Biopsychosocial and spiritual aspects of Parkinson disease: an integrative review.
The purpose of this study is to systematically examine the scientific literature and report the biopsychosocial and spiritual aspects of persons with Parkinson disease and their adaptation to the disease, to discuss methodological challenges associated with researching this phenomenon, and to propose future research. Synthesis of the literature will reveal the state of the science on the holistic approach to care in persons with Parkinson disease. An exhaustive review of the English language peer-reviewed literature published from January 1961 to July 2011 was conducted utilizing Academic Search Premier, MEDLINE, CINAHL, Psych Articles, Psych Info, PubMed, Wiley InterScience, the Cochrane Center Register for Control Trials, Health and Psychosocial Instruments, and SpringerLink databases. Ninety studies were reviewed. Although numerous medical studies focusing on pharmacological agents for Parkinson disease are reported, there are gaps in the literature on the biopsychosocial, spiritual, and holistic approaches in Parkinson disease care. More research is needed to examine the biopsychosocial and spiritual aspects of persons with Parkinson disease.
Parkinson disease (PD) is a chronic, progressive movement disorder affecting approximately 1 million people in the United States (Parkinson's Disease Foundation [PDF], 2011). It is estimated that up to 15% of persons with PD are diagnosed before 50 years of age (Corti & Brice, 2002; Gershanik, 2002; PDF, 2011). One in 100 Americans over the age of 60 years is afflicted with the disease (PDF, 2011). The prevalence increases with age to 3 in 100 adults over the age of 85 years (Whetton-Goldstein, Sloan, Kulas, Cutson, & Schenkman, 1997).
The purpose of this integrative review is to systematically examine the scientific literature and report the biopsychosocial and spiritual aspects of persons with PD and limitations to their adaptation, to discuss methodological challenges associated with researching this phenomenon, and to propose future research. Synthesis of the literature will reveal the state of the science on the holistic approach to care in persons with PD.
Organizing Framework and Method
The literature published between January 1961 and July 2011 was searched with the key words outlined in Table 1, utilizing Academic Search Premier, MEDLINE, CINAHL, Psych Articles, Psych Info, PubMed, Wiley InterScience, Cochrane Center Register for Control Trials, Health and Psychosocial Instruments, and SpringerLink databases. Reference lists of studies were examined for inclusion of other relevant sources. The search was restricted to publications in the English language, under peer-reviewed journals, and with adult human subjects. Case reports, letters, editorials, commentaries, non-research-based reports and abstracts, unpublished manuscripts, reviews, and pharmacokinetic and pharmacodynamic studies were excluded. Ninety studies were reviewed and categorized using Cooper's (1982) methodology.
The state of the science on the pathophysiology, etiologic theories of causation, and risk factors of PD will be discussed. Parkinson disease, also referred to as shaking palsy or "paralysis agitans," was first recognized in 1817 by a British physician, Dr. James Parkinson, in "An Essay on Shaking Palsy" (Parkinson, 1817). It is a chronic, progressive, neurodegenerative disorder characterized by idiopathic degeneration of dopamine-producing cells in the substantia nigra (Corti & Brice, 2002; Rodriguez-Oroz et al., 2009). Oxidative stress is thought to contribute to the reduction of dopamine (Prasad, Cole, & Kumar, 1999; Simon & Beal, 2002). Other theories, however, include the acceleration of normal aging in certain individuals because of losing the protective mechanisms of antioxidative properties and neuroprotection (Golbe & Langston, 1993; Postuma, Gagnon, & Montplaisir, 2010). The later theory supports the premise that the incidence of PD increases with age.
Although the definitive cause of PD remains unknown, since the 19th century, researchers have attempted to identify one causal agent including stress (Charcot, 1878), heredity (deSilva, Khan, & Wood, 2000; Gasser, 1999; Polymeropoulos et al., 1996; Tanner et al., 1999), and infection (Ebmeier et al., 1989; Mattock, Marmot, & Stern, 1988). Currently, PD is thought to be a heterogeneous disease rather than a single disorder (Mouradian, 2002). The progression of Parkinsonian symptoms may be rapid or may take 20 years or more to develop. Four cardinal signs, resting tremor, rigidity, bradykinesia, and postural instability, characterize PD (Olanow, 2004). Other manifestations include dysphagia (Ramig, Countryman, Fox, & Sapir, 2002), difficulties with speech (Ramig et al., 2002; Schulz & Grant, 2000), urinary problems or constipation (Cloud & Greene, 2011; Quigley, 2002), excessive sweating and other skin-related problems (Hubble & Weeks, 2002), small handwriting (Pal, Samii, & Calne, 2002), gait disturbances (Giladi, 2002), and sleep disturbances (Comella, 2002; Gomez-Esteban et al., 2011; Pappert, Goetz, Niederman, Raman, & Leurgans, 1999). Freezing, a hallmark of PD, results in difficulty starting or continuing movements (Giladi et al., 2001; Narabayashi & Nakamura, 1985; Pal et al., 2002). In addition, some biological changes also cause psychological disorders, such as depression and anxiety, in persons with PD (Chow, Masterman, & Cummings, 2002; Pontone et al., 2011).
No standard tests are available to date to diagnose PD (Meara, Bhownick, & Hobson, 1999; Pal et al., 2002). Diagnosis is almost wholly based on clinical findings, with up to 25% of these diagnoses found to be in error at autopsy (Hughes, Daniel, & Kilford, 1992; Lee, 2002). A systematic review of the English language literature from 1999 to 2006 using MEDLINE and Cochrane databases was conducted to assess the state of the science regarding PD diagnosis. Although diagnostic tools exist (see Table 2), results of this review (see Table 3) suggest that there is no consistent clinical tool for the diagnosis of PD.
Treatment is symptomatic rather than curative with levadopa/carbidopa as the mainstay (Carta, Tronci, Pinna, & Morelli, 2005); however, when levadopa wears off, other medications such as Stalevo may be used. Goals of treatment are to alleviate symptoms and maintain independent function (Olanow, 2004). Surgical treatment, for example, deep brain stimulation, is generally reserved for those who no longer respond to their medication or those who experience intolerable medication side effects (Piper, Abrams, & Marks, 2005). Although physical symptoms are critical to the clinical diagnosis, psychological issues have a significant impact on the physical condition of persons with PD and must also be assessed (Ellgring et al., 1993).
Depression is considered the most common psychological problem in the PD population (Gotham, Brown, & Marsden, 1986; Menza, 2002). Epidemiological studies report a wide variance in the rate of occurrence from 4% to 90% (Erdal, 2001; Gotham et al., 1986; Menza & Mark, 1994; Robins, 1976; Starkstein & Merello, 2002), whereas other studies report a midrange of 40%-50% (Cummings, 1992; Hoogendijk, Sommer, Tissingh, Deeg, & Wolters, 1998; Tandberg, Larsen, Aarsland, Laake, & Cummings, 1997). The mean frequency reported in nine studies was calculated by the researchers and found to be 35% with an approximation of 4%-69% (see Table 4). In the most recently reported studies, the frequency of depression appears to have decreased, with a higher incidence reported in the earlier years. However, discrepancies in the reported frequencies may reflect the use of different definitions of depression and assessment strategies. In addition, none of these studies applied demographic methods with random or comprehensive sampling. Therefore, all were subject to patient selection biases. The consistent detection of depression, however, supports a relationship between depression and PD.
The cause of depression in PD is complex involving biochemical disturbances mainly of the serotoninergic or dopaminergic system (Cummings, 1992; Mayeux et al., 1992; Tandberg et al., 1997). Although biochemical disruptions are common in PD, studies report that depression is attributed to the presence of severe and permanent disability (Gotham et al., 1986; Menza & Mark 1994). One study reported that depression was diagnosed in 15% of 100 consecutive patients with PD (Holroyd, Currie, & Wooten, 2005) and concluded that the depression was related to the impairment in activities of daily living (ADL) rather than disability, as suggested by Mayeux et al. and Cummings. Holroyd and colleagues suggested that patients with PD who exhibit poor functioning and impairment in ADL should be closely evaluated for depression.
Conflicting evidence exists regarding a relationship between disease severity and depression. Gotham et al. (1986) and Robins (1976) identified no significant relationship, whereas other investigators have reported inconsistent results (Giladi et al., 2000; Mayeux et al., 1986; Mindham et al., 1976). Menza and Mark (1994), on the other hand, found that depression was significantly correlated with disease severity and disability (r = .33, p < .001). The variability of findings may be partly due to methodological differences and instrumentation.
A comparison of 45 patients with PD and 45 patients with chronic disability, matched for age and gender, indicated that patients with PD were significantly more depressed than the controls (p < .0001); neither gender or severity of illness was related to the depression (Robins, 1976). Starkstein, Berthier, Bolduc, Preziosi, and Robinson (1989) on the other hand, examined correlates of depression in patients with early-onset (<55 years) versus late-onset (>55 years) PD. The early-onset group (see Table 5) experienced a significantly higher rate of depression and had a significantly longer duration of the disease than the late-onset group (F = 8.42, df = 2, 99, p = .0046). The depression scores in the early-onset group were significantly correlated with duration of illness and cognitive impairment (r = .51, change in [r.sup.2] = .15, F = 5.91, df = 1, 31, p < .05 and r = .34, change in [r.sup.2] = .12, F = 4.03, df = 1,31, p < .05, respectively), whereas the depression scores in the late-onset group were significantly correlated with impairments in ADL as evidenced by the increased severity of tremor, akinesia, and rigidity (r = .47, change in [r.sup.2] = .22, F = 18.93, df = 1, 68, p < .01; Starkstein et al., 1989). Kostic et al. (1994) and Schrag, Hovris, Morley, Quinn, and Jahanshahi (2003) reported similar findings of increased depression scores in the early-onset group when compared with the late-onset group.
From a biological standpoint, depression in persons with PD may be a direct result of the reduction of dopamine in the mesolimbic pathway (Chow et al., 2002). The effectiveness of medication therapy provides further substantiation that there is a biological component to the depression in PD (Richard & Kurlan, 1997). Evidence supports the hypothesis that both physiological and psychological factors contribute to depression with dopamine playing a critical role in the development (Mayeux, Stem, Cote, & Williams, 1984; Menza & Mark, 1994). The advancements in medications and technology may be a contributory factor in this assumption.
Anxiety disorders have been reported in 30%-50% of cross-sectional samples (Richard, Schiffer, & Kurlan, 1996; Starkstein & Merello, 2002). Evidence has shown that anxiety occurs more frequently and at an increased rate in persons with PD than in the general population and in those with other neurological disorders (Schiffer, Kurlan, Rubin, & Boer, 1988; Starkstein & Merello, 2002; Stein, Heuser, Juncos, & Uhde, 1990). Likewise, higher rates of anxiety disorders were found in PD subjects than the published norms (Brown & MacCarthy, 1990). Menza, Robertson-Hoffman, and Bonapace (1993) assessed anxiety during a clinical interview of 42 subjects with PD and 21 matched medical controls with chronic debilitating osteoarthritis and found that 12 of the 42 PD subjects (28%) met the Diagnostic and Statistical Manual (DSM) criteria for anxiety disorders (p < .001), compared with one (5%) of the arthritis patients. Whereas, Gotham et al. (1986) reported increased anxiety in both the PD group and an age-matched control group of arthritis patients.
Although there are different types of anxiety disorders, a variety of measures are being used to assess anxiety in the PD population. One of the identified gaps in the literature is the inconsistency in reporting the specific type of anxiety disorder, and when reported, the symptoms are typically classified as an "anxiety disorder." In a comparative study, Schiffer et al. conducted structured clinical interviews with 20 depressed subjects with multiple sclerosis and 16 depressed subjects with PD. The subjects with PD had a significantly higher frequency (p = .0003) of generalized anxiety disorder and panic attacks (75%) when compared with the subjects with multiple sclerosis (10%). Similarly, in a descriptive correlational study of 24 patients with idiopathic PD, nine subjects (38%) had a clinically significant anxiety disorder before the onset of Parkinsonian symptoms (Stein et al., 1990). Of these, seven (78%) developed an anxiety disorder after the PD diagnosis with a trend (p < .10) for higher anxiety scores in younger persons with a shorter duration of disease (Stein et al., 1990). The aforementioned studies utilized the criteria for anxiety disorders as outlined in the DSM. The most commonly reported anxiety disorders were panic disorder, generalized anxiety disorder, and social phobia (Marsh, 2003; Menza et al., 1993; Richard et al., 1996; Schiffer et al., 1988; Stein et al., 1990). Likewise, Vazquez, Jimenez-Jimenez, Garcia-Ruiz, and Garcia-Urra (1993) found panic attacks to be a common finding in 31 (24%) of the 101 PD patients studied. As in depression, a reduction of dopamine is believed to cause anxiety (Menza et al., 1993; Richard et al., 1996; Starkstein & Merello, 2002). Although there is overwhelming evidence to support the prevalence of anxiety in PD, additional studies are needed using larger samples as well as standardized psychiatric interviews and assessments to differentiate relative frequencies of the types of anxiety disorders.
Dementia is one of the more common cognitive deficits reported in the PD population. The prevalence of dementia in PD ranges from 20% to 40% (Brown & Marsden, 1990; Marder, Tang, Cote, Stem, & Mayeux, 1995; Marttila & Rinne, 1976). Mayeux et al. (1988) reviewed medical records of 422 patients with PD and found that dementia occurred at a rate of three times more in persons with late-onset PD (after the age of 70). Other studies have confirmed a higher incidence of cognitive decline in patients with later disease onset (Mohr, Mendis, & Grimes, 1995; Reid et al., 1996). Concurrently, the prevalence of dementia was reported to increase as the stage of the disease progressed; staging was determined by Hoehn and Yahr (1967): (a) stage I, 0%; (b) stage II, 6%; (c) stage III, 16%; (d) stage IV, 35%; and (e) stage V, 57% (Growdon, Corkin, & Rosen, 1990).
One of the main clinical correlates of dementia in persons with PD is the duration of the illness. In a 4-year longitudinal study, Biggins et al. (1992) compared 87 PD subjects with 50 matched control subjects and found that 6% (n = 5) of the 87 PD subjects met the DSM-III-R criteria for dementia upon initial assessment, whereas 10 PD subjects became demented during the follow-up period. Comparatively, none of the controls became demented. Results of the survival analysis confirmed that those who became demented were older at age of Parkinsonian onset and had a longer duration of disease. In a 2-year follow-up period, Bayles et al. (1996) assessed a group of 77 patients with PD and found that 22% (n = 17) of the patients with PD had a 4-point decrement in their Mini Mental Status Examination scores, compared with no change in the 43 normal older control group. The cognitive decline in PD is congruent with the findings of a cohort study conducted by Hughes et al. (2000), in which 83 nondemented patients with PD and 50 normal controls were followed over a 10-year period. A cumulative incidence of dementia (20%) was reported in the PD group, whereas none was reported in the control group. Two significant predictors of dementia in the PD group were age and severity of motor symptoms.
Critical predictors of the development of dementia in a study of 107 newly diagnosed patients with PD were found to be age of diagnosis and duration of illness (Reid et al., 1996). This study identified dementia in 8% of the early-onset (<70 years) group compared with 32% of the late-onset (>70 years) group. Echoing the findings of Reid et al., Katzen, Levin, and Llabre (1998) examined 222 patients with PD and found that the older age of disease onset consistently predicted dementia. Fifty-two nondemented patients and 43 demented patients were studied; lack of education, severity of motor deficit, and late age of onset (>60 years) were significant predictors of dementia. Inconsistencies in reporting the classification systems used to diagnose dementia in the PD population and age of onset were a common occurrence in this review (Erkinjuntti, Ostbye, Steenhuis, & Hachinski, 1997; Mindham, 1999). From the studies reported, it appears that persons with PD experience increased levels of depression, anxiety, and dementia compared with persons without PD.
People with PD experience a notably decreased quality of life and are frequently unable to perform daily functions, such as getting out of bed unaided (Mshana, Dotchin, & Walker, 2011). Because of the unavoidable progression of disabling symptoms, individuals also require assistance with ADL. Longstreth, Nelson, Linde, and Munoz (1992) and Strudwick, Mutch, and Dingwall-Fordyce (1990) examined the effects of PD on ADL and concluded that persons with PD were disabled in all aspects of everyday life. Going to the grocery store, for example, may be a difficult task for persons with PD because of the decreased motor control and rigidity that interferes with normal functioning. These impediments coupled with other disease symptoms lead to a gradual decrease in social activities, such as dining out, and to social insecurities (Ellgring et al., 1993). Furthermore, tremor and akinesia tend to increase dramatically in social situations, leading to freezing (Tan, McGinley, Danoudis, Iansek, & Morris, 2011); therefore, persons with PD tend to avoid social contact by staying at home (Giladi et al., 2001).
Stress has a profound effect on the motor symptoms of PD. Stress-induced increase of motor symptoms, especially those related to tremor and rigidity, is a commonly observed phenomenon in PD (Ellgring et al., 1993). Minor stressors, mostly social in nature, elicit the "psychological Parkinson effect," which is an increase of symptoms in any kind of emotional arousal (Ellgring et al., 1993). Efforts to voluntarily control these symptoms only increase them. In a descriptive correlational study of 93 PD subjects, the most distressing symptoms reported were off-time, limited or absent movement, freezing gait, postural instability, sleep disturbance, and difficulty concentrating. Furthermore, symptom intensity and distress were strongly correlated, (r = .75 and .82, respectively, p [less than or equal to] .01), whereas the relationship of symptom frequency and duration to distress varied by symptom (Backer, 2006). The author concluded that distress makes the Parkinsonian symptoms worse.
Emotional expressivity and its influence on the social context will be discussed. Emotional communication may be severely obstructed by a dissociation of facial expressions, that is, Parkinsonian mask, and emotional feelings (Simons, Pasqualini, Reddy, & Wood, 2004). Although the inner feelings are intact, persons with PD may appear emotionally bland. Incongruent nonverbal behavior may lead to social embarrassment (Ellgring et al., 1993). Therefore, persons with PD often complain about difficulties expressing their personality. The dissociation of feelings and reduction of spontaneous facial expressions in persons with PD have a major negative impact on social interaction (Buck & Duffy, 1980; Katsikitis & Pilowksy, 1988, 1991; Smith, Smith, & Ellring, 1996). The lack of facial expression makes it emotionally diffficult for others to understand the person with PD (Ellgring et al., 1993; Simons et al., 2004). In a study of 19 PD subjects and 26 healthy controls, facial expressivity was examined while subjects were observed watching video clips, conversing, and initiating emotional and nonemotional facial expressions (Simons et al., 2004). The PD group exhibited less spontaneous facial expressivity when conversing with a stranger than the control (M = 33.16, SD = 20.83 and M = 49.17, SD = 17.92, respectively). In addition, apathy; a cluster of physiological, psychological, and motivational features characterized by a reduced interest in pleasurable activities; lack of motivation; difficulties with starting or sustaining an activity to completion; a state of indifference; and flattening of affect have been observed in the PD population (Bogart, 2011; Pluck & Brown, 2002; Schulman, 2002). In a study of 50 patients diagnosed with idiopathic PD, Starkstein et al. (1992) reported that 12% of PD patients showed apathy (F = 5.44, df = 1, 46, p < .05), whereas 30% were both apathetic and depressed (F = 5.60, df = 1, 46, p < .05 and F = 6.55, df = 1, 46, p < .01, respectively). Many of the psychological aspects of persons with PD, particularly social anxiety, have been found to be secondary to self-consciousness and embarrassment regarding Parkinsonian symptoms (Stein et al., 1990). No person with PD is physically, psychologically, and socially unaffected by the disease. Often, the person with PD experiences a constellation of biological, psychological, emotional, and social symptoms.
Spirituality has been identified throughout the literature in relation to holistic care, yet there is no universal definition describing the concept in nursing (Chiu, Emblen, Van Hofwegen, Sawatzky, & Meyerhoff, 2004). Spiritual care, an essential component of holistic nursing, remains a neglected focus in clinical practice (Ameling & Povilonis, 2001). A literature search using the key terms "PD and spiritual," "spirituality," "spiritual care," and "holistic" did not render any results in the aforementioned databases. A broader search using chronic illness/chronic disease and spirituality, with the addition of a complementary therapy database, revealed a plethora of evidence in cancer, depression, the human immunodeficiency syndrome population, and patients with chronic disabling diseases (Fernsler, Klemm, & Miller, 1999; Hall, 1998; Harris, Wong, & Musick, 2010; Klaas, 1998), but not PD. A comprehensive review of spirituality and well-being in patients with chronic illness found support for a positive relationship between spirituality and the ability to cope with chronic disease. Spirituality and a belief in a higher power allow the person to put their condition into perspective and draw strength for adaptation to their circumstances (Harris et al., 2010).
A clinical query search was then conducted on federally and privately funded clinical trials, thus expanding the search using the terms "PD" and "spirituality." Three studies (ongoing and currently recruiting) were located. These three studies identified a plan for a spiritual intervention in the population of the War Veterans experiencing posttraumatic stress disorder using mindfulness, healing touch in patients with leukemia, and a mind--body program in patients with neoplasms. Despite the key word entry of "Parkinson disease," PD was not addressed in any of these three findings.
A new search was thus conducted using the terms "PD and mind-body connection," "mind body interventions," and "complementary therapies." The search revealed three relevant studies: stress management exercises, that is, yoga (Taylor, 2001); expressive therapies of music (Pacchetti et al., 2000); and art (Wadeson, 2003). Spirituality may be viewed as a form as expression. Similarly, music therapy is considered to be a form of self-expression (Pacchetti et al., 2000). In a prospective, randomized, controlled, single-blinded study, 32 persons with PD were randomly assigned to two groups: music therapy (MT) and physical therapy (PT). The active MY consisted of choral singing, voice exercise, and rhythmic body movements, whereas the PT consisted of passive exercises to improve gait and balance. MT had a significant overall effect on motor improvement (p < .0001) as well as emotional functioning (p < .0001), whereas PT was effective for rigidity (p < .0001).
For this review, the concept of spirituality was broadened from a religious, healing perspective to include well-being, "meaning making," and tranquility. The need for a broader perspective became apparent from this integrative review, which illuminated the finding that PD affects a person biologically, psychologically, and socially. To be identified solely as a disease of the brain ignores the fact that PD affects more than the brain; it is a multisystem-disabling disease that affects all aspects of the individual's life and sense of being. Thus, the concepts of "meaning making" and integration emerged. Two relevant studies were retrieved (Salick & Auerbach, 2006; Whittemore, 2005).
The process of integration is a multifaceted person-environment approach in which a life-altering event, such as PD, is incorporated into one's daily life for a sense of balance (Whittemore, 2005). Although the goal of integration is the achievement of optimum or maximum functioning, Whittemore reported a "renewed life purpose and meaning, self-transcendence, and actualization of life potential" as implied consequences of integration (p. 264). The unpredictable nature of PD requires those afflicted to deal with uncertainty on a daily basis. Nursing interventions to facilitate integration may assist in alleviating uncertainty and provide the basis for spiritual care. In addition, an individual may search for "meaning in one's life" when faced with the uncertainties of a life-altering illness (Salick & Auerbach, 2006).
The strong biopsychosocial connection necessitates the need for further studies on the "meaning" of the illness as expressed by the person with the disease to more fully understand the impact of the disease. More qualitative studies are needed to develop new knowledge in understanding how individual's make "meaning" of their disease and integrate their illness experiences into daily life. Clinical interventions may be enhanced when spirituality is approached from a broad, contextual perspective and integration is incorporated into clinical practice. Although the existing research contributes to the current understanding of spirituality and spiritual care, research needs to be conducted in the PD population. This paucity of research represents a major gap in the literature focusing on the holistic, whole-body approach to care in the PD population.
Implications for Adaptation
Little is known about the impact of having PD and the methods used to adapt to an unpredictable and largely uncontrollable disease. Persons with PD may experience a myriad of symptoms varying in severity, thus making the examination and generalization of adaptation a challenge (Frazier, 2000). Adapting to PD is problematic not only for the individual with PD but also for their families because the long-term prognosis is a deterioration of functioning and lifelong medication, which loses its effectiveness over time. Self-image and physiological changes, future expectations, and overall well-being may impede one's ability to adapt to the disease (Dakof & Mendelsohn, 1989; Felton & Revenson, 1984; Jaafar, Gray, Porter, Turnbull, & Walker, 2010; Larson, 1978). Living with a progressive illness without a cure, with fear of falling, and with dependency on others may lead to an array of emotional changes, further compromising one's ability to adapt.
Dakof and Mendelsohn (1989) identified patterns of adaptation in four clusters: (a) cluster I: sanguine and engaged, (b) cluster II: depressed and worried, (c) cluster III: depressed and misunderstood, and (d) cluster IV: passive and resigned. The subjects in cluster III were significantly more impaired in their overall function than the other three clusters and expressed a lack of meaning in their life and feelings of powerless and uselessness because of the increasing dependency on others. Habermann (1996) found that adapting to increasing dependency on others was a key issue for persons with PD. Two chief adaptive demands for persons with PD were asking for help and accepting assistance. A similar finding was reported in Frazier's (2000) study that examined three types of disease-related stressors: physical, cognitive, and psychosocial. Being dependent on others (21%) and fear of being a burden (17%) were the most stressful psychosocial symptoms (p [less than or equal to] .05) with feelings of loss of control (14%). The subjects used a variety of coping strategies, that is, active coping, emotion regulation, and distancing. There was a significant interaction between the coping strategy used and each type of stressor, F(4, 580) = 3.81, p [less than or equal to] .01, but no significant differences among types of stressors, F(2, 290) = 1.95, p = .15. Results confirm that the coping strategy is dependent upon the type of stressor they are experiencing.
Personality traits may be attributed to the difficulty in adapting to the loss of independence and control. Persons with PD are often perfectionists, detail-oriented, hardworking, diligent, and used to being in control (Lamberg, 2001). Certain premorbid personality traits have been reported; those who are introverted, shy, timid, subordinate, less outgoing, nervous, responsible, morally rigid, inflexible, law abiding, and cautious are at a greater risk of developing the disease (Hubble, Venkatesh, Hassanein, Gray, & Koller, 1993; Menza et al., 1993; Paulson & Dadmehr, 1991). The stress experienced by persons with PD is less affected by the following variables: the number and severity of symptoms, the degree in which these symptoms interfere with ADL, the availability and use of a support system, and the patient's perception of their disease (Blenner, 1992; Gurklis & Menkes, 1988; Larsen, 1990; Wineman, Durand, & Steiner, 1994). A unique finding consistent with the literature is that persons with PD succeed in maintaining their self-control and well-being despite the dismal future prospects (Caap-Ahlgren & Dehlin, 2004).
A high sense of coherence, defined as a subjective means of coping with daily life, is associated with positive adaptation and well-being (Caap-Ahlgren & Dehlin, 2004). A sense of coherence is of utmost importance in managing the progressive nature of PD and may serve as a powerful means of coping with complex and difficult life situations that may affect the individual's emotional responses to stressful situations (Caap-Ahlgren & Dehlin, 2004). Persons with PD may also experience well-being from a social network, such as a support group (Lieberman et al., 2005). Well-being, coping, and adaptation are a concern for not only the individual's physical ability/inability but also the whole person with PD. The results of this review show considerable variation in the adaptation of persons with PD.
Analysis and Recommendations
The reviewed studies varied with respect to sample size, methodology, and design, which may have resulted in varied composite results. Most of the research studies were atheoretical, in which they did not include a theoretical or conceptual framework to guide their research. In addition, the lack of a consistent definition and confirmatory criteria to diagnose PD, variation in staging instrumentation, and inconsistencies in identifying disease severity may obscure the true prevalence of PD. There were inconsistencies in the designated age range of early onset versus late onset of diagnosis, criteria critical for continuity in reporting and generalizing findings. Staging of PD is very important because this is a progressive disease and the need for holistic care increases as the disease advances. A weakness in many of these studies is that they did not differentiate the progressive stages of the disease in their findings.
Arguably, the variations in the prevalence rates of depression, anxiety, and dementia are due to methodological inconsistencies between the studies. Moreover, these inconsistencies may have resulted from unclear and inconsistent definitions. Another methodological variable that may account for some of the discrepancies in the prevalence of depression and anxiety is the type of assessment used. In many studies, the type of anxiety disorder was not specified. The need for standardized psychiatric interviews and larger populations is essential to clarify the relative frequencies of the various types of anxiety disorders. Methodological problems may explain the contradictory results in the studies that specifically addressed onset of symptoms. The determination of motor symptoms using various motor scales may prove to be a poor methodological construct. There is no single etiology for dementia in patients with PD. In addition, criteria for diagnosing dementia are lacking, thus limiting the generalizability of study findings. Finally, in the studies reviewed, spirituality was not defined; therefore, a universal definition of spirituality and an additional research in the PD population are recommended.
Research and Practice Implications
The implications for further research suggested by the findings of this review are several. Future research needs to focus on the holistic, whole-body approach (biological, psychological, social, and spiritual aspects) and their adaptation to a chronic, progressive disease. An explicit description of the theoretical under-pinnings as well as the use of a conceptual framework are strongly recommended in an effort to guide research and further the biopsychosocial aspects of PD and identified relationships. The findings of this review have implications for holistic assessment and health promotion, areas recognized as priorities in nursing practice. Implications for nursing suggest that healthcare professionals should assess the biopsychosocial and spiritual aspects of persons with PD. It is important for nurses to understand the holistic nature of PD and the impact of this whole-person approach on their adaptation to this progressive disease. This review has provided substantial evidence that PD affects a person's physiological, psychological, and social well-being. Additional research studies to enhance understanding of the biopsychosocial impact of this disease are recommended.
The purpose of this integrative review was to examine the scientific literature and report the biopsychosocial and spiritual aspects of persons with PD and their adaptation to the disease. Although there is a plethora of medical studies focusing on the pharmacological agents, there are gaps in the scientific literature on the biopsychosocial, spiritual, and holistic approaches to care in the PD population. On the basis of the current knowledge of PD as reflected by this state-of-the-science review, PD is a complex, multisystem disorder in which a holistic approach to care is needed to help understand the nature of the illness and the impact on persons with the disease. Qualitative studies are notably missing and needed to address the paucity of literature on the biopsychosocial and spiritual aspects of persons with PD.
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Questions or comments about this article may be directed to Melinda Hermanns, PhD RN BC CNE, at firstname.lastname@example.org. She is an assistant professor at the College of Nursing, University of Texas, Tyler, TX.
Belinda Deal, PhD RN, is an assistant professor at the College of Nursing, University of Texas, Tyler, TX.
Barbara Haas, PhD RN, is a professor and the Director of PhD in Nursing Program at the College of Nursing, University of Texas, Tyler, TX.
The authors declare no conflicts of interest.
TABLE 1. Key Words for Literature Search Domain of Interest Key Words Biological Parkinson disease and physiological, biological, symptoms, diagnosis Psychological Parkinson disease and psychological, psychosocial, anxiety, depression G Social Parkinson disease and social, community, physical environment, social context, emotion, emotional, emotional expression, stress, stressors, expressivity Spiritual Parkinson disease and spiritual, spiritual well-being, spirituality, spiritual care, holistic Adaptation Parkinson disease and adaptation, coping, coherence, well-being, disease- related stressors, activities of daily living, quality of life TABLE 2. Diagnostic Tools Used in Parkinson Disease Criteria Unified Parkinson's Disease Rating Scale Abnormal Involuntary Movements Scale Activities of Daily Living Beck Depression Inventory Brief Psychiatric Rating Scale Hamilton Depression Scale Hoehn and Yahr Clinical Staging Scale Mini Mental Status Exam Parkinson Psychosis Rating Scale Schwab and England Activities of Daily Living Scale Sickness Impact Profile TABLE 3. A Review of the Evidence 7 on Diagnosis of Parkinson Disease Number of Studies (n = 65) Diagnosis Results 8 Autopsy Support clinical diagnosis 12 Clinical Inconclusive evidence 2 Color vision Inconclusive evidence 8 MRI Insufficient evidence 9 Olfactory Useful, long-term studies are needed 4 Motor, olfaction Useful, long-term studies are needed 18 SPECT Insufficient evidence 4 NMR, ultrasound Insufficient evidence Note. NMR = nuclear magnetic resonance; SPECT = single photon emission computed tomography. TABLE 4. Summary of the Prevalence of Depression Number of Subjects Reference With Parkinson Disease % of Depression Robins (1976) 45 37 Mindham et al. (1976) 50 50 Gotham et al. (1986) 187 69 Mayeux et al. (1986) 49 43 Brown and MacCarthy (1990) 40 25 Menza and Mark (1994) 104 31 Tandberg et al. (1997) 245 30 Hoogendijk et al. (1998) 100 23 Erdal (2001) 71 4 Reference Method of Assessment Robins (1976) RS Mindham et al. (1976) Chart review Gotham et al. (1986) RS Mayeux et al. (1986) SI, DSM-III Brown and MacCarthy (1990) SI Menza and Mark (1994) RS Tandberg et al. (1997) RS Hoogendijk et al. (1998) RS, SI Erdal (2001) RS Note. SI = structured interview; RS = rating scales, DSM-III = Diagnostic and Statistical Manual Third Edition. TABLE 5. Summary of the Prevalence of Depression in Early Versus Late Onset Number of % of Depression (EO) Reference Subjects Major Minor Starkstein 105 <55 years old et al. (1989) 37 24 Kostic 169 <50 years old et al. (1994) 16 14 % of Depression (LO) Reference Major Minor Starkstein >55 years old et al. (1989) 10 17 Kostic >50 years old et al. (1994) 36 11 Note. EO = early onset; LO = Iate onset.