Parkinsonism
Definition
Is a slowly progressing degenerative neurologic movement disorder that eventually leads to disability
The degenerative or idiopathic form is the most common.
Etiology and Incidence
Cause mostly unknown
Degeneration of the neurones in the basal ganglia (substantia nigra, globus pallidus, corpus striatum)
Men > women
Starts at about 50 years
Pathophysiology
Decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia
Neurotransmission is impaired
Neurotransmitters affected are acetylcholine (excitatory) and dopamine (inhibitory) which through copus striatum refine motor movements.
Extra pyramidal symptoms are produced.
Clinical Manifestations
Gradual onset
Chronic, prolonged course
The three cardinal signs are tremor, rigidity and bradykinesia (abmormally slow movements)
Hypokinesia
Gait disturbances (Festinating Gait)
Postural instability
Tremor
Resting tremor, which disappears during purposeful movements of the limbs (non-intentional tremors)
Tremor is rhythmic, slow turning motion like pronation and supination of forearm and the hand.
Pill rolling movements of the thumb
Rigidity
Cog wheel rigidity
Stiffness of the neck, trunk and shoulders
Pain in the shoulder and other parts
Bradykinesia
Patient takes longer to complete most activities
Freezing phenomenon
Lack of arm swinging while walking
Micrographia - shrinking slow handwriting
Mask like face - expressionless
Frequency of blinking decreased
Dyphonia : soft, slurred, low-pitched and less audible speech
Dysphagia may develop with drooling of saliva
Other manifestations
Autonomic symptoms : escessive and uncontrolled sweating, paroxysmal flushing, orthostatic hypotension, gastric and urinary retention, constipation and sexual disturbances
Psychiatric changes : dememtia, sleep disturbances and hallucinations. Depression
Cognitive, perceptual and memory deficits
Associated Complications
Respiratory and urinary tract infections
Skin breakdown
Injury from falls
Adverse effects of medications
Medical Management
Pharmacologic Therapy
Levodopa
In combination with carbidopa (Sinemet)
Budipine
Anticholinergic therapy : Trihexyphenidyl, cycrimine, procyclidine, biperiden, benztropine mesylate
Antiviral drug to reduce rigidity and tremor : Amantadine hydrochloride (Symmetrel)
Dopamine Agonists : Bromocriptine mesylate and pergolide (ergot derivatives). Dopamine agonists are added to the medication regimen when carbidopa or levodopa lose effectiveness.
Pergolide (Permax)
New dopamine agonists : ropinirole hydrochloride (Requip) and pramipexole (Mirapex)
Cabergoline
Monoamine Oxidase Inhibitors (MAO Inhibitors) : selegiline (Eldepryl)
Antidepressants: Tricyclic antidepressants
Antihistamines:
Surgical Management
For selected casesStereotactic surgery and new approaches in transplantation: Thalamotomy and pallidotomy
Neural transplanation: fetal pig neuronal cells
Deep Brain Stimulation: by pacemaker-like brain implants
Nursing Interventions
Improve mobility by specific physiotherapy
Walking : concentrate on walking erect, watch the horizon, wide-based gait, swing the arms, raise the feet while walking, heel-toe placement of the feet with long strides. walking to marching music provides sensory reinforcement.
Breathing execcises while walking
Enhance self-care activities : Bed side rails, rope tied to the foot of the bed to get up without help
Improve nutrition : monitor weight. nasogastric tube or feeding gastrostomy
Enhancing swallowing: semisolid diet. Massaging the facial and neck muscles before meals
Improve bowel elimination : relieve constipation; regular timing, medication, food with fiber content, increased fluid intake
Encourage the use of assistive devices: warming tray to keep food warm, special utensils like non spil cup
Improving communication: speech therapy
Supporting coping abilities: group participation. social and recreational events
Doing things for the patient merel to save time is contrary to the basic goal of improving coping abilities and promoting a positive self-concept
