1. Specialised Nursing Care For People With Parkinson's Disease.
Northern Adelaide Local Health Network
Specialised Nursing Care For People With Parkinson's Disease.
Ruth Withey
Parkinson’s Nurse Consultant
Chronic Disease Management Unit, Lyell McEwin Hospital
Tel:

2. Introduction
Parkinson’s disease is the second most common occurring neurological condition in Australia, after dementia.
It is a chronic, progressive and fluctuating disorder

3. Introduction
The symptoms of Parkinson’s Disease (PD) usually begin slowly, develop gradually and in no particular order
No two people with PD are exactly the same in terms of nature and severity of symptoms, rate at which the condition progresses or response to treatment

4. Introduction
70,000 people are living with Parkinson’s in Australia and around 7,000 in South Australia.
The average age of diagnosis is around 62 years.
1 in 5 people are of working age.
When a person is diagnosed before the age of 50 , the disorder is called “Young-onset Parkinson’s disease”

5. What goes wrong in Parkinson’s disease
In Parkinson’s disease (PD) a small area of the brain called the substantia nigra loses many of its nerve cells
These nerve cells produce the neurotransmitter ‘dopamine’
dopamine is responsible for transmitting signals between the substantia nigra and other parts of the brain and spinal cord, that control coordination of movement.

6. Brain regions affected by Parkinson’s disease

7. Causes of Parkinson’s Disease
The causes are as yet unknown but research has led to some theories:
Multiple cases of Young-onset PD in one family - a link to LRRK -2 and parkin9 gene mutations.
The majority of PD cases are non-familial. Genetic profile may make some people more susceptible to triggers in the environment.
Trauma – head injury with loss of consciousness
Vitamin D – low levels
Drug induced – e.g. Stemetil
New evidence suggests Parkinson’s may start in the gut and spread to the brain via the vagus nerve.

8. Motor Symptoms of Parkinson's Disease
Slowness of movement (bradykinesia)
Muscular rigidity
Tremor
Postural changes leading to walking and balance difficulties.
Tremor
Occurs in about 70% of PWP.
Usually begins with one hand or arm and affects one side of the body.
Classically a resting tremor which often diminishes with voluntary movement.
Made worse by stress, anxiety and fatigue.
Slowness of movement leading to
muscle fatigue and weakness
difficulty with
initiating movements – such as rolling over in bed or rising from a chair
coordinating movements such as turning around and walking.
Muscular Rigidity
Muscles pulling against each other instead of working smoothly together, leading to
difficulty turning due to impaired spinal rotation
difficulty making fine finger movements
problems with muscular cramps and prolonged spasms (dystonia)
‘freezing’ – when initiating movement

9. Non – motor Symptoms
Non - motor symptoms are common in PD and often more troublesome and disabling than motor symptoms.
They include:
Mood disorders such as depression, anxiety and irritability
Cognitive changes such as slowing of thought, attention and planning. Language and memory difficulties, personality changes, dementia.
Hallucinations and delusions

10. Non – motor Symptoms
Sleep disorders such as insomnia, excessive daytime sleepiness, REM sleep (rapid eye movement behaviour disorder), vivid dreams, restless leg syndrome, cramp, difficulty turning in bed.
Orthostatic hypotension
Constipation
Urinary urgency, frequency and incontinence
Vision changes double vision, dry eyes, blepharospasm

11. Non – motor Symptoms Speech difficulties - soft voice
Swallowing problems, drooling or excessive saliva
Sexual difficulties can include erectile dysfunction.
Skin changes
Impulse control disorders – such as binge eating, excessive shopping or gambling, usually a side effect of medications.

12. Medication management
As there is no cure for Parkinson’s at present, drugs are the main treatment to help control the symptoms.
The main aim of drug therapy is to restore the chemical imbalance caused by the loss of the neuro-transmitter dopamine

13. Motor Fluctuations
After 4 -5 years of drug therapy, people may find that the smooth control of their symptoms that their drugs once gave them is no longer dependable
This is more related to the progression of the disease than effects of the medication

14. Motor Fluctuations
The person may experience:
Early wearing “off”
On-off’ phenomenon
Freezing of gait
Dyskinesia - involuntary movements
Dystonia- prolonged muscular contraction

15. Medications
PWPD can often progress to complicated drug regimes to help treat motor fluctuations, requiring specialist nurse support and guidance.
They need to take their medications “On time, every time” to avoid the return of distressing symptoms. This can be difficult when admitted to hospital.
They may need to progress to device assisted therapies such as Apomorphine subcutaneous infusion, Duodopa Intestinal Gel, or Deep Brain Stimulation.

16. Parkinson’s Nurse Consultant
The PNC provides nurse led clinic assessment and support at GP Plus Centres at Modbury and Elizabeth:
Allowing for screening of non-motor symptoms, identification of carer burden, risk of falls, malnutrition, dementia, etc.
The patient is referred on to relevant members of the multidisciplinary team for early intervention.
The patient is referred on to community supports as required.
Exercise is extremely important - patients are referred on to exercise groups, physiotherapy in the home and falls avoidance programs.

17. Multidisciplinary Team
Client
&
Family/carer
Speech
Therapist
Dietician
Physio
O.T
G.P
Neurologist
P.D.N.S
Psychologist & Councillors
P.D.S
Nurse
Pharmacist
Social worker

18. Changes as a result of Parkinson's Nurse role
Phone and clinic support has led to early intervention and troubleshooting of issues.
Improved adherence to medication regimes and the taking of medications on time.
Reduced emergency department presentations and hospital admissions due to:
Dizziness and falls.
Constipation
Anxiety and panic attacks
Infections UTI’s & CI’s - confusion, delirium, hallucinations and paranoia

19. Changes as a result of Parkinson's Nurse role
Early identification and treatment of depression has led to improved Parkinson’s control and quality of life.
Improved access to exercise maintaining balance, posture and strength for longer.
Extra support for people with young onset PD has enabled them to communicate with their employers and remain in employment for longer, access disability support, improve relationships with their partners and family, avoid complications of Impulse control disorders.
Consultive service for inpatients - has improved delivery of medications on time, avoidance of complications from the prescribing of contra indicated medications - reduction of inpatient days.

20. Changes as a result of Parkinson's Nurse role
The introduction of Apomorphine therapy at the LMH has been possible since the role was introduced.
Home visits have led to a better understanding of risks to safety and better access to equipment.
Attending neurology outpatient clinic has enabled greater support to newly diagnosed PWPD and early interventions.
Educational talks on PD have led to better understanding among health professionals and improved care of PWPD.

21. Parkinson’s Nurse Consultant
Referrals are accepted from other health care professionals, GP’s, Neurologists, Geriatricians, residential care facilities, hospital wards and emergency departments.

22. Parkinson’s SA Inc 23A King William Road UNLEY SA 5061
Phone: (08)
Country callers:

23. References
Non - motor symptoms of Parkinson’s disease: diagnosis and management. Saluwa FK, et al. Niger J Med Apr – Jun.
National Parkinson Foundation (Parkinson.org) Non motor symptoms.
The Economic and Quality of Life Burden Associated With Parkinson’s Disease: A Focus on Symptoms. Deborah F. Boland, DO, MSPT, and Mark Stacy, MD. September 22, 2012.