CNUR 204: Unit Ten - Neurological Disorders

Neurological Problems:
● Seizure disorders and epilepsy
● Multiple sclerosis
● Parkinson’s

Seizures:
● Uncontrolled electrical discharge of neurons in the brain that interrupts normal function
● Can be provoked by an underlying cause/illness or due to an unknown cause
● Seizures resulting from systemic and metabolic disturbances are NOT epilepsy if the seizures cease when
the underlying problem is corrected.

What are Seizures?

● Seizures are transient episodes caused by a disturbance in brain activity that cause changes in attention,
behavior, or perception, level of awareness and consciousness.
● Can be provoked by a variety of different things (fever, electrolyte imbalances, etc.)

Seizures are Provoked by Various Other Causes:

● Infants:
- Birth injury
- Congenital defects of the CNS
- Infection (high fever)
- Inborn errors of metabolism
● Children and Adolescents:
- Birth injury
- Infection
- Trauma
- Genetic factors
● Adults:
- Acidosis
- Electrolyte imbalance
- Hypoglycemia
- Hypoxia
- Alcohol and barbiturate withdrawal
- Dehydration
- H2O intoxication
- Stroke
- Heart, lung, liver, kidney disease, lupus, diabetes, hypertension, and septicemia
- Brain tumors (especially in older adults)

Unprovoked Seizures:
● Some people have a single unprovoked seizure with no other cause and then never have another one
● 1/10 will experience a single unprovoked seizure in their lifetime
● NOT EPILEPSY

Epilepsy:
● A brain disorder in which a person is susceptible to having repeat seizures
● At least two spontaneous (unprovoked) seizures more than 24 hours apart (as 70-80% chance another
one will occur).
Possible Causes of Epilepsy:
● Anything that can injure the brain:
- Brain injury during birth
- Neurodegenerative disease
- Head injury
- Lack of oxygen
- Fetal alcohol syndrome
- Lead poisoning Carbon monoxide poisoning
- Meningitis
- Stroke
● A genetic mutation
● A developmental abnormality
● Idiopathic - Most common (not known)
● Whatever the cause, the neurons undergo spontaneous firing
Incidence of Epilepsy:
● The most frequent neurological condition (after migraine), affecting 1/100 people (about 300,000 people
in Canada).
● 75-80% are diagnosed before the age of 18.
● Can happen at any point in the lifespan but onset rates highest in the first year of life and increase again
among seniors.
Types of Seizures:
● Focal (Partial) Seizures:
- Begins within 1 hemisphere of the brain
● Generalized Seizures:
- Widespread seizure activity in both hemispheres of the brain

Phases of a Seizure:
1. Prodromal phase signs or activities that precede a seizure
2. Aural phase (sensory warning)
3. Ictal Phase (seizure activity)
4. Postictal Phase (period of recovery)

Focal (Partial) Seizures:

● Unilateral
● Localized brain involvement
● May remain in one area of the brain, or may spread over time to involve the entire brain (become a
secondary generalized seizure).
● Partial Seizures are further subdivided into:
- Simple Partial seizures
- Complex partial seizures

Simple and Complex Partial Seizures:

● Simple Partial (focal aware) seizures:
- Do not involve loss of consciousness, memory or awareness
- Rarely last longer than 1 minute
- No first aid required
● Complex Partial (now termed Dyscognitive) seizures:
- Involve alterations in consciousness, loss of memory, or awareness
 - Often last longer than 1 minute
- Commonly involve lip smacking or automatisms
- Client may continue doing an activity they were doing before the seizure, but does not remember
doing that activity prior to the seizure (not sure why they are doing it)
- Distortions of visual or auditory sensations
- Alterations in memory (deja vu)
- First aid: stay calm, time the seizure, protect from harm by gently guiding from danger, remain
with person, until full awareness returns

Generalized Seizures:
● Bilateral, synchronous epileptic discharges (affects the entire brain)
● No warning or aura
● Usually the patient loses consciousness

Types of Generalized Seizures:

1. Tonic-Clonic (previously called Grand Mal)
2. Absence
3. Myoclonic
4. Atonic
5. Tonic
6. Clonic

Tonic-Clonic Seizures (Grand Mal):

- Most common type
- Characterized by stiffening of the body (tonic phase) for 10-20 seconds, followed by jerking of the
extremities (Clonic phase).
- Cyanosis, hypoxia, tongue and cheek biting, incontinence and vomiting may occur during the
seizure
- 1-3 minutes in length
- Person is unconscious during the seizure
- The client will be exhausted following the seizure and will have no memory of the seizure
- First aid: stay calm, time the seizure, and protect from harm.
Absence Seizures (formerly known as petit-mal):
● Occurs primarily in children, but can occur in adults
● Brief staring spells that often only last about 9 seconds
● As a result, these can often go unnoticed, especially in children
● The client may experience a brief loss of consciousness
● Can occur up to 100 times per day
● Diagnosis and treatment is crucial
● Some may have other features like eye movements, blinking or automatic behaviors
● Requires no first aid

Myoclonic Seizures:
● Extremely brief (1 second)
● Sudden, excessive jerk of the body or extremities

Atonic Seizures:
● Sudden loss of muscle tone
● Causes the person to drop to the ground (“drop attack”)
● Great risk of Head injury

Tonic Seizures:
● Only involves the tonic phase (muscles stiffen)
● Can result in a “drop attack”, or arm stiffening
Clonic Seizures:
● Only involves the clonic phase (rhythmic jerking movements)

Complications and Limitations Resulting from Seizures:

1. Status Epilepticus:
- State of ongoing, continuous seizures (of any type)
- Neurological emergency
- Brain uses more energy than can be supplied, and permanent brain damage can result
- Tonic-clonic is the most dangerous type as it can cause ventilatory insufficiency, hypoxemia, and
dysrhythmias, hyperthermia, and systemic acidosis
- Can be fatal
2. Severe injury:
- Injury which occurs during a seizure
- Head injury, drowning, burns
- Perinatal seizures associated with severe outcomes for mom and baby
- Any severe injury has the potential to cause death
3. Sudden unexplained death in epilepsy (SUDEP):
- Generally, clients with poor controlled epilepsy
- 1-2 in 1000 people with epilepsy can experience SUDEP.
- Leading cause of death for epileptics
4. Cognitive impairments:
- Depends on the affected area of neuronal firing
- Depends on effects of anticonvulsant medications

Psychosocial Complications - Limitations from Seizures:

 ● Lifestyle limitations and social stigma
● Discrimination with employers and during educational opportunities
● Driving limitations
● Up to 42% of epilepsy clients experience depression
- In turn, depression can lead to increased seizure activity (lack of sleep and stressor)

Assessment and Diagnosis

Subjective Data - Detailed Client Health History:

● Birth and development history
● Family history
● Significant illness or injury
● History of febrile seizures
● Medication history
● Any drug/alcohol use
● Seizure history - details of the event:
- Antecedent events
- Precipitating factors
- Seizure description (onset, duration, frequency, postictal state, automatisms, where did it start?
- LOC?
- Loss of bladder or bowel function
Objective Data - Comprehensive Neurological Assessment:
● Test the cranial nerves
● Inspect and palpate the motor system
● Sensory exam
● Test the reflexes
● Neuro Re-check and GCS

Assessment and Diagnosis:

● Postictal Phase:
- After the seizure, were you told you have confusion, spent time sleeping, weakness, headache, or
muscle ache?
● Precipitating Factors - Did anything seem to bring on the seizure:
- Activity
- Discontinuing medications
- Fatigue
- Stress
Diagnostic Studies:
● Electroencephalography (EEG):
- Most informative investigation to diagnose the type of epilepsy (focal or generalized)
- An ambulatory EEG allows for monitoring for 24-72 hours - this may allow a seizure to actually be
recorded
- Can be done either at home or in hospital while being recorded
- Invasive EEG monitoring
● Magnetoencephalography:
- Done in conjunction with EEG
- Can detect small magnetic fields created by abnormal neuron activity
 - Used for localization of epileptic foci
● Genetic testing
● CT, MRI, PET scan:
- To rule out any structural abnormalities
● CBC, Electrolytes, creatinine, urinalysis, fasting blood glucose:
- To rule out any metabolic disorders

Collaborative Care
Treatment and Nursing Management - Ongoing Management:
● Drug therapy:
- Treated primarily with anti epilepsy medications
- Treatment is aimed at reducing the number of seizures but does not cure epilepsy
- Effectiveness:
- 50% of clients have seizure control
- 30% have a reduction in seizure intensity
- 30% have a reduction in intensity and frequency
- 20% have seizures which are resistant to medications (refractory epilepsy)
● Overall goal:
- Obtain maximum seizure control with minimal side effects (balancing act-need to figure out the
best dose for each individual client)

Drug Therapy for Seizure DIsorders:

● Drugs generally act by stabilizing nerve membranes and preventing spread of the epileptic discharge
● The principles are to begin with a single drug and work the dosage until seizures are controlled OR up until
toxic side effects occur.
● Many of the newer drugs do not require serum drug monitoring as the therapeutic ranges are so large
● Treatment of status epilepticus requires prompt IV treatment of benzodiazepines (either
Lorazepam-Ativan or Diazepam-Valium) as they are a rapid acting anticonvulsant.
- Because they are short acting they MUST be followed by a long acting drug such as
phenytoin-Dilantin or phenobarbital.
● Adverse effects to these meds are slowing of the CNS-diplopia, drowsiness, ataxia, and mental slowing.
● Neurological testing for alertness, testing eyes for nystagmus, hand and gait coordination, cognitive
function and general alertness are assessed for dose related toxicity.
● Do not discontinue drugs abruptly - can precipitate seizures
● If weaning is to occur, the client must be seizure-free for a long period of time (2-5 years), and have a
normal EEG and Neurological exam
● Idiosyncratic adverse effects involve organs outside the CNS:
- Skin rashes
- Mouth-gingiva (hyperplasia)-sometimes requiring surgery to remove the tissue
- Bone marrow - blood dyscrasias
- Liver
- Kidneys

Emergency Situations:
● Emergency medical management should be sought if…
- The person does not have diagnosed epilepsy
 - The seizure lasts longer than 5 minutes
- A second seizure occurs before the person has fully recovered from the first seizure (status
epilepticus)
- If regular breathing does not return when the seizure ends
- The person has diabetes (may be due to hypoglycemia)
- The seizure occurs in water
- If the person is pregnant

Seizure First Aid:

What if the Seizure Does not Stop?

 ● Generally we treat status epilepticus as lasting more than 5 minutes or when the person has 2 seizures
back to back and does not regain consciousness in between.
● In this case, insert an IV and administer medication even if the seizure is still in progress.

Surgical Management of Seizures:

● For patients that have drug resistant epilepsy: surgery may be an option
● Severe surgical therapies are available for treatment of seizures
● The type of surgery depends on the type and location of the seizures
● Resection of the epileptogenic tissue is one option:
- Can result in 55-70% of clients being seizure free in 5 years
- Only partial seizures
- Physician resects as much of the epileptogenic tissue without affecting normal brain activity

Dietary Management:
● Ketogenic Diet - most commonly used
● Medium chain triglyceride diet
● Modified Atkins diet
● Low glycemic index diet

Vagal Nerve Stimulation and Biofeedback:

● Vagal Nerve Stimulation:
- Is used as an adjunct to medication when surgery is not feasible
- Exact mechanism of action is unknown - but thought to interrupt the excessive discharge of
neurons
- It requires a surgically implanted electrode in the neck to deliver impulses to the vagus nerve. The
patient can activate it with a magnet if they feel a seizure coming on
● Biofeedback:
- Is aimed at teaching the patient to maintain a certain brain wave frequency

Seizure Prediction and Detection Devices:

 ● Unfortunately, to this day, working seizure prediction devices are tested only on a research basis using
intracranial electrodes recordings. While exciting, this research has not yet translated into a commercially
available device.
● Seizure detection software has been developed, Seizure detection devices are commercially available
(watch, monitors, bed sensors). They have the capability of sending automatic or manual alert messages
to the person with epilepsy and to caregivers
● Trained service dogs may assist if a seizure occurs

Nursing Management
Treatment and Nursing Management During a Seizure:
● Ensure patent airway
● Remove or loosen clothing
● Turn the patient to one side
● MAY have to support the head if airway compromised
● Protect from injury:
- Do not restrain
- DO NOT place anything in mouth
- Side rail - padded/blanket
- Ease client into a lying position if sitting or standing
- Suction and oxygen if necessary
- Ensure IV access as soon as it is safe
- DO NOT try to stop the seizure

What to Record/Observe During a Seizure:

● What preceded the seizure, when did the seizure occur, how long did each phase last, what occurred in
each phase
● Any loss of consciousness, tongue biting, automatisms, stiffening, jerking, lack of muscle tone
● The body parts involved and their sequence of movement and involvement, autonomic signs (dilated
pupils, excessive salivation, altered breathing, cyanosis, flushing, diaphoresis, incontinence)
● Watch for the presence of autonomic signs, such as dilated pupils, excessive salivation, altered breathing,
cyanosis, flushing, diaphoresis, or incontinence.
● Ensure IV access:
- Anticipate administration of medication
- Valium or Ativan (short-acting)
- Followed by a long-acting drug, such as Dilantin (phenytoin)

When the Seizure is Finished…

● Assist with ventilation post seizure:
- Client may have difficulty breathing post-seizure
- Oxygen or intubation may be necessary
- Suction and oxygen as necessary
● Monitor LOC
● Monitor vital signs - may have decreased SPO2, tachycardia
● Assess memory loss, muscle soreness, speech disorders, weakness, paralysis, sleep period, and the
duration of each.
 ● Assess blood glucose - give Dextrose if needed for hypoglycemia
● Re-orient and provide reassurance to the patient and family
● Provide bowel/bladder care (if incontinent)
● May have diaphoresis, be warm to touch, flushed, pallor, or cyanosis
● May have a headache, provide Tylenol
● Document
● Reassess postictal phase - LOC, vitals, memory loss, neuro re-check, GCS

Health Promotion and Prevention and Patient Teaching

Lifestyle:
● It is important to maintain a regular sleep schedule, get adequate amounts of sleep and practice good
sleep hygiene
● A healthy diet and regular exercise contribute to well being and help to reduce stress which may help to
decrease the chance of a seizure
● Avoiding stress or acquiring techniques to deal with stress (relaxation techniques, counseling, meditation,
yoga) are recommended for everyone with epilepsy.
● Recreational drugs and excessive alcohol ingestion should be avoided as these are potential triggers for
seizures.
● As many people with epilepsy also have associated mood, anxiety, and sleep difficulties, it is important to
treat these conditions as well
● Practicing seizure precautions is important for safety.
Seizure Precautions:
● Encourage the client to avoid activities and environments that might expose them to dangers and threats.
● At home:
- Showers are recommended
- Supervision when cooking
● Avoid high risk sports
● Wear helmets to prevent brain injury (two fold):
- Prevention of brain injury which can cause seizures
- Prevention of head injury for known clients with epilepsy
Patient and Family Teaching:
● Take medications as scheduled
● Wear a medical alert bracelet/card
● Eat regular meals and snacks
● Maintain good health (diet, exercise, sleep)
● It is not necessary to go to the hospital after one seizure event. However, do go to the hospital if the
seizure is prolonged, or if one seizure follows another or if injured.
● Teach family members what to do when the patient has a seizure:
- Stay with the person and be calm
- Protect the head
- Turn the client to the side
- Loosen any restrictive clothing
- Ease the client to the floor if seated
 Multiple Sclerosis and Parkinson’s
Multiple Sclerosis:
● Multiple sclerosis is an autoimmune and neurodegenerative disease of the CNS (brain, spinal cord, and
optic nerve; therefore, mainly affecting vision, memory, cerebellar functions, voluntary and involuntary
movement, and sensation, as well as emotional stability)
● The exact cause is unknown
● It is believed to be a combination of genetic and environmental factors.

Multiple Sclerosis Facts:

● 1 in 340 Canadians have MS (90,000)
● Canada has the highest rate in the world
● 12 Canadians are diagnosed per day
● Saskatchewan has about 3400 people with MS
● DIagnosed between the age of 20-49 (average age 43)
● Women (75%) affected more than men
● Increased prevalence in temperature climate

Etiology of MS:
● Cause is still unknown, research focuses on 4 possible causes:
- Genetic and biological predisposition
- Lifestyle and Environmental factors (Vitamin D, Obesity, smoking, viral infection with Epstein-Barr
virus)

Pathophysiology of MS:
● The disease attacks myelin, the protective covering of the nerves, causing inflammation and often
damaging the nerves
● Caused by autoreactive T cells (Lymphocytes):
- T cells normally cross the blood-brain barrier
- They are like a surveillance crew, their job is to check the CNS for antigens (something ‘foreign’)
and then leave.
- With MS, something triggers the presence of antigens in the CNS, and the T cells stay.
- The presence of T cells triggers an antigen-antibody response (activation of the inflammatory
response)
● This inflammation response leads to demyelination of axons
● Plaque is formed in place of the myelin (Gliosis)
● Myelin is necessary for the transmission of nerve impulses through nerve fibers. Nerve impulses travel
with minor interruptions with slight damage or completely disrupted if damage is substantial and if scar
tissue replaces myelin.
● Plaque formation in MS occurs primarily in optic nerves, white matter in the brain and spinal cord, the
brain stem, and cerebellum

Myelin and Demyelination:

● Myelin:
 - An electrically insulating material, which forms a layer, called a myelin sheath around the axon of
a neuron
- Increases the speed at which impulses travel along the axon
● Demyelination:
- Loss of myelin sheath insulates the nerves

Pathophysiology:
● Oligodendrocytes decrease:
- These are the cells in the CNS that produce myelin
● Astrocytes increase:
- Cells which aid in plaque formation in the brain (gliosis)
● Some remyelination can occur:
- In late 1990s it was discovered that myelin can regenerate (oligodendrocytes can reproduce)
- Some clients will have improvement of symptoms with remyelination
- However, remyelination must occur BEFORE the oligodendrocytes have died
- In the long run, it will not be sufficient to overcome the ongoing changes
- But this is why people will have “exacerbations” of MS

Categories of MS:
● Relapsing-Remitting:
- Unpredictable attacks which may or may not leave permanent deficits followed by periods of
remission
● Primary-Progressive:
- Steady increase in disability without attacks
● Secondary-Progressive:
- Initial relapsing-remitting multiple sclerosis that suddenly begins to have decline without periods
of remission.
● Progressive-Relapsing:
- Steady decline since onset with superimposed attacks
● Benign

Clinical Manifestations of MS:

● Motor:
- Fatigue
- Weakness or paralysis of trunk, head or limbs
- Abnormal gait
- Muscle spasticity
- Lack of coordination
- Bowel and/or bladder dysfunction
- Vision problems
● Sensory:
- Paresthesias (numbness, tingling)
- Visual disturbances like diplopia, blurring
- Tinnitus
- Hearing impairments
- Neuropathic pains
- Sexual dysfunction
● Cerebellar:
- Nystagmus
- Ataxia
- Dysarthria
- Balance
 - Position sense
- Coordination
● Emotional/Cognitive:
- Cognitive impairment - forgetfulness, memory loss
- Depression
- Anger
- Unstable moods
- Apathy
Diagnostic Studies:
● Health history
● Neurological exam, signs and symptoms
- Romberg sign
● Cerebrospinal fluid analysis (CSF) from a lumbar puncture (LP)
● Evoked response testing
● Magnetic resonance imaging (MRI) - most reliable
● Wait and see

Treatment and Nursing Management

Drug Therapy:
● Corticosteroids
● Immunomodulators
● Immunosuppressants
● Stool softeners/laxatives
● Cholinergics/anticholinergics
● Antidepressants
● Muscle relaxants
● Beta-adrenergic blockers
● Anti-seizures/cannabis
● NSAIDs and Analgesics
● CNS stimulant
● Antiemetic

Nutrition Therapy:
● Well balanced diet
● High protein:
- Helps with tissue repair
● Vitamin supplements
- Extra vitamin C can help keep urine acidic and decrease bacterial growth
● High roughage
● Vitamin D is recommended 800-4000 IU/day. This may help with slowing MS but also is good for bone
health.
● Several diets have been advocated for over the years (megavitamin therapies, raw food diet)
● Insufficient scientific evidence supports the effectiveness of these diet therapies

Physical Therapy:
 ● The overall goal of exercise and physical therapies is to decrease spasticity, increase coordination and
muscle strength, improve mobilization, gait, fatigue, and quality of life.
● Water exercises
● Stretching (pilates, yoga)
- Stretching minimizes joint contractures
● Assistive devices
● Balance rest/activity

Alternate Therapies:
● Surgery-neurectomy, rhizotomy, cordotomy for unmanaged spasticity/thalamotomy for unmanaged
tremor
● Nutritionist
● Megavitamin therapy
● Naturopathic remedies
● Chiropractic therapy
● Massage therapy
● Speech therapy
● Acupuncturist
● Cannabis
● Meditation
● Spirituality
● Share-write a blog, keep a diary, confide in a close friend, or attend therapy/support sessions

Nursing Care for Multiple Sclerosis Patients:

● Promote physical mobility
● Manage fatigue
● Prevent injury
● Promote bladder and bowel elimination
● Prevent complications and immobility

Parkinson’s Disease
Parkinson’s Disease Facts:
● 25 Canadians are diagnosed every day in Canada (100,000 Canadians living with Parkinson’s)
● More common in men than women (3:2 ratio)
● Average age of diagnosis is 60
● Symptoms usually appear in fifth decade of life
● Second most common neurodegenerative disease

What is Parkinson’s Disease:

● A progressive neurodegenerative disease of the CNS in the midbrain where there is a loss of dopamine
neurons that make the NT dopamine which is more important for normal movement.
● Characterized by:
- Slowing down in the initiation and the execution of movement (bradykinesia)
- Increased muscle tone (rigidity)
- Shakiness/tremors at rest
- Postural instability
 ● Exact cause is unknown, strong genetic link

Pathological Process:
● Degeneration of dopamine-producing neurons
● These neurons are located in the substantia nigra of the midbrain, which is:
- One part of the basal ganglia
- Contains cells that produce dopamine
- Dopamine is a neurotransmitter, which is essential for normal functioning of the extrapyramidal
motor system, including control of posture, support, and voluntary motion
● Results in dopamine depletion
● Symptoms do not occur until 80% of neurons in substantia nigra are lost

Clinical Manifestations:
● Insidious onset
● Gradual progression of symptoms
● Mild, early symptoms progress to more pronounced symptoms
● Early signs: mild tremor, slight limp and decreased arm swing
● Three cardinal manifestations (classic triad):
- Tremors
- Rigidity
- Bradykinesia (slowing down in the initiation and the execution of movement)

Clinical Manifestation #1 - Tremor:

● Often first sign
● Present in 70-100% of clients at time of diagnosis
● Minimal at first, client is the only one who notices
● More prominent at rest
● Increases with emotional stress or increased concentration
● Described as “pill rolling”:
- Thumb and finger appear to move in a rotary motion, as though a pin or coin
● As disease progresses, it affects fine motor skills
● May involve only one side of body initially
● Tremor can also involve the diaphragm, tongue, lips, and jaw

Clinical Manifestation #2 - Rigidity:

● Present in 90% of clients
● As in tremors, rigidity starts unilaterally and progresses to both sides of body
● Causes jerky motions called “cogwheel rigidity”
- Jerky quality, like a cogwheel having intermittent catches on the pegs
● Client feels muscle soreness, tiredness

Clinical Manifestation #3 - Bradykinesia:

● Extreme slowness to movement
● Difficulty initiating movement, turning over in bed, rising from sitting position
● Loss of automatic involuntary movements:
- Blinking eyelids
- Swinging arms while walking
 - Swallowing saliva
- Adjustments to posture
- Changes in facial expression - blank
- Slow, shuffling gait
- Forward tilt to posture
- Slow, monotonous, slurred speech
● Mask-like facial expression

Other Manifestations:
● Cognitive decline
● Change in abstraction and judgment
● Slow thinking
● Decreased ability to form thoughts, to plan, to make decisions
● Memory loss

Complications of Parkinson’s:
● Neuropsychiatric problems - depression, anxiety, hallucinations
● Dementia can occur (40% of clients)
● Weakness and fatigue
● Masklike, expressionless face
● Sleep disturbances
● Speech and swallowing impairments
● Eczema skin changes - results from increase sweat glands activity
● Loss of smell
● As the disease progressed, complications increase:
- Worsening motor symptoms (dyskinesia, weakness, akinesia as well as swallowing difficulties -
dysphagia leading to malnutrition and aspiration)
- Worsening neurological symptoms (dementia)
- Worsening neuropsychiatric problems (depression, hallucinations, psychosis)
● General debilitation can lead to:
- Pneumonia
- UTI
- Constipation
- Skin breakdown

Diagnostic Studies:
● History of clinical features
● Firm diagnosis only when at least 2 of the 3 classic triad of symptoms is present
● Ultimate confirmation with a positive response to antiparkinsonism drugs
● Research ongoing - genetic testing/MRI

Drug Therapy:
● 3 main classifications to correct the imbalance of dopamine neurotransmitters in the CNS:
1. Stimulate dopamine (Dopaminergic)
- Carbidopa allows more Levodopa to get to the brain by preventing it from breaking
down in the blood.
- Levodopa turns into dopamine in the brain (Levodopa with carbidopa - Sinemet).
 2. Dopamine Agonists: mimics or imitates actions of dopamine (Bromocriptine)
3. Block or antagonize the overproduction of cholinergic neurons in the striatum
- Anticholinergic - corrects imbalances between dopamine and acetylcholine (Cogentin).
Blocks the acetylcholine (The excitatory NT).
- Monoamine Oxidase Inhibitor - inhibits monoamine oxidase, the degradative enzyme of
dopamine - so enhances the effect of dopamine by preventing its breakdown.
● Symptom management:
1. Antihistamines with anticholinergic properties - to manage tremors:
- Benadryl
2. Beta-adrenergic blockers - to manage tremors:
- Propranolol
3. Antiviral - promotes the release of Dopamine from neurons:
- Amantadine

Surgical Therapy:
● Usually used for patients unresponsive to drug management or with severe complications
● Ablation therapy was used for 50 years - replaced now with:
● Deep Brain Stimulation:
- Procedure of choice
- Implanted electrode in brain and connected to generator implanted in chest, under skin like a
pacemaker
- Device delivers electrical impulses to stimulate the area of brain to increase neuronal activity and
aid in symptom control of PSD
● Transplantation of fetal neural tissue into the basal ganglia to provide dopamine producing cells:
- Only treatment that could potentially offer full functional restoration
● Stem cell research:
- Both epithelial and bone marrow cells are currently being studied

Nutritional Therapy:
● Adequate roughage and fruit
● Ample time for eating
● Smaller more frequent meals as less exhausting
● Absorption of Levodopa can be impaired by protein and vitamin B6
● Bradykinesia and dysphagia makes eating slow and can increase risk for choking/aspiration
- Assist to cut into bite size pieces

Nursing Management:
● Assist with ambulation/movement/mobility devices
● Consult physiotherapy/occupational/speech for assist with ADLs and Language Therapy prn
● Promotion of exercise
● Encourage independence in ADLs
● Safety - move slowly to help with balance, low heel without rubber sole, no scatter rugs
● Perform ROM:
- Avoidance of contractures
- Prevent pressure ulcers/wounds
- Prevent clots
 - Prevent respiratory depression/infection
● Carefully monitor swallowing - risk for aspiration:
- Upright position to eat (during and 20 min after)
- Soft and easy to chew foods
● Optimize psychosocial well being:
- Difficulties with speaking, writing, loss of independence, frustration can lead to social withdrawal
and isolation