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A nursing perspective: orthostatic hypotension as an expression of autonomic dysfunction in the patient with Parkinson's disease.

Nurses have historically learned the Parkinson's disease signs and symptoms by the mnemonic TRAP: Tremor at rest, Rigidity, Akinesia, and Postural instability. Nurses have learned that Parkinson's pathophysiology is presented as low dopamine in the substantia nigra of the brain. Nurses learn the drug levodopa as the prototype for Parkinson's disease. It is essential that student and practicing nurses update their knowledge to develop a fuller understanding of the many aspects of Parkinson's disease so they can skillfully assist patients with Parkinson's disease to carry out their activities of daily living (ADLs). Approximately 0.3% of the United States population has a clinical diagnosis of Parkinson's disease, and about 5% of patients diagnosed with Parkinson's disease are older than 85 years (Nolden, Tartavoulle, & Porche, 2014).

Some nurses are aware of the secondary motor manifestations: dysarthria, dysphagia, hypophonia, micrographia, and the mask-like expression seen in some patients with Parkinson's disease. Even fewer nurses have a working understanding of the non-motor symptoms of Parkinson's disease, which are not as dramatic-looking as tremors. The non-motor symptoms are less prominent in the literature. Non-motor symptoms, such as urinary retention and constipation, are considered to overlap with general aging symptoms. Nolden and colleagues (2014) also suggest that dopamine tends to decrease as patients age.

Non-Motor Symptoms of Parkinson's Disease

Non-motor Parkinson's symptoms include autonomic dysfunction, cognitive-neurobehavioral disorders, sleep disturbance, and loss of sense of smell (anosmia) (Nolden et al., 2014). Cognitive-neurobehavioral disorders in the patient with Parkinson's disease include anxiety, depression, apathy, hallucinations, and impulsivity. As a complication of medication, some patients with Parkinson's disease are at risk for impulsive behaviors, such as excessive shopping to the detriment of their families and loved ones. Researchers suggest that some of the non-motor manifestations of Parkinson's disease may herald the arrival of the disease by as much as 20 years before motor symptoms are seen (Fereshtehnejad & Lokk, 2014; Goldstein, 2014; Nolden et al., 2014).

Autonomic Dysfunction in the Patient with Parkinson's Disease

Both student and practicing nurses must appreciate that orthostatic hypotension is a manifestation of autonomic dysfunction in the patient with Parkinson's disease. This knowledge can improve the care of patients with Parkinson's disease by helping student and practicing nurses anticipate the risks and consequences of non-motor Parkinson's disease manifestations. Such manifestations can lead to falls with or without injury, and reduced quality of life.

There are several definitions of orthostatic hypotension; however, the literature suggests a decrease of 20 mm HG systolic or 10 mm Hg diastolic within three minutes of standing. Most cases are identified within the first minute of standing (Figueroa, Basford, & Low, 2010) with an associated increase in heart rate. Sanchez-Ferro, Benito-Leon, and Gomez-Esteban (2013) add that a positive tilt table test with the patient positioned at least 60 degrees, complaining of orthostatic symptomatology, such as lightheadedness or dizziness, is also a positive sign of orthostatic hypotension (Fereshtehnejad & Lokk, 2014).The purpose of the tilt table test is to determine if there is arterial baroreflex failure in the heart (Fereshtehnejad & Lokk, 2014).

Neurogenic Orthostatic Hypotension

It is important to distinguish between neurogenic and non-neurogenic causes of orthostatic hypotension. Other processes are described in the literature, including pure autonomic failure (PAF) and familial dysautonomia, which may also result in orthostatic hypotension. Multiple system atrophy (MSA) is a progressive neurodegenerative disorder characterized by symptoms of autonomic nervous system failure combined with motor control symptoms, such as rigidity and loss of muscle coordination. MSA is often misdiagnosed as Parkinson's disease in the early disease process.

Neurogenic orthostatic hypotension (NOH) occurs within the context of a disease process characterized by nervous system lesions, such as in Parkinson's disease (Figueroa et al., 2010), and is the focus of nursing knowledge and inclusion into evolving nursing curricula and practice. Approximately 40% of patients with Parkinson's disease have NOH (Goldstein, 2014). Goldstein and Yehonatan (2009) describe correlates with NOH, including reduced levels of plasma dihydroxyphenylglycol (DHPG) and lower norepinephrine levels. A novel perspective is that Parkinson's disease is not only a movement disorder with dopamine loss, but also a dysautonomia with norepinephrine loss in the sympathetic nervous system of the heart (Goldstein, 2014). NOH is characterized by baroreflex failure in the heart that results in cerebral hypoperfusion, manifested by difficulty thinking and lightheadedness (Figueroa et al., 2010). This impaired baroreflex function occurs as a loss of sympathetic innervation in the left ventricular myocardium (Goldstein, 2014). Many student and practicing nurses may not understand the significance of cardiac baroreflex failure as a defining characteristic of Parkinson's disease. Further, postmortem studies suggest that baroreflex failure with loss of sympathetic innervation in the heart is a distinguishing feature of the patient with Parkinson's disease (Goldstein & Yehonatan, 2009). The relationship between the neurologic and cardiac manifestations suggests that patients diagnosed with Parkinson's disease who have an intact innervation of the left ventricle will have a questionable or even discarded Parkinson's disease diagnosis (Camargo et al., 2014).

Non-neurogenic hypotension occurs in disease states that are not characterized by nervous system lesions, but result in a decrease in blood pressure when moving from the sitting to standing position. Typical causes of non-neurogenic hypotension include volume depletion from severe diarrhea, venous pooling, complications of congestive heart failure and sepsis (Figueroa et al., 2010).The same orthostatic phenomenon occurs in non-neurogenic hypotension, except that these patients do not have the associated nervous system lesions.

Cardiac Physiology of Parkinson's disease

Dopaminergic Parkinson's disease medications, such as pramipexole (mirapex) and ropinirole (requip), are known to cause orthostatic hypotension (Nolden et al., 2014). Goldstein and Yehonatan (2009) suggest that Parkinson's medications do not cause NOH, rather the impaired baroreflex-cardiovagal function is the root issue, and Parkinson's medications exacerbate an existing cardiac sympathetic denervation issue. The presence of baroreflex failure exaggerates the Parkinson's patient's response to medications that are known to lower blood pressure. Symptomatic NOH is more prevalent in patients with Parkinson's disease who struggle with gait and posture, rather than those who are tremordominant (Fereshtehnejad & Lokk, 2014). NOH is associated with postural sway, impaired attention and memory, and an increase in falls (Fereshtehnejad & Lokk, 2014). Important information for all nurses to learn includes the three main components of NOH in Parkinson's disease (Fereshtehnejad & Lokk, 2014):

* Noradrenergic denervation in the left ventricle.

* Noradrenergic denervation in non-cardiac regions, such as the renal cortex and thyroid gland.

* Arterial baroreflex failure.

Refaat, Hotall, Anderson, and Reis (2015) remind clinicians to carefully investigate cardiac complaints from patients with Parkinson's disease, especially left ventricular physiology, as Parkinson's patients with NOH will have acute preload reduction.

Assessment of Orthostatic Hypotension in the Parkinson's Patient

Curiously, the Parkinson's disease screening tool most often used--the Unified Parkinson's Disease Rating Scale (UPDRS)--contains just one item on NOH and is listed as a complication of therapy. This item has low sensitivity (Fereshtehnejad & Lokk, 2014). There are other recommended scales that contain autonomic scales and include more NOH items, such as the Autonomic Scale for Outcomes of Parkinson's Disease (SCOPA-AUT) and the Composite Autonomic Symptom Scale (COMPASS) (Sampaio, Goetz, & Schrag, 2012). SCOPA-AUT detects the presence and severity of NOH and may show changes in NOH over time (Sampaio et al., 2012). Such screening tools are essential to incorporate into the education of the nursing curricula for the benefit of new nurses and important information for practicing nurses.

Nursing Interventions for the Patient with Parkinson's Disease

A pathophysiological co-occurrence with NOH is the existence of supine hypertension, which often occurs at night when the patient with Parkinson's disease is sleeping (Figueroa et al., 2010). Supine hypertension is considered to be a blood pressure greater than 180/110 (Sanchez-Ferro et al., 2013). The goal of treatment is not achievement of normotensive status, but rather, to include both nonpharmacologic and pharmacologic interventions. One basic intervention is to ensure that the patient with Parkinson's disease has a blood pressure cuff In the home, and a support person to ensure blood pressure readings are taken at periodie intervals when supine and upright. Blood pressure monitoring is important when new medications are added or changed, as well as for symptomatic monitoring. The patient with Parkinson's disease and support member are encouraged to keep a written log of supine and upright blood pressures with corresponding heart rates. A next basic step is for the patient with Parkinson's disease and clinician to collaboratively review the medication list, with special attention to cardiac medications, whose mechanism of action is to reduce blood pressure. Other medications, such as tricyclic antidepressants and trazadone, are also known to potentiate orthostatic hypotension (Figueroa & Colleagues, 2010). Levodopa and dopamine agonists used to treat Parkinson's symptoms can reduce blood pressure and may need to be adjusted based on Individual symptoms.

Non-pharmacologic measures to help patients with NOH include drinking water up to 2 liters per day as tolerated, especially in the morning when orthostatic stress may be more prevalent (Sanchez-Ferro et al., 2013). If tolerated, patients with Parkinson's disease can increase their dietary salt to 8 grams per day, although patients generally do not know their sensitivity to the effects of salt (Sanchez-Ferro et al., 2013). Small, frequent meals are also encouraged (Sanchez-Ferro et al., 2013). Elevating the head of the bed improves the endocrine regulatory system, thereby reducing supine hypertension during sleep (Fereshtehnejad & Lokk, 2014). If the patient is taking blood pressure medications, consideration can be given to administering these medications in the evening to ease potential supine hypertension. It is essential that the care plan for the patient with Parkinson's disease is individualized to accommodate the patient's needs, lifestyle, and social supports. A regular exercise program can help to decrease pooling of blood in the periphery. To reduce venous pooling, which reduces blood return to the heart, the clinician may recommend an abdominal binder to shunt blood to the core and compression hose to help blood in lower extremities return to the heart. Additional nonpharmacologic maneuvers may address NOH but have not been verified in the literature: tip toeing, leg-crossing, bending forward, and squatting (Sanchez-Ferro et al., 2013).

A number of medications can be utilized to improve NOH. Commonly used medications to address NOH include fludrocortisone (Florinef[R]), which necessitates potassium level monitoring, and midodrine (Figueroa et al., 2010). Kanjwal, Karabin, Elmer, Kanjwal, and Grubb (2012) describe a study at the University of Toledo Syncope and Autonomic Disorders Center in which pyridostigmine (Mestinon[R]) was used with patients with a known Parkinson's disease diagnosis. The medication was shown to improve standing heart rate, standing blood pressure, and baroreceptor sensitivity (Kanjwal et al., 2012). Droxidopa (Northern[R]) received FDA approval in 2014 for orthostatic hypotension in Parkinson's disease, MSA, and RAF (Brooks, 2014). This new drug has a black box warning related to potential increased supine hypertension (Brooks, 2014).

Recommendations for Nursing Students and Practicing Nurses

As nursing faculty seek to revise their curricula and as practicing nurses maintain evidence-based practice, it is essential to broaden the cardinal signs and symptoms of Parkinson's disease from TRAP to include non-motor symptoms. The pathophysiological basis of this disease process must be broadened to include autonomic dysfunction and orthostatic hypotension. The assessment tools to determine the presence and extent of NOH in the patient with Parkinson's disease are important for nurses to gauge the presence and extent of NOH. It is also important for nurses to understand the relationship between NOH and supine hypertension, along with the goals of therapy. Finally, nurses must be aware of the wide and expanding array of nonpharmacologic and pharmacologic interventions to ensure delivery of the most current and evidence-based nursing care to our patients with Parkinson's disease.

References

Brooks, M. (2014). FDA dears Droxidopa for neurogenic orthostatic hypotension. Retrieved from http://www.medscape.com/viewarticle/820786 20150516023717784560442

Camargo, C.H., Hoffmann, H.A., Luciano, J.J., Blood, M.R., Schafranski, M.D., Ferro, M.M., & Myochi, E. (2014). Orthostatic hypotension and its relationship to the clinical course of patients with Parkinson's disease. Journal of Alzheimer's Disease and Parkinsonism, 4(5), 1-4.

Fereshtehnejad, S.M., & Lokk, J. (2014). Orthostatic hypotension in patients with Parkinson's disease and atypical Parkinsonism. Hindawi Publishing Corporation--Parkinson's Disease, I-10. doi: 10.1155/2014/475854 201504271600221390483618

Figueroa, J.J., Basford, J.R., & Low, PA. (2010). Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleveland Clinic Journal of Medicine, 77(5), 298-306.

Goldstein, D.S. (2014). Dysautonomia in Parkinson's disease: Neurocardiological abnormalities. Comparative Physiology, 4(2), 805-826. 20150427221307129033696720150427155713501723170

Goldstein, D.S., & Yehonatan, S. (2009). Neurogenic orthostatic hypotension: A pathophysiological approach. Circulation, 119, 136-146. 201504271536011463149309

Kanjwal, K., Karabin, B., Elmer, L, Kanjwal, Y, & Grubb, B.P. (2012). Preliminary observations from acetylcholine esterase inhabitation in symptomatic orthostatic hypotension of Parkinson's disease. The Journal of Innovations in Cardiac Rhythm Management, 3, 762- 765.201504262319421778360963

Nolden, L.F., Tartavoulle, T, & Porche, D.J. (2014). Parkinson's disease: Assessment, diagnosis, and management. Journal for Nurse Practitioners, 10(7), 500-506.20150427155522399712085

Refaat, M., Hotait, M., Anderson, W.D., & Reis, S.E. (2015). Orthostatic hypotension presenting as chest pain in a woman with Parkinson's Disease. Journal of Cardiology & Current Research, 2(3). Retrieved from http://medcraveonline.com/JCCR/JCCR-02-00059.pdf

Sampaio, C, Goetz, C.G., & Schrag, A. (Eds.). (2012). Rating scales in Parkinson's disease. New York, NY: Oxford University Press, Inc. 201504272246291377739310

Sanchez-Ferro, A., Benito-Leon, J., & Gomez-Esteban, J. C. (2013). The management of orthostatic hypotension in Parkinson's disease. Frontiers in Neurology, 4(64), 1-11.

Patricia J. Bartzak, DNP, RN, CMSRN, is a Clinical Nurse, Burn/Trauma Unit, Brigham & Women's Hospital, Boston, MA, and Edmond J. Safra Visiting Nurse Faculty Scholar 2014. She is the "Joining Forces" Column Editor.
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Author:Bartzak, Patricia J.
Publication:MedSurg Nursing
Date:Nov 1, 2016
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