MS6.pdf

10/24/23, 3:17 PM Realizeit for Student Assessment and Diagnostic Findings Although laboratory tests and imaging studies are not helpful to the provider in diagnosing PD, ongoing research with PET and single-photon emission CT scanning has been helpful in understanding the disease and advancing tr...

10/24/23, 3:17 PM Realizeit for Student Assessment and Diagnostic Findings Although laboratory tests and imaging studies are not helpful to the provider in diagnosing PD, ongoing research with PET and single-photon emission CT scanning has been helpful in understanding the disease and advancing treatment. Currently, the disease is diagnosed clinically from the patient’s history and the presence of two of the four cardinal manifestations: tremor, rigidity, bradykinesia, and postural changes. Early diagnosis can be challenging because patients rarely are able to pinpoint when the symptoms started. Often, a family member notices a change such as stooped posture; a stiff arm; a slight limp; tremor; or slow, small handwriting. The medical history, presenting symptoms, neurologic examination, and response to pharmacologic management are carefully evaluated when making the diagnosis. Diagnosis is often confirmed by a positive response to a levodopa trial (Hickey & Strayer, 2020). The Revised Movement Disorder Society Unified Parkinson Disease Rating Scale (MDS-UPDRS) is a helpful assessment tool as it measures the disease progression including motor and nonmotor symptoms, and includes treatment complications (AANN, 2019). Medical Management Treatment is directed toward controlling symptoms and maintaining functional independence, because no medical or surgical approaches in current use prevent disease progression (AANN, 2019). Care is individualized for each patient based on presenting symptoms and social, occupational, and emotional needs. Pharmacologic management is the mainstay of treatment, although advances in research have led to more surgical options. Patients are usually cared for at home and are admitted to the hospital only for complications or to initiate new treatments. Surgical Management The limitations of levodopa therapy, improvements in surgical techniques, and new approaches in transplantation have renewed interest in the surgical treatment of PD. In patients with disabling tremor, rigidity, or severe levodopa-induced dyskinesia, surgery may be considered. Although surgery provides symptom relief in select patients, it has not been shown to alter the course of the disease or to produce permanent improvement. Stereotactic Procedures Thalamotomy and pallidotomy are ablative procedures that were formerly used to relieve symptoms of PD such as tremors. However, these procedures permanently destroy brain tissue and are rarely used today. Deep brain stimulation (DBS) has largely replaced ablative procedures in the surgical treatment of PD. DBS involves surgical implantation of an electrode into the brain in either the globus pallidus or https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUFUzXhwrkmByRPKGm7XOkO3V8uhfXYXOmPZGy%2b… 1/4 10/24/23, 3:17 PM Realizeit for Student subthalamic nucleus. Stimulation of these areas may increase dopamine release or block anticholinergic release, thereby improving tremor and rigidity. Levodopa medication dose may be able to be reduced, thus improving dyskinesias. Patients eligible for DBS are those who have responded to levodopa but are impaired by dyskinesias, have had the disease for at least 5 years, and are disabled by tremor. Patients with dementia and atypical PD are usually not considered for surgical procedures. PD rating scales and specific neurologic tests are used to identify patients who are eligible. Surgical treatment typically occurs 10 to 13 years after diagnosis (AANN, 2019). A CT or MRI scan is used to localize the appropriate surgical site in the brain. Then, the patient’s head is positioned in a stereotactic frame (see Fig. 65-4). After the surgeon makes an incision in the skin and a burr hole, an electrode is passed through to the target area to the subthalamic nuclei or globus pallidus. The desired response of the patient to the electrical stimulation (i.e., a decrease in rigidity) is used to confirm electrode placement. Electrode placement is completed on one side of the brain at a time; bilateral electrodes are usually placed (AANN, 2019). Electrodes are then connected to a pulse generator that is implanted in a subcutaneous subclavicular or abdominal pouch (see Fig. 65-5). The battery-powered pulse generator sends high-frequency electrical impulses through a wire placed under the skin to a lead anchored to the skull (see Fig. 65-6). These devices are not without complications that can result from both the surgical procedure needed for implantation (e.g., weakness, paresthesias, confusion, hemorrhage) and the device itself (e.g., infection, lead leakage) (Hickey & Strayer, 2020). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUFUzXhwrkmByRPKGm7XOkO3V8uhfXYXOmPZGy%2b… 2/4 10/24/23, 3:17 PM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUFUzXhwrkmByRPKGm7XOkO3V8uhfXYXOmPZGy%2b… 3/4 10/24/23, 3:17 PM Realizeit for Student Neural Transplantation Ongoing research is exploring transplantation of porcine neuronal cells, human fetal cells, and stem cells to replace degenerated striatal cells (Kirkeby, Parmar, & Barker, 2017). Legal, ethical, and political concerns surrounding the use of fetal brain cells and stem cells have limited the exploration of these procedures. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUFUzXhwrkmByRPKGm7XOkO3V8uhfXYXOmPZGy%2b… 4/4