Parkinson’s Disease:

Clinical Implications for

1
Fall Prevention
Adam G. Riner, MSN, RN, AGCNS-BC, CHPN
Director of Care Management
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Objectives 2

• Describe Parkinson’s Disease – pathology, prevalence and

treatment trends.
• Discuss reasons why individuals with Parkinson’s Disease pose a
particular challenge for fall prevention.
• Identify four methods in which fall prevention programs can
include interventions that target individuals suffering with
Parkinson’s Disease.

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What is Parkinson’s Disease? 3
• Parkinson’s Disease (PD) is a chronic, progressive neurodegenerative disorder
characterized by slowness in the initiation and execution of movement
(bradykinesia), increased muscle tone (rigidity), tremor at rest, and gait
disturbance
• The exact cause of PD is unknown and although it’s not considered a hereditary
condition, genetic risk factors should be evaluated for their interplay with
environmental factors – about 15% of patients with PD have a positive family
history for the disease
• The pathologic process of PD involves degeneration of dopamine-producing
neurons in the substantia nigra of the midbrain which disrupts the normal
balance between dopamine and acetylcholine in the basal ganglia
• Dopamine is responsible for functioning of the extrapyramidal motor system,
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including control of posture, support and voluntary motion (manifestations of PD
do not occur until 80% of neurons in substantia nigra are lost
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PD and Lewy Bodies 5

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Non-Motor symptoms of PD 10

• Depression
• Anxiety
• Apathy
• Fatigue
• Pain
• Urinary retention
• Constipation
• Erectile dysfunction

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Complications of PD 11

• Dyskinesias (spontaneous, • Dysphagia (trouble swallowing)

involuntary movements) • Aspiration
• Weakness • Urinary tract infections (UTI)
• Increased neurologic problems • Skin breakdown
(higher risk of dementia) • Orthostatic hypotension
• Neuropsychiatric problems
• Depression
• Hallucinations
• Psychosis
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Sleep Disturbances and PD 12

• Sleep problems are common and include difficulty staying asleep at

night, restless sleep, nightmares, and drowsiness or sudden sleep onset
during the day.
• In particular, rapid eye movement (REM) behavior disorder is a
preparkinsonian state that occurs in about one third of patients with
PD. It is characterized by violent dreams and potentially dangerous
motor activity during REM sleep.

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What is the Prevalence of PD? 13

• Nearly one million will be living with Parkinson's disease (PD) in the
U.S. by 2020, which is more than the combined number of people
diagnosed with multiple sclerosis, muscular dystrophy and Lou
Gehrig's disease (or Amyotrophic Lateral Sclerosis)
• Approximately 60,000 Americans are diagnosed with PD each year.
• More than 10 million people worldwide are living with PD.
• Incidence of Parkinson’s disease increases with age, but an estimated
four percent of people with PD are diagnosed before age 50.
• Men are 1.5 times more likely to have Parkinson's disease than
women. Eldercare Services
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Impact on Healthcare system 16

• The combined direct and indirect cost of Parkinson’s, including

treatment, social security payments and lost income, is estimated
to be nearly $25 billion per year in the United States alone.
• Medications alone cost an average of $2,500 a year and
therapeutic surgery can cost up to $100,000 per person.

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Current Treatment Options 18

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Current Treatment Options (Pharmacologic) 19

• Sinemet (Levodopa/Carbidopa)
• Requip (repinirole) / Mirapex (pramipexole)
• Neupro (rotigotine) transdermal patch
• Anticholinergic drugs (Cogentin) or antihistamines
(diphenhydramine)
• Exelon (rivastigmine) / Aricept (donepezil)
• Amitriptyline

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Medical Interventions 20

• Deep brain stimulation (DBS) – placement of an electrode in the

thalamus, globus pallidus, or subthalamic nucleus and connected
to a generator placed in upper chest (now individualized)
• Ablation surgery – involves locating, targeting, and destroying an
area of the brain affected by PD
• Transplantation – transplantation of fetal neural tissue is inserted
into the basal ganglia and designed to provide dopamine-
producing cells in the brain (research ongoing)

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Complementary Therapies 21
• Progressive relaxation (sensory
• Nutrition therapy deprivation)
• Deep breathing • Guided imagery
• Yoga • Acupuncture
• Tai Chi • Dance
• Chiropracty • Music
• Meditation/Mindfulness • Pet
• Massage • Theracycle (forced rate
• Whole body vibration therapy exercise)
• Psychotherapy • Audiology consult (innerEldercare
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issues)
Future of Treatment Options 22

• Use of medical marijuana (THC / CBD)

• Dietary management (research ongoing)

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Falls and Parkinson’s Disease 24

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Does the lack of dopamine produced in the

brain increase the risk of falls?

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Do dopaminergic drugs increase postural stability?

Do they decrease the risk for falls?

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When do individuals with PD fall? 29

• Position changes
• Turns
• Doorways
• Changes in flooring (color block changes)
• Obstacles
• Footwear
• Medications (orthostatic hypotension)
• Amyloid deposition in the brain
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Fall Risk 30

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What do we know right now? 32

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Disruption in the neural pathway from the

brainstem (responsible for upright posture and
balance)

Disruption in neural pathway originating in

frontal lobe (higher functioning)

These are contributory – NOT CAUSATIVE

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Distraction and displacement in Parkinson’s

Disease

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 Fix the Freeze 35

• Have patients who are at risk for falling and tend to “freeze”
while walking do the following:
• Consciously think about stepping over imaginary or real lines on the floor
• Drop rice kernels and step over them
• Rock from side to side
• Lift the toes when stepping
• Take one step backward and two steps forward
• Laser shoes

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Friendly Fixes 38

• Work with caregivers to share knowledge

• Use an upright chair with arms and elevate the back by 2 inches
• Remove rugs and excess furniture
• Elevate toilet seat and add arms
• Simplify clothing through use of Velcro and zippers instead of strings and
buttons/holes
• Manage sleep problems
• Work to address psychoemotional well-being
• Promote cognitive exercises
• Address nutritional needs
• Daily exercise regimen Eldercare Services
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 Resources 43

• https://www.Parkinson.org
• KP Neuroscience Movement
Disorders Program (1470 Maria
Ln, Ste 420, Walnut Creek, CA)
• PD Active (Berkeley/Oakland)
https://pdactive.wordpress.co
m/
• Dance Moves Me! For PD
(Walnut Creek)
http://dancemovesme.com/
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References 48

• https://parkinson.org/Understanding-Parkinsons/Statistics
• Duffy, J.R. (2013). Motor Speech Disorders: Substrates, Differential Diagnosis, and
Management (3rd ed.). St. Louis, MO: Elsevier Mosby.
Fritsch, T., Smyth, K. A., Wallendal, M. S., Hyde, T., Leo, G., & Geldmacher, D. S.
(2012). Parkinson disease: research update and clinical management. Southern
medical journal, 105(12), 650–656.
• Marras, C., Beck, J. C., Bower, J. H., Roberts, E., Ritz, B., Ross, G. W., Abbott, R.
D., Savica, R., Van Den Eeden, S. K., Willis, A. W., Tanner, CM, on behalf of the
Parkinson’s Foundation P4 Group (2018). Prevalence of Parkinson’s disease across
North America. Npj Parkinson's Disease, 4(1), 1–7.
• National Institutes of Health. (2013). NINDS Parkinson's Disease Information
Page. Retrieved from
http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_disease.htm

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