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Parkinson's Nurse Navigator
A Newsletter for Nurses in Neurology
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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 |
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Improving the care of the hospitalized Parkinson's patient
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Case study:
A 79 y.o. woman with Parkinson's disease for 8 years was admitted to the hospital after a fall and hip fracture that required surgery. She did well post-operatively and was progressing with physical therapy. On the morning of discharge two days after surgery her nurse noted a worsening of motor function with increase in rigidity, bradykinesia, increasing trouble getting out of bed and difficulty with walking. She was also a 'little bit confused.' A neurology consultation was obtained for 'progression of Parkinson's disease and medication recommendations.'
Overview
Parkinson's disease is a chronic and progressive neurologic condition that impacts mobility, mood and thinking functions. The onset of disease is generally in the fifth or sixth decade of life. Our current medical and complementary therapies typically provide good control of symptoms during the first few years after diagnosis. As the condition worsens over time, Parkinson's symptoms can become more challenging to manage due to medication side effects, disease progression and concurrent medical problems. One of the most important points to remember about Parkinson's disease is that it is a chronic condition that slowly changes with time. An important caveat to this rule of thumb is sudden changes in PD medications, the addition of a new medication or an increase in an existing medication can lead to abrupt changes in your patient with PD.
Clinical pearl: Abrupt or acute changes in mobility, behavioral or cognitive function should be thoroughly investigated for alternative causes other than PD.
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Presenting Symptoms in Emergency Room | |
The most common presenting symptom to the emergency department will vary depending on the duration of disease, age at diagnosis and medications. The acute problems noted below can occur in any patient with PD at any time although the incidence increases with disease severity.
Mood disorders to include uncontrolled anxiety, panic attacks, depression, and suicidal ideation
Autonomic dysfunction to include orthostatic or labile blood pressure changes, dizziness and syncope
Cognitive disorders to include confusion, delirium, psychosis, fluctuating alertness, hyper somnolence
Gastrointestinal disorders to include dysphagia, bowel impaction or obstruction, cachexia
Urinary disorders to include urinary tract infection, urinary retention
Aspiration pneumonia which can occur in the absence of overt swallowing complaints
Motor dysfunction to include falls, freezing of movement, severe dyskinesia, severe tremor, rapid debility, pain from dystonia or unknown cause
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Contra-indicated Medicines and Symptoms | |
Psychosis. Confusion, delirium, and hallucinations are very common problems that result in hospitalizations or complicate hospital stays. Patients with cognitive dysfunction, dementia, those suffering systemic illness or other acute stressor will be at risk for new onset or worsening psychosis. Unfortunately, patients with PD cannot tolerate the antipsychotics used to control psychosis in the hospital setting. Antipsychotic medications block dopamine which is the underlying deficiency in Parkinson's disease. Giving a dopamine blocking agent to a patient with PD can cause severe muscle rigidity and associated rhabdomyalysis, dysphagia and complete inability to move. Quetiapine and clozapine are the two antipsychotic agents tolerated by PD patients and less likely to worsen motor symptoms. If an antipsychotic medication is needed, quetiapine is first choice as clozapine requires hematologic monitoring.
Contraindicated medicines. There are certain medicines that are contraindicated as listed below
- Antipsychotics as outlined above
- Antiemetics that block dopamine such as Compazine, meclizine and Phenergan.
- Meperidine, methadone, tramadol, St Johns Wort, cyclobenzaprine, and dextromethorphan should not be used with the MAO B inhibitors rasagiline and selegiline.
- SSRIs should be used with caution when coupled with an MAOB inhibitor. Signs of serotonin syndrome include
- CNS- agitation, restlessness, change in mental status
- Diarrhea, diaphoresis or fever
- Motor- muscle excitability as noted with twitching, tremor, hyper-reflexia, myoclonus
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Differential Diagnosis for Acute Decline in Function
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Systemic Illness. Treating acute change in motor or cognitive function requires look for cause other than PD. Systemic illness can worsen functional status in the acute setting. Abrupt decline in function should prompt a search for comorbid illness such as infection (UTI), dehydration, metabolic problems (glucose), endocrine (thyroid), nutritional deficiencies (B12 and iron), toxicities (vitamin overdose, prescription medication interactions), respiratory (aspiration pneumonia) coronary (arrhythmia, dehydration) or central nervous system (stroke) etiologies.
Medication side effects. In addition to the above list, medication side effects can be the triggering effect for a rapid change in your patient requiring hospitalization. Anticholinergic medications are a common class of medications that can cause a sudden delirium, urinary retention, blurred vision and hallucinations. Many of the symptoms associated with PD are treated with medications that have anticholinergic properties to include urinary urgency and frequency, insomnia, mood disorders and pain. Narcotics, sleep aids, anxiolytics, bladder and muscle antispasmodics are examples of medications that can cause problems with fatigue, weakness, orthostasic hypotension, confusion and hallucinations
Fluctuating Disease and Medication Timing. Once hospitalized, your patient with PD will require ongoing medication management in order to stabilize motor function while preserving cognition. Advancing Parkinson's can be associated with fluctuating symptoms. 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. Dyskinesias are uncontrolled, involuntary movement described as writhing, choreiform or irregular movements of the body.
This simply means that PD medicines must be given on time to prevent or reduce motor fluctuations. If medicine is delayed their effect can wear off leaving your patient with painful muscle rigidity, very slow movement, heightened fall risk, worsening gait shuffling or freezing of movement, imbalanced, increased tremor and muscle spasms. A delay in medication can even result in worsening dysphagia and aspiration risk until medications are resumed. The length of time your patient will respond to each dose of medication depends on disease severity, medication potency and the half-life of the drug. In addition, in advanced disease, protein can interfere with medication absorption (levodopa only) and further reduce the duration of medication effectiveness. In very advanced patients, protein can cause complete dose failure where the patient will not experience any benefit from the dose taken close to meal time.
Getting the PD medication dose just right will require monitoring by your nursing and rehabilitation staff. Basically, too little medication results in suboptimal symptom management and too much medication results in confusion, hallucinations, somnolence or excessive involuntary movement called dyskinesia. Dyskinesia is commonly mistaken for tremor which can lead to overdosing your patient since tremor may prompt the treatment team to increase the PD medication dose.
Clinical pearl: With fluctuations in mind, it is imperative that PD medications be given within 15-20 minutes of the prescribed dose time to avoid or limit the morbidity and complications associated with an under-medicated patient. Pain is a common problem when PD medications wear off.
Rehabilitation. While your patient is in the hospital, you can consult with your interdisciplinary team to enhance recovery and decrease length of stay. Initiate rehabilitation therapy before discharge to your community and potentially reduce future hospital re-admissions. Physical therapy can evaluate and treat mobility, rigidity, range of motion, flexibility, endurance, stamina and posture, and safety. Occupational therapy can evaluate and treat upper extremity strength, range of motion, flexibility, energy conservation, medication management, safety, assistance with ADL performance and adaptive strategies, vision and cognitive therapy. Speech and swallowing therapists are critical in patients with dysphagia, weight loss, drooling and communication. Some speech and language pathologists also provide cognitive therapy services.
Clinical pearl: Deconditioning can happen quickly in a fragile patient with Parkinson's. If a patient has motor fluctuations, it is important to evaluate and treat the patient in both on and off states. This may require therapeutic visits at different times of the day.
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Case Study Conclusion | |
There are many causes for decline in motor and cognitive function as noted in our patient two days after surgery. The most important thing to remember is that abrupt decline in function is not a reflection of disease progression but a change in function due to another cause. The following possibilities require exploration prior to change in PD medicines:
- Addition of new medicines that can cause confusion, hallucinations or weakness. Narcotics, sleep aids and anxiolytics are commonly used after orthopedic surgery.
- Medication error or change in timing. Delayed medication can cause wearing off and decline in motor function.
- Time of evaluation. Obtaining a history of disease and symptom fluctuations is important. It is not uncommon for staff to 'get report' about a patient doing well during one shift and then note difficult during the subsequent shift due to fatigue, change in medication timing and motor fluctuations.
- Systemic illness. Urinalysis, metabolic panel, CBC, cultures, oxygen saturation, orthostatic blood pressure recordings and cardiopulmonary evaluation can point to other caused of decline.
- Psychological stress. Fear of discharge coudl pose additional stress and affect function.
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Sierra Farris Author | |
Ms. Farris is a certified Physician Assistant anf for the past 13 years has concentrated specifically on Parkinson's disease and deep brain stimulation for the past 11 years. She has optimized DBS stimulation settings for more than 700 patients, including people with Parkinson's disease, tremor, dystonia, pain, multiple sclerosis, Tourette's syndrome and brain injury. She has authored several peer reviewed articles about DBS, care models and bioethics and continues to participate as a clinical and medical device research investigator. Ms. Farris also serves as a consultant for technical services at Medtronic.
In 2006, she was awarded both the Outstanding Physician Assistant-Physician Team Award from her professional national society and Alumni of the Year award from the State University of New York at Stony Brook. Ms. Farris earned her second B.S. degree in Physician Assistant Studies from the State University of New York at Stony Brook and a Master's in Clinical Neurology from the Nebraska University Medical Center. Her second Master's degree in Philosophy with concentration in Bioethics from Cleveland State University, completed in the 2011.
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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. | |
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