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

2. 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?

3. 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.

4. Prevalence Second most common neuro-degenerative disease
Effects 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

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

6. 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

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

8. 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!)

9. 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

10. 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

11. 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.

12. What does PD look like?

13. 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

14. 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.

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

16. DA is a Hatch of Sea Turtles

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

18. After Crossing the Blood Brain Barrier
COMT
Monoamine Oxidase

19. 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

20. 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

21. 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.

22. 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

23. Patient Centered Care Holistic Approach Physical Psychiatric
Psychosocial
Medical

24. 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

25. 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

26. 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

27. 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

28. 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

29. QUESTIONS?