Transcript Camerron Parkinson´s disease talk

“Cases in Sudden
Deterioration in
Parkinsons Disease”
Department of Neurology
Patrick Browne
RGN, RNP, BNS, BSc, PG Dip. HSc (ANP), MHSc.
Movement Disorders Advanced
Nurse Practitioner Candidate
Our Main Lesson…
Outline for Cameroon PD talk
Focus of this talk:
How general nurses can help
recognise what is wrong in the
causes of SUDDEN
DETERIORATION in Parkinsons
A Quick Word on Subtypes
Case examples
How does deterioration present?
Why do we see deterioration in Parkinsons Disease?
What can be done – concentration on constipation?
Take Home Messages
Final Word – Recognising the Dopamine Dysregulation
Syndrome
A Quick Word on Subtypes
Thinking of Parkinsonism
Pakinsonism the description of “looking like
Parkinsons Disease”
A Quick Word on Subtypes
What looks like Parkinsons
1 Parkinsons
2 Parkinsons Dementia
3 Lewy body Disease Dementia
4 Progressive Supranuclear Palsy
5 Multiple Systems Atrophy
6 Iatrogenic Parkinsons – after Phenothiazines
8 Other dementias with a Parkinsonian flair - FTD
with Parkinsonism
Case Studies 1
–John is a 72 yr old man
–Admitted to St Ritas
–From St Elsewhere NH
–Parkinsons much worse recentl;y
–Getting bad for years
–No change with medications
–NBO x 10/7
Case Studies 2
–Peter is a 74 yr old man
–Admitted to St Finbarrs ward for Hip
fracture
–PD x 9 yrs – but doing well
–Day 2 post op – severe tremor
–Can’t walk – thinks leg hurting him
Case Studies 3
–Paul is a 74 yr old man (twins)
–Admitted to St Finbarrs ward for Hip
fracture
–PD x 9 yrs – but doing well
–Day 2 post op – severe tremor
–Can’t walk – tablets not working any
more
Case Studies 4
–Patrick is a 74 yr old man (triplets)
–Admitted to St Finbarrs ward for Hip
fracture
–PD x 9 yrs – but doing well
–Day 2 post op – severe tremor
–Sickness and Vomiting after the
operation
Case Studies 5
–Mary is a 62 yr old lady
–Admitted to CCU with acute
coronary syyndrome
–Had had PD x 6 yrs - doing pretty
well but dyskinesia
–Now poor mobility and dyskinesia
are very much worse – can’t go
home
Case Studies 6
–Catriona is 84 yr old lady
–PD x 12 yrs
–In nursing home
–Slowly worse
–Was told in clinic “ It’s all just
constipation !!!”
–Horrendous diarrhoea for 3/7 “left in
a mess”
How does deterioration present?
Presentations of deterioration
First of all Parkinson’s is a chronic progressive
neurological disease charachterised by a slow
decline
Therefore we need to recognise the difference
between a slow natural decline - (which may
be rescuable as well) and a more sudden
deterioration
How does deterioration present?
Presentations of deterioration
1)
2)
3)
4)
5)
6)
7)
8)
Worsening tremor
Stiffness in muscles / limbs
Slowness moving and walking
Poor balance - falls
“Freezing” in gait
Confusion / delerium esp in elderly
Hallucinations especially in elderly
Daytime Sleepiness – especially in the elderly
How does deterioration present?
Presentations of “sudden” deterioration
- or in practical terms :
- Taking to the bed
- Just not getting up any more
- Has PD a long time and just getting worse
- Is this the final stage of a vicious circle of decline
that has been going off the rails for months???
Therefore sudden ==== subacute
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 1 CONSTIPATION
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 1 CONSTIPATION
CASE 6:
– Catriona is 84
– PD x 12 yrs
– In nursing home
– Slowly worse
– Was told in clinic “ It’s all just constipation !!!”
– Horrendous diarrhoea for 3/7 “left in a mess”
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 1 CONSTIPATION
• Bacterial overgrowth from bowel into gut prevents
absorbtion of drugs
• Slow GastroIntestinal transit affects absorption of
drugs
• Make the persons simply feel unwell
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 1 CONSTIPATION
–
–
–
–
–
–
–
John is a 72 yr old man
Admitted to St Ritas
From St Elsewhere NH
Parkinsons much worse recently
Getting bad for years
No change with medications
Student Nurse finds out NBO x 10/7 COMMON SCENARIO
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 2 Illness / Infection
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 2 Illness / Infection
CASE 3
– Paul is a 74 yr old man (twins)
– Admitted to St Finbarrs ward for Hip #
– PD x 9 yrs – but doing well
– D2 post op – severe tremor
– Can’t walk – tablets not working any more
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 2 Illness / Infection
CASE 3
– In Pauls case – intercurrently unwell because of
infection leading poor swallow leading to acute renal
failure AND this is why his Parkinsons is worse
– Changing Sinemet to qid from tid WILL NOT WORK
and probably make him worse.
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 3 Stress Related Episode
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 3 Stress Related Episode
–
–
–
–
Mary is a 62 yr old lady
Admitted to CCU with acute coronary syyndrome
Had had PD x 6 yrs - doing pretty well but dyskinesia
now poor mobility and dyskinesia are very much worse – can’t go home
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 4 Dehydration
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 4 Dehydration
– NO CASE EXAMPLE
– It’s an obvious common problem – swallow – meal times – foods they like
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 5 Drugs and Medication
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 5 Drugs and Medication
– Key Questions
–
–
–
–
–
IN HOSPITAL (and in the nursing home if new there:
1) Is the time the same as at home as in Hospital
2) Are we using protein drinks in Hospital
3) Is the food totally different – the PROTEIN
4) Are they the correct drugs – medication error
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 5 Drugs and Medication
– Key Questions
– AT HOME:
– 1) Are they taking the tablets
– 2) Is there a new regime at home with food – has the
daughter taken over – Does the home help now give
drugs with food
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 6 use of Neuroleptics or other containdicated
drugs
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 6 use of Neuroleptics or other contraindicated
drugs
CASE 4
– Patrick is a 74 yr old man (triplets)
– Admitted to St Finbarrs ward for Hip #
– PD x 9 yrs – but doing well
– D2 post op – severe tremor
– Sickness and Vomiting after the operation - STEMITIL
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 6 use of Neuroleptics or other contraindicated
drugs
– The obvious example – drugs used for sedation
– The phenothiazines serenace (haloperidol) etc
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 7 Depression
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 7 Depression
– No Case example
– We have to remember that Depression is extremely common in
PD – both because of having the Disease and what the disease
does – whole brain disorder – often counselling and or drugs
especially will help with this.
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 8 Acute / Chronic Pain
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 8 Acute / Chronic Pain
CASE 1
- Peter is a 74 yr old man
– Admitted to St Finbarrs ward for Hip #
– PD x 9 yrs – but doing well
– D2 post op – severe tremor
– Can’t walk – thinks leg hurting him
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 8 Acute / Chronic Pain
– This causes exactly the same problems to the person as stress –
the drugs are less effective.
– Always remember – everything that goes wrong in PwP is NOT
due to Parkinsons
– Is it a disc – Is it an Infection – Is it sciatica – Are we controlling the
pain in Hospital after a “normal” common procedure.
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 9 Anxiety / Panic Attack
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 9 Anxiety / Panic Attack
– NO CASE EXAMPLE
– This is similar to the depression and stress situation –
however Anxiety leads to more dramatic sudden
problems like FREEZING
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 10 Poor Sleep / Lack of Sleep
Why do we see deterioration
–What are the top 10 causes of
deterioration in PD?
– 10 Poor Sleep / Lack of Sleep
–
–
–
–
–
Feature of PD
REM Sleep behavour disorder
He Kicks wife – she wakens and then wakens him – COMMON
Leads to sleep inversion and makes everything worse
Straightforward solutions – Clonazepam to regularise the sleep
pattern
– IN HOSPITAL – hard to sleep – noise / blackout blinds
What can be done
–Touch Talk Time
• These are key values lacking in the our
modern health services model
What can be done
–Touch Talk Time
• but the opportunity to take the time to
identify the cause is critical:
• If we have two options
– PATIENT WORSE
» GIVE MORE SINEMET
or
»FIND OUT WHY PwP WORSE
What can be done
–The CONSTIPATION issue
–1) Warn the patient, their family, the
nursing home
– There will be rough days ahead . . .
What can be done
–The CONSTIPATION issue
–2) Think of the Dam
– Dam blocks
– Dam overflows – the flood
– But the Bulk of the dam is till there –
perhaps even made worse by the
constipating agents
What can be done
–The CONSTIPATION issue
–3) Strategies
– Movicol – 6 sachets in a litre of water with fruit juice taken over the
morning
– NaPico sachet Picolax
– NaPico as laxoberyl
– Stool softener – lactulose
– Senna
– All the natural options – Fruit / Fibre / Fybogel
– FLUID FLUID FLUID FLUID vs Speed to get to toilet concerns
What can be done
–The CONSTIPATION issue
–3) Therefore a TEAM APPROACH to
consitipation – engaging:
•
•
•
•
•
Person with Parkinsons
Family
Nursing Staff
Nursing Home
Doctors
Take Home Messages
A deterioration in PD is usually going
to be due to one main factor going off the rails
And then…..
There is the descent into chaos
Take Home Messages
Problem
And the person
will get back
to normal
Allow time
Identify the Cause
Treat the cause
Take Home Message 1
People with Pakinson’s have a severe
incurable Brain Disease….
But Are FIXABLE
Often by very simple measures where
nursing staff
have a key role in advocacy, identification
and amelioration
Take Home Message 2
When there is sudden (Acute)
or Sub Acute deterioration
There is usually NO need to adjust
the Parkinsons’ medication
unless
Absolutely Necessary