Parkinson's

Question 1

What is Parkinson’s

Answer 1

Chronic, slow, progressive disorder caused by loss of dopaminergic neurons in the substantia nigra of the basal ganglia

Question 2

Causes

Answer 2

Idiopathic- most common

Secondary:

• Postencephalitic
• Artherosclerotic
• Drug induced: antipsychotics, antihypertensives
• Toxin induced
• Trauma to midbrain

Question 3

Symptoms

Answer 3

• Tremors
• Rigidity of muscles: stiffness
• Akinesia/bradykinesia
• Postural Instability

Secondary Symptoms

• Difficulty with fine motor function such as writing/eating
• Soft monotone voice
• Mask like face
• General fatigue and weakness
• Autonomic manifestations
• Cognitive impairments/dementia

Question 4

Autonomic Dysfunction

Answer 4

• Drooling
• Seborrhea
• Dysphagia
• Excess perspiration
• Constipation
• Urinary hesitancy and frequency
• Orthostatic hypotension

Question 5

Stages (Hoehn & Yahr)

Answer 5

1. I - Mild , unilateral
2. II - Bilateral- early postural changes
3. III - Bilateral, impaired postural reflexes but still able to ambulate.
4. IV - Fully developed. Severe, marked disability
5. V - Confined to bed/ w.c.; Cannot perform ADL

Question 6

Diagnosis

Answer 6

• Through the history and clinical findings.
• MRI may appear normal.
• SPECT imaging supports diagnosis but not in common use.
• CT & MRI helpful in ruling out other illnesses.

Question 7

Problems

Answer 7

• Main risks are for falls, dysphagia.
• Impaired mobility
• Body image disturbances
• Impaired communication- written and verbal
• Hazards of immobility
• UTI/s

More Problems

• Constipation
• Skin problems
• Inability or decreased ability to perform ADL
• Self Esteem
• Knowledge Deficit re disease and/or medications and treatments
• Cognitive deficits

Question 8

Impaired physical mobility r/t rigidity, bradykineasi and akenesia

Answer 8

1. assist with ambulation to assess degree of impairment and to prevent injury
2. perform active ROM to maintain ROM, prevent atrophy, and strengthen muscles
3. teach techniques to assist with mobility by instructing patient to step oiver imaginary line, rock side to side *to initiate leg movements because these are helpful in fealing with akinesia while walking *

Question 9

Impaired verbal commination r/t dysarthria, tremor, bradykenesia

Answer 9

1. Allow sufficient time for communicatio to reduce patient’s frustration
2. encourgage deep breaths before speaking
3. Provide alternative communication methods such as picture books or flash cards *because muscle involvement has impaired writing and speaking ability *

Question 10

Imbalanced nutrition less than body requirements r/t dysphagia

Answer 10

1. monitor swalling ability during drug administration and mealtime to evaluate pt’s level of impairment and minimize risk of aspiration
2. provide soft solid and thick liquid diet *because these are more easily swallowed *

Question 11

Monoamine Oxidase B Inibitor

Answer 11

• Selegiline (Eldepryl). Rasgiline
• Given in early stages to delay need for L-dopa., later as adjuntive therapy
• Increased response to L-dopa.
• Blocks metabolism of central dopamine
• 5mg at breakfast and at lunch
• Causes insomnia not given after 1pm
• New oral dissolve tablet
• Early as monotherapy 0.5 to 1mg

Question 12

Anticholinergic

Answer 12

• Antagonize transmission of acetylcholine
• Help relieve tremor and rigidity in mild to moderate disease.
• Little effect on bradykinesia
• Cause dry mouth, constip, retention, blurred vision, hallucs, confusion
• Cogentin, Kemadrin, Artane, Benadryl
• Want to know why the patient is really taking it, why will you chose one over the other!!!!!!!!!!!!!!

Question 13

Antiviral

Answer 13

• Amantadine (Symmetrel)
• Promotes synthesis and release of dopamine. May be taken with carbidopa.
• Works on akinesia, rigidity and tremors.
• Can cause leg edema, and psych symptoms like anticholinergics.
• 100mg bid or tid.

Question 14

L-dopa/Carbidopa

Answer 14

• In combination as Sinemet
• Carbidopa is peripheral decarboxylase inhibitor. Then levodopa converts to dopamine.
• Oral dopamine would be metabolized before reaching the brain.
• Levodopa crosses the blood brain barrier and is converted into dopamine.
• For this to happen, the enzyme dopa decarboxylase must be present.

But we want this to happen in the brain, not in the peripheral tissue- for 2 reasons:

1. to lessen s.e.’s such as nausea
2. to increase the therapeutic effect.

Inhibitors are given to prevent:

• The inhibitor does not cross the blood brain barrier to :
• This way the dosage of L-dopa can be reduced.
• Carbidopa is the inhibitor.
• Dosage : 100/25mg QID- L-dopa/carbidopa
• Also comes in CR 200/50mg QID
• After 3-5 years benefits decrease
• Absorbed in the upper jejunum
• Competes with amino acids for absorption so best given on empty stomach
• Common side effects: orthostatic hypoension, hallucinations, confusion, sleepiness, nausea
• Sufficient fluid intake

Question 15

Dopamine Receptor Antagonist

Answer 15

• Act directly on dopamine receptors
• 5 dopamine receptors D1-5
• Ergot deriviatives: Bromocriptine (Parlodel) & Pergolide (Permax) (off the market)
• Nonergolines: Mirapex & Ropinirole (ReQuip)
• Decrease fluctuation in response to L-dopa
• Often initial treatment for PD and L-dopa introduced later.
• Given alone or as adjunct.

Question 16

COMPT inhibitors

Question 17

Drug general principles

Answer 17

• Give meds on time
• Caution with swallowing
• Ensure patient understands plan and rationale
• antihypertensives, diuretics, tricyclics can exacerbate hypotensive action of dopaminomimetics.
• On-off phenomenon
• Drug Holiday
• Pyridoxine (vitamin B6) decreases available dopamine.
• Alcohol may antagonize effects of L-dopa
• High protein meals block the effect of L-dopa
• Altho best absorbed on empty stomach may be given with some food to lessen nausea.
• For dry mouth- candy/gum.
• Elastic stockings for orthost. Hypotension

Question 18

Thalamotomy/Pallidotomy

Answer 18

• Lesions made stereotactically to dull overactive pathways.
• Thalamotomy more for tremors.
• Pallidotomy may help all symptoms- can only do one side at a time.

Question 19

Deep Brain Stimulation

Answer 19

Deep Brain Stimulation

• Electrodes placed deep in GP or thalamus and connected to a stimulator-pacemaker.
• Wires are tunneled under the skin
• Stimulator turned on-off with magnet
• Same effect as surgery with no tissue destruction

Question 20

Global Care

Answer 20

• People with PD are usually cared for at home, and may continue to work and lead their usual lives for a long time.
• Maintain indepedndence as long as possible.
• Direct care, support, education and monitoring- main nursing functions.
• Manage symptoms and treat complications
• Collaborative interdisciplinary model of care.
• CLSC’s
• Parkinsons Society and Support groups