Parkinson's Nurse Navigator
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Issue: #1 May 2011
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,

Colleen Crowley

Executive Director
877-980-7500 | colleenc@nwpf.org

Medication Adherence in Parkinson's

Improved quality of life for people with Parkinson's requires adherence to a  prescribed treatment plan.  This is especially important in the care of Parkinson's disease given the complex treatment protocols, medication timing issues, cognitive challenges and motor fluctuations observed in many patients. 

In this article, nurse practitioner Cherrie Gould, MSN, NP-C shares her insights and helpful tips designed to enhance therapeutic outcomes through improved medication compliance.

Why is medication ahderence and timing so important for people with Parkinson's?

 

Parkinson's disease is a progressive neurodegenerative disease that affects 1-2 out of every 1000 people in the United States.  It is known to be a disorder that most commonly affects those over the age of 65 with 3 percent of this population being affected. The classic motor symptoms of Parkinson's disease are rigidity, tremor, bradykinesia (slowness) and postural instability (balance).  Motor symptoms are caused by a gradual loss of dopaminergic neurons in the brain resulting in significant disability.  The mainstay treatment for this disease is medication aimed at supplementing dopaminergic activity in and around the basal ganglia with the goal of improved motor control. Clinical management of Parkinson's disease is dependent on taking medications at specific times throughout the day thereby allowing dopamine supplementation to be as consistent as possible during the waking hours.  Levodopa which is the "gold standard" for Parkinson's has a short half-life of approximately 2 hours which complicates and intensifies the need for frequent dosing throughout the day. 

Motor fluctuations further complicate the medication treatment complexity.  Motor fluctuation refers to the change in motor or symptom control in response to a single medication dose. Patients initially respond well to levodopa, the mainstay of therapy, with potential improvement in all motor symptoms in early disease.  Each dose of medication effectively treats symptoms from one dose to the next allowing smooth control throughout the day.  Unfortunately as the disease progresses, response to treatment, namely levodopa, changes between one dose and the next.  The risk of developing these fluctuations increases with disease duration, disease severity, and total levodopa dose. Approximately 40% of patients with disease duration greater than 5 years experience motor fluctuations but more recent data suggests early problems such as dyskinesia can occur even after one year of therapy (Ahlskog, 2002, Fahn ,1999). Motor complications can be divided into two broad categories, motor fluctuations and dyskinesia.  

Motor fluctuations are defined as a fluctuation in response to medication dose with re-emergence of parkinsonian symptoms.   This first presents as an end of dose wearing-off of treatment effect.  Over time motor fluctuations can change from a predictable end of dose phenomenon to a more random fluctuation.   The time period of medication effectiveness and resulting control in motor symptoms is often referred to as on-time.  Conversely, off-time describes the time period in which there is a wearing off of medication effectiveness or lack of effect.  Treatment of motor fluctuations requires more frequent dosing, or use of adjuvant agents as described below.  However, medication increases can be associated with and limited by dyskinesia. 

Clinical pearl:  Early in the disease, patients do not experience a wearing off effect of medicines and often need reminders to take their next dose.  A patient that is experiencing end of dose wearing off is aware (because of symptom discomfort) that their next dose of medicine is due. They may require more frequent dosing of medicine, sometimes as frequently as every 2-3 hours. Even a brief delay (15 minutes) in dose administration by caregiver, hospital, or nursing home staff can lead to serious discomfort and morbidity.

Is adherence to medication a problem for people with Parkinson's? 

Medication adherence is poor despite the motor disability that can occur with poor medication compliance and the importance of medication timing. Tarrants (2010) analyzed medication compliance in a retrospective analysis of 29,682 patients.  Only 53.5% had compliance rates greater than 80% and 46.5% were noncompliant (compliance rate less than 80%).  The study also found that compliance was higher in patients who were on monotherapy with rasagiline (an MAO-B inhibitor, dosed once daily) than those individuals taking carbidopa/levodopa or carbidopa/levodopa/entacopone, selegiline, pramiprexole or ropinirole (all dosed more than once daily).

 

 

 

Accurate measurements of adherence depend on the measuring method used such as self report, pill count, and rating scales (Elm et al., 2007; Grosset et al., 2006).  Real time questionnaires and individual computerized monitoring device may yield more accurate data  As many as  51.3% of individuals with PD missed at least one medication dose per week and over 20% missed greater than 3 doses per week(Leopold et al., 2004).  Grosset  found that up to 19% of patients used less than 80% of their medicine when measured by an electronic monitoring system.

 

 

The clinical implications for noncompliance are significant for the clinician as medication adjustments are made on patient report of PD symptoms which can vary widely if medication schedule is not adhered to in a precise manner. 

 

 

 

 

 

 

What factors lead to poor medication compliance?

 

Poor medication adherence is associated with many factors including age, education, regiment complexity, and efficacy.  These factors are outlined below (Grosset et al., 2005; Leopold et al., 2004).   

Patient factors: 

a.        The younger the patient the poorer the compliance

b.      Gender difference in adherence are not found within symptomatic chronic disease (Dunbar, 2002)

c.       Personal philosophy regarding the use of therapeutic medications affects compliance.

d.      Productive employment increases medication compliance

Treatment factors:

a.       Compliance is affected by number of side effects caused by the drug

b.      Cost and insurance coverage can affect medication compliance

c.       Multiple dosing throughout the day negatively affect medication compliance, the more complex the schedule the more likely compliance will weaken.

What strategies can improve compliance? 

  How do meals interfere with medicine efficacy and compliance?  

  
Protein, specifically branched chain amino acids in the diet interfere with transport of levodopa across both the intestinal mucosa and the blood brain barrier thereby reducing concentrations of L-dopa in the brain (Jankovic, 2007).  This slowed and/or reduced absorption can limit medication efficacy especially in patients that are experiencing motor fluctuations and require doses at a specific time to reduce symptomatic off time.  Often patients with motor fluctuations require multiple doses daily for optimal motor control and the timing of individual doses is further complicated by mealtime. 

 

Meals, medicine timing and patient compliance- a tiered and practical approach.

a.       Non- levodopa therapies can be taken with meals to reduce nausea.  Titrate all medications slowly to decrease incidence of side effects.

b.      In patients experiencing motor fluctuations, levodopa therapy should be taken hour prior to meals or two hours after meals to avoid amino acid competition.  This may not be necessary in early disease when fluctuations are not a concern.  Care is individualized to patient needs at this stage and levodopa can be taken with food if nausea or lifestyle necessitates.

Patient management tips: The following tips can help you and your patient's success with medication.

a.       Set up medication ahead of time using pill boxes (available at most pharmacies).

b.      When possible, involve care partners in medication decisions and review of treatment strategies.

c.       Review medication at each visit for potential changes that can be made with cost, simplicity, and practical dosing strategies that fit an individual's lifestyle.

d.      Use once daily dosing (long acting dopaminergic agonist, once daily MAO B inhibitors) when appropriate.

e.      Set the medication up a week ahead of time, saving time each day.

f.        Take the day's box with you to work or when you are out.

g.       Use an alarm on a watch or a timer to tell you when it's time for your meds.

h.      If confidentiality is an issue, excuse yourself to the restroom and take your medication there.

i.        If nausea is a problem with either levodopa or dopamine agonists, keep snacks and bottled water in your car and at work.  

j.        Associate the taking of medication with daily events, like brushing your teeth.

k.       Place stickers or reminder notes on places such as a medicine cabinet or refrigerator. Some patients buy a small magnetized white board with dry-erase markers and list pills on the board, marking the board with each medication.  Each day, the board is marked after taking the medication.

l.        Use reminder systems to help remember when to take the next dose. There are medication boxes that have built-in alarm systems that can be set to sound off at the right times. Patients can use cell phones, alarm clocks and all kinds of other memory aids. 

Technology can help without being an excessive burden.  A few valuable links are http://medication-reminders.com or https://www.pillphone.com/PillLogin.htm

 

Nurses role in education

Encourage your patients to take it at the same time every day, this will reduce off time and increase "on" time.  This will also help your patient establish a routine or schedule, reducing missed doses.  Remind your patient that levodopa has a short half-life so doses equally spaced throughout the day increases effectiveness.

Provide patients with detailed information about the importance of continuous dopaminergic blood and brain levels (Ahlskog, 2002).  The absolute necessity of taking medication at proper times and in their prescribed doses cannot be overemphasized.

 

Author

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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.

 

Author: Sherrie Gould, MSN, NP-C.  Ms. Gould is a Parkinson's nurse specialist at the Scripps Clinic, Division of Neurology in La Jolla, CA.

References

Tarrants, M. Drug therapies for Parkinson's disease: A database analysis of patient compliance and persistence. The American Journal of Geriatric Pharmacotherapy, Volume 8, Issue 4 Pages 374-383 year?

Grosset KA, Reid JL, Grosset DG. Medicine-taking behavior:  Implications of suboptimal compliance in Parkinson's disease. Mov Disord. 2005;20:1397-1404.

Leopold N A, Polansky  Hurka M R. Drug adherence in Parkinson's disease. Mov Disord 2004. 19513-517

Jankovic, F., Fahn,S. Principles and Practice of Movement Disorders.  Philadelphia: Churchill Livingtstone, 2007

Ahlskog JE, Muenter M. Frequency of levo-dopa dyskinesia and motor fluctuations as estimated from the cumulative literature. Movement Disorders 2002;16:448-58.

Fahn, S Parkinson disease, the effect of levodopa, and the ELLDOPA trial. Earlier vs Later L-DOPA. Archives of Neurology. 56(5):529-35, 1999 May.
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 have become a recognized 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.