Parkinson’s Disease: Pathophysiology For Nurses

Most of us rely on our physical abilities and cannot imagine life without them. Going for a walk, eating a bowl of cereal, drinking a cup of coffee, dressing ourselves etc. are all abilities that we take for granted. Perhaps one of the most heart rendering, difficult situations I can think of is for someone to have those abilities slowly taken away without any hope of them returning. This is what those suffering from Parkinson’s disease face. Parkinson’s disease was first documented in 1817 by a British apothecary named James Parkinson. He published an essay in which he referred to the disease as the Shaking Palsy. In 1865 William Sanders coined the term 'Parkinson's disease' which was later popularized by French neurologist Jean-Martin Charcot (Goetz, 2011). Parkinson's disease is a long-term degenerative disorder of the central nervous system that mostly affects the bodies motor system. The terms 'parkinsonism' and 'parkinsonian syndrome' are used to describe it’s most recognized symptoms. These symptoms include shaking, rigidity, bradykinesia (slow movement), and difficulty walking. And as the disease progresses dementia, depression, and behavioral problems can develop.

Parkinson’s disease is the progressive loss of cells in the substantia nigra part of the brain. This is where Dopamine is produced. Dopamine is a chemical that transmits messages between the areas of the brain that are responsible for activity. For example, it connects the substantia nigra and the corpus striatum to regulate muscle activity. If there is not enough dopamine in the striatum the nerve cells in this area do not work properly. They “fire” out of control. This leads to an inability to direct or control movements. This deficiency is what causes the first noticeable symptoms of Parkinson’s disease. As the disease progresses, other areas of the brain and nervous system breakdown causing significant deficiencies in movement (Mandel, n.d.). Although this is a devastating and debilitating illness, a diagnosis of Parkinson’s disease does not mean you can’t have quality of life. There are therapies that can delay motor symptoms and include medications, physical therapy, occupational therapy, speech therapy, and alternative therapies.

While the exact cause of Parkinson’s in unknown it is thought to involve both genetic and environmental factors. If someone in your family has suffered from the disease you are more likely to have it yourself. There is also an increased risk in people exposed to certain pesticides and herbicides used in farming, toxins released by industrial plants and air pollution and among those who have had head injuries, while there is a reduced risk in tobacco smokers and those who drink coffee or tea (Goetz, 2011). In 2009, the US Department of Veterans Affairs added Parkinson’s to a list of diseases possibly associated with exposure to the Agent Orange.

By 2020 almost one million people in the U.S. will be living with Parkinson's disease, which is more than the combined number of people diagnosed with multiple sclerosis, muscular dystrophy and Lou Gehrig's disease. Approximately 60,000 Americans are diagnosed with Parkinson’s Disease each year (Marras et al., 2018). Perhaps the most well-known individual suffering from this debilitating disease is Michael J. Fox. Michael J. Fox is a 57-year-old Canadian-American actor, comedian, author, and film producer. In 1991 at 29 years-old he was diagnosed with Parkinson’s Disease. Seven years later he decided to share his condition with the public in the hopes of raising awareness, understanding, and improve research efforts. He started The Michael J. Fox Foundation, which focuses on research, including embryonic stem cell research aimed at finding a cure. Fox manages the symptoms of his Parkinson's disease with the drug carbidopa/levodopa and he also had a thalamotomy, a surgical procedure in which an opening is made into the thalamus to improve the overall brain function, in 1998 (Biography of Michael J. Fox).

Parkinson's disease primary treatment goal is to balance out the neurotransmitter’s acetylcholine and dopamine. This is mainly done with medication, but some patients can also choose to have one of three surgical procedures performed. A Thalamotomy, which Michael J. Fox had, a Pallidotomy, or a Deep Brain Stimulator implanted. The most common and effective drug used in the treatment of Parkinson’s is Carbidopa-levodopa. Levodopa is a natural chemical that enters the brain where it is converted to dopamine. Carbidopa protects levodopa from early conversion to dopamine outside your brain. Other medications used are dopamine agonists which don’t change into dopamine but instead mimic dopamine effects in your brain. Examples of this type of drug are Pramipexole (Mirapex) and Ropinirole (Requip). MAO B inhibitors which help prevent the breakdown of dopamine. Some examples are Seleginile (Eldepryl, Zelapar), Rasagiline (Azilect) and safinamide (Xadago). Anticholinergics which help control the tremor associated with Parkinson's disease. And finally, Amantadine which provides short-term relief of symptoms of mild, early-stage Parkinson's disease. It may also be given with carbidopa-levodopa therapy during the later stages of Parkinson's disease to control involuntary movements (dyskinesia) (Approved Medications).

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With deep brain stimulation surgeons place electrodes into a specific part of your brain. The electrodes are connected to a generator in your chest near your collarbone that sends electrical pulses to your brain and may reduce your Parkinson's symptoms. It is the most important therapeutic advancement since the development of levodopa. It is most effective for people who experience disabling tremors and medication-induced dyskinesias. Studies show that benefits from this surgery can last at least five years (Deep Brain Stimulation). Pallidotomy surgery destroys the globus pallidus part of the brain in improve general quality of life. This treatment can help to lessen rigid muscles and ease tremors, improve balance, and improve movement. Pallidotomy can also make medicine work better for people with advanced Parkinson's.

In addition to the above-mentioned treatments there are also alternative remedies such as exercise, massage, meditation, Tai chi, and yoga. These alternative therapies and help reduce stress, alleviate pain, improve flexibility and muscle strength, and balance. According to the Michael J. Fox Foundation there had been a lot of evidence to support the theory that symptoms of Parkinson’s worsen during times of stress. These therapies can help with alleviating anxiety and improve quality of life.

Treatment plans for those with Parkinson’s is especially important. Plans should focus of improving movement and independence. Patients need to be motivated willing to participate in exercises. Having goals in mind is key for both the patient and their health care providers. For patients with Parkinson’s disease short term goals should encourage physical mobility and ADL’s. It is important to keep in mind that each patient is different and therefor goals need to be tailored for their specific needs. Examples of goals might be patient will improve walking ability/endurance walking on a treadmill for thirty minutes, two or three times a week for one month or patient’s movement and flexibility will improve from participating in yoga exercises for thirty to forty-five minutes three times a week for one month. Salgado, Williams, Kotian, and Salgado (2013), suggest that strength exercises, balance and gait training therapy increase the patient’s quality of life, mobility, walking speed, and activities of daily living. All activities can be done at a gym or at home depending of what the patient is more comfortable with. As with any goal safety should always be considered. As opposed to short term goals, long term goals focus on the minimizing the disease symptoms and delaying progression, to maintain quality of life, independence, and mobility. Some examples of long-term goals could be patient will improve strength by ambulating at least 200 feet, three times a day for six months or patient will improve balance and remain free of falls for six months.

As with any goals there needs to be interventions in place for patients to be successful. The primary focus when carrying out these goals is patient safety. Depending on how severe the patient’s symptoms are walking aides such as canes and walkers and bulky utensils should be used. Medication side effects should also be considered. Some side effect of Parkinson’s medications includes dizziness, drowsiness, and muscle contractions. Referrals for occupational and physical therapy would be helpful. Occupational therapy would be able to help with dressing, bathing, and other self-care that the patient may be having difficulties with. Physical Therapy would be able to help with walking, stretching, range of motion, and strength. In some cases, speech therapy can be help if the patient is struggling with swallowing. The goal is to keep the patient from developing complications and minimize symptoms for as long as possible.

Evaluation of each goal needs to be done in order to see how successful they are and what, if anything, needs to be changed. These evaluations should be completed by the nurse, physical therapist, occupational therapist to determine if the goals have been met. If a goal has been met a new one should be set and if they have not, they need to be reevaluated and changed. Why the patient has been unable to meet the goal needs to be addressed so better, more attainable goals can be set. Goals must be evaluated on a regular basis to ensure that the patient is working towards/maintaining their highest level of independence.

References

1. Approved Medications | American Parkinson Disease Assoc. (n.d.). Retrieved March 4, 2019, from https://www.apdaparkinson.org/what-is-parkinsons/treatment-medication/medication/
2. Deep Brain Stimulation (DBS) (n.d.). Retrieved April 4, 2019, from
3. https://www.parkinson.org/Understanding-Parkinsons/Treatment/Surgical-Treatment-Options/Deep-Brain-Stimulation
4. Goetz, C. G. (2011). The History of Parkinson’s Disease: Early Clinical Descriptions and Neurological Therapies. Cold Spring Harbor Perspectives in Medicine:, 1(1), a008862. http://doi.org/10.1101/cshperspect.a008862
5. Mandel, A., MD. (n.d.). Parkinson’s Disease Pathophysiology. Retrieved April 4, 2019, from
6. https://www.news-medical.net/health/Parkinsons-Disease-Pathophysiology.aspx
7. Marras, C., Beck, J. C., Bower, J. H., Roberts, E., Ritz, B., Ross, G. W., Abbott, R. D., Savica, R., Van Den Eeden, S. K., Willis, A. W., Tanner, CM, on behalf of the Parkinson’s Foundation P4 Group (2018). Prevalence of Parkinson’s disease across North America. Npj Parkinson's Disease, 4(1), 1–7.
8. Salgado, S., Williams, N., Kotian, R., & Salgado, M. (2013). An Evidence-Based Exercise Regimen for Patients with Mild to Moderate Parkinson’s Disease. Brain Sciences, 3(1), 87–100. http://doi.org/10.3390/brainsci3010087
9. Surgery for Parkinson’s Disease. (n.d.). Retrieved April 4, 2019, from https://www.webmd.com/parkinsons-disease/guide/parkinsons-surgical-treatments
10. The Biography of Michael J. Fox: On a Quest to Cure Parkinson's Disease. (n.d.). Retrieved March 04, 2019, from https://www.michaeljfox.org/foundation/michael-story.html