Diseases: PARKINSON’S AND MYASTHENIA GRAVIS Jane E. Binetti RN MSN NEURO CONDITIONS 2 Diseases: PARKINSON’S AND MYASTHENIA GRAVIS Jane E. Binetti RN MSN

Parkinson’s Disease Neurodegenerative disease that is chronic and progressive characterized by: Bradykinesia Rigidity Tremor at rest Gait disturbances “Parkinsonism” is a term that encompasses many other conditions than just Parkinson’s Disease

What is it? A breakdown of dopamine producing neurons causes an imbalance between dopamine and acetylcholine Dopamine is a neurotransmitter to the motor system Posture, balance, movement Disease is advanced before sx appear 80% of neurons lost Incidence is 20/100,000 Prevalence >50; Peak onset >70 ~ 15% < 50

What do you see? Sx are very slowly progressive, sometimes not noted Unilateral at first – pts can accommodate Triad of sx is classic presentation: Tremor – often 1st sign, at rest, “pill rolling” Rigidity – jerky movement of muscles Bradykinesia – Pt lacks automatic, involuntary movement

Complications Aside from all the motor deficits pts also suffer: depression, apathy, loss of memory fatigue constipation, impotence With progression of disease: Total immobility or dementia Hallucinations, psychosis Malnutrition, aspiration Risk for falls and sleep disturbances

Diagnostics No specific testing Careful H and P Minimum of 2 of the classic triad sx Best reflection of accurate dx is response to tx Research involves PET scans and MRIs

Collaborative Care Medications used to enhance dopamine or decrease cholinergic action: Dopaminergics: Levodopa (L-Dopa) Levodopa/carbidopa (Sinemet, Parcopa) Dopamine Receptor Agonists Bromocriptine (Parlodel) Pramipexole (Mirapex) Ropinirole (Requip) Rotigotine (Neupro)

More Medication Anticholenergics – decrease activity of acetylcholine to keep balance between L-Dopa and acetylcholine. Trihexyphenidyl (Artane) Benztropine (Cogentin) Biperiden (Akineton) Symmetrel Other drugs used in combination to address specific sx

Surgical Therapy Three surgical therapies can be used for pts who are unresponsive to medical therapy Ablation Done to target areas around the thalamus – used for 50 yrs Deep Brain Stimulation Newer treatment, done with electrode in and around the thalamus and a generator in the chest Programmed like a pacer Transplantation Experimental

Nutrition Dietary concerns include Dysphagia, malnutrition, constipation Pt may need to be fed Absorption of L-Dopa can be impaired by protein and B6 Watch fortified cereals Multivitamins

What do you do? Care centers around maintence of good health Movement – PT Safety – falls Nutritional needs Mental health Maximize quality of life Support groups Compliance

Myasthenia Gravis Autoimmune Disease affecting the neuromuscular junctions Skeletal muscle weakness Age range 10-65 2 times more common in women peak in childbearing years As population ages, male and female are equal 6/100,000 people About 18,000 people with this disease in US

What is it? Antibodies attack acetylcholine receptors Impairs conduction for muscle contraction Some cases wax and wane; stabilize; some rapidly progress No sensory loss, no atrophy, reflexes are intact Exacerbations triggered by: Illness, trauma, stress, pregnancy, temperature

Other exacerbation risks Aminoglycosides Cardiac Drugs Beta–adrenergic blockers, some anti-arrhythmics Anti- Epileptics phenytoin Psych meds: Lithium, benzos, tricyclics Phenothiazines Neuro meds: Neuromuscular blockers

What do you see? Initially, skeletal weakness that improves with rest Facial muscles often first affected Weaker through the day Speech, voice, neck, shoulder Eventually arms and legs

Complications Myasthenic Crises Sudden exacerbation of muscle weakness Triggers: Infection, surgery, trauma Emotional distress, overdose Noncompliance with meds Major risk is respiratory failure Inability to swallow leads to aspiration pneumonia

Diagnostics Detailed H and P EMG and NCS Tensilon Test IV dose of Tensilon Increases muscle contractility Cholinergic Crisis Too much is given and cholinesterase is inhibited Very strong muscle weakness, sweating, pupil constriction IV atropine on hand

Collaborative Care Medications Anticholinesterase: pyridostigmine (Mestinon) Corticosteroids: prednisone Azathioprine (Imuran) Mycophenolate (Cellcept) Cyclosporine (Sandimmune)

Collaborative Care Surgical Therapy Other Therapies Thymectomy Decrease production of AChR antibodies Thymomas Other Therapies Plasmaphoresis – for crisis or pre-op IgG infusions

What do you do? The goal is to optimize muscle function Priorities: Control fatigue Avoid complications Maintain optimal quality of life Priorities: Patent airway Medication administration Assessing side effects Meeting ADLs Support

Nursing Diagnoses Ineffective Breathing Pattern Ineffective airway clearance Impaired verbal communication Imbalanced nutrition Disturbed sensory perception Activity intolerance Disturbed body image