Running Head: PARKINSONS DISEASE

Parkinsons Disease

Table of Contents Abstract .............................................3

PARKINSONS DISEASE Introduction ()................................................................................4 Definition (). .4 Risk Factors ..4 Statistics ...........................................4-5 Prognosis).5-6 Signs and Symptoms (.6-8 Diagnostic Tests and Nursing Implication).8-9 Medical Treatment and Nursing Implication ().9-10 Surgical Treatment and Nursing Implication ()...10-12 Prevention 12-13 Complications ...13-15 Client Teaching)15-16 Latest Technological Advances ().16-17 Conclusion ().17-18 References..............................................................................................................................19-20

Abstract The following document is an exposition of the degenerative and progressive conditions of Parkinson's disease. It highlights some of the treatment options available, appropriate nursing care interventions, desired outcomes for the patients and families afflicted, the latest technological advances and how nurses face the challenge of caring for these patients during the acute and rehabilitation phases from injuries caused by this disease, which present some of the greatest challenges in health care today.

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Parkinsons disease is a progressive neurologic disorder that affects many people in this country. It is mainly considered a motor disease which not only affects motor function but also interferes with many daily living activities of the patient. Parkinsons disease or PD is a degenerative disorder of the central nervous system named after Dr. James Parkinson, a London physician who was the first to describe it in 1817. Its cause is a loss in brain cells, especially in the substantia nigra a brain location which produces dopamine, a kind of relay-communicator that allows neurons to interact correctly, sending the right command at the right time to the right physical part of the body. (MFMER)., 2010). This disease belongs to a group of conditions called movement disorders and of Parkinsonism, the name for a group of disorders with similar features and symptoms such as tremor,

PARKINSONS DISEASE rigidity, bradykinesia, or postural instability. (Parkinson's Disease Foundation (PDF)). Parkinsons affects

mostly people over 60 years old, but it is not limited only to old ages. It is extremely uncommon, but people in their 20s can also be affected. Risk factors concerning Parkinsons disease are still in an investigation status. Therefore not all the causes or risks factors are well known. The only thing that seems obvious is that it affects mostly men and older people; they have the highest probabilities of suffering from the disease. There are several factors that are being studied because they may be related to some kind of brain damage. Among those are: head trauma, exposure to chemicals and pesticides. The most surprisingly is that people who smoke or drink caffeine products are believed to be less exposed to the disease. (MFMER)., 2010) In the United States, Parkinson affects as many as one million Americans, which is more than the combined number of people diagnosed with multiple sclerosis, muscular dystrophy and Lou Gehrigs disease (Parkinson Disease Foundation). That is 1 in 272 people who have the disease. Approximately 60,000 people in the U.S. are diagnosed with Parkinson each year. However, that is not including the thousands of cases that go undetected which is estimated to be 1 in 90 people. Worldwide, around four million people are estimated to be living with Parkinsons disease. Statistics have shown that the risk of developing Parkinson increases with age, with an average onset at age 60, although some people are not diagnosed until their 70s or 80s. There is also early onset Parkinsons disease, which is diagnosed before the age of 40. Juvenile Parkinsons is the term for those diagnosed under 18 years of age. It has also been found that men are more likely to develop Parkinson than women. A recent epidemiological study published in the Journal of Neuroepidemiology, was the largest study of Parkinsons disease in the US, provided interesting data regarding ethnic and regional differences among Parkinsons rates. The study, conducted by Wright Willis and his colleagues, was based on data from 36 million Medicare recipients older than 65 for the years of 1995 and 2000-2005. It found that PD is twice

PARKINSONS DISEASE more likely to affect whites and Hispanics than blacks and Asians. Another finding was the geographic

clusters of PD, being more common in the Midwest and Northeast. This finding, while not conclusive, is of great interest because these two regions of the country are the most involved in metal processing and agriculture, and chemicals used in these fields are the strongest potential environmental risk factors for Parkinsons (Willis et al., 2010). Also consistent with previous studies, is that both the prevalence and incidence of PD steadily increased with age, with little variation. The combined direct and indirect cost of Parkinsons, including treatment, social security payments and lost income from inability to work, is estimated to be nearly $25 billion per year in the U.S. (Parkinson Disease Foundation, 2010). Medication costs for an individual person with PD average $2,500 a year and therapeutic surgery can cost up to $100,000 per patient. Considering the increased life expectancy in the U.S. and worldwide, it is expected to have an increased number of people affected by Parkinsons disease. PD has an estimated prevalence of up to 329/100,000. Although it is common, it can be difficult to diagnose clinically, particularly in early stages, and approximately 5 to 10% of patients with PD are misdiagnosed. Conversely, up to 20% of patients diagnosed as PD reveal alternative diagnoses at autopsy, such as multiple system atrophy (MSA), progressive supranuclear palsy (PSP), AD-type pathology, and cerebrovascular disease. However, it has been suggested that an accuracy of 90% is the best that can be achieved with clinical assessment and clinical diagnostic criteria. Life expectancy for people suffering from Parkinson's disease has improved markedly, in recent years, thanks largely to the increasing availability of more effective drugs and therapies for managing the symptoms of this distressing disease. According to the research from the Albany Medical Center (Drs. Factor and Feustel) and University of Rochester (Dr. Kurlan), NY; Memorial Hospital of Rhode Island (Dr. Friedman), at baseline, 56% of patients had an MMSE(Mini-Mental State Examination) score of <25, 12% were in a nursing home, 95% had hallucinations, and 60% had paranoia. On follow-up, 25% were dead, nursing home placement occurred in 42%, psychosis was persistent in 69%, and dementia was diagnosed in 68%. Select baseline characteristics

PARKINSONS DISEASE predicted individual outcomes: Nursing home placement was associated with the presence of paranoia and older age; persistent psychosis was associated with younger age at onset of PD and longer disease duration; dementia was associated with older age at PD onset and lower initial MMSE score; no characteristics

predicted death. Whether psychosis persisted or not had no significant effect on the development of the other three outcomes. The prevalence of hallucinations at follow-up was not different between groups currently receiving antipsychotics vs. those on no treatment. Psychosis in PD requiring antipsychotic therapy is frequently associated with death, nursing home placement, development and progression of dementia, and persistence of psychosis. Still, it appears the prognosis has improved with atypical antipsychotic therapy based on the finding that 28% of NH patients died within 2 years compared with 100% in a previous study done prior to availability of this treatment. Through the years, there have been many questions surrounding Parkinsons Disease (PD). It has several signs and symptoms and they consist of motor symptoms and non-motor symptoms. The symptoms of Parkinsonism result from the degeneration of nerve cells in the mid-brain and the corresponding loss of the neurotransmitting chemical dopamine produced by those cells. It is not fatal, not infectious, and it cannot be passed on to other members of the family. The characteristic motor symptoms of Parkinsons disease are tremor, rigidity, bradykinesia, and postural instability. Tremors are involuntarily and happen in the hands, fingers, forearm, or foot and are likely to occur when the limb as at rest, but not when the individual is performing tasks. Rigidity has a tendency to increase during movement and may produce muscle pain and facial masking (www.neurologychannel.com/parkinsons disease/symptoms.shtml). Individuals who have advanced Parkinsons syndrome show cognitive rigidity, which are jerky movements with passive muscle stretching, and also show trouble with their gait. They can appear to freeze and may have difficulty starting to walk (Linton, 2007, p. 447). Bradykinesia is slow movement. Since there is decreased dopamine, it causes a delay in transmission of signals from the brain to the skeletal muscles which produce bradykinesia. Postural

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instability shows difficulty in balance and disturbances in gait. This symptom combined with bradykinesia increases the chance of the individual to fall. One way to remember the four major symptoms of Parkinsons Disease is by remembering the acronym TRAP. T Tremor at rest (involuntary trembling of the limbs), R Rigidity (stiffness of the muscles), A Akinesia/Bradykinesia (absence or slowness of movement), and P Postural instability (impaired balance). Since Parkinsons Disease appears to trap the individuals body with his/her brains compromised ability to communicate, then this acronym makes the major four symptoms a lot easier to remember (http://www.umm.edu/parkinsons/signs.htm). There are also secondary motor symptoms associated with Parkinsons Disease. Not all individuals with Parkinsonism will experience them. These symptoms are stooped posture (a tendency to lean forward), dystonia, fatigue, impaired fine motor dexterity and motor coordination, impaired gross motor coordination, decreased arm swing, akathisia, speech problems (such as softness of voice or slurred speech, caused by lack of muscle control), micrographia, difficulty swallowing, and sexual dysfunction (http://www.pdf.org/en/symptoms#primary). As troublesome as the major and secondary motor symptoms are, non-motor symptoms of Parkinsons Disease such as sleep problems and depression, can also be a problem. These symptoms include pain, dementia or confusion, sleep disturbances, constipation, skin problems, depression, fear or anxiety, memory difficulties or slowed thinking, urinary problems, loss of energy, and compulsive behavior such as gambling (http://www.pdf.org/en/symptoms#primary). Many individuals often do not remember when they first started showing early signs of Parkinsonism. Early signs may be faint and may not be noticeable. Signs typically begin on one side of the body and become worse. These signs and symptoms include change in facial expression, failure to swing one arm when walking, flexion posture, frozen painful shoulder, limping or dragging of one leg, numbness, tingling, achiness or discomfort of the neck or limbs, softness of voice, and subjective sensation of internal trembling

PARKINSONS DISEASE (http://www.umm.edu/parkinsons/signs.htm). The important thing to realize about Parkinson's disease is that there is no single cause method to

make a positive Parkinson's disease diagnosis. Advancements in technology have made Parkinson's disease diagnosis more accurate with technology (genetic testing, neuroimaging, testing of the olfactory, autonomic system, and neurophysiological testing). Genetic testing makes it possible to view the disease at a molecular level. Several mutations that contribute to the pathology of Parkinson's disease have been identified. This testing also allows for genetic counseling where couples can find out if they are carriers of the mutated genes and, therefore, how likely they are to pass them on to their children. Neuroimaging such as PET scans are also useful and provide 3D images of the brain which allows one to analyze the unique brain of each patient. A CT scan or MRI may be used to check for signs of a stroke or brain tumor. Single-photon emission computed tomography (SPECT) is used along with a radio labeled compound. The compound will bind onto dopamine receptors and can be viewed using SPECT. This method allows the measurement of the amount of dopamine releasing neurons. The olfactory system is used by the body to detect smell. It is now well established that Parkinson's sufferers have impaired function of this system. Therefore testing this system can be an indicator of Parkinsonism. It usually involves the patient smelling a variety of odors, and then making a choice from a variety of possible answers for each one. (http://www.webmd.com/parkinsons-disease/guide/parkinsonsdisease-exams-and-tests) The autonomic system regulates processes in the body such as cardiovascular, respiratory and digestive function. It is also involved in salivation, perspiration, dilation of the pupils, discharge of urine, and erection. These functions are impaired by Parkinson's. Testing of the autonomic system usually involves examining breathing, heart rate, reflexes and thermoregulation (reaction to temperature). It is difficult to distinguish between Parkinson's and Multiple System Atrophy (MSA) as they share many of the same

PARKINSONS DISEASE characteristics. (http://www.parkinsons.org/parkinsons-diagnosis.html)

Ensure that the patient signed a consent form. Inquire about any allergies to iodine, shellfish or dye. Have the patient remove all jewelry, explain the procedure to the patient and have them remain still during procedure. Allow nothing by mouth (npo) for 4-6 hr before the procedures. Administer prescribe premedications or determined whether any medication should withheld. Have patient empty their bladder if able. Linton, A. D. (2007). Introduction to Medical-Surgical Nursing. Parkinsons syndrome There are currently no medical treatments for Parkinson syndrome. However there are ways to relieve the symptoms of Parkinson syndrome. These include physical therapy, drug therapy and surgical intervention. Clients with Parkinson syndrome are given levodopa combined with carbidopa. Carbidopa delays the conversion of levodopa into dopamine until it reaches the brain. Nerve cells can use levodopa to make dopamine and replenish the brain's dwindling supply. Bradykinesia and rigidity respond best to levodopa combined with carbidopa, while tremor may be only reduced slightly. Other drugs, such as bromocriptine, pramipexole, and ropinirole are also used to reduce the symptoms of Parkinson syndrome. When drugs dont work as effectively, the client may need surgery. A therapy called deep brain stimulation (DBS) is used. In DBS, electrodes are implanted into the brain and connected to a small electrical device called a pulse generator that can be externally programmed. DBS can reduce the need for levodopa and related drugs, which in turn decreases the involuntary movements called dyskinesias that are a common side effect of levodopa. It also helps to alleviate fluctuations of symptoms and to reduce tremors, slowness of movements, and gait problems. DBS requires careful programming of the stimulator device in order to work correctly. Physical therapy programs that include massaging, heat, exercise and gait retraining seems to be the most beneficial. To treat swallowing issues and difficulty with speech, speech therapy has been used. Nursing management for the patient with Parkinsons syndrome is primarily related to maintaining mobility and preventing injury. (Linton, 2007, p. 448) Nurses are a part of the healthcare team to help or to

PARKINSONS DISEASE cope with the client with relief of the symptoms of Parkinsons syndrome. As mentioned in the quote

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maintaining mobility and preventing injury is the most important in nursing. Nurses have to teach the patient with Parkinson disease to exercise regularly to maintain balance and mobility. Also, nurses have to teach the client preventing falls through environmental control. For example, use a handrail to balance them, leaving the lights on at night and removing hazardous objects. Nurses should teach the patient that the drug only relieves the symptoms of Parkinsons syndrome and not cures them. The patient should also be taught the name of the drugs that needs to be taken, when the drug should be taken and any side effects that should be told to the physician. Brain surgery may be considered when drugs fail to control symptoms of Parkinson's disease. Surgery most often becomes a treatment option for people when Parkinson's disease progresses to the point that drugs can no longer control symptoms adequately. Surgery is usually not considered for people who have dementia or psychiatric disorders. Some choices of surgical procedures are Deep brain stimulation, Thalamotomy, Pallidotomy and Neurotransplantation. Deep brain stimulation is a surgical procedure used to treat several disabling neurological symptoms, such as tremor, rigidity, stiffness, slowed movement and walking difficulties. This type of surgery is generally used when the patient is in the advance stages of Parkinsons disease, and has unstable medication responses. Thalamotomy is the thalamus a tiny part of the brain which is destroyed or removed by cutting (ablated), this procedure may help reduce tremor. Thalamotomy is rarely performed these days. It may be used for patients with tremor who have not responded to medication. The procedure does not improve slow movement, walking difficulties or speech problems. Pallidotomy - since the introduction of deep brain stimulation, this procedure is rarely done. The gobus pallidus, a part of the brain, may be overactive in patients with Parkinsons disease, causing a different part of the brain which controls movement to become less active. The surgeon destroys a small part of the globus pallidus by creating a scar, resulting in less activity in that area of the brain, which in turn may help relieve movement symptoms, such as rigidity

PARKINSONS DISEASE and tremor. Neurotransplantation is an experimental procedure in which fetal brain cells (neurons) that produce dopamine are implanted in the area of the brain that controls movement (striatum). In theory, the transplanted neurons can make up for the loss of the normal dopamine-producing cells that occurs in Parkinson's disease. (http://www.webmd.com/parkinsons-disease/guide/parkinsons-disease-surgery)

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Ensure that the patient signed a consent form. Inquire about any allergies to iodine, shellfish or dye. Have the patient remove all jewelry, explain the procedure to the patient and have them remain still during procedure. Allow nothing by mouth (npo) for 4-6 hr before the procedures. Administer prescribe premedications or determined whether any medication should withheld. Have patient empty their bladder if able (Linton, 2007). There is no known way to prevent Parkinsons disease at this time. There are several ways to prevent the disease. In diet, research has shown that people who take multiple antioxidants may have some protection against Parkinsons disease, although the study is investigate. Oxidative stress is one of the intermediary risk factors could initiate and/or promote degeneration of DA neurons in PD. Therefore, supplementation with antioxidants may prevent or reduce the rate of progression of this disease (National Center for Biotechnology Information, 2010). Ascorbate is a major antioxidant in the brain and especially in neurons, where it reaches a 10 mm concentration, and it is an effective radical scavenger against peroxyl and hydroxyl radicals, superoxide, singlet oxygen, and peroxynitrite (Zecca et al, 2008). Antioxidants-rich foods include blueberries, beans, artichokes, etc. Even though its effect is still under studying, research said that fruits, vegetables, high-fiber foods, fish, and omega-3 rich oils may have some protection against PD (webmd, 2010). Daily taking 3,000mg of Vitamin C and 3,200 IU of Vitamin E can progress PD slowly. Vitamin B group is also important in brain functions and enzyme activity. Especially brain dopamine production depends on adequate supplies of Vitamin B6 (ncbi, 2010). Overload of iron in neuromelanin typically occurs in PD where an increase of reactive/toxic iron bound to neuromelanin has been reported (Zecca et al, 2008). Neuromelanin inhibited the

PARKINSONS DISEASE iron-mediated oxidation of ascorbic acid, thus sparing this major antioxidant molecule in brain. The protective effect of neuromelanin on ascorbate oxidation occurs even in conditions of iron overload into

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neuromelanin. The blockade of iron into a stable ironneuromelanin complex prevents dopamine oxidation, inhibiting the formation of neurotoxin dopamine quinones. The above processes occur intraneuronally in aging and PD, thus showing that neuromelanin is neuroprotective. The iron- neuromelanin complex is completely decomposed by hydrogen peroxide and its degradation rate increases with the amount of iron bound to neuromelanin. This occurs in PD when extraneuronal ironneuromelanin is phagocytosed by microglia and iron-neuromelanin degradation releases reactive/toxic iron. Both retrospective and prospective epidemiological studies have consistently demonstrated an inverse association between cigarette smoking and PD, leading to theories that smoking in general and nicotine in particular might be neuroprotective. Nicotine has been shown in animals to stimulate the release of dopamine in the striatum, and to preserve nigral neurons and striatal dopamine levels in laboratory animals with lesioned nigrostriatal pathways (Ross, 2001). Coffee and caffeine consumption have also been shown in epidemiological studies to be inversely related to PD risk. Caffeine is an adenosine A2A receptor antagonist that enhances locomotor activity in animal models of parkinsonism (Ross, 2001). Theophylline, a related compound that has A2A receptor blocking properties, has been shown in one small trial to improve motor function in patients with PD. Life style also helps prevention of PD. Regular exercise such as physical therapy and daily moderate exercise can help maintain normal muscle tone and function. Avoiding toxins such as pesticides, cleaners, and other chemicals used in household cleaning and in agriculture and lawn care have been liked to PD (ncbi, 2010). PD is difficult to come up with ways to prevent it. However, researchers are now looking for a biomarker, a biochemical abnormality that all people with PD might share, that could be picked up by screening techniques or by a simple chemical test given to people who do not have any PD symptoms.

PARKINSONS DISEASE As a person with Parkinsons disease (PD) gets further into the disease, there are many motor and nonmotor or neuropsychiatric complications that take place. Motor complications usually will begin after five years or so resulting in continual changes of the patients medication (We Move 2008).

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Some of the motor complications that may occur are motor fluctuations, freezing, off period dystonia, dyskinesia, and falls. Motor fluctuations are caused by the reduced effects of a dose of levodopa or failure of a dose to work. Some motor movements may be blocked; hesitation when trying to make a turn is one example. This is called freezing and is a complication that may not respond to medication. There may also be off period dystonia before morning dose of medication has been given. Another problem is when levodopa is at its peak action, causing involuntary movements called dyskinesia. As PD advances, usually falls become more frequent. When a patient gets to this stage, it is important for a nurse to assess if the patient may need a cane or even wheelchair (We Move 2008). Some of the nonmotor complications are constipation and urinary problems such as incontinence or retention. These may be due to the disease process or possible side effects of medications used. Also, chewing and swallowing may become difficult in the later stages of PD affecting up to 95% of PD patients (Bunting-Perry, 2007). Many nonmotor complications are neuropsychiatric. Some common ones are depression, psychosis, cognitive impairment and dementia, sleep disorders, and anxiety. Depression is one of the most common psychiatric complications and is believed to affect between 40% and 45% of people with PD. The abnormalities of neurotransmitters are believed to be one cause of depression. Another cause is a persons reaction to finding out about the disease and knowing there is no cure. About 40% of people with PD will be affected by anxiety. Its not sure if this is cause by the psychological reaction to having the disease or because of the neurochemical changes that the disease produces. Psychosis is known to affect 20%-40% of PD patients. They may experience such things as illusions, hallucinations, or paranoid delusions. For example, they may become jealous, thinking their spouse is having an affair. About 50% of PD patients have mild

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cognitive impairment and later in the disease about 30% will get dementia. Sleep disorders will affect 60%98% of patients and can have many causes. Possible reasons are the motor symptoms of the disease, medications, pain, mood disorders, and dementia. Many patients tend to nod off during the daytime which can also contribute to a poor nights sleep (Ferreri, Agbokou, & Gauthier 2006). Due to the many complications of PD patients, nurses should be aware of what to look for when giving care. Certain complications can be easier to assess for and address. Increased fiber, stool softeners, exercise, and good hydration can improve problems with constipation. For swallowing difficulties, the patient and family should be educated about how to help the patient avoid aspiration. Making sure the patient sits upright to eat at meals and for a half hour after, using thickeners for liquids, and eating slowly are all important to teach. Assessing for depression can be difficult because it can have similar symptoms as PD symptoms. It should be checked for during regular visits and may require more direct questioning of the patient and family. Support groups are important resources for patients dealing with depression. For psychotic behaviors, the nurse can help the family to find ways to minimize certain conduct and learn how to best communicate in ways that diffuse the situation rather than causing agitation (Bunting-Perry, 2007). There is much information a nurse can teach clients and their families for the many complications this disease can cause. The diagnosis of Parkinsons disease is usually a traumatic and depressing moment in the life of a person. It is a life changing event that affects not only the client, but the family members as well. One of the first interventions that we should do as nurses is to teach the patient and family how to cope with the anxiety that develops throughout the disease progression. The level of anxiety can be decreased by educating the client about what to expect during the course of the disease. Knowledge is power and this will give the patient a sense of control. We should also teach the patient different techniques to reduce anxiety. Once we have established a decreased level of anxiety the patient will be more focused in understanding the different

PARKINSONS DISEASE treatments available such as medications, therapies, and changes in activities of daily living. This understanding will promote the client's compliance while making life more manageable.

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According to Linton (2007), after assessing the patients level of mobility and capacity to perform self care, we should encourage the patient to remain as independent in self care as possible." (p. 448). It is of utmost importance to encourage the patient to follow up with the medical treatments, including physical and occupational therapies to delay deterioration and improve motor skills. Another important subject is to teach the patient and family members about the risk for injury and how to prevent them. An additional part of the care plan is to teach the patient regarding the significance of a balanced nutrition and exercise program to preserve a healthy body. The use of assistive divices can be a great help to the client and are hightly recomended to avoid injuries. Some recommendations by the National Parkinson's Foundation includes firm shoes with elastic shoelaces or velcro straps to avoid the need to tie shoes, grab bars to provide support when getting in and out of the shower, and hi-lo scoop plates to keep food from sliding off. (National Parkinson Foundation, 2009). As a nurse it is important to remember that one of the main goals is to teach the client new ways to adapt to the disease as it progresses. Being supportive and caring is one of the greatest thing we can do for the patients and families. A lot of progress has been made in Parkinson's disease research. Researchers have come a long way, and have developed drugs and other therapies that help to relieve some of the symptoms of Parkinson's disease. Although no cure has been found yet, Parkinson's disease research continues to make headway. One research is the V1512, is an effervescent formulation of the more soluble form of L-dopa, levodopa methylester, in combination with the decarboxylase inhibitor, carbidopa. Decarboxylase inhibitors enhance absorption of L-dopa and help prevent peripheral side effects that can occur from the rapid systemic decarboxylation of L-dopa to dopamine. The trials have also demonstrated a more reliable drug response in

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comparison with conventional L-dopa preparations. These studies formed the basis of regulatory approval in Italy, where Chiesi already market the drug as rescue (fast-onset) treatment for PD. Another research is the cycling exercise, Theracycle. This type of exercise helps reduced rigidity and tremor, reduced bradykinesia, improved flexibility and balance, improved bladder and bowel function. In other research, gene therapy, using stem cells, was found to reduce some cardinal Parkinson's Disease symptoms, mainly, dyskinesias (the abnormal involuntary movements). Researchers believe that transplanting embryonic stem cells into target cells in Parkinson's disease patients may allow regeneration of dopamine producing cells. Stem cells have the capability of transforming into any other cell in the body. Stem cell research has been a hot topic in the science and political world for several years now. There have been some successes in which symptoms have been reduced in rats (http://www.parkinsons.org/parkinsonsresearch.html). Parkinson's disease is a complex progressive neurological disorder, the symptoms of which are variable throughout the course of the illness. The overall goal of care in patients is to improve prognosis and reduce the impact of the disease on both patients and their care givers with skilled medical and nursing intervention; to maintain functional ability and retain independence. At differing stages of the disease, care requirements will change. Medical treatment with drugs and surgical techniques is effective in Parkinson's disease, but there is also a major role for nurses in helping the patient come to terms with the disease, provision of information and care management. It is suggested that nurses familiarize themselves with this scale in order that the problems that may result as a consequence of the disease can be identified and addressed. Nurses should note that care of the Parkinson's disease patient is multidisciplinary. One professional cannot hope to meet all the needs of a single patient therefore it is essential that effective communication lines between care professionals are established for the good of the patient. The scale can assist in the recognition of these needs, and prompt review and reassessment of the needs as the disease progresses. Providing timely and appropriate

PARKINSONS DISEASE care for patients can do much to enhance quality of life, and the paradigm can provide an aide-memoire to facilitate this process (http://www.pdcaregiver.org/Parkinson_Challange.html).

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References

PARKINSONS DISEASE American Academy of Neurology (2003). Retrieved from www.neurology.org/cgi/content/abstract/60/11/1756 American Parkinson Disease Association Retrieved from http://www.apdaparkinson.org/userND/index.asp Bunting-Perry, L.; Vernon, G.(2007). Comprehensive Nursing Care. New York: Springer Publishing Co. p.79-154 Clinic.com Retrieved from http://www.mayoclinic.com/health/parkinsonsdisease/DS00295/DSECTION=symptoms Ferreri, F., Agbokou, C., & Gauthier, S. (2006). Recognition and management of neuropsychiatric complications in Parkinson's disease. CMAJ: Canadian Medical Association Journal, 175(12), 1545-1552. doi:10.1503/cmaj.060542. Health Communities (2010). Signs and Symptoms. Retrieved from http://www.neurologychannel.com/parkinsonsdisease/symptoms.shtml Linton D, A. (2007). Introduction to Medical-Surgical Nursing. Missouri: Saunders. National Parkinson Foundation. (2009). Activities of Daily Living: Practical Pointers for Parkinson Disease. In N. P. Foundation.

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Parkinson Disease Foundation. (2010). Statistics on Parkinson's - Parkinson's Disease Foundation (PDF) Hope Through Research, Education and Advocacy. Retrieved May 20, 2010, from http://www.pdf.org/en/parkinson_statistics Radiologyinfo. (n.d.). Retrieved March 18, 2010, from PET Scan and Parkinson's Disease: http://www.radiology-info.org/nuclear-medicine-positron-emission-tomography/pet-scan-parkinsondisease.html Report of the Quality Standards Subcommittee of the American Academy of Neurology April 11, 2006, Retrieved from www.aan.com/practice/guideline/index.cfm?fuseaction=home Ross. G.W. (2001). Current Evidence for Neuroprotective Effects of Nicotine and Caffeine Against

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Parkinson's Disease. Vol. 18 Issue 11, p797-806. Retrieved May 25. 2010 from Ebsco-Host. The Medical News, Retrieved from www.news-medical.net/.../Parkinsons-Disease-Prognosis.aspx University of Maryland Medical Center (2010). Marylands Parkinsons Disease and Movement Disorders Center. Retrieved from http://www.umm.edu/parkinsons/ signs.htm U.S. NationalLibrary of Medicine. (2004). Multiple antioxidants in the prevention and treatment of Parkinson'sDisease.Retrieved May 25, 2010 from http://www.ncbi.nlm.nih.gov/pubmed/10511322. We Move. (2008, Dec 7). Complications of Treatment. Retrieved 5 15, 2010, from wemove.org: http://www.wemove.org/par/par_ctre.html WebMD. (2008, 12 08). Retrieved March 18, 2010, from Diagnosing Parkinson's Disease - WebMD: http://www.webmd.com/parkinsons-disease/guide/parkinsons-disease-exams-and-tests Willis, A. W. (2010). Geographic and Ethnic Variation in Parkinson Disease: A Population-Based Study of US Medicare Beneficiaries. Neuroepidemiology, 34, 143-151. Zecca et al. (2008). Neuromelanin can protect against iron-mediated oxidative damage in system modeling iron overload of brain aging and Parkinsons disease. Vol.106 Issue 4. p18661875. Retrieved May 25.2010 from Ebsco-Host.