Exam 15: Multiple Sclerosis & Parkinson's Disease
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| Multiple Sclerosis (MS) | A common, progressive degenerative neurological disease. The myelin sheath, the covering around the axon, is destroyed with inflammation and scarring.
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| 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.
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| 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.
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| Clinical Manifestations of MS | Visual problems.
Urinary incontinence.
Fatigue.
Weakness or uncoordination of an extremity.
Sexual problems such as impotence in men.
Difficulty swallowing.
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| 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
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| 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.
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| Diagnosis of MS: CSF | Shows elevated gamma globulin and a proliferation of gamma/delta T cells
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| Diagnosis of MS: CT Scan | May show enlargement of the ventricles
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| Diagnosis of MS: MRI | May be helpful in the final diagnosis.
Identifying certain hallmark changes in the brain.
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| 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.
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| Spasticity (Skeletal Muscle Relaxants) | For MS.
diazepam (Valium).
dantrolene (Dantrium).
baclofen (Lioresal).
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| Immunomodulating Agents | Interferon beta-1b (Betaseron).
Interferon beta-1a (Avonex).
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| Interferon beta-1b (Betaseron) | SQ q every other day.
Used in ambulatory patients with relapsing-remitting.
MS to reduce frequency of exacerbations.
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| Interferon beta-1a (Avonex) | Given IM once a week.
Decreases the frequency of exacerbations in select patients and slows the progress of physical disability.
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| Immunomodulator: glatiramer acetate (Copaxone) | For use in relapsing MS.
Believed to interrupt the inflammatory cycle.
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| 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.
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| Propantheline bromide (Pro-Banthine) | Promotes elimination.
For urinary frequency and urgency.
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| Cholinergic drugs-bethanechol chloride (Urecholine) | promotes Elimination.
neurogenic bladder-exerts a direct antispasmodic effect on smooth muscles.
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| With MS Stool softener | docusate sodium (Colace) and prune juice are recommended.
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| Common problem with MS | UTIs
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| Interferons therapeutic effects __________ incidence of neurological dysfunction. | reduce
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| nutrition with MS | Well Balanced
High fiber foods with adequate fluids
Obesity makes it more difficult for patient
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| Skin Care with MS | Prevent breakdown
Sensory impairment reduces sensation of discomfort.
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| Activity with MS | Regular exercise with rest periods
Bedrest may be ordered during exacerbations
Physical therapy
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| 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.
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| With MS prepare patients and family for | explosive emotional outbursts
slowness in speech and slowness in ability to respond
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| 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.
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| Dopamine is a | neurotransmitter
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| 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.
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| Patients with cerebrovascular disease often have | parkinsonism-like symptoms
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| Most patients with Parkinsonism have | Degenerative or idiopathic form, for which the term Parkinson’s disease is usually reserved.
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| Onset of Parkinson's Disease | Gradual and Insidious
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| Beginning stages of Parkinson's Disease show | Mild tremor, slight limp, decreased arm swing, change in handwriting
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| Later stages of Parkinson's Disease show | Shuffling, propulsive gait with arms flexed.
Loss of postural reflexes.
Slight change in speech patterns.
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| Subjective data with Parkinson's Disease | Fatigue.
Presence of uncoordination.
Judgement defects.
Emotional instability.
Anxiety.
Depression.
Heat intolerance.
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| 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.
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| 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.
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| Treatment for Parkinson's | Based on easing the S&S of the disease.
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| Surgical interventions for Parkinson's Disease | Destroy portions of the brain controlling rigidity or tremor.
Human Fetal Dopamine Cell Transplant.
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| Anti-Parkinson Agents | Aimed at increasing the levels of dopamine and/or antagonizing the effects of acetylcholine
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| Anti-Parkinson Agents Action | Aimed at restoring natural balance of acetylcholine and dopamine in the CNS
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| 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).
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| 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.
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| Dopaminergic: Direct acting. Bromocriptine (Parlodel) and pergolide (Permax) | Direct stimulation of the dopamine receptors
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| 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%
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| Dopaminergic decrease effectiveness if taken with | Metoclopramide or Phenothiazines.
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| Levodopa (Dopar, Larodopa, L-Dopa) | Increases balance between cholinergic and dopaminergic activity
Allows more normal body movements and alleviate signs and symptoms.
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| 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.
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| 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)
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| Anti-Parkinson Agents Contraindications | Check individual drugs.
Anticholinergics and Dopaminergic: narrow-angle/angle closure glaucoma.
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| Anti-Parkinson Agents Side Effects: CNS | Involuntary movements
Headache
Numbness
Insomnia
Nightmares
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| Anti-Parkinson Agents Side Effects: CV | Orthostatic Hypotension.
Palpitations.
Tachycardia.
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| Anti-Parkinson Agents Side Effects: GI | Nausea.
Vomiting.
Dry Mouth.
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| Anti-Parkinson Agents Side Effects: GU | Urinary hesitancy.
Urine Retention.
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| Anti-Parkinson Agents Nursing Implications | Assess parkinsonian and extrapyramidal symptoms before and throughout therapy.
Monitor BP frequently.
Give w/ food unless contraindicated.
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| Nutrition concerns with Parkinson's Disease | As illness progresses aspiration is a real concern
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| 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
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