Chapter 58: Parkinson's disease

Drugs used to treat dementia r/t. PD

-rivastigmine (exelon) -donepezil (Aricept)

Later stages of PD

-shuffling gait -lost postural reflexes (propulsive gait-appear unable to stop) -contant tremors -hypokinetic dysarthria (speech abnormality -arms flexed

what can agitate PD

-stress -Increased concentration

Preventing falls: PD

-these patients tend to "freeze while walking -teach patient to consciously think about stepping over imaginary objects on floor, rock side to side before stepping, walk to a beat, try to swing arms from front to back, take 1 step back and 2 steps forward

Anticholinergic drugs used in PD

-trihexyphenidyl -benzotropine These reduce acetylcholine activity may be used with antihistamines to manage tremors

Lewy bodies

-unusual clumps of protein -found in brains of patients with PD -unknown cause -presence indicates abnormal brain function -Causes Lewy body dementia (cognitive disorder)

Promoting independence & self-care in patients with PD

-use upright chair with arms -remove rugs and excess furniture -elevated toilet seat -elevate legs on ottoman to decrease dependent ankle edema -slip-on shoes -velcro, hook & look fasteners or zippers instead of buttons

Episodes of hypomobility in PD

-usually occurs within 3-5 years of tx -Inability to rise from chairs, speak, walk ; off episodes (end of dose wearing off sx come back)

sleep problems in PD

-very restless sleep patterns -difficulty staying asleep -violent dreams -potentially dangerous motor activity during REM sleep

Name substances that have been shown to increase the risk of PD

-well water -pesticides -herbicides -Industrial chemicals -wood pulp mills -rural residence -use of prescription drugs or illicit drugs

Dx tests PD

- no specific test -based dx on history and clinical features -requires presence of TRAP -asymmetric onset -confirmation is a positive reposes to antiparkinsonian drugs

stalevo

-combo of levodopa/carbidopa/entacapone -given to patients with advanced PD who have intense motor fluctuations

complications of PD

-complications increase as disease progresses -many motor problems -dementia often occurs -dysphagia may result in malnutrition and aspiration -pneumonia -UTIs -skin breakdown -orthostatic hypotension

Etiology of PD

-degeneration of DA-producing neurons in the substantia nigra of midbrain (occurs when 80% of neurons are lost) -disrupts dopamine-acetylcholine balance in the basal ganglia -effects extrapyramidal motor system

Non-motor symptoms of PD

-depression -anxiety -apathy -fatigue -urinary retention -constipation -ED -memory changes

ablation surgery PD

-finds, targets and destroys area of brain affected by PD -destroy tissue that produces chemical or electrical impulses leading to sx

Patient teaching focus PD

-how to maintain good health -encouraging independence -how to avoid complications

Nursing diagnoses: PD

-impaired physical mobility -Impaired nutritional status -risk for aspiration -risk for fall related injury -Impaired sleep pattern

PD stats

-incidence increases with age -only 4% of people are diagnosed before the age of 50 -Men are 1.5 times more likely to have PD than women

Rigidity in PD

-increased resistance to passive motion when limbs are moved through ROM -cogwheel rigidity- jerky quality, like intermittent catches in passive movement of joint

Goals for patients with PD

-maximize neurologic functions -maintain independence in ADLs -optimize psychosocial well being

Drug induced PD can follow the use of

-metoclopramide (Reglan) -reserpine -methyldopa -lithium -Haldol -chlorpromaznie *amphetamine, meth*

Beginning stages of PD

-mild tremors -might have slight limp -decreased arm swing

Drug alert: levodopa/ carbidopa

-monitor for signs of dyskinesia -effects may be delayed weeks to months -report uncontrolled movements of face, eyelids, mouth, tongue, arms, legs or hands; mental changes; palpitations and difficulty urinating **do not give with food protein reduces absorption**

Nutritional therapy PD

-need appetizing foods that are easy to chew and swallow -provide adequate fiber to reduce constipation -6 small meals a day -limit protein at night (can inhibit levodopa absorption) -give ample time for eating and give bite sized pieces -absorption may also be altered by vitamin B6

Interprofessional care PD

-no cure -care focuses on sx management

what is dopamine essential for

-normal functioning of the extrapyramidal motor system (control of posture, support, voluntary movement)

Deep brain stimulation in PD

-placed electrode in thalamus, globus pallidus or sub thalamic nucleus -connects to a generator placed in the upper chest -targets specific location of brain -programmable -reduces neural activity produced by DA depletion -can improve motor function, reduce use of medications, and reduce dyskinesia **most common surgical treatment** (surgical intervention is only used if the patient does not respond to medication or they have uncontrolled movements)

Nursing interventions for PD

-promote physical exercise and well balanced diet -work to promote independence -assist patients as they make adjustments to their lifestyle to accommodate symptoms

Tx of hypomobility

-apomorphine (Apokyn) -can improve hypomobility -must be given with an antiemetic because of sever N/V -cannot be taken with Zofran because it lowers BP and causes loss of consciousness

Parkinson's disease definition

-Chronic progressive neurodegenerative disorder characterized by bradykinesia, rigidity, shaking (constant tremors), shuffling gait

The nurse observes a 74-yr-old man with Parkinson's disease rocking side to side while sitting in the chair. Which action by the nurse is most appropriate? -Provide the patient with diversional activities. -Document the activity in the patient's health record. -Take the patient's blood pressure sitting and standing. -Ask if the patient is feeling either anxious or depressed.

-Document the activity in the patient's health record Patients with Parkinson's disease are taught to rock from side to side to stimulate balance mechanisms and decrease akinesia.

COMT blockers

-Entacapone (Comtan) -tolcapone (Tasmar) -block COMT which breaks down levodopa in peripheral circulation, in turn prolongs effect of Sinemet **tolcapone is rarely prescribed because it high a high incidence of hepatotoxicity

Pathophysiology of PD

-Exact cause unknown -Possibly a result of complex interplay between environmental and genetic factors -Family hx in 15% of cases -trauma -stroke -hydrocephalus -Infection

surgical transplantation in PD

-Fetal neural tissue in basal ganglia -designed to produce DA-producing cells in brain -this tx is in clinical trials

Onset of PD

-Gradual and insidious with ongoing progression

Levodopa-Carbidopa (Sinemet)

-Primary treatment of PD -levodopa is a precursor to dopamine -carbidopa allows more levodopa to enter brain

A patient with a diagnosis of Parkinson's disease (PD) is admitted to a long-term care facility. Which action should the health care team take to promote adequate nutrition for this patient? -Administer multivitamins every morning and with each meal. -Provide a diet that is low in complex carbohydrates and high in protein. -Give the patient with a pureed diet that is high in potassium and low in sodium. -Provide small, frequent meals throughout the day that are easy to chew and swallow.

-Provide small, frequent meals throughout the day that are easy to chew and swallow

DA receptor agonists

-Ripinirole (Requip) -pramipexole (mirapex) -rotigotine (Neupro)

More clinical manifestations of PS

-Tremor -pill rolling hand tremor -diaphragm, tongue, lips jaw may be involved (speech abnormalities -muscle aches from constant movements -akinesia (loss of voluntary muscle control) - bradykinesia (slow movements) -stooped posture -masked face -drooling **Essential tremor in not associated with PD**

what does drug therapy for PD focus on

-aimed at correcting imbalance of neurotransmitters within CNS (Dopamine & Acetylcholine) -want to increase or enhance the production of DA -blocks effects of overactive cholinergic neurons

amantadine use for PD

-anti-viral -Increases DA release/ blocks DA reuptake -withdrawal can worsen dyskinesia -can be used alone early on and then later with Levodopa

Possible social effects of a chronic neurologic disease include (select all that apply) a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem.

A, B, C

Levodopa/Carbidopa

MOA: increase level of DA in the brain; L-dopa can cross the BBB (unlike regular DA) and is converted by dopa darboxylase in the CNS → DA -Carbidopa = blocks peripheral conversion of L-dopa to dopamine by inhibiting DOPA decarboxylase, given w/ L-dopa to ↑ bioavailability of L-dopa in brain/limit peripheral side effects

Name a famous actor who has Parkinson's disease

Michael J Fox

Motto for Parkinson's

No dope in the park

most common drug used to treat depression in PD

amitriptyline

A 65-yr-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is a. searching the Internet for educational videos. b. helping the caregiver explore respite care options. c. promoting physical exercise and a well-balanced diet. d. teaching about the benefits and risks of ablation surgery.

c

TRAP

tremor, rigidity, akinesia, postural instability