Parkinson's Disease Nursing CE Course

1.0 ANCC Contact Hours AACN Category A

Syllabus

Upon completion of this activity, participants should be able to:

  1. Describe pathophysiological changes that occur in Parkinson’s disease.
  2. List proposed risk factors for Parkinson’s disease.
  3. Describe clinical manifestations associated with Parkinson’s disease.
  4. Describe pharmacological management of symptoms of Parkinson’s disease.
  5. Discuss nursing care aimed at managing/controlling symptoms, promoting independence and dealing with the chronicity of the disease.

The purpose of this activity is to enable the learner to increase their general knowledge of Parkinson’s disease as well as the medical and nursing management of the affected patient. 

Parkinson’s disease (PD) is a progressive, degenerative neurologic disorder manifesting primarily in motor dysfunction (Bauldoff, Gubrud & Carno, 2020; Hoffman & Sullivan, 2017). It is the second most common neurodegenerative disease (Honan, 2019). 

The idiopathic form of Parkinson’s disease is the most common, but there is also a secondary form that can occur from a known or suspected cause (Hinkle & Cheever, 2018; Honan, 2019). 

The incidence of PD is 1.5 to 2 times greater in males than females (Hoffman & Sullivan, 2017). Symptoms of the disease usually first appear in the fifth decade of life with the diagnosis of PD typically occurring between the sixth and seventh decades (Hinkle & Cheever, 2018). However, there have been documented cases diagnosed as early as age 30 (Honan, 2019). 

It is estimated that by 2020, nearly one million people will be living with PD in the United States. Approximately 60,000 Americans are diagnosed with PD each year, and more than 10 million people worldwide are living with PD (Parkinson’s Foundation, n.d.). 

Anatomy and Physiology

The basal ganglia, in coordination with the cerebellum, regulate motor movement by sending information back and forth through the thalamus to the cerebral cortex. The signals coming from the basal ganglia are inhibitory while the signals coming from the cerebellum are excitatory. Coordination of movement is accomplished through a balance between both systems (Hoffman & Sullivan, 2017). 

Pathophysiology

Parkinson’s disease is associated with a decrease in the level of dopamine as a result of the destruction of neuronal cells in the substantia nigra located in the basal ganglia of the brain (Honan, 2019). Typically, the two neurotransmitters acetylcholine (excitatory) and dopamine (inhibitory) counterbalance each other when relaying impulses to the higher motor centers of the brain. As a result, motor movement is controlled and refined (Hinkle & Cheever, 2018; Honan, 2019). When there is a loss of neuronal cells in the substantia nigra of the basal ganglia, dopamine storage is depleted. Consequently, there is a predominance of the excitatory neurotransmitter, acetylcholine, over the inhibitory neurotransmitter, dopamine. Clinical manifestations of PD become apparent when approximately 60% of the neuronal cells in the substantia nigra are destroyed, and the dopamine level is decreased by 80% (Hinkle & Cheever, 2018; Honan, 2019).

Risk Factors

As previously mentioned, PD is primarily idiopathic in origin. However, causative factors include genetics, atherosclerosis, head trauma, brain tumors, environmental toxins (pesticides and herbicides), and chronic use of antipsychotic medications (Hoffman & Sullivan, 2017; Honan, 2019). 

Signs and Symptoms

The clinical manifestations of PD are gradual in onset and progress slowly over a prolonged period (Hinkle & Cheever, 2018; Honan, 2019). Cardinal signs of PD can be recalled through the mnemonic TRAP, which stands for: tremor, rigidity of muscles, akinesia/bradykinesia, and postural disturbances (Honan, 2019). 

Tremor

A slow, unilateral resting tremor is typically present in the majority of patients at the time of diagnosis and is the most common reason why patients initially seek medical evaluation (Hinkle & Cheever, 2018; Honan, 2019). The resting tremor occurs while the extremity is motionless and disappears with purposeful movement (Hinkle & Cheever, 2018; Honan, 2019). The tremor may present as a rhythmic, slow-turning motion of the forearm and hand (pronation – supination) accompanied by movement of the thumb against the other fingers as if rolling a pill between the fingers (Honan, 2019). As the disease progresses, the tremor may become bilateral and affect the patient’s ability to perform activities that require dexterity such as eating and writing (Bauldoff et al., 2020). 

Rigidity

Rigidity manifests as passive resistance to limb movement (Honan, 2019). Passive range of motion of an extremity can result in a jerky movement known as cogwheel rigidity (Bauldoff et al., 2020). An early manifestation of rigidity is the patient complaint of cramping in the hands or toes or shoulder pain (Bauldoff et al., 2020; Honan, 2019). Patients may also complain of stiffness, heaviness, or muscle aches as a consequence of rigidity (Bauldoff et al., 2020). 

Akinesia/Bradykinesia

Akinesia is a lack of movement, while bradykinesia is a delay in the execution of movement (Honan, 2019). As a result, the patient can experience difficulty with initiating actions such as rising from a chair or changing positions while in bed (Hinkle & Cheever, 2018). 

Postural Disturbances

Patients with PD experience a loss of postural reflexes (Honan, 2019). There is involuntary flexion of the head and shoulders resulting in the inability of the patient to maintain the trunk in an upright position while sitting or standing (Bauldoff et al., 2020). As the patient attempts to move the feet under the body’s center of gravity, the result is a shuffling gait with decreased arm swing (Honan, 2019). Additionally, patients with PD have difficulty with pivoting, which can lead to loss of balance and result in forward or backward falls (Bauldoff et al., 2020).

Other Signs and Symptoms

There are also symptoms of PD that result from loss of functions controlled by the autonomic nervous system (Bauldoff et al., 2020). This includes excessive and uncontrolled sweating, paroxysmal flushing, elimination problems (constipation or urinary hesitancy or frequency), orthostatic hypotension, and sexual dysfunction, including erectile dysfunction, decreased libido, vaginal dryness, and anorgasmia (Bauldoff et al., 2020; Honan, 2019; Wright, 2019). Due to the increase in sweat gland activity, the patient may experience eczematous skin changes and seborrhea (Bauldoff et al., 2020). 

In many instances, PD patients will also develop dysphagia, posing a risk for aspiration (Honan, 2019). Dysphonia (soft, low-pitched, nasal-sounding voice) can also occur as weakness of the muscles associated with speech and paralysis of the soft palate develops (Hinkle & Cheever, 2018; Honan, 2019). As dexterity declines, patients develop micrographia (small, shrinking handwriting) (Honan, 2019). The face also appears mask-like (expressionless), and blinking decreases (Hinkle & Cheever, 2018). 

Patients with PD also report sleep disturbances. The ability to fall and stay asleep is affected by increased acetylcholine levels and muscle rigidity makes it difficult to change positions during sleep (Bauldoff et al., 2020). 

Cognitive and psychiatric changes can also occur. Cognitive changes may be evident in the patient’s ability to accurately judge, reason, and make decisions (Honan, 2019). Depression and anxiety are common (Hinkle & Cheever, 2018). Additional manifestations include acute confusion, dementia, and visual and auditory hallucinations (Hinkle & Cheever, 2018; Honan, 2019). 

Diagnosis

There is no specific diagnostic test that differentiates PD from other neurologic disorders. It is diagnosed based on clinical examination findings and an exhaustive history (Bauldoff et al., 2020). Inclusive in history-taking are inquiries regarding occupation, medications (particularly use of antipsychotics and some anti-emetics), history of brain trauma and family history (Porter, Kaplan, Lynn & Reddy, 2018). 

During the neurologic examination the patient will be unable to perform rapidly alternating or rapid successive movements well. During finger-to-nose testing coordination in the client with PD, the tremor abates. Sensation and reflexes are normal, but reflexes may be difficult to elicit due to marked tremor and rigidity (Porter et al., 2018).

It is essential to rule out other potential causes of the patient’s clinical manifestations (Bauldoff et al., 2020). Examples of other neurodegenerative disorders that have some clinical features in common with PD include multiple system atrophy, progressive supranuclear palsy, dementia with Lewy bodies and corticobasal degeneration. Health care providers may test the patient’s responsiveness to levodopa to clarify a diagnosis. A large sustained response supports the diagnosis of PD while modest or no response suggests other possible causes.  Neuroimaging studies may also be necessary to rule out other potential pathologies (Porter et al., 2018).

Once other causes of the current clinical manifestations are ruled out, a diagnosis of PD is made when there is the presence of two or more of the cardinal symptoms (bradykinesia, resting tremor, rigidity or postural instability) (Hoffman & Sullivan, 2017). 

Pharmacological Management and Nonpharmacological Management

Pharmacological Management 

The provider will initiate pharmacological management when the patient’s symptoms become disabling and interfere with activities of daily living (ADLs) (Hoffman & Sullivan, 2017). The goal of pharmacological therapy is to control the client’s symptoms to the greatest possible extent (Bauldoff et al., 2020).

The medications listed below are for oral administration. 

Dopamine Precursors (levodopa/carbidopa [Parcopa, Sinemet]) 

Levodopa is converted to dopamine in the central nervous system. Carbidopa, a decarboxylase inhibitor, prevents premature breakdown of levodopa to dopamine in the peripheral tissues. This medication is useful in the relief of tremors and rigidity. (Bauldoff et al., 2020; Vallerand, 2017).  Side effects of levodopa/carbidopa (Parcopa, Sinemet) include nausea, vomiting, constipation, decreased appetite, orthostatic hypotension, darkening of urine and sweat, and dyskinesias (Hinkle & Cheever, 2018; Vallerand, 2017). Dyskinesias typically begin within 5 to 10 years of taking this medication. They are involuntary movements that include head bobbing, chewing and smacking movements, facial grimacing, and involuntary movements of the trunk and extremities. For this reason, many providers attempt to delay their utilization when possible (Honan, 2019). Patients who take levodopa/carbidopa (Parcopa, Sinemet) may experience an “on-off syndrome”, which is characterized by periods of near immobility (off effect) followed by a sudden return of mobility (on effect). A change in the dosing regimen or switching to another medication may help to minimize this syndrome (Hinkle & Cheever, 2018).  Contraindications to administration include angle-closure glaucoma and malignant melanoma (Vallerand, 2017). 

Important patient education points the nurse should review include rising slowly from a supine or seated position due to the risk for orthostatic hypotension; dividing daily protein intake amongst all meals as high-protein meals can impair the medication’s effectiveness; and adherence to health care provider instructions for laboratory testing (liver function studies, renal function studies, and complete blood count with differential) (Vallerand, 2017). 

Dopamine Agonists (bromocriptine [Parlodel], pramipexole [Mirapex], pergolide [Permax], and ropinirole hydrochloride [Requip]) 

The dopamine agonists are useful in postponing the use of levodopa/carbidopa (Parcopa, Sinemet) therapy, or can be used concurrently (Bauldoff et al., 2020; Honan, 2019). Dopamine agonists mimic the role of dopamine in the brain and consequently decrease tremor and rigidity (Bauldoff et al., 2020; Vallerand, 2017). Side effects include orthostatic hypotension, nausea, and psychologic disturbances (Bauldoff et al., 2020). Contraindications for dopamine agonists include psychotic disorders (Vallerand, 2017). 

Important patient education points the nurse should review include rising slowly from a supine or seated position due to the risk for orthostatic hypotension and notifying the health care provider if new or increased gambling, sexual or other intense urges or psychotic-like behavior occurs (Vallerand, 2017).  

Antiviral Therapy (amantadine hydrochloride [Symmetrel]) 

This medication is often used in the early stages of PD to manage symptoms related to akinesia as well as tremors (Bauldoff et al., 2020; Honan, 2019). The incidence of side effects is low but can include mood changes, confusion, depression, hallucinations, orthostatic hypotension, heart failure, edema of the lower extremities, nausea, urinary retention, headache, and visual changes (Hinkle & Cheever, 2018; Honan, 2019). 

Important patient education points the nurse should review include rising slowly from a supine or seated position due to the risk for orthostatic hypotension; monitoring for signs and symptoms of heart failure, such as sudden weight gain, edema or difficulty breathing; and notifying the health care provider if incomplete bladder emptying is suspected. 

Monoamine Oxidase- B (MAO-B) Inhibitors (rasagiline [Azilect] and selegiline [Eldepryl]) 

MAO-B inhibitors inhibit dopamine breakdown (Hinkle & Cheever, 2018). They can be combined with dopamine agonists to delay the use of levodopa/carbidopa (Parcopa, Sinemet) therapy (Bauldoff et al., 2020). Side effects include dizziness, orthostatic hypotension, insomnia, nausea, dry mouth, headache, and serotonin syndrome (Hinkle & Cheever, 2018; Vallerand, 2017). Selegiline (Eldepryl) is available as a transdermal patch in addition to an oral formula (Vallerand, 2017). 

Important patient education points the nurse should review include rising slowly from a supine or seated position due to the risk for orthostatic hypotension; avoiding consumption of tyramine-containing foods (for example, aged cheeses, fermented meats, beer and ale) due to the risk for hypertensive crisis; and notifying the health care provider if signs and symptoms of serotonin syndrome develop (mental status changes, autonomic instability, neuromuscular changes, and/or gastrointestinal symptoms) (Vallerand, 2017). 

Catechol-O-Methyltransferase (COMT) Inhibitors (entacapone [Comtan] and tolcapone [Tasmar]) 

COMT inhibitors block the function of catechol-O-methyltransferase, which is the enzyme responsible for metabolizing dopamine. They are given in combination with levodopa/carbidopa (Parcopa, Sinemet), which allows for more levodopa to be available for conversion to dopamine in the brain (Honan, 2019). Side effects include nausea, constipation, diarrhea, abdominal pain, hepatotoxicity, back pain, blood in the urine, and orthostatic hypotension (Hinkle & Cheever, 2018; Vallerand, 2017). 

Important patient education points the nurse should review include rising slowly from a supine or seated position due to the risk for orthostatic hypotension; avoiding intake of alcohol; and adhering to health care provider instructions for laboratory testing (liver function studies) (Bauldoff et al., 2020; Vallerand, 2017). 

Anticholinergics (trihexyphenidyl hydrochloride [Artane] and benztropine mesylate [Cogentin]) 

Anticholinergics are used to control tremor by counteracting the action of acetylcholine (Honan, 2019). Side effects include blurred vision, flushing, constipation, dry mouth, hypotension, and urinary retention (they should be used cautiously in patients with benign prostatic hypertrophy) (Hinkle & Cheever, 2018; Vallerand, 2017). Anticholinergics are contraindicated in patients with angle-closure glaucoma. In addition to the oral form, benztropine mesylate (Cogentin) is also available for intramuscular and intravenous administration for acute dystonic reactions and drug-induced extrapyramidal reactions (Vallerand, 2017). 

Important patient education points the nurse should review include rinsing the mouth frequently and using sugarless gum or candy to decrease dry mouth and rising slowly from a supine or seated position due to the risk for orthostatic hypotension (Vallerand, 2017). 

Nonpharmacological Management

Interdisciplinary Collaboration

The physical therapist, occupational therapist, speech therapist, and social worker should all be a part of the interdisciplinary care team (Hoffman &Sullivan, 2017). The physical therapist can provide individualized exercises and activities to promote strength, flexibility, and mobility (Hoffman & Sullivan, 2017). Examples of beneficial exercises may include stretching (stretch-hold-release), range of motion exercises, and postural exercises (Honan, 2019). The physical therapist should also work with the patient on safe walking techniques, which include walking erect with the feet separated (wide base of support) and watching the horizon (Hinkle & Cheever, 2018; Honan, 2019). 

The occupational therapist provides strategies to promote maximal independence and optimize mental functioning (Hoffman &Sullivan, 2017). The therapist can recommend available adaptive or assistive devices that may help with eating as an example. The occupational therapist can also evaluate the patient’s needs in the home environment and can suggest modifications to be made (Honan, 2019). 

The speech therapist should perform a swallow evaluation as swallowing difficulties are common in patients with PD (Honan, 2019). Swallowing problems can be due to poor head control, tongue tremor, delayed swallowing, inability to form a food bolus, or disturbances in pharyngeal motility (Hinkle & Cheever, 2018; Honan, 2019). Collaboration with the speech therapist can help to identify the specific swallowing issues and make appropriate recommendations for diet. The speech therapist can also help to design speech improvement exercises to facilitate communication since PD patients tend to have soft, monotonous speech (Honan, 2019). The nurse can also remind the patient to speak slowly, exaggerate their pronunciation of words, face the listener, and use short sentences (Hinkle & Cheever, 2018; Honan, 2019). 

The social worker can refer the patient to support groups for both the patient and caregiver and can refer to helpful resources such as the American Parkinson’s Disease Association, the National Parkinson Disease Foundation, and the Parkinson’s Disease Foundation (Bauldoff et al., 2020). 

Surgical Management 

For carefully selected patients who may have advanced tremors that are no longer responsive to medications or are impaired by the dyskinesias associated with long-term use of levodopa/carbidopa (Parcopa, Sinemet), deep brain stimulation (DBS) may be considered (Bauldoff et al., 2020; Hinkle & Cheever, 2018). DBS involves the delivery of high-frequency electrical stimulation to targeted areas of the brain identified through CT scan or MRI (Honan, 2019). One or more electrodes are placed in either the globus pallidus or subthalamic nucleus and connected to a pulse generator (Hinkle & Cheever, 2018). With stimulation to these areas, dopamine release may be increased, leading to a reduction in tremor and rigidity (Hinkle & Cheever, 2018). The battery-powered generator is implanted in a subcutaneous pocket in the subclavicular area or abdomen (Honan, 2019). The overall goal is that medication doses may decrease after the insertion of this device (Hinkle & Cheever, 2018). 

Nursing Care and Implications

Improving Mobility 

The nurse’s role in caring for patients with PD is often one of educator. Daily exercise will help to increase muscle strength, improve coordination, decrease muscle rigidity, and prevent contractures (Hinkle & Cheever, 2018). Walking, riding a stationary bicycle, and swimming help to maintain joint mobility (Honan, 2019). Warm baths and massage help to facilitate range of motion exercises (Hinkle & Cheever, 2018). Because patients with PD often lack a normal arm swing, the nurse should remind the patient to make a conscious effort to swing their arms and pick up their feet while walking. The patient may want to practice walking to marching music (Honan, 2019). 

Improving Nutrition

The patient’s weight should be monitored weekly as clients with PD may have difficulty maintaining their weight (Hinkle & Cheever, 2018). Eating requires extra concentration due to chewing and swallowing difficulties as well as the medication-related side effect of dry mouth (Hinkle & Cheever, 2018; Honan, 2019). The client should be seated in an upright position when eating to facilitate the swallow reflex and decrease the risk of aspiration (Hoffman & Sullivan, 2017). Suction equipment should be readily available at the bedside in the event of aspiration and to assist with handling oral secretions (Hoffman & Sullivan, 2017). 

A semisolid diet with thickened liquids is easier to swallow, so the recommendations from speech therapy usually include to avoid thin liquids (Hinkle & Cheever, 2018; Honan, 2019). The nurse can help guide the patient to place food on their tongue, close their lips and teeth, and lift the tongue up and then back to swallow (Honan, 2019). Patients should be encouraged to chew food first on one side and then the other before swallowing (Hinkle & Cheever, 2018; Honan, 2019). To assist with eating and promote independence, a plate stabilizer, no-spill cup and built-up handles for utensils can be of value. The nurse should collaborate with the occupational therapist to secure these devices if applicable and assist the patient with instructions for their use. As PD progresses, the patient may need to have a percutaneous endoscopic gastrostomy (PEG) tube inserted to maintain adequate nutritional intake (Honan, 2019). 

Improving Communication 

The nurse should remind patients with PD to make a conscious effort to speak slowly and deliberately and to take a few deep breaths before speaking (Hinkle & Cheever, 2018). An electronic amplifier may be useful if family members, caregivers, or the healthcare team are having difficulty hearing the patient (Honan, 2019). 

Improving Bowel Elimination

The patient with PD may have severe constipation that is caused by several factors. A weakening of the muscles used for defecation, immobility, decreased fluid intake due to impaired swallowing, decreased autonomic nervous system activity, and adverse effects of medications can all contribute to constipation. The nurse can suggest measures to incorporate in the plan of care: setting a regular time pattern for defecation, consuming foods with moderate fiber content, and increasing fluid intake. A raised toilet seat and allowing ample time for nature to take its course may also be of benefit (Hinkle & Cheever, 2018).

Promoting Self-Care Activities 

Modifications to the PD patient’s environment can help to compensate for disabilities and promote safety and independence. The nurse should counsel the patient to remove any scatter rugs, ensure sufficient lighting throughout the home, and install handrails in all bathrooms and stairwells (Honan, 2019). The occupational therapist can help to determine the types of assistive devices that can be of benefit to the patient. The nurse should encourage the patient or family/caregiver to manage their medication regimen carefully. 

Promoting Sleep 

Medications that are used to treat PD can often contribute to sleep pattern disturbance. As an example, levodopa (Parcopa, Sinemet) can lead to vivid dreams. Measures to promote good sleep patterns include going to bed and waking up around the same time every day, avoiding naps too close to bedtime, limiting caffeine intake, darkening the room, and decreasing any ambient noise (Bauldoff et al., 2020). 

Supporting Coping Abilities 

Patients with PD often experience apathy, loneliness, and embarrassment about their external symptoms. These feelings can lead to depression. Some strategies the nurse can offer to help combat depression include setting achievable goals, physiotherapy, support group participation, medication therapy, and psychotherapy (Honan, 2019). If the patient expresses an interest in medication therapy for mood stabilization, the nurse should refer them to their provider for additional information. As always, the nurse should be watchful for any worsening mood symptoms or suicidality.

Future Research and Trends

Future research should focus on PD patient’s concerns regarding the often-inadequate discussion of sexuality and intimacy issues by health care providers (Wright, 2019). Given that the problem clearly exists, health care providers should take the extra initiative to bring the conversation to the forefront. 

Current available treatment strategies fall under medical and surgical modalities with pharmacological medical management being the cornerstone of treatment while surgical options are limited and rarely used. As reported by Dutta et al., (2019), several studies have linked changes in gut microbiome with associated symptoms of PD. Consequently, administration of probiotic therapy in management of PD bears further investigation (Dutta et al., 2019). 

References

Bauldoff, G., Gubrud, P., & Carno, M. (2020). LeMone & Burke’s medical-surgical nursing clinical reasoning in patient care (7th ed.). Hoboken, New Jersey: Pearson Education.

Dutta, S., Verma, S., Jain, V., Surapaneni, B., Vinayek, R., Phillips, L., & Nair, P. (2019). Parkinson’s disease: The emerging role of gut dysbiosis, antibiotics, probiotics, and fecal microbiota transplantation. Journal of Neurogastroenterology and Motility, 25(3), 363 -376. 

Hinkle, J. & Cheever, K. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing (14th ed.). Philadelphia: PA. Wolters Kluwer.

Hoffman, J. & Sullivan, N. (2017). Medical Surgical Nursing Making Connections to Practice. Philadelphia: PA. F.A Davis Company. 

Honan, L. (2019). Focus on adult health medical-surgical nursing (2nd ed.). Philadelphia, PA.: Wolters Kluwer. 

Parkinson’s Foundation (n.d.) Understanding Parkinson’s. Retrieved August 12, 2019 from https://www.parkinson.org/Understanding-Parkinsons/Statistics

Porter, R., Kaplan, J., Lynn, R., & Reddy, M. (Eds.) (2018). The MERCK manual of diagnosis and therapy (12th ed.). Kenilworth, N.J.: Merck, Sharp & Dohme Corp.

Vallerand, A. & Sanoski, C. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA: F.A Davis Company. 

Wright, J. (2019). Addressing sexuality and intimacy in people living with Parkinson’s during palliative care and at the end of life. British Journal of Nursing, 28(12), 772 – 779.