PARKINSON’S DISEASE

(Idiopathic Parkinsonism or Paralysis Agitans)

• Parkinson's disease (PD or, simply, Parkinson's) is the most common form of
Parkinsonism, a group of motor system disorders.

• Named after James Parkinson. a British physician who first described the disease in a
paper he published as the “shaking palsy” in 1817

• It is a slowly progressing, degenerative neurologic disease that is usually associated

with the following symptoms,

• tremor or trembling of the arms, jaw, legs, and face

• stiffness or rigidity of the limbs and trunk

• bradykinesia (slowness of movement)

• postural instability, or impaired balance and coordination

• The primary symptoms are the results of decreased stimulation of the motor cortex by
the basal ganglia, normally caused by the insufficient formation and action of
dopamine, which is produced in the dopaminergic neurons of the brain. Secondary
symptoms may include high level cognitive dysfunction and subtle language problems.
PD is both chronic and progressive.

• Dopamine is a substance produced in the body which has many effects, including
smooth and coordinated muscle movement.

Prevalence and Incidence

• 50,000- new cases are reported each year

• Males are more affected than females

• Symptoms begin between 40 and 70 years of age with a peak onset on the 60’s.

Risk Factors
• The specific cause of PD is unknown; however, medical experts believe the
symptoms are related to a chemical imbalance in the brain caused by brain-cell death.

• Advancing age. The average age for the onset of PD is 60 years.

• Gender. Fifty percent more men are affected than women, according to the National
Institute of Neurological Disorders and Stroke. However, the reason for this is unclear.

• Family history. Individuals with a parent or sibling who are affected have
approximately two times the chance of developing PD.
Two genes which are linked to PD

a. synuclein- a member of a small family of proteins that are expressed preferentially in the
substantia nigra. One of the major components of the Lewy bodies that are found in brain
tissues of persons with PD.

b. Parkin genes- encoding the protein parkin was linked to an autosomal recessive form of
PD.

• Environmental causes are being researched and the strong consistent findings are
that rural living, exposure to well water, and exposure to agricultural pesticides
and herbicides are related to PD. Currently researchers believe that in most
individuals the cause of PD is a combination of genetics and environmental
exposure.

*endotoxin or lipopolysaccharide – a common airborne environmental and occupational

contaminate in agriculture and other industries.

Parkinson's syndrome, Atypical Parkinson's, or Parkinsonism:

• tumors in the brain

• repeated head trauma

• drug-induced parkinsonism - prolonged use of tranquilizing drugs, such as the

phenothiazines, butyrophenones, reserpine, and the commonly used drug,
metoclopramide for stomach upset.

• toxin-induced parkinsonism - manganese and carbon monoxide poisoning.

• postencephalitic parkinsonism - a viral disease that causes "sleeping sickness."

• striatonigral degeneration - the substantia nigra of the brain is only mildly affected,
while other areas of the brain show more severe damage.

• parkinsonism that accompanies other neurological conditions - such as Shy-

Drager syndrome (multiple system atrophy), progressive supranuclear palsy, Wilson's
disease, Huntington's disease, Hallervorden-Spatz syndrome, Alzheimer's disease,
Creutzfeldt-Jakob disease, olivopontocerebellar atrophy, post-traumatic
encephalopathy, and dementia with Lewy bodies.

The following are the most common symptoms of Parkinson's disease. However, each
individual may experience symptoms differently. Symptoms may include:

• Muscle rigidity - stiffness when the arm, leg, or neck is moved back and forth.

• Resting tremor - tremor (involuntary movement from contracting muscles) that is most
prominent at rest.
 • Bradykinesia - slowness in initiating movement.

• Postural instability - poor posture and balance that may cause falls; gait or balance
problems.

• Symptoms of Parkinson's disease vary from patient to patient. The symptoms may
appear slowly and in no particular order. Early symptoms may be subtle and may
progress over many years before reaching a point where they interfere with normal
daily activities.

The four cardinal symptoms of PD are listed above. Other symptoms are divided into
motor (movement related) and nonmotor symptoms.

Gait and posture

disturbances
Speech and swallowing
disturbances • Shuffling gait

• Hypophonia • Decreased arm-swing.

• Monotonic speech. • Turning "en bloc"

• Festinating speech • Stooped, forward-flexed

posture
• Drooling
• Festination
• Dysphagia
• Gait freezing

• Dystonia (in about 20%

of cases)

Other motor symptoms:

• Fatigue

• Masked faces (a mask-like face also known as hypomimia), with infrequent blinking;

• Difficulty rolling in bed or rising from a seated position;

• Micrographia (small, cramped handwriting);

• Impaired fine motor and gross motor coordination;

• Akathisia (the inability to sit still)

Cognitive disturbances include:

• Slowed reaction time; both voluntary and involuntary motor responses are
significantly slowed.

• Executive dysfunction

• Dementia

• Hallucinations, delusions and paranoia may develop.

• Short term memory loss; procedural memory is more impaired than declarative
memory. Prompting elicits improved recall.

• Non-motor causes of speech/language disturbance in both expressive and

receptive language: these include decreased verbal fluency and cognitive disturbance
especially related to comprehension of emotional content of speech and of facial
expression.

• Medication effects: some of the above cognitive disturbances are improved by

dopaminergic medications, while others are actually worsened.

Perception

• Impaired visual contrast sensitivity, spatial reasoning, colour discrimination,

convergence insufficiency (characterized by double vision) and oculomotor control

• Dizziness and fainting; usually attributable orthostatic hypotension, a failure of the

autonomic nervous system to adjust blood pressure in response to changes in body
position

• Impaired proprioception (the awareness of bodily position in three-dimensional

space)

• Reduction or loss of sense of smell (hyposmia or anosmia) pain: neuropathic,

muscle, joints, and tendons, attributable to tension, dystonia, rigidity, joint stiffness, and
injuries associated with attempts at accommodation

Autonomic

• Oily skin and seborrheic dermatitis

• Urinary incontinence

• Nocturia— up to 60% of cases

• Constipation and gastric dysmotility

• Altered sexual function

• Weight loss, which is significant over a period of ten years.

 As the disease progresses, walking may become affected, causing the patient to stop in
mid-stride or "freeze" in place, and maybe even fall over. Patients also may begin walking
with a series of quick, small steps as if hurrying forward to keep balance, a practice known
as festination.

Pathophysiology

Medications
a. OLDER DRUGS

• Anti-cholinergic

• Dopamine Agonist

Levadopa Combinations (levadopa-carbidopa / sinemet)

Amantadine (Symmetrel)
b. NEWER DRUGS

1. Cathechol o-methyltranferase (COM) inhibitor

1.1. Entacapone (Contan)-used in combination of levadopa and carbidopa.

1.2 Stavelo – a combination of levodopa,cabidopa and entacapone.

1.3 Tolcapone (Tasmar)

2. Monoamine-oxidase (MAO) inhibitors

Selegiline (Eldepryl) - may be prescribed to confer mild symptomatic benefit

before initiating dopaminergics in the treatment of PD.

Ex. Carbex, Eldepryl, Novo-Selegiline

- reduce metabolic breakdown of dopamine

c. INVESTIGATIONAL DRUGS

1. Coenzyme Q10 – may slow the rate of functional declines

2. Dextromethorphan glial – derived neurotrophic factor --- administered directly into

the brain.

Possible Care Plans

Impaired Physical Mobility related to neuromuscular impairment

a. Daily exercise increases muscle strength, improve coordination and dexterity, reduce
muscular rigidity and prevent contractures.

b. Stretching and ROM exercise to promote joint flexibility.

c. Postural exercises are important to counter the tendency of the head and neck to be drawn
forward and down.

d. Warm baths and massage help relax the muscle and relieve painful muscle spasms that
accompany rigidity.

Self- Care Deficit related to tremor and motor disturbance

a. Encourage and support the patient during ADL’s to promote self care.

b. Assist and encourage good grooming to enhance independence and self esteem.

Impaired Verbal Communication related to neuromuscular impairment

a. Instruct client to speak softly and clearly and to pause and take a deep breath at
appropriate intervals during each sentence.
b. Eliminate unnecessary environmental noise to maximize the listener’s ability to hear and
understand the client.

c. Asked client to repeat words that the listener does not understand and the listener watches
the client’s lips and non-verbal expressions for cues as to the meaning of conversation.

d. Instruct client to organize his/her thoughts before speaking and to use facial expression
and gestures if possible to assist with communication.

e. Collaborate with the speech language pathologist, health care team, client and family in
developing a communication plan.

f. If client cannot communicate verbally, the use of alternative methods of communication

such as communication board or computer must be encouraged.

Imbalanced Nutrition less than body requirements related to inability to ingest food
due to biologic factors

.a. Smaller, more frequent meals or commercial powder added to liquids may assist the client
who has difficulty swallowing.

b. Position client with head elevated to facilitate swallowing and prevent aspiration.

d. The client should be weighed once a week and adjustment should be made on diet as
indicated.

e. Record food intake daily or as indicated.

g. Coordinate with the nurse on duty to evaluate the client’s food intake.

Constipation related to medication and decreased activity

a. Encourage a patient to follow regular mealtime pattern to establish regular bowel routine.

b. Increase fluid intake.

c. Eat foods with a moderate fiber content.