Parkinson's Nurse Navigator
A Newsletter for Nurses in Neurology
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Issue: #3 July/2010
Nurse Navigator
Greetings!

The Nurse Navigator is a quarterly e-newsletter focusing on best practices in nursing care for patients with Parkinson's and other related movement disorders. Articles will be written by nurses, mid-levels and specialists with a wide range of experience and expertise.

Since many patients rely on nursing care as their primary contact and information source we thought it would be helpful to provide information, tools and insights from fellow practitioners.

If you know of other colleagues that would benefit from this newsletter, please do forward it along.

Thanks for reading.

Sincerely,
005
Bill Bell
Editor
877-980-7500 | bbell@nwpf.org

Parkinson's - More than just a movement disorder 

Non-motor symptoms often under-recognized and under-treated yet are a major contributor to poor quality of life in Parkinson's disease.

 
Parkinson's disease (PD) is a movement disorder characterized by tremor, rigidity, bradykinesia and postural instability. Focus on these easily identified motor signs often overshadows the many non-motor symptoms that coexist in this disorder. Under recognition of non-motor symptoms by clinicians may reflect the tendency to focus primarily on the more apparent motor features of PD and/or lack of awareness of the non-motor symptoms. Up to 60% of patients suffer from more than one non-motor symptom and 25% have four or more non-motor symptoms.
 
The many non-motor symptoms of PD can be divided into pain, sensory, autonomic, cognitive-behavioral, and sleep phenomenon. A better understanding of these problems allows nurses to play a more pivotal role in patient education regarding the role of non-motor symptoms.
Pain in Parkinson's 

Unique causes of pain in PD are often overlooked or attributed to aging and a few simple questions can help diagnose these problems.
 

"My patient complains of pain in his leg and foot in the morning. Can this be related to Parkinson's disease or is it simply arthritis and early morning stiffness?"

 
Nurses often are the primary clinicians assessing pain in patients and in many cases nurses serve as patient advocates insuring that distress from pain is minimized. You can help diagnose these unique pain syndromes or conditions that have specific treatments that can relieve distress.
 
Pain in PD is usually described as a dull, diffuse, poorly localized aching pain in the muscle belly in contrast to pain localized to the joint pain as is noted with joint disease such as arthritis. Motor symptoms can cause pain and worsen joint pain especially when muscle rigidity impacts the normal range of motion or joint body mechanics. Specific pain syndromes do exist that are more common in PD, namely restless leg syndrome and dystonia both of which can cause pain in the limbs.

Dystonia, defined as a sustained involuntary contraction of muscle that typically leads to muscular pulling, bending, or twisting across a joint. Dystonia often occurs as an end of dose or 'off state' syndrome (described in Nurse Navigator Spring Edition). Pain can be a primary feature of dystonia so it is described here even though it is considered a motor symptom.  Dystonia can be associated with motor 'off' states suggesting that these symptoms may respond to dopaminergic therapy.
 
A good history can often determine if pain is dystonic in nature. For instance - is pain worse in the morning or at end of dose? Is pain associated with certain dystonic patterns such as toe curling, foot inversion and plantar flexion, head pulling or arm flexion?. Smoothing out motor fluctuations with dopaminergic therapy can help off related pain. Intramuscular botulinum toxin injection is also effective although muscle weakness is a potential side effect of this therapy.

Clinical pearl: Dystonia is often aggravated by activity so aggressive massage or physical therapy can sometimes temporarily worsen dystonic pain.

Restless Leg Syndrome 

Restless leg syndrome (RLS) is defined as an uncomfortable feeling (dysasthesia) and sometimes painful sensation in the legs or elsewhere during periods of rest (especially at night) that improves with movement.

 
It may be more common in PD than the general population and can even precede the diagnosis. This problem can lead to significant distress, agitation and trouble with sleep onset. Iron supplementation with ferrous sulfate can be helpful if iron deficiency (ferritin < 50 g/L or iron saturation < 16%) is present but is ineffective in its absence. Levodopa and the dopaminergic agonists ropinirole and pramipexole are effective PD treatments that also treat RLS. In addition, opioids, clonazepam and gabapentin may be helpful.
 

Clinical pearl: Patients with RLS will complain of trouble falling asleep rather than staying asleep. This simple question can help you diagnose this common problem.

Dizziness 

'Dizziness', a complaint that can have different meanings to different people.
 

"My patient complains of dizziness when standing. Is it the Parkinson's, balance, ear problems, medication or other problem?"

 
The word 'dizziness' can be used by people with PD to describe many feelings or symptoms. Understanding the most common causes of dizziness will help you tailor patient education and develop a treatment plan focused on safety.
 
Dizziness upon standing can be from multiple causes. In PD, dizziness can be used to describe imbalance or postural instability and further questioning and testing for balance can identify this problem. Elderly patients are at greater risk for benign positional vertigo, however, these symptoms should also occur while turning in bed and not strictly with orthostatic change in position. Dizziness upon standing is often associated with orthostatic hypotension, an autonomic nervous system dysfunction seen in PD.
 
As a group, autonomic problems increase with age, disease severity, medication use, presence of postural instability, cognitive decline and visual hallucinations. Almost half of patients with PD have orthostatic hypotension. Of concern, individuals with postural instability are at greater risk for experiencing orthostatic hypotension thereby further increasing the risk of injury due to falls. Post-prandial hypotension can also be a problem.
 

Clinical pearl: Home blood pressure monitoring is especially helpful given that measures obtained in the office may not reflect the underlying problem given significant fluctuation in blood pressures. It is not uncommon for a patient to have labile or wide swings in blood pressure. Monitoring blood pressure in sitting and standing position as well as during times of symptoms (dizziness, fatigue, imbalance) can contribute helpful diagnostic information.

 
It is important to remember that orthostatic hypotension can be both a complication of medications and a primary manifestation of the disease. Although all dopaminergic medicines can worsen orthostatic hypotension, the motor benefits of dopaminergic agonists and amantadine should be reviewed in relation to this risk for these patients.
 
Treatment should include fluids, a high salt diet, elastic stockings, fludrocortisone, training in biomechanics and/or the selective a1 agonist, midodrine. Midodrine can be associated with supine hypertension and must be used cautiously in patients with advanced disease that take daytime naps due to fatigue. If post-prandial hypotension is a problem, altering the patient's diet to include smaller but more frequent meals may be helpful. Education about this problem, physical therapy, and occupational therapy can reduce patient's fall risk and keep your patient safe.
Bowel and Bladder

Bowel and bladder problems are common and often distressing complaints in Parkinson's.

"Does Parkinson's affect bowel and bladder control?"

 
Problems with bowel and bladder control are common especially in older patients and the problem is even greater in PD. Bladder control problems can lead to falls when urinary urgency is combined with imbalance. Constipation can be severe enough to lead to hospitalization.
 
Significant constipation can be present in over half of patients. One study reported an increased risk of developing PD in men with infrequent bowel movements. Constipation and defecatory dysfunction can be severe enough to result in colonic dilatation and pseudo-obstruction. Causes include slow colonic transit, weak abdominal strain, decrease phasic contraction and paradoxical increase in puborectalis muscle and anal sphincter activity with straining consistent with pelvic muscle dystonia.
 
Although gastrointestinal symptoms occur in all stages of PD, it is clear that more advanced patients are at greatest risk given advanced disease, reduced activity, altered diet and increase in medicines that may delay gastric and colon transit.
 
Treatment includes reducing 'off' periods, limiting anticholinergic agents, attending to a proper bowel regimen, encouraging fluids and exercise. In addition daily stool softeners, fiber, and polyethylene glycol are effective. Botulinum toxin injection into the puborectalis muscle may improve outlet obstruction.
 

Clinical pearl: Increasing dietary fiber to over 20g and fluids are the first step in treating constipation. Many people with PD take smaller sips, have swallowing problems and therefore do not drink enough fluids. Fluids may also prevent dizziness form orthostatic hypotension.

Nocturnal polyuria, urinary hesitancy and urgency are embarrassing but treatable problems. Urinary incontinence is a significant cause of nursing home placement and falls. Urological abnormalities can be divided into dysfunction of the bladder, urethral sphincter dysfunction or other causes of outflow obstruction, i.e. prostate enlargement in men. The most common complaint by people with Parkinson' is nocturia followed by frequency and urgency.

Treatment of urinary incontinence should begin with assessment for urinary tract infection, stress incontinence in women and prostate enlargement in men. Urinary urgency due to detrusor hyper-reflexia or spastic bladder can improve with anticholinergic antispasmodic agents. However, these should be used with caution in patients that are experiencing hallucinations or cognitive problems.
 

Clinical pearl: Patients with bladder control problems often limit their fluid intake increasing risk of constipation, orthostatic hypotension, dehydration and confusion. One treatment option is to encourage fluids but reduce drinking after dinner or 6pm to reduce the need to urinate at night.

Author

005

Dr. Monique Giroux is the medical director of the Northwest Parkinson's Foundation. She specializes in movement disorders with a focus on rehabilitation and wellness for Parkinson's patients.

References

Abott, R., et al., Frequency of bowel movements and the future risk of Parkinson's disease. 2001.
Kaye, J., et al., Excess burden of constipation in Parkinson's disease: a pilot study. Movement Disorders, 2006. 21(8): p. 1270-1273.
Oka, H., et al., Characteristics of orthostatic hypotension in Parkinson's disease. Brain, 2007. 130: p. 2425-32.
Ondo, W., W. Vuong, and J. Jankovic, Exploring the relationship between Parkinson's disease and restless leg syndrome. Archives of Neurology, 2002. 59: p. 421-424.
Pandya M, Kubu C, Giroux ML.  The many faces of Parkinson's disease:  not just a movement disorder.  Cleveland Clinic Journal 2008:75; 856-865
Shulman, L., et al., Non-recognition of depression and other non-motor symptoms in Parkinson's disease. Movement Disorders, 2002. 8: p. 193-197.
Shulman, L., et al., Comorbidity of the nonmotor symptoms of Parkinson's disease. Movement Disorders, 2001. 16: p. 507-510.
Winge, K., et al., Prevalence of bladder dysfunction in Parkinson's disease. Neurology & Urodynamics, 2006. 25(2): p. 116-122.
NWPF logo

The Northwest Parkinson's Foundation (NWPF) plays a vital role in helping people with Parkinson's live meaningfully with the disease. A large part of our mission is education, both for the medical professional and for patients, caregivers and families. At both levels we have the opportunity to improve the day-to-day for those touched by this debilitating disease set. With the addition of Dr. Monique Giroux as Medical Director, we are positioned to become a leader in professional education as well as patient education.

 

The NWPF currently serves 25,000 people throughout the Northwest and beyond. Our primary constituency resides in the Northwest (Washington, Oregon, Idaho, Montana and Alaska), home of 70,000+ Parkinson's patients.

This program is generously supported by educational grants from Teva Neuroscience.