Medical Nursing (III)

Subtopic:

Parkinson's Disease

Parkinson’s Disease is a slowly progressing neurological condition that affects brain areas responsible for movement control and regulation. It involves the loss of brain cells that produce dopamine, leading to insufficient dopamine production.

Parkinsonism, also known historically as shaking palsy or paralysis agitans, is a degenerative nervous system disorder sometimes linked to cerebral atherosclerosis. This extrapyramidal disorder is named after James Parkinson, who described it as a movement disorder in 1817.

Risk Factors

The cause of Parkinson’s Disease is primarily unknown (idiopathic), but research suggests several contributing factors:

  • Postencephalitic Parkinsonism: This form can develop years after certain types of encephalitis, such as encephalitis lethargica, and may involve oculogyric crises (spasms of eye movements).

  • Drug-Induced Parkinsonism: Certain medications can induce Parkinsonian symptoms, including haloperidol, metoclopramide, phenothiazines, and lithium.

  • Hypoxia: Lack of oxygen, such as from carbon monoxide poisoning.

  • Toxic Substances: Exposure to toxins like manganese.

  • Vascular Issues: Conditions like atherosclerosis (hardening of the arteries).

  • Genetics

  • Atherosclerosis

  • Viral Infections: Such as viral encephalitis.

  • Head Trauma

  • Exposure to Industrial Pollutants

  • Chemical Toxins: Such as manganese.

  • Herbicides

  • Chemical Solvents or Polychlorinated Biphenyls (PCBs)

  • Antipsychotic Drugs

  • Age

  • Sex

Pathophysiology of Parkinsonism

Parkinson’s Disease is characterized by the degeneration of dopamine-producing neurons in the substantia nigra, an area within the basal ganglia located deep in the cerebral hemispheres. Dopamine is a neurotransmitter crucial for controlling and refining motor movements; it acts as an inhibitor, balancing the excitatory effects of acetylcholine. Acetylcholine plays a role in muscle excitation, coordination, and posture.

When the balance between the inhibitory action of dopamine and the excitatory action of acetylcholine is disrupted due to dopamine deficiency, difficulties in controlling and initiating voluntary movements arise, and the effects of acetylcholine become exaggerated. Cellular degeneration in Parkinson’s Disease leads to impairment in the extrapyramidal tracts, which are responsible for controlling semi-automatic and coordinated movements. The exact cause of this neuronal degeneration is unknown, although drugs, genetics, and environmental factors are potential contributors.

Signs and Symptoms of Parkinson’s Disease
Key Signs and Symptoms of Parkinson’s Disease

  1. Tremor: Typically occurs at rest and lessens during voluntary movement or sleep. Characterized by a rhythmic shaking, usually 4-5 cycles per second, that can affect the head, face muscles, limbs, jaw, and lips. “Pill-rolling,” a small, circular thumb movement across the palm, is common and can lead to micrographia (tiny handwriting). Emotional stress can worsen tremors.

  2. Rigidity: Muscles become stiff and inflexible, sometimes causing pain. Rigidity can be constant or intermittent, making fine motor movements difficult.

  3. Akinesia/Bradykinesia/Hypokinesia: Difficulty initiating and executing voluntary movements. Bradykinesia refers to the slowness of movement (e.g., slow walking), while hypokinesia is a reduction in the amount of movement. Rising from a seated position may become challenging, often requiring multiple attempts.

  4. Posture and Balance Issues: Changes in gait include a tendency to walk with small, shuffling steps, often on the toes, which may accelerate. Festination (involuntary quickening of steps) can propel the patient forward or backward until a fall is imminent. Balance is compromised, leading to a stooped posture when upright, difficulty maintaining balance when sitting, and semi-flexed arms.

Other Signs and Symptoms:

  • Pull Test: The patient tends to step backward if gently pulled from behind.

  • Speech Changes: Soft, monotonous, and slurred speech with difficulty initiating speech.

  • Cognitive and Emotional Changes: Slowness in thought and reduced interest in activities.

  • Autonomic Symptoms: Constipation, difficulty urinating (dysuria), and postural hypotension (low blood pressure upon standing).

  • Normal Sensory Function and Tendon Reflexes.

Differential Diagnosis

  • Essential Tremor

  • Dementia with Lewy Bodies

  • Multiple System Atrophy

  • Alzheimer’s Disease

  • Drug-Induced Parkinsonism

  • Corticobasal Degeneration (CBD) and Progressive Supranuclear Palsy (PSP)

Management of Parkinson’s Disease

Medical Management

There is currently no cure for Parkinson’s Disease. However, medications can help manage symptoms like akinesia, rigidity, and tremors.

  • Dopaminergic Agents:

    • Levodopa: A precursor to dopamine that the brain converts into dopamine.

  • Dopamine Agonists: Mimic the effects of dopamine in the brain. Examples include bromocriptine mesylate, levodopa/carbidopa combinations, pramipexole, etc. These help reduce bradykinesia, tremor, and rigidity.

  • MAO-B Inhibitors: Such as selegiline and rasagiline, help slow the breakdown of dopamine in the brain. Side effects may include nausea, hypotension, palpitations, dry mouth, and sleep disturbances.

  • Anticholinergics: Such as trihexyphenidyl, procyclidine, benztropine, and biperiden, help to reduce tremor by blocking the action of acetylcholine in the central nervous system. As a nurse, avoid administering drugs with similar anticholinergic effects, such as some antihistamines, antispasmodics, and tricyclic antidepressants. Monitor for side effects like delirium, blurred vision, constipation, agitation, hallucinations, anxiety, and confusion.

  • Amantadine: Can help improve muscle control and reduce stiffness.

Surgical Management of Parkinson’s Disease

  • Deep Brain Stimulation (DBS): A surgical procedure where electrodes are implanted in specific brain areas. These electrodes are connected to a generator that delivers electrical pulses to the brain. DBS can help alleviate tremor, rigidity, stiffness, and slowed movement.

Facial Nerve Decompression Surgery

In cases of sudden facial paralysis caused by viral infections like Bell’s palsy or Ramsay-Hunt syndrome, facial nerve decompression surgery might be considered as a treatment. Additionally, if the facial nerve has been cut or removed due to injury or surgery, procedures to repair or graft the nerve may be necessary.

Nursing Care

  • Perform range of motion exercises for all joints three times daily.

  • Massage skeletal muscles to alleviate stiffness.

  • Encourage a wide stance (broad base of support) when walking.

  • Advise caregivers to avoid giving the patient pyridoxine (vitamin B6)-rich foods, high-protein meals, and alcohol when they are taking levodopa.

  • Modify the home environment to eliminate potential hazards.

  • Educate the patient about the impact of stress, heat, and excitement on their condition.

  • Encourage frequent changes in position and suggest walking with hands clasped behind the back to improve posture.

  • Monitor the patient’s weight weekly.

  • Implement a plan for small, frequent meals. Advise against consuming high-protein meals around the time of medication administration.

  • Ensure adequate intake of fiber and fluids.

  • Encourage voice regulation exercises such as singing or reading aloud.

  • Monitor sleep patterns, thought disorders, and hallucinations.

  • Encourage prompt response to urges for urination and defecation to ensure complete bladder and bowel emptying. Use stool softeners if necessary, keep a urinal readily available, and monitor bowel habits.

  • Recommend removing carpets and rugs that can cause tripping. Advise the use of walking aids and suggest wearing easy-to-put-on shoes with smooth soles.

  • Explore alternative therapies such as massage, Tai Chi, yoga, pet therapy, and meditation.

  • Suggest joining Parkinson’s support groups.

Diagnosis

  • PET Scan (Positron Emission Tomography): May reveal decreased dopaminergic activity in the substantia nigra.

  • Unified Parkinson’s Disease Rating Scale (UPDRS): Involves a cognitive interview to assess the severity of the disease.

  • CT Scan: Usually appears normal.

  • MRI: Usually appears normal.

Complications

  • Dysphagia (difficulty chewing and swallowing)

  • Depression

  • Anxiety

  • Dementia

  • Constipation

  • Smell dysfunction

  • Sexual dysfunction

  • Orthostatic hypotension (low blood pressure upon standing)

  • Bladder problems

  • Sleep disorders

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