Nursing Care Of Patients With Neurocognitive Disorders PDF

Nursing Care of Patients with Neurocognitive Disorders Nursing Process for Management of Care P. Miskin, DHSc, MScN, RN, PHN 1 Central Concept: Cognition ▪ Cognition: ▪ All the processes involved in human thought ▪ Domains: ▪ Perception ▪ Memory ▪ Executive function 2 Central Concept: Cognitive Impa...

Nursing Care of Patients with Neurocognitive Disorders Nursing Process for Management of Care P. Miskin, DHSc, MScN, RN, PHN 1 Central Concept: Cognition ▪ Cognition: ▪ All the processes involved in human thought ▪ Domains: ▪ Perception ▪ Memory ▪ Executive function 2 Central Concept: Cognitive Impairment ▪ Varies in severity from mild to moderate to severe Delirium Global cognitive disorders Dementias Cognitive impairment Amnesias Focal cognitive disorders Aphasias Cortical hemispheric defects Executive function / behavior do 3 Delirium: Main Points ▪ A state of acute, transient cognitive impairment ▪ Acute syndrome ▪ Associated with other episodic / acute health challenges ▪ Elderly population especially vulnerable ▪ Possible at any age ▪ Major impact on health outcomes ▪ Reversable ▪ Early detection essential! 4 Delirium: Etiology and Pathophysiology ▪ The pathophysiologic mechanism poorly understood ▪ Neuroimaging studies indicate involvement of both cortical and subcortical structures including: thalamus, basal ganglia, pontine reticular formation ▪ Evidence suggest that acetylcholine may be a critical fact or Theoretical integration: ▪ Multifactorial etiology ▪ Interaction of patient’s underlying condition with precipitating factors ▪ May be the initial sign of other health problems such as urosepsis, pneumonia, myocardial infarction, etc. 5 Delirium: Risk Factors Predisposing factors: ▪ Advanced age ▪ Male ▪ Baseline cognitive impairment ▪ Depressions ▪ Visual impairments ▪ Hearing impairment ▪ Functional impairment ▪ Substance abuse Precipitating factors: ▪ Acute disease / infection ▪ Multiple medications ▪ Immobility / physical restraints ▪ Indwelling catheters! / Invasive lines ▪ Pain ▪ Fluid and electrolyte imbalances ▪ Withdrawal ▪ Environmental factors 6 Delirium Mnemonic: Drugs Elimination Liver and other organs Infection Respiratory Injury Unfamiliar environment Metabolic Clinical Presentation Hyperactive Hypoactive Mixed 7 Delirium: Assessment Early signs and symptoms: ▪ Inability to concentrate ▪ Irritability ▪ Insomnia ▪ Loss of appetite ▪ Restlessness Advanced signs and symptoms: ▪ Agitation ▪ Misperception ▪ Misinterpretation ▪ Hallucinations ▪ Impaired reality testing ▪ Manifestations may be confused with dementia and depression ▪ More likely to be delirium if the person exhibits ▪ Sudden cognitive impairment ▪ Disorientation ▪ Clouded sensorium 8 Delirium: Assessment ▪ Health Hx ▪ Physical examination ▪ Risk factors present? ▪ Med reconciliation ▪ Standardized cognitive assessment tools: ▪ Mini Mental State ▪ Cognitive Assessment Method (CAM) ▪ Labs 9 Delirium: Planning, Implementation, Evaluation Identify patients at risk: ▪ Neurologic disorders ▪ Sensory impairment ▪ Advanced age ▪ Recent surgery ▪ Sleep deprivation ▪ Hospitalization ▪ Multiple comorbidities Nursing management: ▪ Eliminate precipitating factors ▪ If infection > antibiotics ▪ Reorientation and behavioral interventions ▪ Manage risk for immobility and skin breakdown ▪ Support the family and caregivers 10 Delirium Prevention Measures ▪ Maintain sleep schedule ▪ Engage pt. in communication ▪ Maintain nutrition/fluid needs ▪ Play soothing music as appropriate ▪ Ambulate as much as possible ▪ Play television during day and off at night ▪ Out of bed—in the chair ▪ Lights on during day and off at night ▪ Eyeglasses clean and in place ▪ Keep environment quiet at night ▪ Hearing aids operational and in place ▪ Familiar objects from pt. home in room ▪ Pt. reoriented and addressed by name 11 Delirium: Pharmacotherapeutics ▪ Reserved for those patients with severe agitation: ▪ Low dose antipsychotics: ▪ Haldol(Haloperidol) ▪ Risperidone (Risperdal) ▪ Olanzapine (Zyprexa) ▪ Quetiapine(Seroquel) ▪ Short-acting Benzodiazepines: ▪ Lorazepam (Ativan) ▪ Used cautiously because many of the drugs used to manage agitation have psychoactive properties 12 Delirium - all too common scenario… ▪ Background ▪ Mr. F. is 89 years old with a hx of HTN and hearing loss ▪ He lives independently with some instrumental ADL assistance from his daughter. ▪ Situation ▪ His daughter found him on the floor, incoherent, very lethargic and febrile. He smelled of urine. ▪ He appeared not to have eaten for at least a day. ▪ His daughter took him to the hospital. ▪ Mr. F. was in the ED for more than 6 hours. ▪ Lab and imaging tests were ordered. ▪ Mr. F. was admitted to the hospital for possible UTI and further testing. Delirium - all too common scenario… ▪ Situation (continued) ▪ No delirium assessment performed in ED. ▪ No specific communication occurred with the daughter about her father’s medical history. ▪ When the daughter asked about her father’s condition, she was told, “We are waiting for the hospital attending physician to confirm the orders from the ED.” ▪ After several hours, Mr. F. has become extremely incoherent and very agitated. He was unable to sleep, and the nurse requested the the physician order Benadryl. ▪ Over a period of approximately 12 hours, Mr. F. had not been given anything to eat or drink. Delirium - all too common scenario… ▪ Situation (continued) ▪ The following day, the diagnosis for UTI was confirmed. ▪ He was not ambulating and continued to be incoherent and agitated. ▪ Physical and chemical restraints were ordered, and a Foley catheter was inserted. ▪ On the third day, a NG tube was inserted for feeding since he continued to decline and was not eating. ▪ He was confined to bed his entire stay; even though he stabilized by the 4th day, and his UTI resolved. ▪ No one had spoken with the daughter about her father’s medical, functional and social history. ▪ Mr. F. was discharged on the 5th day to a nursing facility. ▪ He was unable to return to his home and independent living situation. Dementia ▪ Syndrome ▪ Dysfunction or loss of: ▪ Memory ▪ Orientation ▪ Attention ▪ Language ▪ Judgment ▪ Reasoning ▪ Other possible signs and symptoms: ▪ Personality changes ▪ Behavioral problems such as ▪ Agitation ▪ Delusions ▪ Hallucinations ▪ Social and vocational domains: ▪ Work ▪ Social responsibilities ▪ Family responsibilities 16 Dementia ▪ Not a normal part of aging! ▪ Affects 15% of older Americans ▪ Half of the patients in long-term care facilities have dementia ▪ ~100 causes of dementia ▪ Across cultural / socioeconomic groups ▪ Important risk factors ▪ Advanced age ▪ Family history ▪ Infectious diseases can result in vascular and neurodegenerative changes that can lead to dementia ▪ Bacterial meningitis ▪ Viral encephalitis ▪ Dementia caused by treatable conditions potentially reversable ▪ Prolonged exposure may make dementia irreversible 17 Dementia: Etiology and Pathophysiology ▪ Due to treatable and non-treatable conditions ▪ Most common causes: Lewy Body Disease 10% Vascular Dementia 20% ▪ Neurodegenerative conditions ▪ Vascular disorders ▪ Other causes: ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Toxic or metabolic diseases Immunologic diseases or infections Systemic diseases Trauma Cancer Ventricular disorders Seizure disorders Drugs Alzheimer’s Disease 60% Other Types Pick’s disease Normal pressure hydrocephalus Creutzfeldt-Jakob disease 18 Dementia: Assessment ▪ Onset depends on cause: ▪ Insidious and gradual ▪ Neurologic degeneration dementia is usually gradual and progressive over time ▪ Abrupt ▪ Vascular dementia tends to be abrupt or progress in a stepwise pattern 19 Dementia: Assessment Early - Mild ▪ Forgetfulness beyond what is seen in a normal person ▪ Short-term memory impairment ▪ Geographic disorientation ▪ Difficulty recognizing numbers ▪ Loss of initiative and interests ▪ Decreased judgment Middle - Moderate ▪ Impaired ability to recognize close friends and family ▪ Wandering, getting lost ▪ Delusions, hallucinations ▪ Agitation and behavioral issues ▪ Loss of remote memory ▪ Confusion ▪ Impaired comprehension ▪ Apraxia ▪ Receptive and expressive aphasia Late - Severe ▪ Little memory, unable to process information ▪ Difficulty eating, swallowing ▪ Cannot understand words ▪ Incontinence ▪ Repetitious words or sounds ▪ Unable to perform ADL ▪ Immobility 20 Dementia vs. Depression ▪ Depression often mistaken for dementia and vice versa ▪ Manifestations of depression, especially in older adults ▪ Sadness ▪ Difficulty thinking and concentrating ▪ Depression: ▪ ▪ ▪ ▪ Fatigue Apathy Feelings of despair Inactivity ▪ Dementia and depression occurring together can cause extreme intellectual deterioration ▪ Depression alone or with dementia is treatable 21 Dementia vs. Delirium vs. Depression Del iri um Dementi a Sud den , over ho urs to d ays Slo wly, over m on ths H yp oglycem ia, fever, d ehydration , h yp oten sion in fec tion, o th er co ndition s that d is rupt bo dy's ho me ostasis; ad ve rs e drug reac ti on; h ead inju ry; chan ge in environ men t (e.g., h osp italization ); pain; e mo tio nal Im paired mem o ry, ju dgme nt, calcu latio ns, attention span ; can fluc tu ate th rough th e da y Alte red Alz heimer's disease , vascu lar disease , hum an im m uno deficien cy virus infectio n, neuro logical d is ease, c hron ic alc oh olism , head tra um a Imp aire d me mo ry, ju dgm ent, calcu latio ns, attention span , abstract thinking; agn os ia Not altered Difficulty co nce ntratin g, forge tfuln ess , in atten tion C an be in creased or red uce d; res tles snes s, beh avio rs may wo rs en in e ven ing (s und own syn drom e); sleep wake cyc le m ay be revers ed Not altered; b ehaviors may wo rsen in eve ning (sun down synd rom e) R apid s win gs; can be fearfu l, anxious , s usp iciou s, aggressive, h ave h allu cin atio ns and /o r d elus ion s R apid , in app ro priate, incohe re nt, ram blin g Flat; de lus ion s U sually decreased ; leth argy, fatigu e, lack of m otivatio n; m ay sleep p oorly and awaken in early m orn ing Extrem e sadn ess, ap ath y, irritability, an xiety, p aranoid id eation Slow, flat, low Onset Cause or Contr ibu tin g fact ors Cogn iti on Level of Consci ousness Act iv it y Le vel Emot ion al St ate Speech and Languag e Prog nos is Depressi on R eversible with pro per and tim ely tre atme nt Inco heren t, slow (s om etime s due to effort to fin d the right word), in app ro priate, ramb ling, re petitio us Not reversible, p rogressive M ay h ave b een gradu al with exace rb ation d uring c ris is L ifelo ng histo ry, lo sses, lo nelines s, cris es, dec lining h ealth, me dical c on dition s N ot altered R eversible with p ro per and 22 tim ely tre atmen t Dementia: Assessment ▪ Determining causes ▪ Reversible or nonreversible? ▪ Thoroughly patient history: ▪ Medical ▪ Neurologic ▪ Psychologic - use MMSE ▪ Imaging studies ▪ PE / screening to r/o other conditions: ▪ Cobalamin (vitamin B12) deficiencies ▪ Hypothyroidism ▪ Possibly neurosyphilis 23 Vascular Dementia: Assessment ▪ AKA ‘multi infarct dementia’ ▪ Loss of cognitive function due to: ▪ Ischemic lesions or ▪ Hemorrhagic lesions ▪ Mostly caused by cardiovascular disease ▪ Narrowing and blocking of cerebral arteries > ischemic injury ▪ May be caused by a single stroke or by multiple strokes ▪ Risks factors: ▪ Smoking ▪ Cardiac dysrhythmias ▪ Hypertension ▪ Hypercholesterolemia ▪ Diabetes mellitus ▪ Coronary artery disease ▪ Familial history Decreased perfusion Ischemic injury Loss of function 24 Vascular Dementia: Assessment ▪ Diagnosis based on: ▪ Presence of cognitive loss ▪ Presence of vascular brain lesions ▪ Exclusions of other causes of dementia ▪ Vascular dementia can be prevented ▪ Preventive measures include treatment of risk factors ▪ Cholinesterase inhibitors used for patients with AD are also helpful in patients with vascular dementia ▪ Donepezil (Aricept) 25 Alzheimer’s Disease ▪ Chronic, progressive, degenerative disease of the brain ▪ Most common form of dementia ▪ 60-80% of all cases of dementia ▪ Most live 8-10 years after being diagnosed ▪ Incidence slightly higher is African and Hispanic Americans ▪ May be related to socioeconomic status or access to health care, not ethnicity ▪ Women more likely to develop AD ▪ Have longer life expectancy than men ▪ Individuals with Down syndrome are at high risk for AD 26 Alzheimer’s Disease ▪ Society ages = more people with Alzheimer’s disease (AD) ▪ Currently 5.7 million in the U.S. ▪ By 2030 AD >8 million ▪ By 2050 >14 million ▪ High burden of disease ▪ One of the costliest health problems worldwide 27 AD: Etiology and Pathophysiology ▪ The exact etiology of AD is unknown ▪ Age is the most important risk factor ▪ Age of onset determines type: ▪ Early onset (under age 60) ▪ Late onset (over age 60) ▪ If pattern of inheritance within a family present = familial AD (FAD) ▪ Earlier onset ▪ More rapid disease course ▪ If no familial connection can be made = sporadic AD ▪ AD is NOT a normal part of aging! 28 AD: Etiology and Pathophysiology Non-modifiable risk factors: ▪ Age ▪ Traumatic brain injury ▪ Genetic susceptibility (ApoE) ▪ Down Syndrome ▪ Family history of AD Modifiable risk factors: ▪ Cardiovascular risk factors ▪ Oxidative stress ▪ Metabolic syndrome / diabetes ▪ Hypertension ▪ Overweight / obesity ▪ Chronic inflammation ▪ Other factors 29 AD: Etiology and Pathophysiology ▪ Presence of abnormal clumps (neuritic or senile plaques) and tangled bundles of fibers (neurofibrillary tangles) in the brain ▪ Changes in brain structure and function: ▪ Amyloid plaques ▪ Neurofibrillary tangles ▪ Loss of connections between cells and cell death 30 AD: Etiology and Pathophysiology 31 AD: Assessment ▪ Gradual loss of mental and physical capacities ▪ Pathologic changes precede S&S of dementia from 5 to 20 years ▪ Progression evaluated using dementia staging: 1. Mild / MCI 2. Moderate 3. Advanced / late ▪ Behavioral manifestations due to changes in the brain ▪ Not intentional or controllable by the individual with AD ▪ Some patients develop psychotic manifestations ▪ Cognitive impairments with: ▪ ▪ ▪ ▪ Dysphasia Apraxia Visual agnosia Dysgraphia 32 AD: Assessment Dx: ▪ Primarily a Dx of exclusion ▪ No single clinical test ▪ Early evaluation of pt with MCI ▪ Comprehensive patient evaluation: ▪ Complete health history ▪ Physical examination ▪ Neurologic assessments ▪ Mental status assessments ▪ Laboratory tests ▪ Behavioral manifestations due to changes in the brain ▪ Not intentional or controllable by the individual with AD ▪ Some patients develop psychotic manifestations ▪ Cognitive impairments with: ▪ Dysphasia ▪ Apraxia ▪ Visual agnosia ▪ Dysgraphia 33 AD: Assessment Early S & S – Mild Dementia ▪ Memory loss that affects job skills ▪ Difficulty performing familiar tasks ▪ Problems with language ▪ Disorientation to time and place ▪ Poor or decreased judgment ▪ Problems with abstract thinking ▪ Misplacing things ▪ Changes in mood or behavior ▪ Changes in personality ▪ Loss of initiative Middle Stage – Moderate Dementia ▪ Unable to recognize friends/family ▪ Wandering, getting lost ▪ Apraxia ▪ Delusions, hallucinations ▪ Confusion / agitation ▪ Loss of remote memory ▪ Impaired comprehension ▪ Receptive and expressive aphasia ▪ Insomnia ▪ Behavioral problems 34 AD: Assessment Late Stage – Severe Dementia ▪ Little memory, unable to process information ▪ Difficulty eating, swallowing ▪ Cannot understand words ▪ Incontinence ▪ Repetitious words or sounds ▪ Unable to perform self-care activities ▪ Immobility 35 AD: Planning / Implementation Collaborative care: ▪ No cure at this time ▪ Collaborative management: ▪ Controlling decline in cognition ▪ Controlling other undesirable manifestations Foci / goals of nursing care: ▪ Maintain functional ability for as long as possible ▪ Maintain a safe environment ▪ Minimize injuries ▪ Meet personal care needs ▪ Maintain dignity ▪ Support families 36 AD: Planning / Implementation ▪ Diagnosis of AD is traumatic for both the patient and the family ▪ The patient may respond with ▪ Depression ▪ Denial ▪ Anxiety and fear ▪ Isolation ▪ Feelings of loss ▪ Assess for depression and suicide risk! ▪ Pain management ▪ Difficulty expressing physical complaints, including pain ▪ Assess other clues, including the patient’s behavior ▪ Eating and swallowing difficulties ▪ Feeding apraxia ▪ Oral care ▪ Infection prevention ▪ Elimination problems 37 AD: Planning / Implementation ▪ Communication principles: ▪ Use a calm, reassuring, nonthreatening approach ▪ Smile ▪ Approach the patient from the front ▪ Address the patient by name ▪ Limit decision making ▪ Be patient ▪ Frequently reorient the patient (NOT in late stages!) ▪ Acknowledge patient fears ▪ Respond to tone, not content ▪ Remove stimuli for hallucinations, fears ▪ Don’t argue with delusions ▪ Don’t reinforce delusions ▪ Maintain consistent routine (esp. late stage) 38 AD: Planning / Implementation - Pharmacotherapeutics ▪ Acetylcholinesterase Inhibitors/Cholinesterase Inhibitors ▪ Galantamine(Razadyne),Donepezil(Aricept), Rivastigmine (Exelon) ▪ Are used in the treatment of mild and moderate dementia ▪ Memantine (Namenda) for middle to late stages of AD 39 AD: Planning / Implementation - Pharmacotherapeutics Management of behavioral problems: ▪ Conventional antipsychotics for acute episodes of agitation, aggressive behavior, and psychosis ▪ Atypical antipsychotics for long term treatment, have more favorable sideeffect profile ▪ SSRIs used to treat the depression often associated with AD. ▪ Antiseizure drugs can act as mood stabilizers ▪ Valproic acid (Depakene) ▪ Carbamazepine (Tegretol) ▪ Exploratory use of estrogen and ginko biloba 40 AD: Planning / Implementation for Continuity of Care ▪ Family members and friends care for the majority of individuals who suffer from AD in their homes ▪ Nurses in educational supportive role and possible case management ▪ Regular assessment, monitoring, and support are needed ▪ Teach that the progression of the disease is variable ▪ Effective management of the disease can slow the progression of the disease and ↓ the burden on the patient, caregiver, and family ▪ Adult day care options 41 AD: Planning / Implementation for Continuity of Care ▪ In early and middle stages of pt can still benefit from stimulating activities that support independence and decision making in protective environment ▪ Behavioral problems ▪ Repetitiveness, delusions, illusions, hallucinations, agitation, aggression, altered sleeping patterns, and wandering ▪ Safety ▪ Minimize risk in the home environment AD: Planning / Implementation for Continuity of Care Caring for caregiver: ▪ AD disrupts all aspects of personal and family life ▪ Caregivers spend significantly more time on caregiving tasks than counterparts caring for other patients ▪ Caregivers exhibit more adverse consequences in terms of impact on their employment, mental and physical health, family conflict, and caregiver strain Lewy Body Disease ▪ Lewy bodies (intraneural cytoplasmic inclusions) in the brainstem and cortex ▪ Combined features of AD and Parkinson’s disease: ▪ Disabling mental impairment progressing to dementia, ▪ Fluctuation in cognitive function, ▪ Visual hallucinations, and ▪ Features of Parkinson’s disease, especially rigidity. ▪ Dg based on clinical signs and symptoms and confirmed at autopsy Creutzfeldt-Jakob Disease (CJD) ▪ Rare and fatal brain disorder thought to be caused by a prion ▪ Worldwide, CJD affects one in a million individuals each year ▪ There are three types of CJD ▪ Sporadic CJD ▪ Hereditary CJD ▪ Acquired CJD ▪ A variant of CJD was first described in the mid-1980s and is also known as mad cow disease Creutzfeldt-Jakob Disease (CJD) ▪ Earliest symptoms are memory impairment and behavior changes ▪ The disease progresses rapidly with: ▪ Mental deterioration ▪ Involuntary movements ▪ Weakness in the limbs ▪ Blindness ▪ Coma ▪ There is no diagnostic test for CJD ▪ There is no treatment for CJD ▪ Emphasis is on reducing the risk of acquiring CJD via food products Frontotemporal Dementia (FTD) ▪ Pick disease a subtype of FTD ▪ A rare brain disorder characterized by disturbances in behavior, sleep, personality, and eventually memory ▪ Relentless in its progression ▪ Psychiatrists often see these patients first ▪ There is no specific treatment ▪ The diagnosis can be confirmed at autopsy Normotensive Hydrocephalus ▪ An uncommon disorder characterized by an obstruction in the flow of CSF ▪ Symptoms: ▪ Dementia ▪ Urinary incontinence ▪ Difficulty in walking ▪ Possible causes ▪ Meningitis ▪ Encephalitis ▪ Head injury ▪ If diagnosed early, treatable by surgery ▪ Shunt inserted to divert the fluid away from the brain 48 Parkinson’s Disease (PD) ▪ Disease of basal ganglia characterized by: ▪ Slowing down in the initiation and execution of movement ▪ ↑ Muscle tone ▪ Tremor at rest ▪ Impaired postural reflexes 49 PD: Etiology and Pathophysiology ▪ Diagnosis ↑ with age ▪ Peak onset being in the 6th decade ▪ Onset before 50 is likely related to genetic defect ▪ More common in men, ratio of 3:2 ▪ Symptoms may occur after ingestions or exposure some chemicals ▪ Some condition may precipitate (e.g. encephalitis lethargica, stroke) Central feature: ▪ Degeneration of dopamineproducing neurons in substantia nigra of the midbrain ▪ Disrupts dopamineacetylcholine balance in basal ganglia 50 PD: Assessment ▪ Symptoms when 60-80% of neurons in the substantia nigra lost ▪ Classic Triad of Clinical Manifestations ▪ ▪ ▪ Tremor Rigidity Bradykinesia Symptoms lead to postural instability ▪ Progression may involve only one side of the body initially ▪ Beginning stages may involve only mild tremor, slight limp, or ↓ arm swing ▪ Later stages may have shuffling, propulsive gait with arms flexed, and loss of postural reflexes ▪ 51 PD: Assessment Tremor: ▪ More prominent at rest and is aggravated by emotional stress or ↑ concentration ▪ Described as “pill rolling” ▪ May involve diaphragm, tongue, lips, and jaw ▪ Benign essential tremor, which occurs during voluntary movement, has been misdiagnosed as Parkinson’s 52 PD: Assessment Rigidity: ▪ Jerky movement when the joint is moved ▪ Cogwheel rigidity ▪ Caused by sustained muscle contraction and consequently elicits: ▪ Complaint of soreness ▪ Feeling tired and achy ▪ Pain in the head, upper body, spine, or legs ▪ Inhibits the alternating contraction and relaxation in opposing muscle groups, thus slowing movement 53 PD: Assessment Bradykinesia: ▪ Slowing down in initiation and execution of movement ▪ Evident in loss of automatic movements: ▪ Blinking, ▪ Swinging of arms while walking, ▪ Swallowing of saliva, ▪ Blank facial expression with decreased facial movements. 54 PD: Assessment Complications: ▪ Caused by progressive deterioration / loss of spontaneous movement ▪ Dysphagia can lead to malnutrition or aspiration ▪ Difficulty speaking d/t loss of tongue mobility and decreased movement of facial muscles ▪ Debilitation may lead to pneumonia, urinary tract infections, and skin breakdown ▪ Gait slows, and turning is difficult ▪ Gait usually consists of rapid, short, shuffling mini-steps ▪ Posture is with head and neck bent forward and legs flexed 55 PD: Assessment ▪ Autonomic manifestations: ▪ Universal issues for Parkinson’s disease patients ▪ ▪ ▪ ▪ ▪ Constipation Urinary incontinence Sexual dysfunction Excessive drooling Orthostatic hypotension ▪ Falls and other injuries ▪ Sleep disorders ▪ Pain ▪ Seborrhea, dandruff, excessive sweating, conjunctivitis, difficulty reading ▪ Decreased sense of smell ▪ Neuropsychiatric complications: ▪ Depression ▪ Anxiety ▪ Cognitive deterioration and dementia ▪ Side effects of drugs, particularly levodopa 56 PD: Assessment Dx: ▪ No specific tests ▪ Diagnosis based solely on history and clinical features ▪ Firm diagnosis can be made when at least 2 of 3 characteristics of classic triad (tremor, rigidity, and bradykinesia) are present ▪ DaT scan ▪ Ultimate confirmation of the disease is a positive response to antiparkinsonian drugs 57 PD: Pharmacotherapeutics ▪ Goal: correction of imbalances of neurotransmitters within the CNS ▪ Enhance or release supply of DA ▪ Antagonize or block the effects of overactive cholinergic neurons in the striatum ▪ Levodopa with carbidopa (Sinemet)still the gold standard ▪ Precursor of DA and crosses blood-brain barrier ▪ Converted to DA in the basal ganglia ▪ Carbidopa inhibits an enzyme that breaks down levodopa before it reaches the brain ▪ Stalevo-contains levodopa, carbidopa and entacapone-->helps to extend levodopa’s duration of action. 58 PD: Pharmacotherapeutics ▪ Initiation of therapy is with a dopamine receptor agonists ▪ bromocriptine (Parlodel) ,ropinirole (Reqiup), pramipexole (Mirapex) ▪ Amantadien – increases dopamine production ▪ MAO-B inhibitors-(selegiline, rasagiline) may delay need for levodopa or used together ▪ COMT inhibitors (e.g. entacapone, tolcapone) give with levodopa, may ↓ dose of levodopa and reduces “off” phases of PD ▪ Anticholinergics are also used in management to ↓ activity of acetylcholine e.g. trihexphenidyl (Artane), benztropine (Cogentin) 59 PD: Pharmacotherapeutics ▪ Antihistamines with anticholinergic or β-blockers for tremors: ▪ diphenhydramine (Benadryl) ▪ propranolol (Inderal) ▪ Antiviral agent amantadine (Symmetrel) is effective though exact mechanism is unknown ▪ As disease progresses, combination therapy is often required ▪ Excessive amounts of dopaminergic drugs can lead to paradoxic intoxication ▪ Pimavanserin approved for PD psychosis 60 PD: Other Therapeutic Modalities ▪ Surgical Therapy ▪ Procedures aimed at relieving symptoms in patients who are usually unresponsive to drug therapy ▪ Deep Brain Stimulation ▪ Involves placing an electrode in either the thalamus, globus pallidus, and subthamic nucleus ▪ Connected to a generator placed in the upper chest ▪ Device is programmed to deliver specific current to targeted brain location 61 PD: Planning / Implementation ▪ Nutritional therapy: Nursing foci / planning: ▪ Food that is easily chewed and ▪ Impaired physical mobility swallowed ▪ Adequate roughage and fluid ▪ Risk for fall / injury ▪ Speech therapy with swallowing ▪ Imbalanced nutrition: less than evaluation body requirements ▪ Upright while eating ▪ Avoid straws ▪ Impaired verbal communication ▪ Several small meals to prevent ▪ Maintain independence as long fatigue as possible ▪ Levodopa absorption decrased by protein ▪ Optimize psychosocial well-being ▪ Physical / occupational therapy 62 Questions & Answers ☺ 63