Early Onset Parkinson’s Disease: What NPs need to know

PATRICIA H. COX, DNP, MPH, FNP-BCASSISTANT PROFESSOR, UNIVERSITY OF PORTLAND

VISITING NURSE FACULTY, PARKINSON’S FOUNDATION

MELODY RASMOR, EdD, FNP, ARNP-BC, COHN-SASSISTANT CLINICAL PROFESSOR, WASHINGTON STATE UNIVERSITY

VISITING NURSE FACULTY, PARKINSON’S FOUNDATION

Special thanks

The Parkinson’s Foundation is working toward a world without Parkinson’s disease. Formed by the merger of the National Parkinson Foundation (NPF) and the Parkinson’s Disease Foundation (PDF) in August 2016, the mission of the Parkinson’s Foundation is to invest in promising scientific research that will end Parkinson’s disease and improve the lives of people with Parkinson’s, and their families, through improved treatments, support and the best care.

Disclosure statement:

We have nothing to disclose during our presentation.

Objectives

Define Parkinson’s and describe prodromal symptoms Describe the pathophysiology of early Parkinson’s Discuss and analyze case studies of early prodromal

Parkinson’s Explore early interventions that NPs can use to assist

their patients Identify the elements of a Parkinson’s neuro

assessment

Parkinson Disease Defined

A neurodegenerative movement disorder- It presents with motor deficits, cognitive, affect challenges, and autonomic nervous system dysfunction.

Dopamine depletion, is the hallmark of its motor presentation.

This presentation will hopefully provide a better understanding of the pathophysiology of Parkinson and early recognition of the disease.

Facts 4,500 years ago – Ancient

Indian medicine –“kampavata”

1817 – James Parkinson - “the shaking palsy”

PD is the 2nd most common neurodegenerative disorder after Alzheimer’s Disease

1-2 million people in the U.S. 10 million people worldwide

The 14th leading cause of death

Occurrence expected to increase two-fold by 2005-2030 in individual aged > 50 years

Costs

Exceeds 14.4 billion dollars in U.S. More than 6 billion dollars in direct medical costs Direct medical costs per patient estimated 10-14,000

dollars annually Direct + Indirect costs approximately 22,800 dollars

annually

Disability

Reduced quality of life Impairment of activities of daily living

(walking, dressing, shopping) Impairment of instrumental activities

of daily living (meal preparation, money management, medication management)

Social isolation (embarrassed over physical symptoms of disease)

Demographics

Gender differences- Men>women Younger age of onset- more symptoms Age not related to severity or progression 2-3% increase in older adults >65 years

Risk Factors

Advancing Age

Men more likely than Women

Heredity- Having a close relative with Parkinson's increases the chances that you'll develop the disease. Risks still small unless you have many relatives in your family with Parkinson's.

Environmental Exposure- herbicides and pesticides may put you at a slightly increased risk of Parkinson's disease.

Risk Factors

Risk Factors

Parkinson’s Definition

Neurological Motor Disease Affects Dopamine Neurons in Substantia

Nigra Pars Compacta Symptom onset correlates with

advanced neurodegeneration

Parkinson’s Disease-4 Cardinal Symptoms

Tremor (resting) Muscle Rigidity Bradykinesia Postural Instability

Parkinson Disease Motor Clinical Manifestations

Decreased arm swing when walking Micrographia (small hand writing) Hypophonia Masked face, decreased blinking Shuffling, slow gait Stooped posture

CARDINAL SYMPTOMS OF PARKINSON’S DISEASE

https://www.youtube.com/watch?v=d0NYC1JICLA

Pathophysiology

The substantia nigra pars compacta is located deep in the mid brain.

These neurons are large dopamine neurons that degenerate in PD

Literally all patients receive a late diagnosis since motor symptoms, required for diagnosis, are manifested when approximately 60% of the neurons of the substantia nigra pars compacta (SNpc) are lost

SUBSTANTIA NIGRA PARS COMPACTA

How Is Prodromal (Early) Parkinson’s Disease Different?

Non-Motor Neurological Disease Preceded PD Diagnosis Affects Dopamine Neurons in the SNpc Characterized by premotor PD features Onset prior to advanced neurodegeneration

Life course of disease and need for early diagnosis

Why isn’t it identified earlier? Mean delay 3-6 years from first symptoms, some

for 10+ years Underreporting & Under-recognition of NMS

• Lack of PCP systematic questioning & knowledge

• Lack of inter-professional collaboration• “I’m just getting old.”• The great copycat• Knowledge inadequacies

Prodromal Symptoms

Olfactory impairment(hyposmia)-90% REM Sleep Behavior Disorder Autonomic Dysfunction Anxiety/Depression/Apathy Mild Cognitive Impairment (MCI) Fatigue Hallucinations Restless leg (Akathisia) Diffuse Pain Seborrhea/melanoma Decreased blink response

Movement Disorder Society (MDS) Prodromal PD Criteria

Diagnosis of prodromal PD relies on clinical non-motor markers

Speed of progression from prodromal PD to PD is unpredictable

Criteria is based on estimated risks and symptoms Criteria development relied on prospective studies Estimates criteria predicts prodromal PD with >80%

likelihood

Prodromal PD in Primary Care

Increased Awareness of Prodromal PD

Evidence is only informative

Diagnosis still relies on MDS Clinical Criteria for PD

Proposed Algorithm

Put Algorithm here

Why NPs need to know more

Early Parkinson’s-vague symptoms Patients frustrated with multiple diagnosis Complex disease with no diagnostic test Lack of diagnosis, delayed referrals, delayed

treatment

Why should we evaluate patients with Non-motor symptoms?

Time to plan Physiotherapies to prolong quality of life NPs incorporate patient’s feelings and thoughts Early referral allows for neurology evaluation and

possible treatments/studies

How can NPs evaluate patients early to make a difference?

Know your patient’s normal to detect subtle changes Broaden your differential for olfactory/gustatory

changes Mimics other disease processes: Sleep disturbances,

IBS, essential tremor, stress incontinence, depression, dementia, metabolic diseases, cerebrovascular disease, Lewy body disease, Huntington disease, multisystem atrophy-so think Parkinson’s

Time for a Case Study

So…you have a 50 something year old white female coming to see you and she discloses she is in the process of getting a divorce and she is depressed. She reports that her boss has noticed some postural changes and shuffling. She has no tremor, no constipation and she does Jazzercise 2-3 x week.

She has HTN, Thyroid Disease, Metabolic syndrome, is Vitamin D deficient and she is post-menopausa1. She works full time, is a non-smoker and drinks a glass of wine per night.

The Michael J Fox Foundation

https://www.michaeljfox.org/foundation/news-detail.php?watch-our-latest-video-what-is-parkinson-disease

Here is the Neuro Exam

Conduct a dexterity test-Ask patient to finger tap. Maintained speed over 10-15 seconds and maintained amplitude. Slowing speed, decreasing amplitude, pauses/arrests in finger and foot taps are consistent with bradykinesia

Observe walking-gait, ataxia, freezing, limitations in turning

Observe for reduced arm swing Observe rising out of a chair. Perform the Pull Test.

www.toolkit.parkinson.org/sites/toolkit.parkinson.org/files

Questions?

Acknowledgements

Gwyn M. Vernon, M.S.N., R.N., C.R.N.P.Co-Founder and National Director, Parkinson's Disease Foundation

The Edmond J. Safra Visiting Nurse Faculty Program

Nikkiel Lefebre, RN, BSN, MN, FNP

Elizabeth Teeling, BSc, RN-BSN, MN, FNP

References

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References

Parkinson’s Disease Foundation (2016). Diagnosis. Retrieved from: http://www.pdf.org/en/diagnosis

Postuma, R., Berg, D., Stern, M., Werner, P., Olanow, C., Oertel, W.,…Deuschl, G. (2015). MDS clinical diagnostic, criteria for Parkinson’s disease. Movement Disorders, 30(12), 1591-99

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U.S. Department of Health and Human Services Centers for Disease Control and Prevention, 2012

Wright-Willis, A., Evanoff, B. A., Lian, M., Criswell, S. R., & Racette, B. A. (2010). Geographic and ethnic variation in Parkinson disease: A population-based study of US Medicare beneficiaries. Neuroepidemiology, 34(3), 143-151. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2865395/

Melody with “Parky” and Nikkiel Lefebre