Early Nursing Intervention in Parkinson's Disease CE
Parkinson's disease (PD), is a multisystem neurodegenerative process that results in both motor and nonmotor symptoms. Quality of life (QOL) is significantly impaired for both the patient and the family. Therapy should focus on early detection and alleviation of motor/nonmotor symptoms and improvement of QOL for the patient and his or her entire support system. Patients, families, and healthcare providers often do not recognize the nonmotor symptoms as being related to PD.[1-6]

Although there is no consensus about when to start therapy, early treatment is thought to maintain QOL more effectively than delayed treatment. Considerations for early treatment include the effect of PD symptoms on lifestyle and employment, the patient's role within the family system, attitudes about medication, and patients' perceptions of QOL.[1,6-9]

Clear Communication About Motor Symptoms

Treatment starts with a comprehensive and accurate assessment. The motor assessment is the most obvious. Asking about tremor, rigidity or stiffness, balance, and slowness of movement is imperative; however, using language the patient and family will understand is paramount to effective ongoing communication. For example, patients may better relate to terms such as "shake" instead of "tremor," and "falling backward" or "feeling lightheaded or dizzy" when they stand up or stand too long rather than "losing your balance." The practitioner might also ask whether the patient's feet "get stuck" when first trying to walk or when going around a corner or through a doorway or if they feel stiff and achy or have pain with movement. Instead of asking whether the medicine wears off, try asking whether the medication "holds them" from dose to dose; does it seem like the tremor gets worse or is it more difficult to move as it gets closer to the next dose of medication. Asking the patient whether his or her legs and arms feel "wiggly" or whether sitting still is difficult during the hour or so after medication dosing will help to assess for dyskinesias.

These are questions that are easily understandable to the patient and caregivers. Not only do these questions assess motor symptoms but they also provide insight into the impact on daily function and, ultimately, QOL. If motor difficulties seem to be present, in addition to referring for medical treatment, instruct the patient and family to consider shoes with smooth gliding soles and to avoid shoe bottoms that are tacky and stick to the floor. The patient should also avoid loose fitting shoes such as sandals and slippers. Make sure the patient and family learn to allow extra time for activities.[10] Using diversion techniques such as pretending to step over a step, using a laser to spot a point on the floor, or counting can override usual neuronal pathways and achieve smoother movement.

Educating the patient and family about accepted medical terms like bradykinesia, rigidity, freezing, dyskinesia, and wearing-off is also important to enable them to relate their symptoms to their disease process and interventions, and improve communication with the healthcare team. In fact, lack of education about the disease process, symptoms, and treatment is often cited as an unmet need of the patient and the family.[3,11]

Medication Considerations

Education also should include information about medications. This involves discussing realistic expectations, side effects, dosing regimen (which can become very complicated), and mechanisms of actions.

The timing of medications to maximize function and minimize dysfunction is important. When assessing patients, ask what medications they take and to the best of their ability the exact timing of medication. Often, simply adjusting the timing of medication can help eliminate troubling symptoms. Morning off time can be a major obstacle and may be minimized by adjusting the first dose of the day to when the patient first wakes up (as opposed to waiting until after morning care and breakfast). Protein binding can interfere with the therapeutic effect of levodopa. If levodopa is being used, taking medication 30 minutes before meals or 60 minutes after meals or with a low-protein meal can help reduce motor fluctuations and maximize medication effect.

Exercise

In addition to medication, regular aerobic exercise, range of motion, strength, balance, and fitness should be encouraged, particularly low-impact activities such as walking, gardening, yoga, PilatesTM, and swimming. An exercise regimen should be incorporated into the patient's day soon after diagnosis and should continue throughout the disease process.[4,10] Not only will the patient receive the general health benefits of these programs but exercise also helps to reduce stiffness, prevent falls, and maximize mobility and endurance.

Research has demonstrated that intensive sports activities in early to middle stages of PD improve mood and motor function and sleep quality.[4,12] Timing of PD medication in relationship to exercise may help patients achieve maximum benefit from the program. Community recreational centers that focus on senior exercise programs can also help promote socialization and give the family and caregivers a respite.

Olfactory Dysfunction

Olfactory dysfunction is highly prevalent in PD. As one of the earliest signs of PD, loss of smell often predates motor symptoms by years.[1,3,6,13] Educating the patient and family that this is a common finding in PD can be reassuring and help to support the diagnosis of PD.[1,14] Although no intervention can improve this dysfunction, it can affect a patient's nutrition and appetite and needs to be addressed.[4,6]

Discuss nutrition with the patient and appropriate family members and caregivers. Find out what he or she enjoys eating and try to find strategies to make food more appealing, flavorful, and calorie-rich. Consider referring the patient to a nutritionist. Speech therapy can also be considered if swallowing is impaired, but this is less frequent in patients with early disease.

Sleep Disorders

Sleep disorders can have significant impact on patients' and caregivers' QOL and well-being.[3,4,11] Asking questions about daytime sleepiness and restless, agitated, or violent movements during sleep can expose underlying sleep disorders. Asking about mood and affect may reveal underlying issues of depression that can interfere with sleep quality. Formal sleep studies are usually needed to accurately diagnose and treat these problems. Reviewing sleep hygiene; caffeine, alcohol, and fluid consumption; and timing of medications can provide clues to factors that may interrupt sleep patterns.

Limiting stimulating drugs (including caffeine) to morning and early afternoon, minimizing daytime naps, and restricting fluids to prevent nocturia can improve nighttime sleep consistency. If the patient is having difficulty turning over in bed, giving the last dose of PD medication at bedtime may help; sometimes using satin sheets can facilitate smooth turning. Melatonin in doses of 3-12 mg has been shown to be beneficial for sleep. Afternoon physical activity and exercise may also improve sleep quality.[4,6,12,15,16]

Mood and Cognitive Symptoms

Psychiatric symptoms, especially related to depression and anxiety, are present early in PD[3-6,12,14,17] and are major contributors to poor QOL.[1,3,4,6,12,13,17] Early and frequent assessment of mood is essential.[4] Patients don't often admit to being depressed. Ask questions such as: Are you still doing things you like to do or are you no longer interested? Do you feel sad and blue? Do you feel like crying sometimes? Are you grumpy? These kinds of questions can be more revealing than asking if a patient is depressed.[6] The views of the family and caregivers can also be helpful. The Geriatric Depression Scale short form, Beck Depression Inventory, and the Beck Anxiety Inventory are quick and easy tools to help assess mood problems reliably and validly.[12,15] Formal neuropsychiatric evaluation may be necessary.[1,3,4] Encourage patients to keep a journal of their mood in relationship to on/off states. If moods worsen with these states, adjusting existing therapy may help, such as manipulating medication or adding a dopaminergic medication.

Cognitive impairment in the form of executive functioning difficulties is frequently seen in patients with early PD and needs to be assessed, as this can interfere with professional and personal daily activities.[1,3-5] If severe, this can cause disability. Treating associated factors such as anxiety, depression, sleep disorders, and fatigue; streamlining polypharmacy; and neurocognitive rehabilitation therapy may improve this domain.[3-6,17]

The nurse should also evaluate safety issues such as the patient's ability to manage his or her own medications, to drive, and to live independently. Substance abuse should also be evaluated as it can compound the issues of anxiety, depression, and cognitive impairment.[4,15]

Autonomic Dysfunction

Constipation is a common autonomic dysfunction of PD seen early in the disease.[3,14] It can be caused by the PD itself but secondarily can be the result of decreased movement, diet, fluid restriction, other comorbid diseases, and polypharmacy.[10] Exercise and increasing fiber, fruits, vegetables, and fluid intake can reduce constipation. The dietary herbal extract Dia-Kenchu-To and symbiotic yogurts have been beneficial in managing constipation in PD. If possible, discontinuing anticholinergic medications can be helpful. Stool softeners, laxatives, and enemas should be added only when necessary.[4,10,15,18]

Bladder dysfunction can be neurogenic in nature, but issues of mobility, enlarged prostate in men, or prolapsed uterus in women can be contributory. Constipation can put additional pressure on the bladder and magnify the problem. Behavioral interventions such as a toileting schedule; reducing bladder irritants such as alcohol, spicy foods, caffeine, and aspartame; and improving contributing factors such as constipation can minimize bladder issues without medication intervention. Biofeedback also can be of benefit and is often offered through rehabilitation services such as physical therapy. Fluid restriction in the evening hours can also minimize nocturia and thus improve sleep habits.

Orthostatic hypotension (OH) can be related to decreased fluid and salt intake, a direct effect of PD, medication side effects, comorbid disease processes, and polypharmacy. OH can lead to safety issues and frequent falls. Maintaining a systolic blood pressure above 90 mm Hg is the goal. If appropriate, increasing salt and hydration can help. Salt can be increased with salt tablets 3-4 times/day or drinking a soda every day. Increasing the level of the head of the patient's bed by 4-6 inches, a leg-holding exercise before getting up from a supine position,[19] compression stockings, abdominal splinting, and eating small frequent meals also can combat OH. Teaching the patient to avoid prolonged standing, limit exposure to heat, and eliminate alcohol can be useful. Evaluating the patient's medications and eliminating or reducing non-PD medication may be necessary. Sometimes patients need to be placed on medication such as fludrocortisone or midodrine to normalize blood pressure. Monitoring for supine hypertension is also important.[4,5,15]

Other Symptoms

Pain is often an unrecognized symptom of PD; pain is frequently caused by rigidity and dystonia and responds favorably to dopaminergic therapy. Exercise programs to promote range of motion, flexibility, and movement can help reduce pain associated with PD.[3,4,6]

Erectile dysfunction, loss of libido, and anorgasmia are thought to be a primary effect of PD and not related to medication. Contributing factors include depression, role changes by patient and caregiver, and perceptions of lost physical attractiveness. Because of embarrassment by both the patient and the healthcare provider, this issue is usually not discussed.[3,4] Simple questions such as, "How is your intimate relationship with your spouse (or significant other)?" can open the door comfortably for everyone. Urologic referral should be made to rule out other pathology. If the primary cause is found to be neurogenic in nature, sildenafil and similar products are often effective. Sexual counseling should also be considered, especially if secondary contributing factors are found.[16,20]

Conclusion

Recognizing, assessing, and intervening in all domains of PD is an essential role for the nurse caring for patients with PD. It may not be reasonable to expect to review every system every visit, but each system needs to be addressed in an ongoing and repetitive manner over time. Understanding the multifactorial nature and interrelationship of motor and nonmotor symptoms of PD is crucial to planning effective interventions to maintain patient function and QOL. Patient and family education of disease process, terminology, medications, and interventions helps to meet the wide-ranging needs of those affected. Referring families to valid Web sites and associations is often an invaluable resource. Ultimately, it is the patients' perception of QOL at any stage that we need to respect in managing this disease.

Patient Resources

American Parkinson Disease Association www.apdaparkinson.org National Parkinson Foundation www.parkinson.org Parkinson's Action Network www.parkinsonsaction.org Parkinson's Disease Foundation www.pdf.org Young Onset Parkinson's Association www.yopa.org Healthcare Resources

Worldwide Education and Awareness for Movement Disorders [WE MOVE] www.mdvu.org Clinicaltrials.gov www.clinicaltrials.gov Supported by an independent educational grant from Teva Neuroscience.