Transcript PARKINSON`S DISEASE - 123seminarsonly.com

PARKINSON’S DISEASE
(Idiopathic Parkinsonism or Paralysis Agitans)
PARKINSON’S DISEASE
• Parkinson's disease (PD or, simply,
Parkinson's) is the most common
form of Parkinsonism, a group of
motor system disorders.
• Named after James Parkinson.
a British physician who first
described the disease in a paper
he published as the “shaking
palsy” in 1817
• It is a slowly progressing,
degenerative neurologic disease
that is usually associated with the
following symptoms,
– tremor or trembling of the arms,
jaw, legs, and face
– stiffness or rigidity of the limbs and
trunk
– bradykinesia
(slowness
of
movement)
– postural instability, or impaired
balance and coordination
• The primary symptoms are the results
of decreased stimulation of the motor
cortex by the basal ganglia,
normally caused by the insufficient
formation and action of dopamine,
which
is
produced
in
the
dopaminergic neurons of the brain.
Secondary symptoms may include high
level cognitive dysfunction and subtle
language problems. PD is both
chronic and progressive.
• Dopamine is a substance produced in
the body which has many effects,
including smooth and coordinated
muscle movement.
Prevalence and Incidence
• 500,000 – currently suffer PD in USA
• 50,000- new cases are reported
each year
• Males are more affected than
females
• Symptoms begin between 40 and 70
years of age with a peak onset on
the 60’s.
Risk Factors
• The
specific cause of PD is
unknown; however, medical experts
believe the symptoms are related to a
chemical imbalance in the brain caused
by brain-cell death.
• Advancing age. The average age for
the onset of PD is 60 years.
• Gender. Fifty percent more men are
affected than women, according to the
National Institute of Neurological
Disorders and Stroke. However, the
reason for this is unclear.
• Family history. Individuals with a
parent or sibling who are affected have
approximately two times the chance of
developing PD.
Two genes which are linked to PD
a. synuclein- a member of a small
family of proteins that are
expressed preferentially in the
substantia nigra. One of the
major components of the Lewy
bodies that are found in brain
tissues of persons with PD.
b. Parkin genes- encoding the
protein parkin was linked to an
autosomal recessive form of PD.
Risk Factors
• Environmental causes are being
researched and the strong consistent
findings are that rural living, exposure
to well water, and exposure to
agricultural
pesticides
and
herbicides are related to PD. Currently
researchers believe that in
most
individuals the cause of PD is a
combination
of
genetics
and
environmental exposure.
*endotoxin or lipopolysaccharide – a
common airborne environmental and
occupational
contaminate
in
agriculture and other industries.
Parkinson's syndrome, Atypical Parkinson's, or
Parkinsonism:
• tumors in the brain
• repeated head trauma
• drug-induced parkinsonism - prolonged use of tranquilizing drugs,
such as the phenothiazines, butyrophenones, reserpine, and the
commonly used drug, metoclopramide for stomach upset.
• toxin-induced parkinsonism - manganese and carbon monoxide
poisoning.
• postencephalitic parkinsonism - a viral disease that causes
"sleeping sickness."
• striatonigral degeneration - the substantia nigra of the brain is only
mildly affected, while other areas of the brain show more severe
damage.
• parkinsonism that accompanies other neurological conditions such as Shy-Drager syndrome (multiple system atrophy), progressive
supranuclear
palsy,
Wilson's
disease,
Huntington's
disease,
Hallervorden-Spatz syndrome, Alzheimer's disease, Creutzfeldt-Jakob
disease, olivopontocerebellar atrophy, post-traumatic encephalopathy,
and dementia with Lewy bodies.
Four primary symptoms of
Parkinson
•
•
•
•
The following are the most common
symptoms of Parkinson's disease. However,
each individual may experience symptoms
differently. Symptoms may include:
Muscle rigidity - stiffness when the arm,
leg, or neck is moved back and forth.
Resting tremor - tremor (involuntary
movement from contracting muscles) that is
most prominent at rest.
Bradykinesia - slowness in initiating
movement.
Postural instability - poor posture and
balance that may cause falls; gait or balance
problems.
Other symptoms of
Parkinson's disease (PD):
• Symptoms of Parkinson's disease vary
from patient to patient. The symptoms
may appear slowly and in no particular
order. Early symptoms may be subtle
and may progress over many years
before reaching a point where they
interfere with normal daily activities.
• The four cardinal symptoms of PD are
listed above. Other symptoms are
divided into motor (movement related)
and nonmotor symptoms.
Gait and posture disturbances
• Shuffling gait
• Decreased arm-swing.
• Turning "en bloc"
• Stooped, forward-flexed posture
• Festination
• Gait freezing
• Dystonia (in about 20% of cases)
Speech
and
swallowing
disturbances
• Hypophonia
• Monotonic speech.
• Festinating speech
• Drooling
• Dysphagia
Other motor symptoms:
• Fatigue (up to 50% of cases);
• Masked faces (a mask-like face also
known as hypomimia), with infrequent
blinking;
• Difficulty rolling in bed or rising from a
seated position;
• Micrographia
(small,
cramped
handwriting);
• Impaired fine motor dexterity and
motor coordination;
• Impaired gross motor coordination;
• Akathisia, the inability to sit still.
Cognitive disturbances include:
• Slowed reaction time; both voluntary and involuntary
motor responses are significantly slowed.
• Executive dysfunction
• Dementia
• Hallucinations, delusions and paranoia may develop.
• Short term memory loss; procedural memory is more
impaired than declarative memory. Prompting elicits
improved recall.
• Non-motor causes of speech/language disturbance in
both expressive and receptive language: these include
decreased verbal fluency and cognitive disturbance especially
related to comprehension of emotional content of speech
and of facial expression.
• Medication effects: some of the above cognitive
disturbances are improved by dopaminergic medications,
while others are actually worsened.
Sleep
• Excessive daytime somnolence
• Initial, intermediate, and terminal
insomnia
• Disturbances in REM sleep:
disturbingly vivid dreams, and
rapid eye movement behavior
disorder, characterized by acting
out of dream content — can occur
years prior to diagnosis
Perception
• Impaired visual contrast sensitivity, spatial
reasoning, colour discrimination, convergence
insufficiency (characterized by double vision) and
oculomotor control
• Dizziness and fainting; usually attributable
orthostatic hypotension, a failure of the autonomic
nervous system to adjust blood pressure in
response to changes in body position
• Impaired proprioception (the awareness of
bodily position in three-dimensional space)
• Reduction or loss of sense of smell
(hyposmia or anosmia) pain: neuropathic,
muscle, joints, and tendons, attributable to tension,
dystonia, rigidity, joint stiffness, and injuries
associated with attempts at accommodation
Autonomic
• Oily skin and seborrheic
dermatitis
• Urinary incontinence
• Nocturia— up to 60% of cases
• Constipation and gastric
dysmotility
• Altered sexual function
• Weight loss, which is significant
over a period of ten years.
• As the disease progresses,
walking may become affected,
causing the patient to stop in
mid-stride or "freeze" in place,
and maybe even fall over. Patients
also may begin walking with a
series of quick, small steps as if
hurrying forward to keep balance,
a practice known as festination.
Risk/Related Factors
Age, Genetics, Drugs, Toxins,Headtrauma
Destruction of dopaminergic neuronal cells in the
substantia nigra in the basal ganglia
Depletion of dopamine stores
Degeneration of the Dopaminergic nigrostriatal pathway
Imbalance of Excitatory (acethylcholine) and inhibiting
(dopamine) neurotransmitters in the corpus striatum
Impairment of extre pyramidal tracts controlling
complex body movements
Tremors, Rigidity, Bradykinesia
Diagnosis
• Neurological examination
(including evaluation of symptoms and
their severity)
• Trial test of drugs - when symptoms
are significant, a trial test of drugs
(primarily levodopa [L-dopa]) may be
used to further diagnose the presence
of PD. If a patient fails to benefit from
levodopa, a diagnosis of Parkinson's
disease may be questionable.
• Computed tomography scan (Also
called a CT or CAT scan.)
• Magnetic
(MRI)
resonance
imaging
Other Tests to Roll out
Secondary Causes
• Drug Sreening – to determine the
presence of medications or toxins
• Upper GI Series – shows delayed
emptying, distention and possibly
megacolon
with severe
constipation
• CBC – shows low hemoglobin and
hematocrit due to anemia
• Chemistry Profile – reflect low
protein and albumin levels related to
the clients
inability to buy and
prepare meals
Medication for Parkinson's disease:
a. OLDER DRUGS
•
Anti-cholinergic
•
Dopamine Agonist
2.
Levadopa Combinations (levadopa and carbidopa )
3.
Amantadine (Symmetrel)
b. NEWER DRUGS
1. Cathechol o-methyltranferase (COM) inhibitor
1.1. Entacapone (Contan)-used in combination of
levadopa and carbidopa.
1.2 Stavelo – a combination of levodopa,cabidopa and
entacapone.
1.3 Tolcapone (Tasmar)
2. Monoamine oxidase (MAO) inhibitors
Selegiline(Eldepryl) - may be prescribed to confer mild
symptomatic benefit
before initiating dopaminergics in the treatment of PD.
Ex. Carbex, Eldepryl, Novo-Selegiline
- reduce metabolic breakdown of dopamine
c. INVESTIGATIONAL DRUGS
1. Coenzyme Q10 – may slow the rate of functional
declines
2. Dextromethorphan glial – derived neurotrophic factor -- administered directly into the brain.
B. Surgical Treatment
•
•
•
•
Lesion surgery (burning of tissue)
Deep brain stimulation (DBS)
Neural grafting or tissue transplants
Pallidotomy and thalamotomy are rarely done
anymore. They involve the precise destruction of very
small areas in the deep part of the brain that cause
symptoms.
• Neurotransplantation surgery
• Fetal Tissue Transplantation is an experimental
and highly controversial procedure. Fetal substantia
nigra tissue either human or pig is transplanted into
the caudate nucleus of the brain.
1. Impaired Physical Mobility related to
neuromuscular impairment
a. Daily exercise increases muscle strength,
improve
coordination
and
dexterity,
reduce muscular rigidity and prevent
contractures.
b. Stretching and ROM exercise to promote
joint flexibility.
c. Postural exercises are important to counter
the tendency of the head and neck to be
drawn forward and down.
d. Warm baths and massage help relax the
muscle and relieve painful muscle spasms
that accompany rigidity.
2. Self- Care Deficit related to
tremor and motor disturbance
• a. Encourage, teach and support
the patient during ADL’s to
promote self care.
• b. Assist and encourage good
grooming to enhance
independence and self esteem.
3. Impaired Verbal Communication
related to neuromuscular impairment
a. Instruct client to speak softly and clearly and to pause and
take a deep breath at appropriate intervals during each
sentence.
b. Eliminate unnecessary environmental noise to maximize
the listener’s ability to hear and understand the client.
c. Asked client to repeat words that the listener does not
understand and the listener watches the client’s lips and
non-verbal expressions for cues as to the meaning of
conversation.
d. Instruct client to organize his/her thoughts before
speaking and to use facial expression and gestures if
possible to assist with communication.
e. Collaborate with the speech language pathologist, health
care team, client and family in developing a
communication plan.
f. If client cannot communicate verbally, the use of
alternative methods of communication such as
communication board or computer must be encouraged.
3. Imbalanced Nutrition less than body
requirements related to inability to ingest food
due to biologic factors
a. Smaller, more frequent meals or commercial powder added
to liquids may assist the client who has difficulty
swallowing.
b. Position client with head elevated to facilitate swallowing
and prevent aspiration.
d. The client should be weighed once a week and adjustment
should be made on diet as indicated.
e. Record food intake daily or as indicated.
f. As disease progresses and swallowing becomes more of a
problem, supplemental feedings become the main source
of nutrition to maintain weight.
g. Coordinate with a registered dietician to evaluate the
client’s food intake.
h. If the client has difficulty swallowing coordinate with
speech language pathology to conduct an extensive
swallowing evaluation in order to develop an individualized
dietary plan.
4. Constipation related to
medication and decreased activity
a. Encourage a patient to follow
regular mealtime pattern to
establish regular bowel routine.
b. Increase fluid intake.
c. Eat foods with a moderate fiber
content.