Create grade A’ inservice on Parkinson’s disease

Here’s what nurses, aides must know

HomeNurse in Wayne, PA, recently polled staff about which inservices they would like, and nurses suggested Parkinson’s disease (PD) as a topic. "They wanted to understand this disease better and how to help patients adjust to their limitations of this disease," says Diane Gibson, RN, MMgtHCA, director of client services for HomeNurse. "We have a few clients who have Parkinson’s, and they wanted some down-to-earth good tips and good practical information about the disease."

Gibson asked an expert, Bobbie Hurka, BSN, RN, CNRN, to design a comprehensive inservice on Parkinson’s disease. Hurka is the coordinator of the American Parkinson Disease Association Information and Referral Center and clinical coordinator of the Parkinson’s Disease and Movement Disorder Center at Crozer-Chester Medical Center in Upland, PA. She outlines her guidelines as follows:

1. Discuss the history of PD.

Parkinson’s was first described in 1817 by an English doctor, James Parkinson, in a book called An Essay on the Shaking Palsy. "He had six patients who had similar presentations," Hurka says. The characteristics were:

• a tremor at rest that started at one side;
• slow movements, called bradykinesia;
• a shuffling gait;
• rigidity.

Until the 20th century, the disease was called the shaking palsy or its Latin equivalent, paralysis agitans.

2. Describe its pathophysiology.

PD is a disorder of the central nervous system. It’s the result of a degeneration of nerve cells in the deep part of the brain, the basal ganglia, and it involves the loss of nerve cells or neurons in the brain stem area, the substantia nigra. These cells make dopamine. "Dopamine is the neurotransmitter that is responsible for enabling people to move in a smooth, coordinated fashion," Hurka says.

A variety of other movement disorders may have similar symptoms. (See story on movement disorders, p. 23.) "I really stress when I lecture that there are 12 to 20 different disorders that can masquerade as Parkinson’s disease, and sometimes they are misdiagnosed," Hurka adds.

Medical experts suspect there may be a genetic predisposition to this disease and some kind of environmental impact, but the cause is still unknown, she says. A survey by Robert Wood Johnson Medical School in New Brunswick, NJ, showed that 53% of PD patients had at least one relative with the disease.1

3. Go over the cardinal signs of PD.

The first symptoms typically are feelings of weakness and fatigue, shaking or trembling, usually in the hands and usually on one side, and a dragging of one leg. Later, PD patients may become stooped. (See description of PD signs and symptoms, inserted in this issue.)

"Home health aides need to understand what the symptoms of Parkinson’s disease are: slowness of movement, rest tremor, rigidity demonstrated in the fact that the person is having a lot of trouble moving and cannot get out of the chair," Hurka says.

Also, PD is chronic and usually slowly progressive. Some of the other diseases with similar symptoms progress more rapidly.

4. Cover basic medications.

The current gold standard is Sinemet, also called carbidopa/levodopa. If a patient is given this medication but is uncertain whether it has improved the symptoms, the patient probably doesn’t have Parkinson’s disease, or else the dose is too low, she says. "We do not have any medication that slows down the progress of the disease, so as the disease progresses, the patient needs more medication or a different combination of medication."

Generally, patients need to take the drug on awakening and at least a half an hour before meals, although they should take it at other times if needed. Nurses should suggest patients keep a diary so they can learn how to augment their schedule, Hurka says. For example, if at 2 p.m. each day the medication has worn off, and the next dose isn’t scheduled until 4 p.m., the schedule may need to be changed. "A person with Parkinson’s disease can’t wait an hour for the next dose. They need to learn how to take regular Sinemet on an as-needed basis."

Medications may need to be adjusted monthly or even weekly. PD patients may find their med ication stops working suddenly; without any warning, they can’t move. This can be frightening. "If aides notice this problem, then they need to go to the caregiver and tell them that they think the patient’s Parkinson’s symptoms have come back and the medicine has worn off," she says. Aides also should notify the agency’s nurse about this type of problem, and the nurse can contact the physician.

5. Describe medication side effects.

The most common medication side effects are problems with too much movement, such as writhing, dancing motions called dyskinesia. "Unfortunately, people misinterpret that and think it’s part of Parkinson’s, so they give them more medication, and that makes symptoms worse," Hurka says. "Or the family will call the doctor and not describe what is happening accurately by saying the patient is shaking, and the doctor interprets this as tremors."

Nurses and physicians need to ask caregivers when the symptoms began because the timing is critical. For example, if the symptoms begin one-half hour to an hour after the patient has taken the medication, it’s probably a side effect of the medication. But if it starts one-half hour before medication time, it’s more likely a real tremor.

Sometimes dyskinesia occurs just as the medication is wearing off, so caregivers and nurses need to describe the symptoms carefully. Other side effects include hallucinations, delusions, and paranoia. "The more cognitively impaired a person is, the more susceptible they are to having that side effect from medication," she says.

These drugs activate dopamine receptor sites in the brain, she adds. "They need to be dealt with in a very aggressive way, and we have very good medications to deal with that, and they do not mimic Parkinson’s symptoms."

The anti-psychotomimetic drugs commonly used to treat PD patients with hallucinations and delusions include Zyprexa, Seroquel, and Clozaril, which are expected to eliminate the hallucinations and delusions. (See list of contraindicated drugs, inserted in this issue.)

6. Outline how the disease progresses.

The disease typically has a 15- to 20-year progression, and patients may live a normal life span. In the first five years of diagnosis, a patient will function normally. Usually, the disease is diagnosed within one to two years after symptoms have begun.

"Patients may be functional for 10 or 20 years, depending on how cognitively intact they are, and how cautious they are so they don’t fall," Hurka says.

Three serious problems can occur as a consequence of the disease:

• The patient falls and breaks a hip.
• The patient contracts pneumonia.
• The patient has urinary tract infections that go unrecognized because he or she has trouble communicating.

"Whenever a Parkinson’s disease patient has a change in mental status, the first thing I do is get an urinalysis on them because any kind of stress changes their mental function," she says.

As the disease progresses, a patient may be walking and then suddenly freeze. "They can’t move their feet; they’re stuck, and that sets them up for falling because their feet can’t move and their upper bodies fall," Hurka says.

If this happens, the home health aide or nurse should tell the patient to stop moving. If a chair is handy, have the patient sit down, relax, and then start again. Another trick is to have the patient march in place or to put something in front of the patient’s feet that can serve as a visual cue. "I have a cane with iridescent straw that sticks out, and when people are stuck, I say, Well, step over that straw,’ and they can do that," she explains.

Reference

1. Duvoisin RC, Golbe LI, Mark MH, et al. Parkinson’s Disease Handbook. Staten Island, NY: The American Parkinson Disease Association Inc.; 1998, pp. 16-17.

Sources

Diane Gibson, RN, MMgtHCA, HomeNurse, 512 W. Lancaster Ave., Suite 2, Wayne, PA 19087-3190. Phone: (610) 975-9600.

Cynthia Holmes, PhD, Program Coordinator, Amer ican Parkinson Disease Association Information and Referral Center, University of Arizona, 2501 E. Elm St., Tucson, AZ 85716. Phone: (520) 326-5400. Fax: (520) 326-8591.

Bobbie Hurka, BSN, RN, CNRN, Coordinator, Amer ican Parkinson Disease Association Information and Referral Center and Clinical Coordinator, Parkinson’s Disease and Movement Disorder Center, Lewis House, Crozer-Chester Medical Center, One Medical Center Blvd., Upland, PA 19013-3995. Phone: (610) 447-2911. Fax: (610) 447-2925.

Rosemary Regan, RN, Parkinson’s Coordinator, American Parkinson Disease Association Referral and Information Center, Staten Island University Hospital, 475 Seaview Ave., Staten Island, NY 10305. Phone: (718) 226-6129. Fax: (718) 226-6531.