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M6 13-005

Exam 15: Multiple Sclerosis & Parkinson's Disease

Multiple Sclerosis (MS) A common, progressive degenerative neurological disease. The myelin sheath, the covering around the axon, is destroyed with inflammation and scarring.
Causes of MS Cause is unknown: Viral infection? Onset 15 – 50 years old. Women > Men. Greater incidence in temperate climates. Higher rate among relatives – genetic link inconclusive.
Etiology/Pathophyiology of MS Proliferation of gamma/delta T-cells in CSF. Moderators of the Immune System. In MS, T-Cells attack the body End result is damage to the myelin sheath.
Clinical Manifestations of MS Visual problems. Urinary incontinence. Fatigue. Weakness or uncoordination of an extremity. Sexual problems such as impotence in men. Difficulty swallowing.
Assessment of MS (Subjective Data) Patient's understanding of the disease process. Presence of eye problems. Weakness or numbness of a part of the body. Fatigue, Emotional instability. Bowel bladder problems. Vertigo, Ataxia , Tremor. Loss of joint sensation. Impotence. Pain is unc
Assessment of MS (Objective Data) Nystagmus. Muscle weakness and spasms. Changes in coordination. Spastic, ataxic gait. Evidence of behavior changes.   Urinary incontinence. Difficulty swallowing. Intention tremors of the upper extremities.
Diagnosis of MS: CSF Shows elevated gamma globulin and a proliferation of gamma/delta T cells
Diagnosis of MS: CT Scan May show enlargement of the ventricles
Diagnosis of MS: MRI May be helpful in the final diagnosis. Identifying certain hallmark changes in the brain.
Medical Management of MS No cure, no single treatment for all symptoms. Control of symptoms: -Adrenocorticotropic hormone (ACTH). -Corticosteroids Effects of ACTH and steroids are unknown.
Spasticity (Skeletal Muscle Relaxants) For MS. diazepam (Valium). dantrolene (Dantrium). baclofen (Lioresal).
Immunomodulating Agents Interferon beta-1b (Betaseron). Interferon beta-1a (Avonex).
Interferon beta-1b (Betaseron) SQ q every other day. Used in ambulatory patients with relapsing-remitting. MS to reduce frequency of exacerbations.
Interferon beta-1a (Avonex) Given IM once a week. Decreases the frequency of exacerbations in select patients and slows the progress of physical disability.  
Immunomodulator: glatiramer acetate (Copaxone) For use in relapsing MS. Believed to interrupt the inflammatory cycle.
Antineoplastic / Immunosuppresant mitoxantrone (Novantrone) Reduces both B and T lymphocytes. Given intravenously monthly. Cannot be used for more than 2-3 years due to cardiac toxicity.
Propantheline bromide (Pro-Banthine) Promotes elimination. For urinary frequency and urgency.
Cholinergic drugs-bethanechol chloride (Urecholine) promotes Elimination. neurogenic bladder-exerts a direct antispasmodic effect on smooth muscles.
With MS Stool softener docusate sodium (Colace) and prune juice are recommended.
Common problem with MS UTIs
Interferons therapeutic effects __________ incidence of neurological dysfunction. reduce
nutrition with MS Well Balanced High fiber foods with adequate fluids Obesity makes it more difficult for patient
Skin Care with MS Prevent breakdown Sensory impairment reduces sensation of discomfort.
Activity with MS Regular exercise with rest periods Bedrest may be ordered during exacerbations Physical therapy
Control of Environment with MS Avoid hot baths Prevent traveling during the warmest part of the day Provide air-conditioned surroundings during the summer Provide a peaceful and relaxed environment.
With MS prepare patients and family for explosive emotional outbursts slowness in speech and slowness in ability to respond
Parkinson's Disease Syndrome that consists of A slowing down in the initiation and execution of movement (bradykinesia), -Increased muscle tone (rigidity) -Tremor -Impaired postural reflexes. No known cure.
Dopamine is a neurotransmitter
Causes of Parkinson's Disease Possible genetic link. Encephalitis lethargica, or type A encephalitis. Intoxication with a variety of chemicals. Drug-induced parkinsonism.   Patients with cerebrovascular disease often have parkinsonism-like symptoms.
Patients with cerebrovascular disease often have parkinsonism-like symptoms
Most patients with Parkinsonism have Degenerative or idiopathic form, for which the term Parkinson’s disease is usually reserved.
Onset of Parkinson's Disease Gradual and Insidious
Beginning stages of Parkinson's Disease show Mild tremor, slight limp, decreased arm swing, change in handwriting
Later stages of Parkinson's Disease show Shuffling, propulsive gait with arms flexed. Loss of postural reflexes. Slight change in speech patterns.
Subjective data with Parkinson's Disease Fatigue. Presence of uncoordination. Judgement defects. Emotional instability. Anxiety. Depression. Heat intolerance.
Objective data with Parkinson's disease. Tremor (Pill rolling). Bradykinesia. Rigidity & loss of postural reflexes (cogwheel). Mask-like appearance on the face. Drooling. Moist, oily skin. Constipation. Scaly, erythematous rash.
Diagnosis of Parkinson's Disease No specific test. Clinical examination. history. Pt response to medication confirm. CT scan (may show Cerebral atrophy). EEG may show slurring. Upper GI may show decreased motility.
Treatment for Parkinson's Based on easing the S&S of the disease.
Surgical interventions for Parkinson's Disease Destroy portions of the brain controlling rigidity or tremor. Human Fetal Dopamine Cell Transplant.
Anti-Parkinson Agents Aimed at increasing the levels of dopamine and/or antagonizing the effects of acetylcholine
Anti-Parkinson Agents Action Aimed at restoring natural balance of acetylcholine and dopamine in the CNS
Dopamine Receptor Agonists (Anticholinergic)-Indirect acting Blocks central cholinergic receptors Is indicated in treatment of mild cases of Parkinson’s disease and control of extrapyramidal reactions. Examples: benztropine mesylate (Cogentin) and trihexyphenidyl HCL (generic only-formally called Artane).
Presynaptic Dopamine release enhancer Potentiates the action of dopamine in the CNS-Indirect acting.  Example- amantadine HCL (Symmetrol).  Interacts with anticholinergic drugs, sulfonamide antibiotics, quinidine, and thiazide diuretics.
Dopaminergic: Direct acting. Bromocriptine (Parlodel) and pergolide (Permax) Direct stimulation of the dopamine receptors
Dopaminergic: Direct acting Carbidopa-levodopa (Sinemet) Increases levels of dopamine and levodopamine. lower dosage is needed than with single-dose therapy). Efficiency may increase 75%
Dopaminergic decrease effectiveness if taken with Metoclopramide or Phenothiazines.
Levodopa (Dopar, Larodopa, L-Dopa) Increases balance between cholinergic and dopaminergic activity Allows more normal body movements and alleviate signs and symptoms.
Anti-Parkinson Agents. Pramipexole (Mirapex) and ropinirole (Requip)-direct acting. Act by direct stimulation of the dopamine receptors in the brain.  They may be used alone in early Parkinson’s disease or as adjuncts to levodopa in advanced stages.
Anti-Parkinson Agents. Monoamine Oxidase (MAO) Inhibitor-indirect acting.  May slow Parkinson’s disease and need for increased medication.  May prolong life span  Examples: selegiline HCL (Eldepryl)
Anti-Parkinson Agents Contraindications Check individual drugs. Anticholinergics and Dopaminergic: narrow-angle/angle closure glaucoma.
Anti-Parkinson Agents Side Effects: CNS Involuntary movements Headache Numbness Insomnia Nightmares
Anti-Parkinson Agents Side Effects: CV Orthostatic Hypotension. Palpitations. Tachycardia.
Anti-Parkinson Agents Side Effects: GI Nausea. Vomiting. Dry Mouth.
Anti-Parkinson Agents Side Effects: GU Urinary hesitancy. Urine Retention.
Anti-Parkinson Agents Nursing Implications Assess parkinsonian and extrapyramidal symptoms before and throughout therapy. Monitor BP frequently. Give w/ food unless contraindicated.
Nutrition concerns with Parkinson's Disease As illness progresses aspiration is a real concern
Elimination Concerns with Parkinson's Disease Diet is well balanced with high-fiber foods and roughage  Assure adequate fluids  Stool softeners are usually prescribed  Suppositories Prune juice  Mild cathartics such as MOM
Created by: jtzuetrong