Parkinson’s Disease NCLEX Review
In this article about Parkinson’s Disease, we’re diving deep to give you a really thorough understanding of what you need to know for your nursing school exams. This content is based off the Parkinson’s lesson I created for my course Med Surg Solution, so if you find it helpful, then you may want to check it out here. You can listen to this information on the go by tuning in to episode 198 of the Straight A Nursing podcast wherever you get your podcasts or right here.
Parkinson’s Disease (PD) is a progressive neurodegenerative disease that affects mobility. It occurs due to two pathological processes:
- The accumulation of Lewy bodies, which are clumps of a protein called alpha-synuclein in the brain
- A premature loss of dopamine producing neurons
The portion of the brain that produces dopamine is the substantia nigra. This is the area of the brain that degenerates in patients with PD. A key consequence of decreased dopamine levels is the inability to refine voluntary movement. Parkinson’s also reduces the sympathetic nervous system’s influence on the heart, blood vessels and other areas of the body. This causes a wide range of symptoms, which we’ll look at using the Straight A Nursing LATTE method.
L: How does the patient LOOK?
The four key symptoms that can help you differentiate Parkinson’s Disease from other neurological disorders are:
- Tremor. These are involuntary movements that occur at rest and are usually first noted in the arms, but can also occur in feet, legs, jaw, mouth or tongue. The classic tremor with PD is “pill rolling” which is the movement of the thumb with other fingers. Note that tremors worsen with fatigue and decrease with active movement.
- Muscle rigidity. The patient may report “freezing” or feeling like they are stuck in place.
- Postural instability
- Bradykinesia or akinesia (slow or no movement)
For the patient to be diagnosed with PD, they have to have at least two of these key symptoms. It’s important to note that PD usually does not become symptomatic until the individual has lost 70-80% of the dopamine producing neurons, making it difficult to diagnose early. And, because PD is a progressive disease, symptoms will worsen over time. For example, motor manifestations, such as tremors, usually begin asymmetrically and progress to affecting both sides of the body as the disease condition worsens.
Other key signs/symptoms that may be reported or noticed are:
- The patient may report their handwriting has changed with the letters becoming small and cramped. This is called micrographia and is often an early symptom.
- A mask-like facial expression due to rigidity of facial muscles. This rigidity can lead to dysphagia and drooling.
- Hypophonia (soft voice) and other changes in speech such as hesitation, repetitive words, halting speech or even slurring. You’ll often see the speech of a PD patient described as monotonous.
- In addition to postural instability, individuals with PD will have poor balance, difficulty with gait, and may take small, shuffling steps.
- Psychologically the patient may report depression, be irritable, express apathy, feel anxious or insecure.
- They are also likely to report sexual dysfunction, fatigue, muscle cramps and even pain.
- Sleep disturbances are also quite common due to a variety of sleep disorders such as restless legs syndrome, excessive daytime sleepiness, insomnia, co-existing obstructive sleep apnea, periodic limb movements of sleep (PLMS), and something called rapid eye movement (REM) – sleep behavior disorder (RBD).
- More than 30% of Parkinson’s patients will experience some cognitive impairment at some point as the disease progresses, varying from mild impairment to severe dementia.
- In the later stages, patients can also experience Parkinson’s Disease psychosis which includes visual hallucinations or delusions.
Disruptions to the autonomic nervous system can cause a variety of symptoms. These include
- Orthostatic hypotension
- Excessive sweating
- Bladder problems such as urinary frequency and urge incontinence
- GI disruptions revolve around slowed peristalsis leading to bloating, gas, loss of appetite, early satiety, nausea, abdominal discomfort and constipation
A: How do you ASSESS the patient?
- Assess for the four key PD symptoms: tremor, rigidity, postural instability and bradykinesia or akinesia.
- Observe the patient’s gait, posture and ability to ambulate. THINK PATIENT SAFETY! You want to increase mobility as much as possible, but also want the patient to be safe and avoid falls.
- Assess the patient for depression. Ask about symptoms of depression such as loss of energy, insomnia or excessive sleeping, loss of pleasure in hobbies and thoughts of suicide. Any time a patient expresses suicidal ideation, this is a medical emergency and you must not leave that patient alone. They should stay under 1:1 observation until the crisis has passed and the individual has been cleared by a psychiatrist.
- Assess the patient for anxiety. Ask about symptoms such as feelings of unease, worry or panic. Assess for physical symptoms of anxiety such as difficulty breathing or swallowing, cold sweats or heart palpitations.
- Assess the patient’s short-term memory, attention, concentration, problem solving, etc.
- Assess the patient for pain. Pain can be related to coexisting conditions such as arthritis and peripheral neuropathy, or can be related to PD directly. Dystonia (sustained posture of neck, arms, legs or feet), restlessness and muscle and joint pain are all common causes of pain in individuals with Parkinson’s.
- Assess for orthostatic hypotension, which can put the patient at risk for falls. Orthostatic hypotension can be caused by medications or loss of sympathetic innervation in the heart and blood vessels.
- Assess the patient’s speech pattern for soft voice, slurring, word repetition, halting speech, rapid speech, hesitation, etc.
- Assess the patient for bowel and bladder problems (urinary incontinence or retention, constipation)
- Assess the patient for any difficulty swallowing. Dysphagia puts the patient at high risk for aspiration.
- Assess the patient’s nutrition status, appetite, and weight.
T: What TESTS will be conducted?
Diagnosis of PD is based on clinical findings after other neurologic diseases are eliminated. Like Alzheimer’s, there are no specific diagnostic tests. However, cerebrospinal fluid analysis may show decreased dopamine levels.
Other diagnostics such as MRI or single-photon emission computed tomography (SPECT) may be ordered to rule out other possible central nervous system health problems. Positron emission tomography (PET) and SPECT may be used to detect a loss of dopamine producing neurons.
Evaluations related to the symptoms of PD can include:
- Speech therapy evaluation to assess for dysphagia and aspiration risk
- Barium swallow study to assess for aspiration
- Occupational therapy evaluation
- Physical therapy evaluation
T: What TREATMENTS will be provided?
Treatments for Parkinson’s disease revolve around symptom management.
Medications are aimed at increasing mobility and the patient’s ability to perform ADLs. Dopaminergic drugs and dopamine agonists relieve symptoms by enhancing dopamine levels, inhibiting the body’s ability to break down dopamine or mimicking the action of dopamine.
Combination carbidopa-levodopa drug (Sinemet) is given to reduce tremor and rigidity.
- Because regular dopamine cannot cross the blood brain barrier, we give its metabolic precursor, levodopa.
- Carbidopa prevents the destruction of levodopa, which is why the drugs are often given as a combination.
- Sinemet is given on an empty stomach to increase absorption and transport across the BBB.
- One unwelcome adverse effect with long term use of levodopa is dyskinesia (involuntary movements). The dyskinesia becomes progressively more severe as the levodopa dose increases.
- Other significant and life-threatening adverse effects are GI related such as GI bleeding, obstruction, perforation and ischemia. It can be toxic to the liver, cause pancreatitis and even peritonitis. Some common, less serious adverse effects are nausea, vomiting and constipation.
Dopamine agonists enhance dopamine by stimulating dopamine receptors in the brain. They are typically used to decrease tremor and rigidity as well as restless leg syndrome, and are most effective during the first 3-5 years of use.
- Examples are apomorphine (Apokyn), pramipexole (Mirapex) and ropinirole (Requip). There’s also one called rotigotine (Neupro) that is available as a continuous transdermal patch. It is often used to improve adherence in patients who have cognitive impairment or dysphagia.
- Some of the benefits of dopamine agonists are that patients typically have less incidence of dyskinesia and less of a “wearing off” phenomenon. A wearing off phenomenon is where the patient has a loss of responsiveness to the drug over time.
- Adverse effects include orthostatic hypotension, hallucinations, sleepiness and drowsiness, confusion and lower extremity edema. The patient could also exhibit excessive impulse behaviors such as gambling, shopping, sex, and eating. This is thought to be due to overstimulation of dopamine receptors in the area of the brain responsible for instant gratification.
- You may see a dopamine agonist used in conjunction WITH levodopa to reduce “off time” or to enhance the effects of levodopa. “Off time” means the medication is not working as effectively, and symptoms start to show up again. This often occurs when it’s almost time for the next dose and the previous dose is losing effectiveness.
COMT inhibitors are utilized to prolong the action of levodopa. Catechol O-methyltransferases (COMTs) are enzymes that inactivate dopamine. By blocking these enzymes, we can prolong levodopa’s action in the body. An example is entacapone (Comtan), which is often used in combination with levodopa. Side effects include a harmless dark coloration to the urine as well as diarrhea, confusion and hallucinations. Entacapone should be taken with food to minimize GI upset.
MAO-B inhibitors are used to increase dopamine concentrations by slowing an enzyme that breaks down dopamine. The drug selegiline (Deprenyl) is often given with levodopa to patients with early or mild PD symptoms, and promising research suggests MAO-B inhibitors may slow the progression of PD. These medications can cause dry mouth, nausea, dizziness, constipation. When taken with tyramine-containing foods or stimulants such as cold medication, they can cause hypertensive crisis.
MAO-B inhibitors can cause serious drug-drug interactions:
- Concurrent administration with opioids can cause a fatal reaction involving severe excitation, rigidity, hypertension or hypotension, and coma.
- When taken with SSRIs, serotonin syndrome can occur. It is recommended that MAO-B inhibitors be discontinued two weeks before SSRIs are initiated.
- Concurrent administration with TCAs can lead to seizure, hyperpyrexia, behavioral changes and even asystole. Like with SSRIs, the recommendation is to stop MAO-B inhibitors two weeks before starting TCA therapy.
Antiviral drug – amantadine (Symmetrel) potentiates the action of dopamine in the CNS.
- Amantadine may be given in early stages to reduce symptoms. It is especially beneficial in reducing dyskinesias in patients with advanced PD when used with levodopa.
- Common side effects include nausea, dry mouth, insomnia, confusion, hallucinations, swelling of the feet, and lightheadedness. In rare situations, amantadine can cause urinary retention and a web-like purple skin discoloration called livedo reticularis.
Adenosine A2a antagonists are used in coordination with carbidopa/levodopa to reduce “off” time. An example is the medication istradefylline (Nourianz).
Anticholinergic drugs were the earliest medications used to treat PD.
Recall that acetylcholine and dopamine maintain a balance in the brain. Anticholinergics block the effect of ACh to restore the normal balance of dopamine, which reduces PD symptoms.
Anticholinergics, such as benztropine (Cogentin) are used for severe tremors and rigidity, and are rarely the primary choice for pharmacologic treatment. They should be used carefully or avoided in older adults due to anticholinergic side effects (urinary retention, dry mouth, blurry vision, and decreased short term memory). Research shows that an additional side effect may be cognitive slowing, which is another reason to possibly avoid using them in the elderly.
Acetylcholinesterase inhibitors such as rivastigmine and donepezil are given to address the cognitive impairment of patients with PD who also have dementia. Common side effects include bladder control issues, drooling and tremor.
Medications used to relieve the additional symptoms of Parkinson’s disease include:
- Baclofen is used to decrease muscle spasms.
- Atropine sulfate is given to reduce saliva production and drooling.
- Zolpidem tartrate (Ambien) is used to improve sleep.
- Venlafaxine is used for depression, but it is avoided if the patient is taking an MAO-B inhibitor due to the risk of a potentially fatal reaction.
Surgery may be an option when drugs are not effective in managing symptoms:
- Deep brain stimulation involves the implantation of electrodes in the brain. These electrodes are connected to a pulse generator that is placed under the skin (much like a cardiac pacemaker). The generator is programmed to deliver an electrical current which helps to decrease dyskinesias.
- Stereotactic pallidotomy is an “awake surgery” that involves the insertion of an electrode or rod into the target area of the brain (a small section of the globus pallidus). This target area receives a mild electrical stimulation and the patient’s response is assessed for reduction of rigidity symptoms. The probe can be repositioned to find the ideal location, and then a permanent lesion is made that destroys the tissue…leading to continued reduction in rigidity symptoms for the patient…studies show improvements can last up to 4 years.
Nursing interventions for a patient with Parkinson’s disease revolve around reducing risks, preserving motor function and fostering independence as much as possible.
- The two biggest safety concerns are falls and aspiration.
- Reduce fall risk where you can. For example, because of the shuffling gait, rugs and cords are significant trip hazards. Ensure grab bars are in place in the bathroom and that the environment is well lit.
- Monitor the patient’s ability to eat and swallow. Collaborate with a speech-language pathologist (SLP) for a swallow evaluation if necessary. The speech pathologist may also teach the patient specific exercises to strengthen muscles for breathing, speech and swallowing.
- Coordinate with PT and OT to keep the patient as independent and mobile as possible, always with an eye toward safety.
- When communicating with the patient, allow extra time for them to respond. If the patient cannot communicate verbally, try alternative methods such as communication boards and computers.
- When a patient with Parkinson’s is in the hospital, try to maintain the same medication schedule the patient uses at home. The easiest thing to do is to have the caregiver bring the patient’s medications into the hospital for a thorough medication reconciliation.
- Promote a diet with adequate fiber to prevent constipation, adequate hydration to reduce muscle cramping, and increased calories to maintain an ideal weight (many patients experience early satiety).
E: How do you EDUCATE the family?
There are a LOT of things to teach a patient or caregiver about Parkinson’s disease. These are just a few:
- General Parkinson’s symptom management:
- Teach the patient to speak slowly and clearly.
- Teach the caregiver to allow extra time for the individual to respond.
- Remind caregivers that the patient may experience impulse control issues, altered cognition, depression and anxiety, and that the patient cannot control these symptoms.
- Teach caregivers about resources for support, stress management and respite care.
- Teach the patient and family to weigh the patient once per week and to monitor nutritional intake.
- Promote good sleep hygiene. Encourage the patient to establish regular sleep and wake times, reduce caffeine, limit naps and avoid eating within several hours before bed .
- As for medications…
- Teach the patient/family that all drugs must be taken exactly as prescribed and that sudden cessation can cause serious adverse effects and worsening symptoms. The only time they should stop taking medication is when the MD has prescribed a drug holiday.
- Teach the patient that some medications require titration and that it may take several weeks to reach a therapeutic level…be patient.
- Teach patients taking MAOIs to avoid tyramine which can be found in cheese, aged/smoked/cured foods, sausage, red wine and beer.
- Teach the patient to avoid herbal supplements, OTC medications and alcohol, as they may interfere with their medications.
- Vitamin B6 supplements and foods containing high amounts of Vitamin B6 should be avoided when taking levodopa as it can reduce the medication’s effectiveness. These include organ meats, fish, starchy vegetables (ex: potatoes), non-citrus fruits and fortified cereals.
- When disease is mild, patients may still be driving so instruct them to avoid operating a motor vehicle (or other heavy machinery) when taking medications that cause drowsiness.
- To prevent falls and improve mobility
- Teach the patient to move slowly when changing from lying to sitting or sitting to standing, due to the risk for orthostatic hypotension.
- Teach the patient that regular exercise routines such as walking, strength training, swimming, cycling, and Tai Chi help maintain and possibly even improve coordination, mobility and balance.
- Teach the patient to rock back and forth to initiate movement.
- Teach the patient to purposefully lift their feet while walking.
- And…always teach the patient/caregiver that changes in condition must be reported to the MD ASAP. Symptoms such as altered mental status, severe uncontrolled movements, blurred vision and difficulty breathing require immediate attention.
Another element of the LATTE method that I’ve started adding is evaluation. How would you evaluate the effectiveness of your interventions? As always, evaluation is going to depend on the specific patient and interventions. Some examples include:
- The patient will avoid falls
- The patient will state when and how to take medications correctly
- The patient will demonstrate getting up from a seated position slowly without incidence of fall due to orthostatic hypotension
- The patient will maintain adequate weight
I hope this helps you understand Parkinson’s Disease. If you’d like to dive deeper, check out Med Surg Solution where we’ll dive a bit deeper with video-based teaching and a handy study guide! See you there.
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Pahwa, R., Swank, S., & University of Kansas Medical Center. (2020). Medications: A Treatment Guide to Parkinson’s Disease. https://www.parkinson.org/sites/default/files/attachments/Medications-Treatment-Guide- to-Parkinsons-Disease.pdf
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