PARKINSON’S DISEASE
 Is a chronic, progressive neurologic
disease affecting the brain centers
responsible for control and regulation of
movement due to depletion of
dopamine.
 It’s a neuro disease that gradually starts
to affect movement.
 The dopaminergic neurons in the part of
the brain called substantia nigra have
started to die.
 There is no intellectual impairment,
no paralysis, no loss of sensation
 Common among 60 above, less
commonly affects the younger people.
PATHOPHYSIOLOGY
 DECREASE dopamine production in
the substancia nigra of the brain
which is responsible for the symptoms
of Parkinsonism.
 The dopaminergic neurons in the part of
the brain called substantia nigra have
started to die.
DOPAMINE- is a neurotransmitter that
promotes muscle relaxation
Significance of this area? This area is part of
the basal ganglia which is part of the midbrain
that controls movements.
What is the role of these dopaminergic
neurons? They release the
neurotransmitter dopamine, which allows us to
have accuracy with movement. Therefore, if
they are dying this will lower the amounts of
dopamine available to our body for normal
movement.
Why is there the signs and symptoms of
tremors, rigidity etc.? Normally in the nervous
system there is a balance
between acetylcholine (an excitatory
neurotransmitter) and dopamine (an inhibitory
neurotransmitter).
Therefore, the loss of dopamine leads to more
acetylcholine being able to produce more
excitatory affects to the neurons in the basal
ganglia and this leads
to overstimulation…..tremors, rigidity
(increased cholinergic activity).
Other predisposing factors
 Unknown
 Virus
 Drugs
 Genetic
Key Points about Parkinson’s Disease
 The disease tends to occur in older age
60+ (however it can affect younger
people…example: Michael J. Fox was
diagnosed with PD at the age of 29).
 There is currently no cure (there are
medications to relieve signs and
symptoms).
 Signs and symptoms are subtle (some
patients don’t notice them at first) and
they will become worse overtime.
 Signs and symptoms may present on one
side or one extremity and progress to the
others overtime.
CLINICAL MANIFESTATIONS
Mainly motor symptoms: affects how the
patient is able to move
 Tremors at rest- hands, arms, legs
(even lips and tongue) improves with
movement-Initial sign (pill rolling and
resting tremors- non intention tremors)
 Pill-rolling: tremors of
the hands and
fingers….looks like the
patient is rolling a pill
between fingers and
hands.
 Resting tremors
 Stiffness of extremities (arms DON’T
swing with gait
 SHUFFLING GATE-
this is tip toe walking
starting at a slow pace
 which keep on
increasing until the
client assumes a chewing and swallowing
running pace.
 COGWHEEL
RIGIDITY- due to
decrease dopamine
production. (3rd sign).
when moving the
patient’s arms passively
toward the body they NURSING INTERVENTIONS
jerk or push back
slightly Safety Issues:
 BRADYKINESIA-
slow muscle movement,
not associated with
muscle weakness (2nd
sign)
 difficulty swallowing
(drooling), Face mask-
like: expressionless
 AKINESIA- absence of
muscle movement, or
inability to move the
muscles
voluntarily….”freeze
up”
 Impaired verbal fluency
 Flattened affect (mask like facial
expression)-without expression
 Coordination issues- Stooped posture
 Issues with the muscles used for
chewing food, swallowing, and
speaking: soft or slurred speech,
problems swallowing (aspiration)
 Fatigue
 Soft monotonous voice
 Shaking, small hand writing
Non-motor Signs
 Depression, Constipation: digestion
slows down
 Loss of smell
NSG DX
 Impaired physical mobility r/t to tremor,
slow muscle movement and rigidity
 Altered nutrition Less than Body
requirement due to motor difficulty in
 Impaired Verbal communication r/t
decrease speech volume and facial
muscle involvement
 Constipation r/t diminished motor
function
 Patient needs to wear low heel
shoes and avoid rubber soles (they
tend to stick to the floor and can
cause tripping). The soles should be
smooth (not slick).
 For balance: move slowly when
changing positions…rubber tip cane that
is single point can help.
 Education on how to deal with
freezing episodes (some patients have
them and they can occur randomly). For
example, it can occur in the legs, and it
feels like the shoes suddenly become
stuck to the ground and they can’t move.
 Try to change direction of
movement….rather then continue
going to the side go forward.
 Use cane or walker with a laser…
it provides a laser line on the
floor that will help the patient
find a landmark for when
freezing episode happens and
helps the patient coordinate their
next step.
 Consciously lift the legs (as in
marching) with each step or
pretend they are walking over an
object.
 DON’T push through the freeze
up.
 Use handrails in bathroom and shower,
elevated toilet seat, non-slip shoes and
socks, removes rugs and make sure pets
are away from feet etc.
NUTRITIONAL/DIGESTION
 Frequent small feedings
 Instruct the pt to chew deliberately and
slowly using both sides of the mouth
 Maintain Low CHON at daytime, and
High CHON at night,
 Liquid diet to soft diet for dysphagia
 Increase fluid intake and fiber to prevent
constipation.
 Aspiration precaution- Upright position
when feeding
 Avoid taking antiparkinson’s
medication (Carbidopa/Levodopa)
with a high protein meal (meats, eggs,
dairy, beans) because they interfere with
how the body can absorb the medication
(makes medication less effective).
 At risk for weight loss because of the
struggle with swallowing, chewing,
depression, and hard to feed self due to
rigidity
 Needs foods that are soft, easy to
swallow, and chew…speech therapy to
evaluate…recommend consistency of
fluids
 Drink plenty of fluids 2 L per day
(unless contraindicated) with high fiber
foods….example fresh fruits and
vegetable and stool softener per MD
order- to Prevent constipation:
 Assess last bowel movement and bowel
sounds along with palpation of
abdomen.
IMPROVING MOBILITY
 Daily exercise- walking, riding on
stationary bike, gardening, swimming.
 Do stretching and postural exercises
- Swing arms
- Raise the feet while walking, use
heel toe gait
 Take warm bath and massage to relax
the muscles
 Firm bed to prevent contractures
Psychosocial Issues: autonomy very
important!
Help them with locating utensils for eating,
cooking etc….. there are special types of
cookware for PD like spoons, forks, bowls,
knives to maintain autonomy
isolation:
 local support groups with other
people who have PD
 exercise
Don’t stress patient about activities or hurry
them…stress increases symptoms….wait for
medication to peak so the most dopamine
will be the most available.
Dress patient in shirts without buttons or
zippers…easy to put on…replace articles of
clothing with Velcro and shoes that don’t
have to be tied.
Maximizing Communication
 Teach pt to do facial exercises (smiling
and frowning) and breathing methods: to
obtain appropriate pronunciation and
intonation
 Speak in short sentences
PHARMACOTHERAPY
DOPAMINERGICS
 these drugs improve muscle flexibility.
 Levodopa
LEVODOPA (DOC)
 A precursor of dopamine can cross the
blood brain barrier.
 Low CHON in day time and High
CHON diet at night the absorption of the
drug is slows down by high CHON and
Vit B6.
SIDE EFFECTS OF LEVODOPA
 M-Mental confusion
 I-Insomnia
 R-Renal Damage
 O-Orthostatic HPN
 N-Nausea and Vomiting
CARBIDOPA with LEVODOPA (Sinemet)
 adds more dopamine to the brain
 Carbidopa reduces destruction of
levodopa in the blood stream, making
more available to the brain.
 Carbidopa helps to prevent levodopa
from being broken down in the blood
before it enters the brain (hence more
enters the brain) and lessens the side
effect of nausea and when levodopa
enters the brain it turns into dopamine
 SE: Nausea and involuntary movements
Nursing Consideration in Carbidopa-
Levodopa therapy
 takes up to 3 weeks to notice a decrease
in symptoms when beginning treatment
 Symptoms of dyskinesia may take
weeks or months to be controlled.
 don’t be alarm if body fluids turn a dark
color/ Urine may turn into reddish
brown with exposure to air
 after long term usage the drug may wear
off before next dose and cause signs and
symptoms. Entacapone “Comtan”: a
COMT can be prescribed to help
decrease this from happening
 Monitor the VS. Orthostatic
hypotension (Weakness, Dizziness)
 Gradual change of position. To prevent
orthostatic hypotension.
 Advise the clients to avoid
Phenothiazines, Pyridoxine,
Reserpine, MAOI, Aldomet- These
block the effects of Levodopa
Monoamine oxidase inhibitors (MAOI)
 MAOI’s enhance norepinephrine
activity
 MAOI’s + Carbidopa Levodopa=
Hypertensive Crisis
 PA- Parnate (tranylcypromine)
 NA- Nardil (phenelzine)
 MA-Marplan (isocarboxacid)
Aldomet (Methyldopa)- potentiates effects of
Carbidopa-Levodopa
 Avoid foods when on Carbidopa-
Levodopa therapy such as VIT B 6 rich
foods and tyramine rich foods
Vit B 6 rich foods- tuna, pork, dried beans,
salmon, beef liver. It blocks the effect of
levodopa.
TYRAMINE rich foods
 may cause Hypertensive crisis
 Cheese, Dairy Cream, Yogurt, coffee,
 chocolate, bananas, Raisins, Italian
green beans, Liver, Pickled herring,
Sausage, Soy sauce, Yeast, Beer, Red
wine
DOPAMINE AGONIST
 Acts on the dopamine receptors
 Activate dopamine receptors in the brain
helps with improving movement
 Amantadine, Parlodel, Requip
Symmetrel (Amantadine HCL)
 (antiviral: prevents influenza A…
antiparkison as well): helps with
symptoms by stimulating
dopaminergic activity in the CNS
 signs of skin lesions, seizures,
depression
Parlodel (Bromocriptine)
 light headedness-
Requip (Ropinizole hcl) Rasagiline “Azilect”: increases dopamine by
 stimulates dopamine receptors/ stopping the activity of MOA…improvement of
dopamine agonists: symptoms
 Side effects: drowsiness major side
effect (educate NOT to take when about Educate about limiting foods with tyramine:
to drive, cook, or operative machinery hypertensive crisis
etc.)  aged cheese
 smoked or cured meats (pepperoni,
ANTICHOLINERGIC bacon, hot dogs)
 reduce rigidity and some tremors in PD.  fermented food and beer
 blocks acetylcholine by decreasing
rigidity, saliva (drooling), improved Catechol O Methyltransperase Inhibitors
movements  increase the amount of levodopa
 Cogentin (Benztropine) concentration in the brain
 Artane (trihexyphenidyl  Tasmar (Tolcapone), Comtan
 Kemadrin (Procyclidine) (Entacapone)
 Parsidol (Ethopropazine)  Entacapone “Comtan” (catechol-O-
 Akineton (Biperiden) methyltransferase inhibitors) used with
levodopa/carbidopa to prevent the
“wearing off” of the drug before the
NURSING CONSIDERATIONS
next dose is due….blocks COMT
enzyme that will break down the
Side Effects: levodopa in the blood to allow it to last
 Increase PR, urinary retention, and longer.
constipation. Monitor VS, UA and
bowel sounds. Advise to void before
taking the drug.
 Decrease salivation. Relieve dry mouth COMPLICATIONS
with hard candy, ice chips or sugarless  Dementia
chewing gum.  Aspiration
 Photopobia. use sunglasses  Injury from falls
 NOT for people with GLAUCOMA!!
Advise the client to have routine eye
examinations. To determine the
presence of IOP which indicates
GLAUCOMA.
 NO or avoid alcohol, cigarette, caffeine,
and aspirin to decrease gastric irritation.
 Education: NEVER abruptly stop
taking (increases signs and symptoms
seen in Parkinson disease),

MAO Inhibitor Type B (Monoamine

Oxidase Inhibitor Type B):

Selegiline Hcl (Eldepryl)

 inhibits breakdown of dopamine thus
prolonging action of levodopa