Parkinson's Disease

Question 1

Parkinson disease (PD)

Answer 1

a chronic, progressive neurodegenerative disorder characterized by slowness in the initiation and execution of movement (bradykinesia), increased muscle tone (rigidity), tremor at rest, and gait changes.

Question 2

Parkinsonism

Answer 2

syndrome made up of disorders that mimic PD;

Symptoms of parkinsonism have occurred after exposure to a variety of chemicals and metals

Question 3

Drug-induced parkinsonism

Answer 3

can follow therapy with metoclopramide, methyldopa, lithium, haloperidol, or chlorpromazine.

can be seen after the use of illicit drugs like methamphetamine.

Question 4

Clinical Manifestations

Answer 4

Early: mild tremor
a flattened affect
slowing of ADLs (dressing, feeding)
decreased arm swing
Shoulder rigidity

Later: shuffling gait and appear unable to stop
hypokinetic dysarthria)

Question 5

Tremor

Answer 5

often the first sign

more prominent at rest and lessens with purposeful movement

worsened by stress or increased concentration

“pill rolling”

can involve the diaphragm, tongue, lips, and jaw

Question 6

essential tremor

Answer 6

occurs during voluntary movement. It is not neurodegenerative and is usually familial.

Question 7

Rigidity

Answer 7

is the increased resistance to passive motion when the limbs are moved through their range of motion (ROM).

responsible for symptoms including mask face, lack of arm swing, difficulty getting out of chairs, and trouble with buttoning clothing.

Question 8

Bradykinesia

Answer 8

(slowness of movement) is present in both spontaneous and automatic movements.

accounts for the stooped, bent forward posture, masked face (deadpan expression), drooling of saliva, and shuffling gait (festination) that are typical of a person with PD (Fig. 63.9).

Question 9

Postural Instability

Answer 9

Patients may describe being unable to stop themselves from going forward (propulsion) or backward (retropulsion).

increases their risk of falling

Question 10

“pull test”

Answer 10

Assessment of postural instability where the examiner stands behind the patient and gives a tug backward on the shoulder, causing the patient to lose their balance and fall backward.

Question 11

Complications

Answer 11

dysphagia and malnutrition or aspiration

weakness may lead to immobility

Orthostatic hypotension

dyskinesias (spontaneous, involuntary movements), weakness, and neuropsychiatric problems (e.g., depression, hallucinations).

Question 12

Diagnostic Studies

Answer 12

The diagnosis is based on the history and clinical features. Clinical diagnosis requires the presence of 2 of the 4 main manifestations (tremor, rigidity, bradykinesia, and postural instability) and asymmetric onset.

Disease is confirmed with a positive response to antiparkinsonian drugs (levodopa or DA agonist).

Question 13

Drug Therapy

Answer 13

dopaminergic or anticholinergic

Question 14

Levodopa with carbidopa (Sinemet)

Answer 14

is the primary treatment for symptomatic patients

Prolonged use often results in dyskinesias

effects may be delayed for several weeks to months.

Teach patient or caregiver to report any uncontrolled movement of face, eyelids, mouth, tongue, arms, hands, or legs; mental changes; palpitations; and problems urinating.

Do not take with meals.
Limit Vitamin B6 intake.
Teach about ways to decrease dry mouth.

Protein ingestion can impair the absorption of levodopa. Limiting protein intake to the evening meal can decrease this problem.

Question 15

Rotigotine (Neupro)

Answer 15

DA receptor agonist

transdermal patch applied once daily.

Question 16

apomorphine (Apokyn, Kynmobi)

Answer 16

DA receptor agonist

can improve movement in hypomobility (“off”) episodes

Patients must take it with an antiemetic drug because it causes severe nausea and vomiting when taken alone.

It cannot be taken with antiemetics in the serotonin (5-HT3) receptor antagonist class (e.g., ondansetron) —> can lead to very low BP and loss of consciousness

Question 17

Anticholinergic drugs:
trihexyphenidyl and benztropine (Cogentin)

Answer 17

decrease the activity of Ach. Providing balance between cholinergic and dopaminergic actions can help with tremors and rigidity.

Stop if swallowing problems occur.
Avoid alcohol, hot weather.
Use safety measures if CNS effects occur.

Question 18

episodes of hypomobility; Off episodes

Answer 18

can occur toward the end of a dosing interval with standard medications (end-of-dose wearing off) or at unpredictable times (spontaneous “on/off”).

Question 19

amantadine

Answer 19

Do not stop abruptly.
Use safety measures if CNS effects occur

Question 20

Surgical Therapy

Answer 20

DBS and ablation

Question 21

DBS

Answer 21

reversible and programmable.

can improve motor function and reduce dyskinesia.

DBS is indicated for patients who have had PD over 5 years, with dyskinesias, and are unable to tolerate or not controlled with drug therapy.

Question 22

Ablation surgery

Answer 22

involves finding, targeting, and destroying an area of the brain affected by PD. The goal is to destroy tissue that produces abnormal chemical or electrical impulses leading to tremors or other symptoms.

Question 23

Nursing implementation

Answer 23

Promoting physical exercise

promote independence and self-care

Encourage well-balanced diet

Proper management of sleep problems