acute akienesia or neuroleptic malignant syndrome
  • give oral and written information about risks and record that discussion has taken place
43
Q

Follow-up:

review non-motor symptoms that can occur…

A
  • screen for depression
  • daytime sleepiness and REM sleep behavior disorder
  • orthostatic hypotension
  • risk for impulse control disorders with dopaminergic therapy; provide education, support, and contact instruction should disorders develop
  • psychotic symptoms of hallucinations and delusions
  • PD dementia
  • Drooling
44
Q

Expected course

A

chronic, progressive neurological disorder with high mortality

45
Q

Expected course

Neurology and/or movement disorder specialist may consider….

A
  • deep brain stimulation surgery
  • levodopa/carbidopa intestinal gel
  • stem cell treatments
  • palliative care offers opportunities to make shared decisions and discuss options for future management
46
Q

Possible complications

A
  • multiple falls
  • aspirations pneumonia
  • dementia
  • depression
  • accidents from falls

NURS 640 (12 decks)

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