PARKINSONS DISEASE- is a disorder of the nervous system that affects muscle control.

Named after British physician James Parkinson, who first described it in 1817. He called the disorder paralysis agitans, Latin words that mean shaky palsy. Epidemiology Parkinsons disease occurs in people all over the world. The incidence in men slightly higher than in women. Caucasians (white race) have a higher incidence of the disease than people of other races. People most commonly develop Parkinson disease around the age of 60, and the incidence rises with age. At least 10 % of cases occur in people under age 40, and a rare form of the disease affects teenagers. Cause Most people with Parkinsons disease are described as having idiopathic Parkinsons disease (having no specific cause). Less common causes of Parkinsons disease include: a. genetics o Suspected gene codes (when mutated) that may be responsible for the development of the disease: - Alpha-synnuclein - Parkin - Ubiquitin. Researchers still do not understand the function of alpha-synnuclein, but parkin and ubiquitin may play a role in cleaning up abnormal deposits of proteins in the cell. When the genes that produce these proteins are mutated, parkin and ubiquitin are unable to prevent protein deposits from building up. The accumulation of these deposits may play a role in nigral cell degeneration. o Doctors found that if one twin (among identical twins) developed the disease before age 50, the chance was higher that the other twin would develop the disease. Identical twins have the same genetic makeup. This study suggests that the identical twins both have a gene that places them at risk for the disease. b. environmental factors o Presence of an environmental toxin (poisonous chemical) released as a byproduct from machines and other technology. o Garden pesticides and insecticides o Certain people may develop parkinsonism if they are exposed to other agents, including carbon monoxide, cyanide, manganese, certain tranquilizers, and some rare viruses, or if they suffer head injuries or strokes. These parkinsonism diseases may be initially mistaken for Parkinson disease. o May be related to increasingly longer life spans that enable people to reach an age when the physical effects of Parkinson disease become more apparent. o The chemical MPTP, a byproduct created in the synthesis of certain illicit drugs, is linked to the development of a disease in some drug abusers that closely resembles Parkinson disease. c. free radicals - cause cell damage, injuring the lining of cell membranes, destroying mitochondria (the cells energy-producing organelles), and triggering cell death. o Dopamine-producing cells are particularly vulnerable to free-radical destruction. o Antioxidants- molecular scavengers that defend cells from free-radical destruction. Further research may identify antioxidants that may be useful in blunting the actions of free radicals

Pathophysiology Parkinson disease develops as a part of the brain known as the substantia nigra degenerates: midbrain subtantia nigra nigral cells dopamine striatum activates nerve cells normal muscle activity In people with Parkinson disease, nigral cells deteriorate and die at an accelerated rate, and the loss of these cells reduces the supply of dopamine to the striatum. Without adequate dopamine, nerve cells of the striatum activate improperly, impairing a persons ability to control movement. People with Parkinsons disease have a decreased number of nerve fibers in the heart. These results suggest that the disease affects nerves in organs outside the brain and may explain symptoms common in people with Parkinson disease, such as a drop in blood pressure when a person stands up, constipation, and difficulty urinating. Stages of Parkinsons Disease: I. Unilateral involvement only, usually with minimal or no functional impairment. II. Bilateral or midline involvement, without impairment of balance. III. First sign if impaired righting reflexes, evidenced as unsteadiness as the client turns or demonstrated when the client is pushed from standing equilibrium with the feet together and eyes closed. Functionally, the client is somewhat restricted in activities but may have some employment potential, depending on the type of employment. Clients are physically capable of leading independent lives, and their disability is mild to moderate. IV. Fully developed, severely disabling disease; the client is still able to walk and stand unassisted but is markedly incapacitated. V. Client is confined to bed or wheelchair unless aided. Symptoms

Clinical Manifestations of Parkinsons disease A. Manifestations Related to Motor Dysfunction Nonintention tremor- maximal when the limb is at rest and decreased with purposeful, voluntary movement. Bradykinesia or akinesia- slowed movements; inability to initiate voluntary movements Slowed speech, low amplitude Poor articulation o Hypophonia- soft speech. Speech quality tends to be soft, hoarse, and monotonous. o Festinating speech- excessively rapid, soft, poorly intelligible speech. Decreased eye movements (i.e., blinking) Masklike, expressionless face Rigidity- stiffness; increased muscle tone. In combination with a resting tremor, this produces a ratchety, cogwheel rigidity when the limb is passively moved. Posture and gait disturbances Trunk tilted forward Festination- a combination of stooped posture, imbalance and short steps. It leads to a gait that gets progressively faster and faster often ending in a fall. Shuffling gait- characterized by short steps, with feet barely leaving the ground, producing an audible shuffling noise. Small obstacles tend to trip the client. Gait freezing- characterized by inability to move the feet, especially in tight, clustered spaces or when initiating gait. Retropulsion- walking backwards Turning en bloc- rather than the usual twisting of the neck and trunk and pivoting on the toes, the client keeps his neck and trunk rigid, requiring multiple small steps to accomplish a turn. Dystonia- abnormal, sustained, painful twisting muscle contractions, usually affecting the foot and ankle. This causes toe flexion and foot inversion, interfering with gait. Foot dystonia can be a presenting symptom of Parkinsons disease, especially in younger patients. Other Motor Dysfunction Drooling- most likely caused by a weak, infrequent swallow and stooped posture Dysphagia- impaired ability to swallow. Can lead to aspiration, pneumonia, and death. Fatigue (up to 50% of cases) Micrographia- small cramped handwriting Complications: falls, fractures, impaired communication, malnutrition, social isolation

B. Manifestations Related to Autonomic System Dysfunction Skin problems Seborrhea- an abnormal discharge from the sebaceous glands, forming an oily coating on the skin. Excess sweating on face and neck, absence of sweating of trunk and extremities Mottled skin Heat intolerance Orthostatic hypotension- failure of the autonomic nervous system to adjust blood pressure in response to changes in body position Urinary incontinence, typically in later disease progression Constipation Complications: skin breakdown, dizziness, falls, constipation C. Manifestations Related to Cognitive and Psychologic Dysfunction Dementia Memory loss Lack of insight and problem-solving ability Declining intellectual abilities Anxiety Apathy or abulia: abulia translates from Greek as the absence or negative of will; apathy is an absence of feeling or desire Depression Complications: loss of ability to function, social isolation D. Sleep Disturbances Excessive daytime somnolence Initial, intermediate, and terminal insomnia. Muscle rigidity may compromise sleep because the client has lost the ability to change position. This lack of muscle movement causes the client to awaken and consciously shift position. E. Sensation Disturbances Impaired visual contrast sensitivity, spatial reasoning, color discrimination, convergence insufficiency (characterized by double vision) and oculomotor control Anosmia- loss of sense of smell Pain: neuropathic, muscle joints and tendons, attributable to tension, dystonia, rigidity, joint stiffness, and injuries associated with attempts at accommodation.

Treatment
Drugs Used to Treat Parkinson Disease At present there is no cure for the disease, but a variety of medications, known as antiparkinson drugs, provide dramatic relief from symptoms. Antiparkinson drugs restore the chemical dopamine in the brain or imitate dopamines actions. Drug Type Levodopa Dopamine agonist Anticholinergic Function Generic Name ( Trade Name )

Enhances conversion of levodopa to dopamine in Levodopa (Laradopa); levodopa/carbidopa (Sinemet, the brain. Sinemet CR,Atamet); levodopa/benserazide (Madopar) Mimics the action of dopamine by activating nerve Bromocriptine (Ergoset, Parlodel); pergolide (Permax); cells in the brain. pramipexole (Mirapex); ropinirole (Requip) Blocks action of acetylcholine, a brain chemical Trihexiphenidyl (Artane, Trihexy); biperidine (Akineton); that becomes overactive when dopamine levels benztropine (Congentin) drop. Blocks action of an enzyme that breaks down dopamine in the brain. Blocks action of an enzyme that breaks down levodopa in the body, permitting more levodopa to reach the brain. Selegiline (Eldepryl, Movergan) Tolcapone (Tasmar); entacapone (Comtan)

MAO-B inhibitor COMT inhibitor

Amantadine

Stimulates release of dopamine from Amantadine (Symadine, Symmetrel) nerve cells in the brain and may block acetylcholine action.

Deep brain stimulation- the most used surgical means. In this procedure, the patients head is immobilized in a halo-like device called a stereotaxic frame. Using an MRI, the surgeon locates the thalamus, the globus pallidum, or a related region called the subthalamic nucleus in the brain. After drilling a small hole in the skull, the surgeon inserts a probe deep in the brain to the target tissue. A short burst of electricity sent through the probe normalizes the electrical activity in the brain region, reversing the symptoms of Parkinsons disease. This surgery is relatively safe, and symptom relief is immediate. But as with any surgery, risks are involved, including the chance that a stroke may develop. Caregiver Management Clients with Parkinsons disease have complex and, ultimately, multisystem needs. Deficits in mobility and self-care are common. As the disorder progresses, nutritional and airway-related problems are common. The following are caregiver interventions according to impaired physical mobility, impaired verbal communication, altered nutrition: less than body requirements, and sleep pattern disturbance. Impaired Physical Mobility Clients with Parkinsons disease have impaired mobility for several reasons, including tremors, gait pattern disturbances, and alterations in body positioning, such as forward bending of the trunk. Poor self-esteem may contribute to clients lack of motivation and willingness to be mobile. Perform ROM exercises at least twice a day, emphasizing the trunk, neck, arms, hips, and legs. Maintaining joint mobility promotes better function and strength, improving gait pattern. Contractures can be prevented with consistent ROM exercises. Consult with a physical therapist to develop an individualized exercise program. A program specific to the client supplies motivation as well as helping the client maintain muscle tone, flexibility, and mobility. Ambulate at least four times a day. Exercise fosters independence and self-esteem. Incorporate assistive devices, such as canes, splints, or braces, as indicated. Adaptive equipment improves balance, protects joints, and promotes proper anatomic positioning. The following interventions are recommended when safety is a concern: Slightly elevate the back legs of chairs and raise the toilet seat to help the client rise to a standing position from a sitting position. Wear shoes with Velcro closures.

 Remove potential hazards, such as unanchored throw rugs, from the home environment. Install handrails and nonskid surfaces to bathing area. Ensure adequate lighting throughout the home, and in outside areas, especially in areas where transfers are common. Check garage, carports, and sidewalks. Safety measures prevent potential complications that may result from falls or other accidents and promote self-esteem through self-care. Parkinsons disease is a disorder common in older people, who are at greater risk for falls resulting from orthostatic hypotension, osteoporosis, poor vision, and other problems causing disorientation and confusion, such as Alzheimers disease. Impaired Verbal Communication Diminished vocal amplitude and loss of muscular control can impair the clients ability to speak. Both caregivers and family members need to remember that clients require sufficient time for selfexpression; an unhurried approach is recommended. Seek input from family members when determining alternative methods of communicating with the client. Assess the clients current communication abilities speech, hearing, and writing. Assessment forms the basis for planning appropriate care. Communication involves both sending and receiving messages. Develop methods of communication appropriate to clients coordination abilities, such as writeon, wipe-off slate; flash cards with common phrases; pointing to objects. Individualizing a method of communication decreases anxiety and isolation. Consult with a speech pathologist to develop oral exercises and interventions that will facilitate speaking. The Parkinsons disease process affects the muscles of speech and swallowing. Remind the client to speak more loudly, if possible. A low, monotonous voice is characteristic of the client with Parkinsons disease; verbal cues remind clients to alter behavior. Altered Nutrition: Less Than Body Requirements Tremors, altered gait, and impaired chewing and swallowing can cause nutritional problems in the client with Parkinsons disease. As the disorder progresses, interventions for ensuring optimal nutrition need to be adapted to the clients functional abilities. Assess the clients swallow reflex prior to initiating any feeding program. During the initial stages of the disorder, some clients may have a diagnosis of Altered Nutrition: More Than Body Requirements if kcal intake exceeds energy expenditure. Assess the clients nutritional status and self-feeding abilities; consult with occupational therapist or speech therapist, if needed. An initial assessment of abilities ensures that interventions are individualized to the clients current functional abilities. Provide foods of proper consistency as determined by the clients swallowing function. The client can aspirate food that is too liquid. Weigh the client weekly. Early recognition of weigh loss allows for intervention. Teach eating methods to decrease tremors, such as holding a piece of bread in the hand that is not holding an eating utensil. Nonintention tremor may be reduced through purposeful activity. Monitor diet for foods high in bulk and fluids. Several anti-Parkinsons medications can cause constipation. Sleep Pattern Disturbance Rigidity and weakness can cause clients with Parkinsons disease to lose the ability to move and change positions during sleep. The resulting discomfort causes periods of wakefulness. Modify life-style activities that affect sleep: Institute a routine of activities with limited rest periods during the day; avoid napping close to bedtime. Avoid strenuous exercise in the evening. Daytime sleeping may contribute to decreased nighttime sleeping. Vigorous exercise just before bedtime may act as a stimulant.

 Incorporate diet modifications, such as limiting caffeine and alcohol intake. Caffeine is a stimulant, and alcohol may cause early-morning awakenings, increased daytime sleepiness, and nightmares. Avoid nicotine products in the evening. Nicotine is a stimulant that may delay falling asleep and cause nighttime awakenings. Drink a glass of milk before bedtime. Milk contains L-tryptophan, which produces sedative effects by shortening the time taken to fall asleep (sleep latency). Assess and modify the environment to aid in sleep; for example, darken the room, and decrease noises. Reducing environmental stimuli decreases sleep disturbances. Definition of Terms Articulation- the way of speaking; way of pronouncing words and syllables Bilateral- having to do with two or both sides Flexion- bending of a joint in the body by the contraction of a muscle Gait- way or manner of moving on foot Insomnia- the persistent inability to fall asleep or to remain asleep long enough to become rested Midline- a line marking the middle of a body Neuropathic- caused by nervous disease Oculomotor- having to do with the moving of the eyeball in the socket Palsy- paralysis; lessening or loss of power to feel, to move, or to control motion in some part of the body Ratchety- jerky Somnolence- sleepiness; drowsiness Stroke- an attack of paralysis caused by injury to the brain when a blood vessel breaks or becomes obstructed Thalamus- a part of the brain involved in the transmission of sensory messages Unilateral- affecting one side only Subthalamus/ hypothalamus- a part of the brain that lies above the pituitary gland and regulates many body functions. It is involved with the control of body temperature, sexual function, weight, fluid balance and blood pressure.