Neurodegenerative Diseases: Multiple Sclerosis, Parkinson's, and Alzheimer's Disease PDF

Multiple Sclerosis Parkinson’s Disease Alzheimer’s Disease Week 4 Learning Objectives 1. Using case studies, apply knowledge of assessment/diagnostic findings and collaborative management/interventions and examine the lived- experience of clients experiencing neurodegenerat...

Multiple Sclerosis Parkinson’s Disease Alzheimer’s Disease Week 4 Learning Objectives 1. Using case studies, apply knowledge of assessment/diagnostic findings and collaborative management/interventions and examine the lived- experience of clients experiencing neurodegenerative disorders in hospital and in the 2. Using the nursing process, apply evidence-informed knowledge and life span considerations to collaboratively develop a client-centered care plan) 3. Create a teaching plan based on client learning needs 4. Use scenarios to: practice communication to develop a therapeutic relationship prioritize and perform nursing interventions engage in client teaching 5. Use a systematic approach (head-to-toe and/or SBAR) to communicate 2 Resources Lewis (2023) PP PP 1523- 1541- 1533; 1556 3 Multiple Sclerosis Characterized Chronic, by progressive, disseminated degenerative demyelination autoimmune of nerve fibres disorder of the of the brain, central spinal cord, nervous and the optic system (CNS) nerves The disease usually affects Average onset those between is 30 to 35 20 and 50 years of age. years of age. 4  Etiology and Pathophysiology Related to environmental The cause is exposure, such unknown. as an infection Autoimmune in Multiple genes nature confer Demyelination susceptibility to continues with multiple progressive loss of sclerosis. nerve function 5 Manifestations Rapid, Motor, sensory, progressive Remissions and Clinically cerebellar, and deterioration in exacerbations isolated emotional some in others syndrome conditions individuals Primary- Secondary- Progression- Relapsing- progressive progressive relapsing remitting 6  FIG. 61.4 Common effects of multiple sclerosis on bodily systems. 7  Motor Spasticity of muscles Scanning speech Diplopia Weakness or paralysis of limbs, trunk, and head 8 Sensory Numbness and tingling Patchy blindness (scotoma) Blurred vision Vertigo and tinnitus ↓ Hearing 9 Cerebellar Dysphagia Dysarthria Ataxia Nystagm us 10 Emotional Anger Depressi on Euphoria 11 Diagnostics How do you think a patient feels when undergoing a diagnosis workup? Based primarily on history, clinical manifestations, and presence of multiple lesions over time measured by MRI Certain laboratory tests are used as adjuncts to clinical examination. Lumbar Punctiure Cerebrospinal fluid (CSF) analysis ↑ In oligoclonal immunoglobulin G (IgG) Presence of oligoclonal banding Evoked responses are often delayed because of ↓ nerve conduction from the eye and ear to the brain To be diagnosed with MS patient must have At least two inflammatory demyelinating lesions in at least two different locations Damage or an attack occurring at different times All other possible diagnosis ruled out 12  Subjective data Important health information Symptoms Viral infections or vaccinations Weight loss, dysphagia Residence in cold or temperate Urinary frequency, urgency, climates dribbling or incontinence, Physical and emotional stress retention; constipation Pregnancy Muscle weakness or fatigue, Medications tingling or numbness, ataxia, malaise Blurred or lost vision, diplopia, vertigo, tinnitus Decreased libido, sexual and erectile dysfunction Anger, depression, euphoria, isolation 13 Objective Apathy, Scanning inattentivene Tremor Nystagmus Ataxia speech ss Hyper- Muscular Spasticity ↓ Hearing Paresis reflexia weakness Foot Paralysis Dysarthria dragging 14 15 Plan Maximize Maximize neuromuscular function Maintain independence in activities of daily living for as long as Maintain possible Manage Manage fatigue Optimize Optimize psychosocial well-being Adjust Adjust to the illness Reduce Reduce factors that precipitate exacerbations 16 Management: Medications Main Others Corticosteroids Antispasmodics Immunosuppressants CNS stimulants Immunomodulators Anticholinergics Acetylcholinesterase inhibitors Tricyclic antidepressants antiseizure 17  Interventions Help Reassure Assist Prevent Focus Teach Teach Teach Help patient Reassure Assist patient During acute Focus teaching Teach patient Teach self- Teach identify patient during in dealing with exacerbation, on building Good balance of catheterization adequate triggers and the diagnostic anxiety caused prevent major general exercise and rest if necessary. intake of fibre develop ways phase. by diagnosis. complications resistance to Minimize caffeine to aid in to avoid them of immobility. illness. intake regular bowel Nutritious well- or minimize Avoiding fatigue, habits. balanced meals their effects. extremes of hot and cold, exposure to infection 18 Zena's Story | Caring for someone with MS (2:42) Patient and Family Perspective 19 Parkinson's Pathophysiology and Etiology Pathological process of PD involves degeneration of dopamine (DA)-producing neurons in substantia nigra of the midbrain. Disrupts dopamine–acetylcholine balance in basal ganglia Disease of basal ganglia characterized by Slowing down in the initiation and execution of movement ↑ Muscle tone Tremor at rest Impaired gait changes Exact cause unknown Not considered a hereditary condition but not sure if genetics plays a role or not Exposure to well water, pesticides, herbicides, industrial chemicals, and wood pulp mills may increase risk. Exposure to carbon monoxide and manganese Medication-induced Can also be seen after use of illicit drugs, including amphetamines and methamphetamines 21 Manifestations Onset is gradual and insidious. Classic triad of PD, “TRAP” Tremor Rigidity Akinesia Postural instability Beginning stages may involve only a mild tremor, slight limp, or ↓ arm swing. Later stages may have a shuffling, propulsive gait with arms flexed, and loss of postural 22 reflexes. Tremor So minimal initially that only the patient may notice it More prominent at rest and is aggravated by emotional stress or ↑ concentration Described as “pill rolling” because the thumb and forefinger appear to move in rotary fashion Rigidity Increased resistance to passive motion when limbs are moved through range of Manifestati motion (ROM) Rigidity is typified by a jerky quality (cogwheel rigidity) when the joint is moved. Occasional catches in passive movement of a join Caused by sustained muscle contraction and consequently elicits the following: Muscle soreness Feeling tired and achy on: Motor Pain in the head, upper body, spine, or legs Inhibits alternating contraction and relaxation in opposite muscle groups, thus (TRAP) Akinesia slowing movement Bradykinesia is the slowing down in initiation and execution of movement. Evident in loss of autonomic movements Blinking Swinging of arms while walking Swallowing of saliva Self-expression with facial movement Minor movements of postural adjustment Postural instability Propulsion or retropulsion 23 Diagnostics Diagnosis is based solely on history No specific tests and clinical features. Clinical diagnosis requires the presence of TRAP. 24 Manifestations: Non Motor Urinary retention Constipation Erectile dysfunction Memory changes Sleep conditions 25  Complications As disease Orthostatic progresses, Dementia Dysphagia General hypotension complications often occurs may debilitation may occur. increase may lead to pneumonia, result in Motor urinary tract Could result in malnutrition symptoms infections falls and and (UTIs), and injuries Dyskinesias aspiration. Weakness skin Akinesia breakdown. Neurological conditions Neuropsychiat ric conditions 26 If there are no diagnostics How is the disease confirmed? The ultimate confirmation of PD is a positive response to antiparkinsonian medications. 27 Aimed at correcting imbalances of neurotransmitters within the CNS Antiparkinsonian medications Manageme Enhance or release supply of DA Antagonize or block the effects of overactive cholinergic neurons in the striatum nt: Levodopa with carbidopa (Sinemet) is often the first Medication medication used. s Effectiveness of Sinemet could wear off after a few years of therapy. Other Antiviral agent (amantadine) Anticholinergics are also used in management. ↓ Activity of acetylcholine Antihistamines with anticholinergic or β-adrenergic blockers are used to manage tremors MAO-B inhibitors, selegiline, and rasagiline may be combined with Sinemet. Entacapone blocks the enzyme that breaks down levodopa in the peripheral 28 circulation.  Genome therapy Experimental therapy Procedures aimed at relieving symptoms Surgical therapy Used in patients who are usually unresponsive to medication therapy or have developed severe motor complications Managem ent: Other Has been used to treat PD for over 50 years Ablation surgery Has been recently replaced by deep brain stimulation (DBS) Involves placing an electrode in the thalamus, globus pallidus, or subthalamic nucleus Deep brain Connected to a generator placed in the stimulation (DBS) upper chest The device is programmed to deliver specific current to a targeted brain location Transplantation of fetal neural tissue into the Earlier research was largely abandoned after basal ganglia provides mixed results but recent improvements in dopamine-producing transplant techniques have renewed interest 29 cells in the brains of in this as a potential option. 30 Assessment Describe your health assessment foci Health Subjective Objective History 31  Health History History Medications Changes CNS trauma Tranquilizers (haloperidol Excessive salivation Cerebrovascular disorders [Haldol] and Dysphagia Exposure to metals and phenothiazines) Weight loss carbon monoxide Methyldopa Difficulty initiating Encephalitis Amphetamines movements, falls, loss of dexterity Constipation Incontinence Diffuse pain in head, shoulders, neck, back, legs, and hips Depression Mood swings Hallucinations 32  Blank faces, Ankle Seborrhea Dandruff infrequent edema blinking Postural Tremor at “Pill hypotensio n Drooling rest rolling” Objectiv Poor e Subtle Cogwheel coordinatio Dysarthria dementia rigidity n Bradykines Contractur Stooped Shuffling ia es posture gait 33 Plan Experience Experience improved/ stable symptoms Maximize Maximize neurological function Maintain independence in activities of daily living (ADLs) for as Maintain long as possible Optimize Optimize psychosocial well-being 34 Goal Safety Promote Decrease risks falls independence behaviour escalations malnutrition 35 Promote physical exercise and a well-balanced diet. Limit the consequences from decreased mobility. Specific exercises to strengthen muscles involved with speaking and swallowing Teach maintenance of good health, independence, and avoidance of complications. Problems secondary to bradykinesia can be alleviated by Consciously thinking about stepping over an imaginary object on the floor Rocking from side to side before stepping forward Walking to a beat, such as music Interventi Trying to swing both arms from front to back Lifting toes when stepping Going one step back and... two steps forward ons Simplify clothing by wearing clothing without buttons and hooks. Use elevated toilet seats. Nutritional therapy Malnutrition and constipation can be serious consequences. Patients with dysphagia and bradykinesia need appetizing food that is easily chewed and swallowed. Several small meals should be taken to prevent fatigue. Levodopa can be impaired by protein and B 6 ingestion Assist patients as they make adjustments to their lifestyle to accommodate symptoms. Caregivers may also experience stress associated with disease progression (e.g., 36 Evaluation Describe evaluative factors of success Fully met Partially met Unmet 37 Seniors' Care at NYGH: Parkinson's disease (4:16) what are the strategies that can be employed to support the patient? 38 Alzheimer’s Disease Sherpath 40 Dementia Broad term for slow progressive cognitive decline Many types Dement ia 1. 2. Alzheimer's Vascular 3. dementia others Alzheimer’s Disease It is Chronic, progressive, degenerative disease of the brain Most common form of dementia Familial AD Pathophysiology and Etiology Changes in brain structure and function Amyloid plaques Neurofibrillary tangles Loss of connections between cells and cell death 42 Dementia: Clinical Manifestations Pathological changes precede by 3–20 years. clinical The 8 A’s of dementia manifestations Categorized Mild (early) similarly to those Moderate (middle) for dementia Severe (late) 43  8 A’s Altered Anosognos Attentional Amnesia Aphasia Apraxia Agnosia Apathy perception ia deficits 44 Dementia Old age and Part of later Not a normal family stages of part of aging history are diseases risk factors 45 Dementia: Behavioural Changes How do We Assess? Occur in 50 to 60% of patients Often not persistent Not intentional but a way of communicating May communicate emotion Behavioural and psychological symptoms of dementia (BPSDs) may worsen in acute care settings. Use gentle-persuasive approaches (more information got to Gentle Perusasions Apporach Informtion Link) Assess patient’s Physical status Environment Reassure patient about their safety. 46 Strategies Communicate Effectively Stay near the patient, use touch as Adapt to patient’s rhythm Focus on care appropriate Other strategies Redirection Distraction Reassurance Some patients can experience sundowning. Behavioural disturbance Behaviour should be assessed for the underlying cause sundowning Engage patient in Create a quiet, calm Maximize exposure Uninterrupted Sleep hygiene activities during the 47 environment. to daylight. nighttime sleep day.  Safety Special attention to home Identify Risks environment to decrease risk Injury from falls Home safety checklist Wandering Supervision is needed Injury to others and self The nurse can help the Fire or burns caregiver in assessing Impaired judgement and the home environment decision making for safety risks. Vulnerability to elder Wandering is major abuse concern. Patients with dementia can register with Safely 48 Pain management How to Recognise Pain? Pain should be recognized and treated promptly. Pain management is complex. Monitor patient’s response. Rely on other behavioural cues of pain and signs of distress. 49 GPA Approaches in Dementia Care (2:44) 50 Mild Dementia – Early What are strategies Nurses can Use? Difficulty Short-term Loss of Mild recognizing memory initiative and forgetfulness what numbers impairment interests mean Confusion Difficulty Poor about location finding the Anxiety judgement of familiar right word places 51 Middle Dementia – Intermediate What are strategies Nurses can Use? Anxiety, mood swings, jealousy, irritability Difficulty completing tasks, learning new things, recognizing family members, language, logic Flat affect Hallucinations, delusions Impaired attention Increasing memory loss Loss of impulse control, interest in hygiene and remote memory Poor insight Sleep disturbances, wandering 52  As You Watch these Videos 1 2 3 4 Describe the Reflect on Reflect on Do you have manifestatio what went what went experiences ns you see well wrong to share 53 Bathe |UCLA Alzheimer's and Dementia Care (4:28) 54 Caregiver Training: Agitation and Anxiety | UCLA Alzheimer's and Dementia Care Program(5:45) 55 Disturbances | UCLA Alzheimer's and Dementia Care Program (5:04) 56 Late Dementia – Severe What are strategies Nurses can Use? Progression to Repetitious Aggressive loss of facial words or behaviours expression sounds Loss of Difficulty appetite, most eating, Seizures memories, swallowing social skills Hallucinations Sexual , delusions, Incontinence disinhibition agitation Inability to Inability for understand self-care words 57 Eating and Swallowing Difficulties Nutritional deficits Loss of interest in food Decreased ability to self-feed Comorbid conditions When chewing and swallowing become difficult, use Puréed food Thickening liquids Nutritional supplements Other Strategies Quiet and unhurried environment Easy-grip utensils Offer liquids frequently. Finger foods may enable self-feeding. Short-term possibilities Alternate routes of nutrition other than oral. 58  Interventions : Acute Diagnosis is traumatic for patient and family Patients with dementia may be hospitalized for other health conditions. Patient and or Family often responds with Depression Denial Anxiety and fear Isolation Grieving The nurse should assess for depression and suicidal ideation. Provide support and referral as required. The nurse should also assess family members and their ability to cope and to accept the diagnosis. Ongoing monitoring is important. Work in collaboration with the patient’s caregiver. Teach the caregiver how to manage care. 59 Being a millennial caregiver for a parent with Alzheimer’s (4:48) 60  Care Giver Support Dementia disrupts Caregivers also Legal matters and all aspects of Caregiver strain is exhibit negative Work with family personal care personal and common effects on planning family life. Very stressful work, Sexual relations Assess stressors. family roles, Identify coping mental and strategies. physical health Find a support group. Local Alzheimer Society chapter 61  Interventions: Ambulatory and Home Care Family members and Various facilities Medications must be should be evaluated. In early stages, taken regularly. friends care for most Consider stage of dementia memory aids (e.g., Medication adherence can Advance care persons with when choosing a facility. calendar) may be challenging. planning dementia in their Nursing care intensifies over provide benefit. homes. time. Adult day care can Medications must be Adult day care can provide In early stages, taken regularly. provide Caregiver respite memory aids (e.g., Medication adherence can Advance care Caregiver respite Stimulation for AD patient calendar) may be challenging. planning Stimulation for AD patient provide benefit. 62 Interventions: Health promotion Strategies to prevent dementia Early recognition Exercise Oral Care Infection prevention Skin care Elimination 63  Oral Care In late stages, The patient may Inspect the the patient will Dental pocket food, mouth regularly be unable to conditions are adding to and provide perform oral likely to occur. potential tooth mouth care. self-care. decay. 64 Infection Prevention – What are the Risk factors for this Population? Common Urinary tract Manifestatio infection ns need Pneumonia Ultimate prompt cause of evaluation death in and many treatment. patients with dementia 65 Skin Care Treat rashes, In late stages, Change areas of patients are at Keep skin dry patient’s redness and risk for skin and clean. position skin breakdown. regularly. breakdown. Incontinence, immobility, and undernutrition 66 Elimination Urinary and fecal incontinence during middle to late stages Constipation Regular may relate to toileting or immobility, behavioural dietary retraining intake, may decrease decrease in episodes. fluids. 67 Goals and Evaluation Remains in Functions at Verbalizes reality of restricted area highest level of health situation during ambulation cognitive ability and activity Performs self-care, Uses effective bathing, dressing, coping strategies and toileting with to manage grief assistance as related to diagnosis needed of dementia Uses assistive Experiences no devices injury appropriately for ambulation support 68 Summary Progressive chronic diseases Focus on stability and reducing exacerbations or progression Family care giver support and education Interprofessional approach Nursing Interventions paramount 69 Reminder Week 5 Test # 1 (25%) Content: Weeks 1-4 Duration: I.5 hours 60 Marks – MC & SATA 15 Marks - Short Answer/Alternative Format Questions Total Marks: 75 70