Parkinson's Disease

  1. General information
    1. A progressive disorder with degeneration of the nerve cells in the basal ganglia resulting in generalized decline in muscular function; disorder of the extrapyramidal system
    2. Usually occurs in the older population
    3. Cause unknown; predominantly idiopathic, but sometimes disorder is postencephalitic, toxic, arteriosclerotic, traumatic, or drug induced (reserpine, methyldopa [Aldomet], haloperidol [Haldol], phenothiazines)
    4. Pathophysiology
      1. Disorder causes degeneration of the dopamine-producing neurons in the substantia nigra in the midbrain
      2. Dopamine influences purposeful movement
      3. Depletion of dopamine results in degeneration of the basal ganglia.
  2. Assessment findings
    1. Tremor: mainly of the upper limbs, "pill-rolling," resting tremor; most common initial symptom
    2. Rigidity: cogwheel type
    3. Bradykinesia: slowness of movement
    4. Fatigue
    5. Stooped posture; shuffling, propulsive gait (see Figure 4.4)
    6. Difficulty rising from sitting position
    7. Masklike face with decreased blinking of eyes
    8. Quiet, monotone speech
    9. Emotional lability, depression
    10. Increased salivation, drooling
    11. Cramped, small handwriting
    12. Autonomic symptoms: excessive sweating, seborrhea, lacrimation, constipation; decreased sexual capacity
  3. Nursing interventions
    1. Administer medications as ordered
      1. Levodopa (L-dopa)
        1. increases level of dopamine in the brain; relieves tremor, rigidity, and bradykinesia
        2. side effects: anorexia; nausea and vomiting; postural hypotension; mental changes such as confusion, agitation, and hallucinations; cardiac arrhythmias; dyskinesias.
        3. contraindications: narrow-angle glaucoma; clients taking MAO inhibitors, reserpine, guanethidine, methyldopa, antipsychotics; acute psychoses.
        4. avoid multiple vitamin preparations containing vitamin B6 (pyridoxine) and foods high in vitamin B6.
        5. be aware of any worsening of symptoms with prolonged high-dose therapy: "on-off" syndrome.
        6. administer with food or snack to decrease GI irritation.
        7. inform client that urine and sweat may be darkened.
      2. Carbidopa-levodopa (Sinemet): prevents breakdown of dopamine in the periphery and causes fewer side effects.
      3. Amantadine (Symmetrel): used in mild cases or in combination with L-dopa to reduce rigidity, tremor, and bradykinesia.
      4. Anticholinergic drugs: benztropine mesylate (Cogentin), procyclidine (Kemadrin), trihexyphenidyl (Artane)
        1. inhibit action of acetylcholine
        2. used in mild cases or in combination with L-dopa
        3. relieve tremor and rigidity
        4. side effects: dry mouth, blurred vision, constipation, urinary retention, confusion, hallucinations, tachycardia
      5. Antihistamines: diphenhydramine (Benadryl)
        1. decrease tremor and anxiety
        2. side effect: drowsiness
      6. Bromocriptine (Parlodel)
        1. stimulates release of dopamine in the substantia nigra.
        2. often employed when L-dopa loses effectiveness.
      7. Eldepryl (Selegilene) a MAO Inhibitor inhibits dopamine breakdown and slows progression of disease
      8. Tricyclic antidepressants given to treat depression commonly seen in Parkinson's disease
    2. Provide a safe environment.
      1. Side rails on bed; rails and handlebars in toilet, bathtub, and hallways; no scatter rugs
      2. Hard-back or spring-loaded chair to make getting up easier
    3. Provide measures to increase mobility.
      1. Physical therapy: active and passive ROM exercises; stretching exercises; warm baths
      2. Assistive devices
      3. If client "freezes," suggest thinking of something to walk over.
    4. Encourage independence in self-care activities: alter clothing for ease in dressing; use assistive devices; do not rush client.
    5. Improve communication abilities: instruct client to practice reading aloud, to listen to own voice, and enunciate each syllable clearly.
    6. Refer for speech therapy when indicated.
    7. Maintain adequate nutrition.
      1. Cut food into bite-sized pieces.
      2. Provide small, frequent feedings.
      3. Allow sufficient time for meals, use warming tray.
    8. Avoid constipation and maintain adequate bowel elimination.
    9. Provide psychologic support to client/significant others; depression is common due to changes in body image and self-concept.
    10. Provide client teaching and discharge planning concerning
      1. Nature of the disease
      2. Use of prescribed medications and side effects
      3. Importance of daily exercise: walking, swimming, gardening as tolerated; balanced activity and rest
      4. Activities/methods to limit postural deformities: firm mattress with a small pillow; keep head and neck as erect as possible; use broad-based gait; raise feet while walking
      5. Promotion of active participation in self-care activities

FIGURE 4.4 The shuffling gait and early postural changes of Parkinson's disease shown in (A). (B) and (C) show an advanced stage of the disease with head held forward, mouth open, and inability to stand.