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Nursing care of patients with late-stage Parkinson's disease.

Abstract: Patients in the late stages of Parkinson's disease may be significantly disabled for many years, often because of their increasing inability to tolerate therapeutic doses of antiparkinson drugs. Their status and management have been overlooked in the literature. Few current healthcare professionals have cared for patients with Parkinson's disease in the prelevodopa era and do not understand how severe awl protracted the illness can be without effective treatment. This article describes a practical approach to the nursing management of severely affected patients (i.e., Hoehn and Yahr Stage 4-5) who no longer derive consistent, therapeutic benefit from their drugs. Specific problems these patients face are adverse drug reactions such as postural hypotension, psychosis, and confusion, as well as difficulties with nutrition, elimination, mobility and falling, communication, sexuality, memory, and mood. Nursing interventions can help minimize the effect of these problems on the patient.

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Parkinson's disease (PD) is a common, progressive, neurological disorder with far-reaching medical and psychosocial implications. The incidence of PD is rising at a rate faster than can be explained by the aging population (Lilienfeld & Perl, 1994). A detailed description of PD and its treatment is beyond the scope of this article; see Lang and Lozano (1998a, 1998b) and Noble (2000) for reviews.

Briefly, PD results from damage to pigmented neurons in the substantia nigra ha the midbrain, leading to a reduction in the levels of the neurotransmitter dopamine. The cause, or causes, of this are unknown, but genetic mad environmental factors may be implicated (Calne, 2000). Damage to these neurons eventually results ha emergence of the cardinal signs and symptoms of PD (Table 1).

Neuronal loss in the substantia nigra is faster initially and then follows a curvilinear time course, eventually slowing to that of normal age-related attrition. Further deterioration continues as a result of normal age-dependent dopaminergic cell loss. Slowing of PD progression occurs at a stage when considerable damage has already occurred (Lee et al., 1994; Schulzer, Lee, Mak, Vingerhoets, & Calne, 1994). Thus, the late stages of PD may be protracted, unlike those in other neurodegenerative disorders such as amyotrophic lateral sclerosis, Alzhehner's disease, and Huntington's disease (Hille et al., 1999; McDonnell et al., 2001).

In the early to middle stages of PD, symptoms can be well controlled with a variety of medications and surgical procedures (Table 2). These patients, especially those with good access to medical care, may continue to lead independent and productive lives, because only these patients can make the return visits to their physicians that are so necessary for optimum management. Independent PD patients with well-controlled symptoms represent the tip of an iceberg. The majority of people with PD have advanced, disabling illness, are unable to tolerate therapeutic doses of antiparkinson medication, and are hidden from society. Patients with late-stage PD have limited access to medical care outside the home or facility where they reside, and their care has not been comprehensively addressed. In this paper, late-stage PD is defined as patients meeting the criteria for stages 4 and 5 of the modified Hoehn and Yahr Scale (Hoehn & Yahr, 1967; Table 3). The mobility of these patients may fluctuate, depending on drug efficacy and tolerance. Thus, the staging may be fluid rather than fixed. For example, patients at Stage 4 may improve on occasion to Stage 3 or worsen to Stage 5.

This article identifies and describes common problems associated with late-stage PD and provides suggestions for appropriate nursing intervention. Some problems such as dementia, impaired communication, and postural instability are not easily amenable to any corrective intervention, but knowledge and understanding of them are still essential for good care. A hill discussion of psychosocial and caregiver issues is beyond the scope of this paper. Recent, peer-reviewed literature is presented together with suggestions for further reading, where appropriate.

General Principles of Management

Medical and surgical treatments for PD are summarized in Table 2. Few PD patients at Stage 4 or Stage 5 Hoehn and Yahr (Table 3) are candidates for stereotactic surgical procedures (e.g., thalamotomy, pallidotomy, deep-brain stimulation), because numerous studies have shown that the outcome in older, more severely affected patients is poor (Lozano, 2003; Welter et al., 2002). However, nurses may care for patients who have had such surgery since its revival in the mid-1990s; see Lozano (2003) for a full review of surgery for PD.

The majority of drugs used to treat PD replace or mimic dopamine in the brain. Contrary to what patients may feel antiparkinson drugs don't stop working, nor do patients become "immune" to them. However, their efficacy can appear to decline as symptoms progress. This is often because the doses of antiparkinson drugs needed to improve symptoms precipitate psychiatric disturbances, leaving patients unable to tolerate therapeutic doses (Calne & Cable, 1997). Nevertheless, without adequate drug intake, mobility and quality of life are reduced, and the risk for falls, aspiration pneumonia, urinary tract infections, and death increases. Even in the face of severe PD with cognitive or psychiatric changes, sufficient antiparkinson drug intake is essential for maintaining at least the integrity of the swallowing reflex (Fuh et al., 1997). In late-stage PD, drugs such as anticholinergics, amantadine, and dopamine agonists may have to be withdrawn completely due to psychiatric side effects. Patients may tolerate only small doses of levodopa. PD patients with dysphagia need crushed standard levodopa (Calne & Calne, 1997). Liquid levodopa is an option if swallowing a crushed tablet is impossible (Kurth, 1997). If swallowing or mental status is impaired, PD patients should always be supervised when they take their tablets. Dysphagia and tube feeding are discussed in more detail later in this article.

Orthostatic Hypotension

Orthostatic hypotension is defined as a decrease in systolic blood pressure of at least 20 mm Hg, a decrease in diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing, or both. Patients with orthostatic hypotension may be symptomatic with dizziness and fainting or asymptomatic (Onrot, 1998). Patients with late-stage PD are at risk for hypotension because of varying degrees of autonomic disturbance and the fact that many antiparkinson drugs lower blood pressure (Mathias, 1998). PD patients with a combination of postural hypotension and severe impairment of postural reflexes are major candidates for falls and fractures. Five-minute supine followed by 3-minute standing blood pressure recordings are essential as diagnostic measures. Triggers for dizziness and fainting in PD patients are as follows:

* adding dopaminergic drugs to the regimen of a patient who is already taking antihypertensives or other blood pressure-lowering drugs (e.g., tricyclic antidepressants)

* increasing the dose of antiparkinson drugs too quickly, particularly dopamine agonists

* taking dopaminergic drugs on an empty stomach

* the hour following medications or a meal

* getting up too quickly from a recumbent position after a bowel movement or urinating

* warm weather, dehydration, and hot baths.

Strategies to prevent dizziness and fainting include the following:

* Increase fluid and salt intake.

* Have a drink of clear liquid, tea, or coffee before rising and sit on the edge of the bed for 5-10 minutes before standing (see hydration; Hodder, 1997).

* Remain seated for 20-30 minutes after a main meal or dose of medication and for a few minutes after a bowel movement.

* Sit down to towel off after a hot bath or shower and to urinate (men).

* Stay out of hot sun.

* Never stand still (particularly after exercise) because blood will pool in the legs (Calne, Baisley, Coughlan, Shaw, & Traviss, 2003).

* Reduce, stop, or replace other drugs known to lower blood pressure.

* Take medications with food.

* Increase medication doses slowly (every 5-7 days).

If postural hypotension persists despite these measures, a physician may order an antihypotensive agent such as fludrocortisone or midodrine (Mathias & Kimber, 1999). Surgical support stockings can be expensive and tend to be abandoned due to the difficulty in putting mere on, for a full review of orthostatic hypotension, see Mathias mad Kimber (1999).

Genitourinary

PD patients most commonly experience urinary problems such as frequency and urgency, though retention can result from the use of anticholinergic drugs (e.g., trihexyphenidyl, benztropine). A significant challenge for the clinician is determining whether a patient has a surgical problem such as prostate hypertrophy or whether the symptoms are related to autonomic dysfunction fur which surgery not only does not help but can actually exacerbate the problem (Chandiramani, Palace, & Fowler, 1997). An evaluation by a urologist is necessary to exclude obvious urinary problems such as prostatic hypertrophy. If urinary tract and swallowing problems are present and significant soon after the onset of parkinsonism, this may signify that the patient has multiple system atrophy (MSA), which can mimic PD (Hodder 1997).

Nurses can recommend that their patients ask their urologist to talk to their neurologist before making any decisions about whether to undergo surgery. For both male and female patients, incontinence pads may be preferable to having a surgical procedure that could be ineffective. Modern pads are unobtrusive and come in a variety of designs. Patients can be reassured that the use of incontinence pads is widespread and that their use may be preferable to living with the anxiety of incontinence, which eventually leads to social isolation. Male patients may find using a condom catheter particularly useful when traveling; however, late-stage patients may need assistance applying it.

Sexuality

It is important that nurses not make assumptions about sexuality in elderly patients with chronic disease. Sexual dysfunction is common ha both men and women as they age and PD can exacerbate it (Basson, 1996; Welsh, Hung, & Waters, 1997). Sexual dysfunction may be due to a variety of problems that include autonomic dysfunction, depression, diabetes, hypothyroidism, fatigue, and loss of self-esteem. Patients may have difficulty achieving or maintaining an erection or reaching orgasm. In patients who are severely disabled, the act of coitus may be physically impossible but the need and wish for sex remain. A variety of therapeutic approaches is available for both men and women, but when a couple is involved, both should be involved in any discussions about treatment (Calne & Basson, 2000). Hypersexuality due to "dopa mania" or a premorbid pattern of sexual behavior can be a source of distress to the patient, spouse, family, and nursing staff members in care facilities (Robinson, 2003; Uitti et al., 1989). A consultation with a member of a sexual medicine clinic can be helpful for both the patient and the staff. Team nursing in these circumstances can reduce unwanted interactions between patients and staff members.

Nutrition, Hydration. and Elimination

Patients with late-stage PD may develop dysphagia, which may lead to weight loss, insufficient drug intake, dehydration, choking, aspiration, and death (Bine, Frank, & McDade, 1995; Clarke, Gullaksen, Macdonald, & Lowe, 1998; Cushing, Traviss, & Calne, 2002). Some patients who are cognitively intact and with fewer disabilities may benefit from intensive therapy to improve swallowing (Sharkawi et al., 2002). Patients who have difficulty chewing and swallowing their food should adopt an upright and chin-down position. Food that is sour to the taste may be easier to swallow (Logemann et al., 1995). The sourness may provide a proprioceptive cue to swallow. For the same reason, patients with dysphagia may be able to swallow carbonated rather than clear liquid liquids (Cushing et al.).

Caregivers should know how to perform the Heimlich maneuver. If a patient's level of swallowing impairment and frequency of choking episodes are disproportionately worse than other physical symptoms and cognitive state and if he or she can tolerate anesthesia, a gastrostomy feeding tube may be considered. The patient can then obtain sufficient drug therapy and nutrition without choking. All drugs (excluding controlled-release preparations) can be crushed with a little water and put down the tube, which is then clamped for 30 minutes (Calne & Calne, 1997). However, the long-term implications and consequences of inserting any kind of feeding tube should be discussed fully with the patient, family, and care team (Keizer, 2001).

Smaller meals supplemented with high-energy snacks enable the patient to obtain adequate nutrition (Cushing et al., 2002). Some vocal proponents still promote a protein-restricted diet that enjoyed some popularity in the late 1980s (Pincus & Barry, 1987). It was effective for only a very limited number of patients, expensive, and difficult to adhere to in a home setting (Pare, Barr, & Ross, 1992). The introduction of controlled-release levodopa has eliminated the need to adopt protein restriction as a therapeutic intervention (Cushing et al.). However, distributing protein evenly throughout the day can be an effective measure for those patients who suspect an interaction between protein and their antiparkinson drugs (Carter & Nut-t, 1995; Cushing et al.).

The lay press has expressed concerns about dairy products and their interaction with drugs for PD, and many PD patients have abandoned them for no proven reason. The general public, including PD patients, also has been persuaded that they are lactose intolerant and eschew dairy products as a result. Lactose intolerance is much more rare than is generally believed (McBean & Miller, 1998). Suarez, Adshead, Fume, and Levitt (1998) have shown that even people with lactose malabsorption can tolerate enough dairy product to obtain 1,500 mg calcium a day. Patients with advanced PD need the easily digested protein and calcium that dairy products provide (Cushing et al., 2002).

Bradykinesia may interfere with eating. Pre-cutting food before serving it to a patient will reduce self-consciousness and promote good nutrition. Some PD patients may prefer eating alone because the anxiety of keeping others waiting. The spluttering, choking, and feeling of being part of a spectator sport may interfere with their ability to enjoy their food (Cushing et al., 2002).

Frequent meals and snacks require extra attention to dental hygiene. A compact-head electric toothbrush is useful because little wrist movement is necessary. If PD patients have neither teeth nor dentures, a dietitian can advise on calorie requirements and food preparation (Cushing et al., 2002).

Maintaining adequate hydration is important for PD patients who are prone to constipation, orthostatic hypotension, and drug psychosis (Calne & Calne, 1997). This is difficult even if liquid is close at hand, because the patient may not be able to lift the glass, and someone else has to remember to offer liquid throughout the day. Even mild temperature increases can induce dehydration if fluid intake is inadequate (Calne et al., 1997). Sorbets, smoothies, and fruit are mostly water, mad patients might find these easier to swallow. If excess nocturnal micturition is an issue, patients can drink as much as possible before 4 pro, then use liquids to aid in swallowing food and tablets only until bedtime.

Impaired swallowing and a stooped posture can cause accumulation of saliva, resulting in drooling, choking episodes and excoriation around the mouth and chin. Pal, Calne, Calne, and Tsui (2000) have shown that botulinum toxin injections can be an effective treatment for excessive saliva. Rinsing the mouth before meals with something cold and sour (e.g., lemon juice and soda water) can improve the enjoyment of eating by drying saliva secretions.

Chronic constipation is common in all stages of PD. Patients experience two kinds of constipation: (a) dry, hard stools that are painful to pass and Co) incoordination of rectal muscles that prevents normal stool from being expelled (Ashraf et al., 1995). Antiparkinson drugs, slowed gut motility, immobility, and dehydration may all be responsible. Although a daily bowel movement is unnecessary, patients should not go for days without one. Stool softeners and gentle laxatives such as fruit lax, small doses of bulking agents, or milk of magnesia may be needed daily. Stronger laxatives, suppositories, and enemas may also be needed. A washcloth wrung out in warm water or a finger can stimulate sluggish rectal muscles (Ashraf et al., 1995). The routine need for laxatives must be balanced against the fact that patients with PD who are constipated have increased susceptibility to life-threatening complications such as obstruction, perforation, volvulus, mid paralytic ileus (Marinella, 1997; Pfeiffer & Quigley, 1999; RosenthaI & Marshall, 1987). Nurses can reinforce the need for a good preventive bowel management program. See Pfeiffer (1998) for a complete review of gastrointestinal problems in PD. A Parkinsonspecific bowel management program is available from Parkinson Society Canada (www.parkinson.ca).

Mobility, Safety, Exercise, and Communication

Mobility in late-stage PD may eventually be severely impaired and, when combined with severe bradykinesia, can result in most of the waking hours being spent performing activities of daily living (ADLs; Andersen, 1999; Berry & Murphy, 1995; Carter et al., 1998). The combination of decreased mobility, postural instability, and gait disturbance increases the risk for falling and fractures (Gray & Hildebrand, 2000; Rajput, Pahwa, Pahwa, & Rajput, 1993). Falls represent one of the biggest concerns in middle- to late-stage PD for the patient who is still mobile. A hip fracture in a PD patient who is frail and elderly can be catastrophic. The use of hip protectors has been studied in Scandinavia due to the higher incidence of osteoporosis in this area. Kannus et al. (2000) studied the use of hip protector pads in a large group of elderly Finnish patients at risk for falling. They found a statistically significant reduction in fractures among those patients at risk who consented to wear them. Rates were 21 per 1,000 person-years in the hip protector user group and 46 per 1,000 in the control group. In an editorial accompanying the paper, Rubenstein (2000) wrote the following:
 Hip protectors offer a powerful new method for
 reducing the risk of hip fracture. Their use should
 be strongly encouraged for persons at increased
 risk (i.e., those with osteoporosis and a high risk
 of falling, such as those with impaired gait or balance
 and weakness) and particularly for those
 residing in healthcare institutions, because they
 are likely to be frail. Future research should focus
 on ways to improve the acceptability of hip protectors
 and on better defining time subgroups that
 can derive particular benefit from their use (pp.
 1562-1563).


At the Pacific Parkinson's Research Centre, Vancouver, BC, Canada, experience has shown that patients still need to be convinced of their risk for falling and that hip protectors are most effective when used in a facility where trained staff can help residents with their use.

Complications such as hypostatic pneumonia and pressure sores may develop, resulting in accelerated debility. Rehabilitation consultations are appropriate for decisions about safety and assistive devices such as canes, walkers, wheelchairs, and protectors for the hips and knees. The decision to use assistive devices should be individualized, because inappropriate devices may be more of a hindrance than a help. For instance, walkers with wheels seem to increase time festinating gait, and patients may fall over the walker (Melnick, 1993). Patients can fall in homes that may be "minefields" of slip rugs, end tables, and tight corners. Patients with PD also may fall as a result of poor vision and cataracts (Dargent-Molina et al., 1996) or poor visual contrast (Hutton, Morris, Elias, Varma, & Poston, 1991). For example, a patient with PD may trip over a brown rug on a brown floor or not be able to distinguish the sidewalk from the pavement. Eyeglasses with light blue lenses may sharpen contrast (Hutton & Morris, 2001; Hutton, Morris, & Elias, 1993). Stooped PD patients who wear bifocal lenses may trip while walking, because they are looking through the reading portion of their lenses. A PD patient who falls frequently, whether at home or in a facility, would benefit from an occupational or physical therapy assessment. Pastural hypotension is another important cause for falls in PD, and the need to try and accommodate this cannot be overemphasized.

The amount of exercise a patient can tolerate depends on the level of disability. Exercise should be undertaken when drug efficacy is at its best. Even regular simple exercise such as walking and stretching is good for self-esteem (Baatile, Langbein, Weaver, Maloney, & Jost, 2000), but no studies have yet determined whether physical exercise benefits subjects with neurological impairment in patients older than 65 years (Eldar & Marincek, 2000).

When late-stage PD patients require regular assistance for ADLs, their rigidity puts nurses and other caregivers at risk. Performing ADLs or carrying out exercises with an immobile "off" patient or transferring such a patient can result in injury to both patient and caregiver. Wherever possible, ADLs and exercise should be timed to coincide with optimum drug benefit. This is impractical when the patient is bedridden, because there may be no noticeable periods of drug benefit. Nurses should not try to care for these patients without help under these circumstances.

Cramps are common in PD, and patients who keep their muscles and tendons stretched may overcome them more easily (Calne et al., 2003). In bed-bound patients, active or passive movements, frequent changes in position, and simple breathing exercises can prevent complications such as contractures, pressure sores, deep-vein thrombosis, and hypostatic pneumonia. At this stage the patient will be unable to cooperate fully and the body will be rigid. Nurses must practice good body mechanics when helping these patients, and they can reduce the risk of personal injury by not working alone.

Hypophonia due to PD can be treated with percutaneous collagen augmentation of the vocal folds (Berke, Gerratt, Kreiman, & Jackson, 1999). Some patients benefit from speech therapy sessions (Sharkawi et al., 2002). However, the intensive Lee Silverman Voice Therapy (LSVT) program reported by Sharkawi et al. requires enormous effort on file part of the patient and may not be realistic in patients with PD who are severely disabled. With anarthric or aphonic patients, asking yes/no questions, avoiding questions with multiple-choice answers, and using alphabet boards or devices, such as speaking dictionaries, may help with communication.

Sleep Disturbances

Sleep disturbances are common in PD (Bliwise et al., 1995; Pal, Calne, Samii, & Fleming, 1999). Excessive daytime somnolence can be due to any dopaminergic drug (Hobson et al., 2002; Sanjiv et al., 2001). This finding is contrary to earlier reports that daytime somnolence occurred with only ropinirole and pramipexole (Etminan, Samii, Takkouche, & Rochon, 2001; Frucht, Rogers, Greene, Gordon, & Fahn, 1999). Drug-induced insomnia is almost always due to selegeline, which during its metabolism is converted to amphetamine (Cable, 1993). Levodopa-induced vivid dreaming can be reduced by taking the last dose several hours before bedtime, though this may decrease nocturnal mobility. Some common suggestions for regulating sleep, such as getting out of bed and doing something else if they can't sleep, are impractical for PD patients. It may take a PD patient and caregiver an hour just to prepare for bed (Pal et al., 1999). Nurses can, however, recommend that patients do not

* go to bed hungry

* have a hot bath or shower less than 2 hours before bedtime

* exercise less than 2 hours before bedtime

* watch television in bed.

See Pal et al. (1999) for a full review of sleep disturbances.

Depression

Depression can occur in as many as 50% of PD patients and have a serious effect on them (Aarsland, Larsen, Karlsen, & Tandberg, 1999; Cummings, 1992). Depression shares many features with late-stage PD (Table 4) and is not easy to detect in patients who are severely disabled. In patients with PD, depression can result in loss of interest and cooperation, which interferes with care delivery. Most antidepressants, including tricyclics and selective serotonin reuptake inhibitors (SSRIs), are well tolerated once early side effects subside and can be taken with antiparkinson therapy (Oertel et al., 2001). Venlafaxine has been shown to be particularly useful in PD because it has no hypotensive effect (Oertel et al.). Electroconvulsive therapy (ECT) can be a highly effective treatment PD patients with depression (Hurwitz, Calne, & Waterman, 1988; Moellentine et al., 1998). Both depression and dementia may be exacerbated by drug-induced psychosis (Aarsland, Larsen, Cummins, & Laake, 1999; Factor et al., 1995; Hurwitz & Calne, 2001). See Oertel et al. (2001) for a comprehensive review of depression in PD.

Drug Psychosis, Confusional States, Hallucinations, Delusions, and Dementia

Drug psychosis and confusion can occur in PD with or without dementia. Confusion refers to a sudden onset of disorientation and muddled thinking that may also be associated with hallucinations and delusions (Hurwitz & Calne, 2001). A nurse may be the first healthcare professional to notice behavioral changes and will thus be in a position to rule out treatable causes such as

* incorrect use of antiparkinson drugs over the last few days

* side effects from, or interactions with, other prescription drugs, over-the-counter supplements, and meperidine

* recent general anesthesia

* recent fever with or without a known infection

* recent travel involving timing and dosing changes

* dehydration

* constipation.

If these causes can be excluded, a physician or advanced practice nurse may order a slow reduction of drug dosage until the confusion or psychosis clears. Unfortunately, the dose at which the sensorium clears is often too low to maintain an adequate level of mobility and may threaten the integrity of the swallowing reflex (Calne & Calne, 1997). Nurses can provide support to the patient while these changes are being undertaken. Family members will appreciate explanations of the difficulties derived from maintaining a clear mental state at the expense of mobility.

Unlike older drugs, such as haloperidol and risperidone, newer antipsychotics such as quetiapine appear not to worsen PD significantly and may be ordered in small doses to provide a balance between maintaining mobility and limiting psychosis (Feedman, 1998; Fernandez, Friedman, Jacques, & Rosenfeld, 1999). Both depression and dementia may be exacerbated by drug-induced psychosis (Aarsland, Larsen, Cummins, et al., 1999; Factor, Molho, Podskalny, & Brown, 1995; Hurwitz et al., 2001).

Hallucinations are sensory experiences without cause, such as seeing or hearing things that are not there. Any dopaminergic drug can cause hallucinations. PD patients on dopamine agonist often report seeing small animals or small children. Reducing drug dosage eliminates hallucinations in the long term (up to 6 weeks), but reduces mobility almost immediately (Calne, 1993). Patients who have insight may choose to live with nonfrightening hallucinations if their drugs are providing good mobility (Calne & Calne, 1997). Family members are often more disturbed by the hallucinations than the patient. Nurses may need to explain to them why the patient has chosen to live with them. However, nurses can monitor patients and immediately report hallucinations that become threatening. They can advise family members to do the same

Paranoid delusions are fixed irrational beliefs, such as when patients believe they are being spied on or that others want to harm them. Elderly patients who are delusional frequently feel they are being poisoned, usually by a spouse or caregiver, and these delusions can interfere with nutritional status and adequate drug intake (Melamed, Friedberg, & Zoldan, 1999); this is distressing for everyone involved with care. If changes in drug therapy are not helpful, the nurse may have to work with family members to identify someone who is not a perceived threat to the patient to deliver food or medicines.

PD patients who are approved for anesthesia and who experience severe drug-induced psychosis that is resistant to changes in drug therapy may benefit from ECT (Factor et al., 1995; Hurwitz et al., 1988). A course of ECT can enable a patient with PD to take a therapeutic dose of antiparkinson drugs and can also provide temporary benefit to PD symptoms (Rasmussen & Abrams, 1991) and depression. To allay the fears of the patient and family, nurses can provide factual information about modern ECT, its benefit, and safety.

Dementia refers to slow loss of memory and other intellectual abilities that interfere with an individual's ability to function. Dementia is usually steadily progressive, making the individual increasingly dependent on others for his or her survival. Treatable causes such as vitamin B-12 deficiency, thyroid deficiency, and depression should be excluded (Cummings, 1988). About 30% of patients with PD develop some form of dementia. Both dementia and psychiatric drug side effects in PD (Table 2) can limit therapeutic options and have a profound effect on the ability to provide adequate physical care or emotional support (Calne & Calne, 1997). The nurse may be the primary professional support for the family of these patients, some of whom will still be cared for at home under difficult circumstances. A nurse's ability to listen and provide even simple suggestions for care will he invaluable to caregivers (Greenberger & Litwin, 2003). See Wolters and Francot (1998) for a review of mental dysfunction in PD.

Comorbidities and Complications

Comorbidities such as osteoporosis, arthritis, diabetes mellitus, cancer, and heart disease exacerbate PD (Bozek & Calne, 2001). Treatment of these problems adds to the burden of medication timing and compliance. Unlike patients at earlier stages, patients with late-stage PD rarely return to previous levels of functioning following an acute illness. Patients who have not succumbed to life threatening illnesses such as cancer, stroke, or myocardial infarction eventually die from the complications of being bed or altair bound due to rigidity, failure to recover from fractures, aspiration pneumonia, pressure sores, an. chronic urinary tract infections (Gorell, Johnson, & Rybicki, 1994). Measures such as chest physiotherapy to prevent hypostatic pneumonia and frequent changing of position, together with the use of water beds and egg crate mattresses to prevent pressure sores, are necessary.

End-of-Life Care

Nurses, whether providing care in acute care hospitals, long-term-care facilities, or community-based settings, are most often the healthcare professional present when a patient is dying. Most patients with PD will have lived an extraordinarily long time with their illness, much of it in a disabled state. As death approaches, nurses who understand PD and its lengthy ramifications are in a unique position to provide the best physical and emotional care to the patient, and emotional support to the family, in a compassionate environment. If acutely ill patients are transferred from home or facility, it is most often to an acute care facility. Although the quality of care in a hospice is highly desirable, space is scarce and PD patients may actually die from an acute infection such as pneumonia over relatively few days, with little pain. Keeping patients comfortable in already familiar surroundings may be preferable. Doing one's best to ensure that the patient has peaceful death is a valuable goal; the death of the patient should not be construed as failure by the nurse.

Summary

Advanced PD is characterized by debilitating physical and neurobehavioral problems requiring skilled nursing rehabilitation, and medical attention. Increased recognition of these problems by healthcare professionals can only improve the quality of care these patients need and deserve. Nurses are the essential component of the multidisciplinary team needed to age late-stage PD. They are often proximate caregivers and form a vital link between the patient and other healthcare professionals.
Table 1. Signs and Symptoms of Parkinson's Disease

Signs Symptom and Treatment Response Summary

Primary
 Tremor * First symptom in 70% of patients; begins on
 one side, present at rest but there can be
 a postural component, socially distressing
 but does not interfere with activities of
 daily living. Often poorly controlled by
 medication.
 Bradykinesia * Slowness and poverty of movement; fine
 movements become clumsy; difficulty
 initiating movement (getting out of a
 chair) with arrests of ongoing movement
 (e.g., turning corners, going through
 doorways).
 Responds well to treatment.
 Rigidity * Increased tone and stiffness in the muscles
 at rest. Responds well to drug therapy.
 Postural instability Inability to make the required rapid
 adjustments to the body's center of
 gravity when standing and walking. Poor
 response to drug therapy; major cause of
 falls; rehabilitation therapy helpful.
 [dagger]
Secondary
 Hypomimia Lack of facial expression resembling
 flattened affect of depression; reduced
 blink rate. May respond to drug therapy.
 Hypophonia Soft voice; speech loses rhythm and shading.
 May respond to drug therapy or intensive
 speech therapy.
 Micrographia Small, cramped, handwriting. May respond to
 Fatigue drug therapy. Everyday tasks take longer
 and require more concentration. Symptoms
 disturb sleep. Drugs for PD can induce
 somnolence. [dagger]
 Depression As many as 50% of PD patients have an
 episode of endogenous depression during
 their illness. [dagger]
 Constipation Immobility, slowed gastric motility and drug
 therapy contribute to constipation.
 [dagger]
 Pain Cramping and muscle stiffness, increased
 mobility can aggravate preexisting joint
 disease.

* Made worse by anxiety

[dagger] More detailed discussion in text

Table 2. Medical and Surgical Treatment for Parkinson's Disease

Drug Therapy Benefit and Use

Levodopa with carbidopa Used as first-line treatment for
 Sinemet CR (controlled release) many patients; improvement in
 Standard Sinemet (immediate mobility and activities of daily
 release) * living and, in some cases, mood;
Levodopa with benserazide fewer side effects with con-
 (unavailable in USA) trolled-release preparations;
 Prolopa, Madopar frequently used in combination
 with COMT inhibitor and/or
 dopamine agonist.

Catechol-0-methyltransferase Prevents peripheral breakdown of
inhibitors (COMT) levodopa; used to extend benefit
 Entacapone (Comtan) of levodopa doses and reduce
 wearing off reactions.

Dopamine agonists
 Bromocriptine (Parlodel) Used as first-line treatment,
 Pergolide (Permax) particularly for young onset
 Ropinirole hydrochloride patients, less likely to cause
 (ReQuip) fluctuations and dyskinesia; used
 Pramipexole dihydrochloride in combination with levodopa.
 (Mirapex)

Anticholinergics, amantadine and
deprenyl
 Trihexyphenidyl (Artane) May help reduce tremor and to a
 Apo-trihex lesser extent, bradykinesia and
 Benztropine (Cogentin) rigidity.

Amantadine (Symmetrel) May relieve rigidity; recently
 shown to help suppress dyskine-
 sias.

Deprenyl or Selegiline (Eldepryl) Mild effect on symptoms; mild
 antidepressant effect.

Stereotactic Surgical Treatment
 Thalamotomy Tremor.
 Pallidotomy Improves dyskinesia and rigidity.

 Deep-brain stimulation of Improves dyskinesia and tremor
 pallidum or high-frequency and rigidity.
 stimulations of subthalamic
 nucleus

Drug Therapy Problems and Side Effects

Levodopa with carbidopa Nausea and loss of appetite,
 Sinemet CR (controlled release) hypotension; "wearing off" effect
 Standard Sinemet (immediate (symptoms reappear before the end
 release) * of the dose interval); dyskinesia
Levodopa with benserazide (free-flowing involuntary move-
 (unavailable in USA) ments or painful dystonia); "on
 Prolopa, Madopar off" effect (abrupt oscillations
 between mobility and rigidity)
 resulting from long-term, high-
 dose treatment, nightmares and
 vivid dreams, confusion at high
 doses or in frail elderly
 subjects.

Catechol-0-methyltransferase Precipitates side effects of
inhibitors (COMT) levodopa, particularly dyskine-
 Entacapone (Comtan) sia; diarrhea (rare).

Dopamine agonists
 Bromocriptine (Parlodel) Nausea, vomiting, hypotension;
 Pergolide (Permax) mild non-frightening hallucina-
 Ropinirole hydrochloride tions; frightening hallucina-
 (ReQuip) tions, delusions; confusion; dif-
 Pramipexole dihydrochloride ficult to achieve benefit compa-
 (Mirapex) rable to levodopa without indu-
 cing side effects.

Anticholinergics, amantadine and
deprenyl
 Trihexyphenidyl (Artane) Confusion, dry mouth, blurred
 Apo-trihex vision, urinary retention.
 Benztropine (Cogentin)

Amantadine (Symmetrel) Psychosis, particularly in the
 presence of renal impairment,
 withdrawal psychosis, livedoreti-
 cularis (spidery red markings on
 lower legs).

Deprenyl or Selegiline (Eldepryl) Insomnia; increases side effects
 of levodopa.

Stereotactic Surgical Treatment
 Thalamotomy Dysarthria, stroke (rare).
 Pallidotomy Cognitive and behavorial distur-
 bance (rare).

 Deep-brain stimulation of Electrode may break and site may
 pallidum or high-frequency become infected (rare); stimula-
 stimulations of subthalamic tor needs to be regulated and
 nucleus battery replaced.

* Generic versions available

Table 3. Modified Hoehn and Yahr Staging
of Parkinson's Disease

Stage Description

 0 No signs of disease
 1 Unilateral disease
 1.50 Unilateral plus axial involvement
 2 Bilateral disease without impairment of balance
 2.50 Bilateral disease with recovery on pull test
 3 Mild to moderate bilateral disease; some postural
 instability; physically independent
 4 Severe disability; still able to stand or walk
 5 Wheelchair bound or bedridden unless aided

Note. From "Paikinsonism: Onset, Progression, and Mortality," by M.M.
Hoehn and M.D. Yahr 1967, Neurology, 17, 427-442.

Table 4. Similarities Between Late-Stage Parkinson's Disease and
Depression

 Late-Stage PD Depression

Loss of spontaneous facial Loss of spontaneous facial
 expression expression
Slowed executive function Slowed executive function
Lack of concentration Lack of concentration
Impaired cognitive-intellectual Impaired cognitive-intellectual
 functions due to Parkinson's functions due to depressive
 dementia pseudo-dementia
Agitation, anxiety Agitation, anxiety
Hallucinations, delusions, Hallucinations, delusions,
 paranoia paranoia
Constipation Constipation
Sleep disturbance Sleep disturbance
Inability to pursue hobbies and Inability to pursue hobbies and
 interests due to physical interests due to apathy
 symptoms
Decreased sexual activity due to Decreased sexual activity due to
 immobility, loss of libido loss of libido and drug therapy
Motor and mental slowing due to Motor and mental slowing due to
 bradykinesia and bradyphrenia psychomotor retardation


Acknowledgments

The authors thank Lynn Beattie, MD FRCPC, Division of Geriatric Medicine UBC, for constructive comments Susan Calne is supported by The National Parkinson Foundation (Miami) Centre of Excellence Grant. Ajit Kumar is supported by the Pacific Parkinson's Research Institute and the University of British Columbia.

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Questions or comments about this article may be directed to: Susan M. Calne, CM RN, by phone at 604/822-7705 or by e-mail at scalne@interchange.ubc.ca. She is a coordinator at the Pacific Parkinson's Research Centre, Vancouver, BC, Canada.

Ajit Kumar, DM, is a senior research fellow, with a special interest in epidemiology and clinical care, at the Pacific Parkinson's Research Centre.
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