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PARKINSON’S DISEASE: AN OVERVIEW
Living with Parkinson’s DiseaseDeborah Orloff, MPH, RNChief Executive Officer
Michigan Parkinson Foundation
Background and Definitions Parkinson’s disease was first described
by Dr. James Parkinson in his paper “An Essay on the Shaking Palsy” in 1817.
Slowly progressive neurodegenerative disorder with no identifiable cause.
The fourth most common neurodegenerative disease of the elderly
Affects about 1% of the population over 55 years of age.
Pathology Massive loss of the pigmented
neurons and gliosis, most prominently in the substantia nigra with presence of Lewy bodies.
Loss of approximately 80% of these neurons results in the presence of clinical symptoms.
Pathology
Courtesy of Kapil D. Sethi, MD
Normal PD
Courtesy of Kapil D. Sethi, MD
Histology of PD Showing Lewy Body
Disease Onset Average age of onset 50-60 years Approximately 5% of cases occur before
age 40 (young onset) Slowly progressive over 10-20 years Early symptoms may be: constipation,
REM sleep disorder, loss of sense of smell, depression
non-specific symptoms: easy fatigability, incoordination, change in writing, pain/tension in one shoulder, depression
Motor Symptoms of PD
Resting Tremor Rigidity (Cogwheel) Bradykinesia (slow movement) or
Akinesia (absence of movement) Postural Instability (balance and
coordination)
Tremor First Sign in 75% of patients
Occurs at rest
Does not need to be present to make a diagnosis
Typically on ones side of body and involves a distal extremity (hand, leg)
Rigidity
Stiffness caused by an involuntary increase in muscle tone
Can affect all muscle groups Often presents as back, neck or
shoulder discomfort Often dismissed as arthritis;
referrals to orthopedists initially
Akinesia/Bradykinesia “Absence of Movement” Describes the difficulty Parkinson’s
patients have in initiating and executing a motor plan.
Early signs include microphagia (small writing) and loss of dexterity.
Facial: Drooling, hypomimia (masked face).
Vocal: hypophonia (soft voice).
Postural Instability
Usually the last motor sign to appear. Often the most disabling and least
treatable problem. No single factor alone is responsible. “Freezing” is a form of akinesia which
is most problematic during ambulation and often leads to falls.
Non-Motor Symptoms Dysautonomias (problems in functioning of
the autonomic nervous system) *constipation *impotence *urinary problems *orthostatic hypotension *regulation of heat *sensory disturbances
*problems swallowing *pain
Non-Motor Symptoms, con’t Speech problems
Behavioral problems, including: depression anxiety
panic attacks agitation
Sleep Disorders
Non-Motor Symptoms, cont. Loss of smell
Constipation
Cognitive (thinking) problems, including dementia
Fatigue
PARKINSON’S SYMPTOMS
VARIABLE—from person to person
VARIABLE—from day to day
VARIABLE—response to treatment
Parkinsonism
A clinical syndrome characterized by specific motor deficits including tremor, akinesia, bradykinesia, rigidity and postural changes/instability.
An underlying cause is usually identified: chemicals (drugs), structural NPH, or possibly a neurodegenerative disorder (PSP, MSA)
Clinical Features That May Suggest a Diagnosis Other Than PD
Early onset of postural instability
Axial more than appendicular rigidity
Poor response to adequate dosages of levodopa
Early dementia
Supranuclear gaze palsy
Treatment and Intervention
Non-pharmacologic
Exercise Education Nutrition Group Support
Treatment and Intervention Pharmacologic Intervention
Considerations:
*Degree of functional impairment *cognitive impairment
*Age (potential side effects) *Cost
Treatment and Intervention
Newer agents are being introduced at greater ages with success.
Research into an effective agent for neuroprotection is ongoing.
Neuroprotection remains controversial.
How is P.D. Treated? First Line *rest and relaxation *exercise *stress management *nutrition *rehab therapy–ot, pt, speech *mental health counseling *education *support (e.g. support groups)
Medication
Complex: Know action, dosage, side effects, how respond.
Used to treat symptoms, not cure. No two people respond the same. Own responses vary. Need to monitor and change
medication regime over time.
Medication, con’t Newly diagnosed: may hold off until
symptoms interfere
May start with low levels and work upwards.
May use multiple medications.
PD meds may interact with others.
Types of Medications Anticholinergics Levodopa (Sinemet CR, Atamet) Amantadine MAO Inhibitors (NO DEMEROL OR
ANTIDEPRESSANTS) Dopamine Receptor Agonists Catechol-O-Methyl Transferase (COMT) Selegeline
Frequent Side Effects of Meds Orthostatic hypotension Memory loss or confusion Agitation Depression Hallucinations and psychosis Sleep disturbances/daytime sleepiness Nausea Motor Fluctuations
Challenges of Medications Timing Monitor and adjust Side effects Complications Drug interactions Cost Frustration Incorporating med regimen into
setting
Surgery Surgery does not cure or stop the
progression. Destruction of cells Deep brain stimulation Pallidotomy Thalamomtomy Gene transfer (beginning stages) Fetal and adrenal grafting (stem cells)
EXPERIMENTAL
Surgical Treatments Deep Brain Stimulation Surgery
* Insertion of an electrode into the brain to deliver electrical stimulation which dampens tremor, rigidity, dyskinesia.
*Reversible
*Sites vary depending on diagnoses
Current Research Cause of PD
Restoration
Neuro-protection
New Pharmacologic Agents
Different Modes of Administrating Drugs
Management
Physical Therapy
Occupational Therapy
Speech and Language Therapy
Mental Health Counseling
Treatment Goals
Reduce incidence and severity of symptoms
Maintain independence
Work together as a team
IMPLICATIONS FOR CARE Provide information Medication
Management Skin Care Elimination (bowel,
bladder) Comfort Rest Cognition
Mental health Safety Cognition Sleep Communication General Health Family
education/support Community
Resources
Role: Medication Management
Correct dose and time Properly administer Track behavior Drug interactions Swallowing difficulties Report problems Document, communicate
Provide Expert Care : COMMUNICATION Speech production Facial expression Slowed thinking Slowed responses Information
processing, including memory, concentration, confusion
Stress increases
problems
Depression
Dementia
Handwriting
Family talks for
PWP
Communication, continued Management
Assess for hearing problems, also Allow time - patience Quiet environment Positive communicative atmosphere Structure conversations, use familiar words Adult topics and routine Encourage communication Referrals: Speech and Language Pathology Assistive devices
Communication, continued
Identify problems Document Communicate to other team
members Develop plan that works for PWP
and family Evaluate
Safety Management Assess for risks Identify probable causes Review previous incidents Develop plan Monitor outcomes, revise as
necessary Referrals: Physical Therapy,
Occupational Therapy, Speech and Language Pathology, Dietitian
Safety Management:Ambulation Ambulation
Avoid rubber or crepe soled shoes Visual, auditory cues Identify problem areas, e.g. narrow
hallways, doors Remove hazards, e.g. area rugs Concentrate on one task at a time Ambulatory aids Avoid pivot turns
ADL’S: MANAGEMENT Symptoms vary/abilities vary
Perform tasks at times of optimum functioning
Give medications so optimal time for tasks is at peak medication time
Frustration = PATIENCE Person with PD/Caregiver
Referrals: Occupational Therapy Assistive Devices
Sleep Problems Different sleep problems Assess when person is having difficulty:
falling asleep, awakening during the night, early awakening, napping during the day, etc.
Difficulty normally moving in bed Other problems lead to interrupted sleep,
including other medical problems, depression, anxiety, pain, RLS
May be related to medications
Sleep Problems: Management
Sleep hygiene
Medications
Alter PD medications
Treat depression
Physical aids, e.g. satin sheets
Special Issues in LTC Settings Connecting with health professional
knowledgeable about management of Parkinson’s disease.
Medication management. Complexity of care and course. Hospitalization. Communication/cognition issues. Maintaining in mainstream of life. Family interactions. End of Life issues.
Objectives in Long Term Care Assist individual and family to obtain
optimal functioning: physically, emotionally, spiritually.
Provide highest quality of care to assist individual to achieve a state of wellness consistent with the quality of life desired by the patient.
Assist individual and family to achieve a satisfactory end of life experience.
Where to get help
Michigan Parkinson Foundation 30400 Telegraph, Suite 150 Bingham Farms, MI 48025 800-852-9781; [email protected]
www.parkinsonsmi.org