A Primer for Clinicians and Administrators Parkinson’s Disease A Primer for Clinicians and Administrators

Objectives Define Parkinson’s Disease (PD) Describe the disease’s prevalence and etiology Explain the symptoms of PD Discuss the drug and non-drug management of the disease Illustrate pertinent patient care issues for Assisted Living Facilities Take home for clinicians: Understand PD patients so that you can better care for their particular needs. Take home for administrators: Understand this growing segment of the patient population and also the challenges facing your staff. Questions for the audience: Does anyone here have PD or know anyone personally who does? How many people here are clinicians? Administrators? Has anyone (clinicians) worked with PD patients?

What is Parkinson’s Disease? Parkinson’s Disease is a progressive, incurable neurodegenerative disease characterized by significant motor and non-motor dysfunction which results from the loss of dopamine secreting neurons in the substantia nigra pars compacta.

Prevalence Second most common neuro-degenerative disease Effects 1-1.5 million people in the US Effects 1% of those over 60 and 4% of those over 80 Lifetime risk is 1 in 40 Number of people effected in the US expected to double by 2030

Who is the Average PD Patient? White Male Non-smoker Well educated Over 65 years old

Etiology Idiopathic Risk Factors Protective Factors >60% loss of dopamine producing neurons (critical threshold is 100,000 neurons) in the substantia nigra. Lewy body concentration in the substantia nigra Risk Factors Head trauma, well water, living in urban areas, living in rural areas, farming, exposure to industrial solvents, depression, excess body weight, genetics. Protective Factors Smoking Caffeine and coffee Possibly ibuprofen

Symptoms Motor Symptoms Cardinal Manifestations Tremor Bradykinesia (slow movement) Rigidity Non-Motor Symptoms Psychiatric Nervous system (autonomic dysfunction)

Motor Symptoms Cardinal Symptoms Tremor - “pill rolling” Worse at rest and lessened with purposeful movement Bradykinesia - slow movement Major cause of disability Includes flat affect, slowed blinking and impaired swallowing Rigidity – Resistance to passive movement around a joint “Cogwheel” or “Lead Pipe” Leads to postural instability (FALLS!)

Non-Motor Symptoms Psychiatric Non Psychiatric Cognitive dysfunction and Dementia Psychosis (hallucinations and delusions) Depression Anxiety Non Psychiatric Fatigue Loss of smell Sleep disturbance Autonomic dysfunction (sexual dysfunction, orthostasis (FALLS!), constipation, etc) Pain

PD Dementia (PDD) Primary problem is with executive function Visuospatial disturbances Less memory loss (effects retrieval of learned memory) No aphasia, or apraxia Looks very similar to Lewy Body Dementia Effects 78% of PD patients

Pathophysiology Dopamine (DA) producing neurons in the substantia nigra pars compacta (SNpc) begin to die. This leads to abnormal movement patterns by decreasing cortical input.

What does PD look like? https://www.youtube.com/attribution_link?a=xEGfphnS5Pw&u=/watch%3Fv%3D3-wrNhyVTNE%26feature%3Dem-share_video_user

Treatment Pharmacologic Surgical Non-pharmacologic Mainstay of therapy Deep brain stimulation Used for cases of treatment resistant or advanced PD Non-pharmacologic Exercise Diet Support network

Dopamine DA is a neurotransmitter and what nt’s do is that they are released from a neuron when that neuron is stimulated and they basically tell the next neuron in the chain what to do. It relays the message by binding to receptors that are specific to it. Once the nt has been released from the first neuron and has done it’s duty it is degraded by enzymes so that it doesn’t hang out too long and keep sending the same message over and over again. In PD we lose the neurons that contain DA so when we try to start a movement and we get to the part of the neural chain that these neurons usually fill, they aren’t there and we get a very weak signal going forward and that’s why we see tremors and bradykinesia and rigidity.

Medications What can drugs do? Replace DA Stimulate DA receptors Prevent the metabolism of DA Prevent the relative overactivity of acetylcholine

DA is a Hatch of Sea Turtles

Before Reaching the Blood Brain Barrier Dopa Decarboxylase (AADC) COMT

After Crossing the Blood Brain Barrier COMT Monoamine Oxidase

Drugs Used to Treat PD Dopamine replacement Levodopa (LDOPA) Dopamine agonists Ropinerole Pramipexole Rotigitine Anticholinergics Trihexylphenidate Bentropine Drugs to reduce metabolism of dopamine AADC inhibitor Carbidopa COMT inhibitor Entacapone MAO inhibitor Rasagiline Selegiline

Medication Issues Complicated dosing regimens May take meds up to every 3-4 hours even through the night Very heavy pill burden Nursing intensive Timing is CRITICAL Expensive LDOPA dosing and product assignment is confusing “ON/OFF” time

Medication Side Effects LDOPA Too much causes dyskinesia (disturbing extra movement) Can cause hallucination/delusion Nausea/Vomiting Dopamine agonists Hallucinations Impulsive behavior (sexual, gambling) Anticholinergics Confusion Delirium Worsens constipation, urinary symptoms, etc.

Non-Pharmacologic Therapy Diet Protein can decrease absorption of LDOPA Not usually a problem but can be considerable issue in advanced disease Better to take meds on empty stomach unless cause nausea Some patients have disphagia and require soft/pureed food Exercise / Physical Therapy Effective for maintaining quality of life Tai Chi most effective form of exercise (yoga/dance) Important to provide physical activity options and support

Patient Centered Care Holistic Approach Physical Psychiatric Psychosocial Medical

Issues in Assisted Living: Physical Facilities need to have adequate movement assist devices in place. E.g handrails, ramps, lifts, low beds, walking devices Physical therapy and exercise directed specifically for PD patients. E.g. tai chi, water based exercise, weight training Adequate staffing to assist patients with ADL’s

Issues in Assisted Living: Psychiatric PD patients should be regularly screened for signs of dementia, depression, anxiety, and psychosis If detected, referral to the patients medical team is essential Ensure that medication regimen is adhered to strictly Provide on sight counseling Educate staff on the proper procedure for handling demented and floridly psychotic patients

Issues in Assisted Living: Psychosocial PD patients benefit greatly from extended support networks Facilities should encourage and facilitate regular support group meetings Allow and encourage family support as much as possible Provide activities that will accommodate the movement difficulties of PD patients

Issues in Assisted Living: Medical Nursing and care staff is essential to the medical management of PD patients Medication regimens MUST be followed precisely and consistently Provide transportation to and from medical appointments Be prepared to care for patients following surgical intervention

Take Home Points PD is progressive and uncurable It involves both motor and non-motor symptoms The management of PD centers around medication therapy The drug regimens required to treat the disease are both complicated and cumbersome Assisted living facilities will see increased PD populations as time goes on and must be prepared to care for them PD patients are generally very knowledgeable and compliant patients who flourish if properly cared for

QUESTIONS?