1. “Cases in Sudden Deterioration in Parkinsons Disease” Department of Neurology Patrick Browne RGN, RNP, BNS, BSc, PG Dip. HSc (ANP), MHSc. Movement Disorders Advanced Nurse Practitioner Candidate

2. Our Main Lesson…

3. Outline for Cameroon PD talk Focus of this talk: How general nurses can help recognise what is wrong in the causes of SUDDEN DETERIORATION in Parkinsons

4. A Quick Word on Subtypes Case examples How does deterioration present? Why do we see deterioration in Parkinsons Disease? What can be done – concentration on constipation? Take Home Messages Final Word – Recognising the Dopamine Dysregulation Syndrome

6. A Quick Word on Subtypes Thinking of Parkinsonism Pakinsonism the description of “looking like Parkinsons Disease”

7. A Quick Word on Subtypes What looks like Parkinsons 1 Parkinsons 2 Parkinsons Dementia 3 Lewy body Disease Dementia 4 Progressive Supranuclear Palsy 5 Multiple Systems Atrophy 6 Iatrogenic Parkinsons – after Phenothiazines 8 Other dementias with a Parkinsonian flair - FTD with Parkinsonism

9. Case Studies 1 –John is a 72 yr old man –Admitted to St Ritas –From St Elsewhere NH –Parkinsons much worse recentl;y –Getting bad for years –No change with medications –NBO x 10/7

10. Case Studies 2 –Peter is a 74 yr old man –Admitted to St Finbarrs ward for Hip fracture –PD x 9 yrs – but doing well –Day 2 post op – severe tremor –Can’t walk – thinks leg hurting him

11. Case Studies 3 –Paul is a 74 yr old man (twins) –Admitted to St Finbarrs ward for Hip fracture –PD x 9 yrs – but doing well –Day 2 post op – severe tremor –Can’t walk – tablets not working any more

12. Case Studies 4 –Patrick is a 74 yr old man (triplets) –Admitted to St Finbarrs ward for Hip fracture –PD x 9 yrs – but doing well –Day 2 post op – severe tremor –Sickness and Vomiting after the operation

13. Case Studies 5 –Mary is a 62 yr old lady –Admitted to CCU with acute coronary syyndrome –Had had PD x 6 yrs - doing pretty well but dyskinesia –Now poor mobility and dyskinesia are very much worse – can’t go home

14. Case Studies 6 –Catriona is 84 yr old lady –PD x 12 yrs –In nursing home –Slowly worse –Was told in clinic “ It’s all just constipation !!!” –Horrendous diarrhoea for 3/7 “left in a mess”

16. How does deterioration present? Presentations of deterioration First of all Parkinson’s is a chronic progressive neurological disease charachterised by a slow decline Therefore we need to recognise the difference between a slow natural decline - (which may be rescuable as well) and a more sudden deterioration

17. How does deterioration present? Presentations of deterioration 1)Worsening tremor 2)Stiffness in muscles / limbs 3)Slowness moving and walking 4)Poor balance - falls 5)“Freezing” in gait 6)Confusion / delerium esp in elderly 7)Hallucinations especially in elderly 8)Daytime Sleepiness – especially in the elderly

18. How does deterioration present? Presentations of “sudden” deterioration - or in practical terms : - Taking to the bed - Just not getting up any more - Has PD a long time and just getting worse - Is this the final stage of a vicious circle of decline that has been going off the rails for months??? Therefore sudden ==== subacute

20. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –1 CONSTIPATION

21. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –1 CONSTIPATION CASE 6: –Catriona is 84 –PD x 12 yrs –In nursing home –Slowly worse –Was told in clinic “ It’s all just constipation !!!” –Horrendous diarrhoea for 3/7 “left in a mess”

22. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –1 CONSTIPATION Bacterial overgrowth from bowel into gut prevents absorbtion of drugs Slow GastroIntestinal transit affects absorption of drugs Make the persons simply feel unwell

23. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –1 CONSTIPATION –John is a 72 yr old man –Admitted to St Ritas –From St Elsewhere NH –Parkinsons much worse recently –Getting bad for years –No change with medications –Student Nurse finds out NBO x 10/7 COMMON SCENARIO

24. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –2 Illness / Infection

25. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –2 Illness / Infection CASE 3 –Paul is a 74 yr old man (twins) –Admitted to St Finbarrs ward for Hip # –PD x 9 yrs – but doing well –D2 post op – severe tremor –Can’t walk – tablets not working any more

26. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –2 Illness / Infection CASE 3 –In Pauls case – intercurrently unwell because of infection leading poor swallow leading to acute renal failure AND this is why his Parkinsons is worse –Changing Sinemet to qid from tid WILL NOT WORK and probably make him worse.

27. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –3 Stress Related Episode

28. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –3 Stress Related Episode –Mary is a 62 yr old lady –Admitted to CCU with acute coronary syyndrome –Had had PD x 6 yrs - doing pretty well but dyskinesia –now poor mobility and dyskinesia are very much worse – can’t go home

29. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –4 Dehydration

30. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –4 Dehydration –NO CASE EXAMPLE –It’s an obvious common problem – swallow – meal times – foods they like

31. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –5 Drugs and Medication

32. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –5 Drugs and Medication –Key Questions –IN HOSPITAL (and in the nursing home if new there: –1) Is the time the same as at home as in Hospital –2) Are we using protein drinks in Hospital –3) Is the food totally different – the PROTEIN –4) Are they the correct drugs – medication error

33. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –5 Drugs and Medication –Key Questions –AT HOME: –1) Are they taking the tablets –2) Is there a new regime at home with food – has the daughter taken over – Does the home help now give drugs with food

34. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –6 use of Neuroleptics or other containdicated drugs

35. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –6 use of Neuroleptics or other contraindicated drugs CASE 4 –Patrick is a 74 yr old man (triplets) –Admitted to St Finbarrs ward for Hip # –PD x 9 yrs – but doing well –D2 post op – severe tremor –Sickness and Vomiting after the operation - STEMITIL

36. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –6 use of Neuroleptics or other contraindicated drugs –The obvious example – drugs used for sedation –The phenothiazines serenace (haloperidol) etc

37. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –7 Depression

38. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –7 Depression –No Case example –We have to remember that Depression is extremely common in PD – both because of having the Disease and what the disease does – whole brain disorder – often counselling and or drugs especially will help with this.

39. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –8 Acute / Chronic Pain

40. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –8 Acute / Chronic Pain CASE 1 -Peter is a 74 yr old man –Admitted to St Finbarrs ward for Hip # –PD x 9 yrs – but doing well –D2 post op – severe tremor –Can’t walk – thinks leg hurting him

41. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –8 Acute / Chronic Pain –This causes exactly the same problems to the person as stress – the drugs are less effective. –Always remember – everything that goes wrong in PwP is NOT due to Parkinsons –Is it a disc – Is it an Infection – Is it sciatica – Are we controlling the pain in Hospital after a “normal” common procedure.

42. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –9 Anxiety / Panic Attack

43. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –9 Anxiety / Panic Attack –NO CASE EXAMPLE –This is similar to the depression and stress situation – however Anxiety leads to more dramatic sudden problems like FREEZING

44. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –10 Poor Sleep / Lack of Sleep

45. Why do we see deterioration –What are the top 10 causes of deterioration in PD? –10 Poor Sleep / Lack of Sleep –Feature of PD –REM Sleep behavour disorder –He Kicks wife – she wakens and then wakens him – COMMON –Leads to sleep inversion and makes everything worse –Straightforward solutions – Clonazepam to regularise the sleep pattern –IN HOSPITAL – hard to sleep – noise / blackout blinds

47. What can be done –Touch Talk Time These are key values lacking in the our modern health services model

48. What can be done –Touch Talk Time but the opportunity to take the time to identify the cause is critical: If we have two options –PATIENT WORSE »GIVE MORE SINEMET or »FIND OUT WHY PwP WORSE

49. What can be done –The CONSTIPATION issue –1) Warn the patient, their family, the nursing home –There will be rough days ahead...

50. What can be done –The CONSTIPATION issue –2) Think of the Dam –Dam blocks –Dam overflows – the flood –But the Bulk of the dam is till there – perhaps even made worse by the constipating agents

51. What can be done –The CONSTIPATION issue –3) Strategies –Movicol – 6 sachets in a litre of water with fruit juice taken over the morning –NaPico sachet Picolax –NaPico as laxoberyl –Stool softener – lactulose –Senna –All the natural options – Fruit / Fibre / Fybogel –FLUID FLUID FLUID FLUID vs Speed to get to toilet concerns

52. What can be done –The CONSTIPATION issue –3) Therefore a TEAM APPROACH to consitipation – engaging: Person with Parkinsons Family Nursing Staff Nursing Home Doctors

55. Take Home Messages A deterioration in PD is usually going to be due to one main factor going off the rails And then….. There is the descent into chaos

56. Take Home Messages Identify the Cause Treat the cause Allow time Problem And the person will get back to normal

57. Take Home Message 1 People with Pakinson’s have a severe incurable Brain Disease…. But Are FIXABLE Often by very simple measures where nursing staff have a key role in advocacy, identification and amelioration

58. Take Home Message 2 When there is sudden (Acute) or Sub Acute deterioration There is usually NO need to adjust the Parkinsons’ medication unless Absolutely Necessary