PARKINSON’S DISEASE
By: Name
Introduction
This paper is a portfolio based on a learning contract which aims to research and compile medications used in Parkinson’s disease. It will carry an investigated research on the negative drug interactions of people with Parkinson’s disease. As of 2012, Parkinson’s disease is highly prevalent in the world (an estimated 10 million people affected) and the fact that it is still an idiopathic disorder, its cause is yet to be found (Parkinson’s Disease Foundation 2012, p.1).
In this project, evidences of the outcome of the learning contract uses relevant Internet literature search, PowerPoint presentation and videos. There will be a systematic review of literature related to the efficacy along with safety of the available treatments. The literature review aims to identify the therapeutic interventions for which there exists sound scientific support to endorse their application (or avoidance as necessary), and to point where a lack of evidence calls for the need for intense future clinical trials. The specific drug treatments reviewed in this project are: Levodopa, Anticholinergics, Amantadine, COMT inhibitors and DA agonists.
Definition of Parkinson’s disease
Parkinson’s disease is a chronic progressive neurological disease of later life as a result of decreased dopamine production in an individual’s substantia nigra, marked especially by rigidity, tremor of resting muscles, slowness of movement, shuffling gait, and impaired balance (Ronken & Scharrenburg 2002, p.6). Basically, it is a degenerative disorder of the central nervous system. The disease is also known as paralysis agitans or Parkinson’s syndrome.
Literature Review
There has been much research on Parkinson’s disease particularly on its medication. Many journals and research studies have been published in the recent past which reflected different medical interventions to the disease. In 1967, Duvoisin showed that centrally operating cholinesterase inhibitor, physostigmine, was responsible for increased severity of Parkinson’s disease symptoms, and the effects could be countered by anticholinergic drugs (Movement Disorders 2002, p. 7).
According to Aschenbrenner & Venable (2008), Parkinson’s disease occurs naturally and external stimulus such as trauma or virus does not trigger it. Parkinson disease usually affects patients aged 50 years and above. However, researchers have recently established that parkin gene, a mutated gene, can trigger the disease at much younger age (2008, p. 244).
Hallett and Poewe (2008) have expressed that the progress in functional neurosurgery in the recent past stand as the most significant therapeutic advance in the treatment of Parkinson’s disease after the introduction of levodopa. The latter has long been regarded as the most effective pharmacologic intervention for the symptoms of the disease, particularly bradyklnesia and rigidity (Rao et al 2006, p.1). Nashold (1959) demonstrated that the direct injection when conducting neurosurgery of acetylcholine into the globus of persons with Parkinson’s disease resulted in hyped tremor in the contralateral extremities, which was cut down by the subsequent injection of the anticholinergic drug (Movement Disorders 2002, p. 7).
Medication of Parkinson’s disease
There are several treatments (therapeutic interventions) that are available to alleviate the quality of life together with the psychological and physical morbidity of people living with Parkinson’s disease (Bunting-Perry 2007, p. 23). However, it is worth noting that the disease still remains incurable. Antiparkinson drugs are used to treat Parkinson disease, where the objective of the therapy is to restore the lost balance between dopamine and acetylcholine. This can be achieved by blocking the activity of acetylcholine or increasing the action of dopamine (Aschenbrenner & Venable 2008, p. 245). An anti-Parkinson drug refers to any medication used to improve the symptoms of Parkisons disease.
Levodopa
Pharmacologists believe that levodopa is the most effective drug against symptoms of Parkinson’s disease because of its great ability to reduce difficulties of moving part/s or the entire body (alkinesia) and rigidity (Jankovic & Tolosa 2006, 2p. 14). Levodopa, also known as L-dopa, is often combined with carbidopa (Sinemet) so as to raise the amount reaching the brain as well as reduce side effects. However, levodopa has a limitation in that it only slightly improves tremors besides not helping much to ensure balance and other motor symptoms. In addition, levodopa is known to become less effective with time, meaning the dose has to be increased over time. It is also estimated that the drug does not work for about 25 percent of people with Parkinson’s disease.
Side Effects
There are a number of possible side effects of Levodopa. Use of the drug may result in a condition called dyskinesias, which refers to uncontrolled movements of the patient (Bunting-Perry 2007, p. 212). The patient may also experience unpredictable “on-off” responses, low blood pressure, nausea and vomiting, dizziness along with restlessness. Furthermore, a patient is likely to suffer from sleepiness, confusion, visual hallucinations, freezing episodes (“on-off”), unrealistic dreams, and personality changes.
Dopamine Agonists
Dopamine agonists are the other type of drugs used to treat Parkinson’s disease. Their action is the same as that of dopamine, meaning it relays the same messages to the nerve cells of the patient. It stimulates the dopamine receptors instead of replacing it as levodopa does (Jankovic & Tolosa 2006, p. 89). Many researchers believe that these drugs may contain a neuroprotective effect.
On another note, it is recommended to use dopamine agonists prior to levodopa therapy because of their ability to improve tremors, slow movement and rigidity and have relatively less side effects. Dopamine agonists are less likely to cause dyskinesias because dyskinesias are caused by high levels of dopamine in the patient’s system (Woodward & Waterhouse 2009, p. 95). When it is used together with levodopa, patients require less levodopa and experience relatively fewer “on-off” or “wearing off” problems.
Side Effects
Dopamine agonists are not that effective in treating freezing or dementia and postural problems. For people over the age of 65, side effects such as hallucinations or confusion are more common. Other side effects of dopamine agonists include nausea, vomiting, and low blood pressure, loss of appetite, skin discoloration, and malaise (Woodward & Waterhouse 2009, p. 213). In addition, the drug may lead the patient to suddenly fall asleep, which may cause danger. Generally, people who do not respond to levodopa usually do not respond to dopamine agonists. It is recommended that dopamine agonists are started with low dose and then increased slowly so as to minimize the side effects. It is best taken with meals.
COMT Inhibitors
COMT inhibitors are drugs used in combination with levodopa/carbidopa to lengthen the time that levodopa stays in the brain, a mechanism that makes it more effective. They act to lower the amount of levodopa needed (in turn resulting in a reduced dose of levodopa) and help with “on-off” and “wearing off” problems for patients (Woodward & Waterhouse 2009, p. 212). Their mechanism is such that they block an enzyme known as catechol-O-methyl transferase (CoMT), which causes the breakdown of levodopa. This way, they slow the breakdown of levodopa in the body and allow more levodopa to go through the brain and be converted in dopamine. In addition, COMT inhibitors server to improve the balance and motor functions of the patient besides helping fatigue that results from dyskinesias.
Side Effects
The possible side effects of COMT inhibitors range from increased risk of dyskinesias, posture problems, nausea, diarrhea, sleeping difficulty and vivid dreams. Sometimes, the color of the patient’s urine turns to brown or reddish-orange, which is not harmful in itself. Notable examples of COMT inhibitors include Tolcapone (Tasmar) and Entacapone (Adcapone, Entacom, Comtam). They are also found in combination with Levodopa-Carbidopa such as Entacom plus and Syncapone.
MAO-Inhibitors
The fourth type of medicine for Parkinson’s disease is the MAO inhibitors. This drug serves a helping drug for dopamine to last longer in the brain. It is at times used as a first drug treatment as it is less effective with time. When used in conjunction with levodopa, a person can take less levodopa and could experience lesser difficulties between doses.
Side Effects
Some physicians believe that these drugs are harmful when used over a long length of time.
Antiviral Medications
Parkinson disease is also tackled using antiviral medications which decrease dsykinesia in later stages of the disease. This drug can be used by itself or with another drug as well as during early stages. Though effects of the drug wear off after several weeks, anti-viral may be effective once more after discontinuing its use for a while.
Side Effects
Antiviral have side effects such as purple blotching of legs, swelling of legs, hallucinations, confusion, blurred vision, nightmares and depression. In addition, doses of antiviral need to be adjusted downward for patients with reduced kidney functions.
Anticholinergic Medications
Another type of drug for Parkinson’s disease is anticholinergics. These are medicines that act to block the action of acetylcholine which can lead to tremors and muscle stiffness when it is in high levels. Anticholinergics may also assist excess sweating and drooling (problem of excess saliva production). These drugs may be useful for younger patients during early stages of the Parkinson’s disease when symptoms are mild.
Side effects
Anticholinergic drugs are rarely prescribed for older patients because of the high risk of confusion, memory loss and urinary hesitancy especially in males. Popular examples of this drug type include Artane or Cogentin. Primary anticholinergic agents currently in use are benztropine and trihwxyphenidyl. On the other hand, the drug is less resourceful for balance, slowness and walking problems.
Amantadine
This is a drug with a range of functions, but its greatest beneficial effect is that it enhances the release of dopamine and let it stay longer at the site of action. Amantadine can be integrated as a monotherapy during early stages of Parkinson’s disease especially in younger patients. The mechanism of action of amantadine has been an area for debate for a long time, but recent consensus suggest that the symptomatic effect can be “mediated through the blockade of the N-methyl-D-aspartate subtype of glutamate receptor within the brain” (Adler & Khlskog 2000, p. 127).
Administration of amantadine is started with one 1000-mg tablet on a daily basis and preceded to two or three tablets daily. Relatively, amantadine is less expensive compared to other antiparkinsonian agents. Sometimes, it may assist in reducing dyskinesias (Adler & Ahlskog 2000, p. 105). Furthermore, the medicine may have a stimulatory effect and thus benefit people with tiredness.
Side Effects
Withdrawing this drug suddenly may be tragic, because it could worsen the disease. The common side effects of amantadine include insomnia, nausea, lightheadedness or dizziness, swelling of the ankles, hallucinations or confusion in older people, and a mottled appearance of the lower leg skin (Tuite 2009, p. 87).
Issues Related to Professional Development of Nurses
People with Parkinson’s disease, a complex and debilitating condition, always need round-the-clock individualized nursing care that is customized to meet their medical needs so as to achieve optimal symptom control as well as improve quality of life. In other words, nurses specialized in Parkinson’s disease is required and thus the need for professional training and development. A Parkinson’s disease nurse specialist is a specialist practitioner whose primary skills include clinical leadership, development of nursing knowledge, research awareness, serving as consultant educator and change agent, as well as an evaluator of care (Woodward & Waterhouse 2009, p. 54).
The specialist nurses are therefore instrumental on helping people with Parkinson’s disease to manage their medications and offer valuable advice and information about living with the condition. In addition, the specialist nurses are needs to provide emotional support to both patients and their respective families throughout the patient’s experience i.e. from diagnosis, through treatment stages, to the end-of-life care. The need for professional development of nurses is supported by the findings of recent studies which revealed that twice as many people with PD regard their specialist nurses as the most helpful in having them understand their local Parkinson’s services as compared to their neurologist (Parkinson’s UK 2011, p. 3).
Specialist Parkinson’s nurses are faced with challenges relating to developing infrastructures that support continuous professional development. The main issue relates to compulsory post basic education for the specialist nurses (Tuite 2009, p. 215)
Discussions & Analysis
This project has enabled the researcher to gain valuable information on the learning contract whose aim was to research and compile a learning package on the medications used in Parkinson’s disease. The learning strategies adopted for this project were appropriate considering that there is sufficient research using education packages from other areas, appropriate text books, web/literature search and input of colleagues.
Clinical Decision Making and Collaboration Process
Clinical decision making process for people with Parkinson’s disease entails taking all available information and then formulating a plan to address current problems and anticipate future ones (Aschenvrenner & Venable 2008, p. 154). The clinical decision making process for the PD follows evidence-based practice, practice guidelines, together with staging best interventions for an individual.
When the administration of PD medications commences, the first role of the physical therapist is to evaluate the patient’s response to the type of medication through a dose-response trial. This entails measuring impairments of body function together with activity limitations at close and regular intervals across when the individual is both “on” and “off “of their medication (Morris 2012, p. 2). By tabulating or graphing the patient’s response to medication basing on these variables, the physical therapist, medical practitioners or other health care professionals provides data about the positive and negative effects of medication to the person. This in turn, it allows careful adjustment of the type and dosage of medication in line with the person’s needs whilst avoiding undesirable movement disorders like dyskinesia, dystonia or hypokinesia (Morris 2012, p. 2). Furthermore, it provides the therapist with necessary information pertaining to the residual movement disorders still apparent regardless of the best possible medication intervention. This can help clinical decision making besides assisting the physical therapist and patient to determine the priorities and objectives of treatment together.
Clinical decision making in a small number of people living with PD especially those recommended for neurosurgery is assisted by the use of a laboratory-based three-dimensional gait analysis (3-DGA). Specialized physical therapists measure the locomotor performance using 3-DGA so as to quantify the results of therapy, surgery or other interventions applied on people with PD (Aschenvrenner & Venable 2008, p. 87). Clinical decision making for persons with PD who need augmentative and alternative communication is a continuous, dynamic, collaborative process. Planning early interventions through the course of PD enable patients to participate in decision making pertaining to communication in the last stages of their lives.
Reflection of the Learner
Prior to the completion of the learning contract, the researcher had limited knowledge regarding to the Parkinson’s disease and the treatment options of the disease. The researcher initially understood that Parkinson’s is a neurological condition with insignificant prevalence. Following the completion of the learning contract, the researcher has much understanding of the meaning of Parkinson’s disease, its risk factors, its national and global prevalence, and the different medications available for its management. In addition, the completion of the learning contract has enabled the researcher to recognize aspects of the disease that requires more medical research so as to establish the ultimate cure of the disease.
The self-directed learning module had a number of positive outcomes for the researcher. As a self-directed learner, the researcher was highly motivated, independent, persistent, self-confident and goal oriented. The learner had an opportunity to be a manager for the entire learning experience as opposed to typically being an information provider, which enabled transition from reactive to proactive role. In addition, the researcher had a chance to practice high-level self-discipline so as to complete the learning contract as required. The self-directed learning was also appropriate for the learner considering that the understanding of disease processes and treatment of such diseases as Parkinson’s is constantly changing. In view of the rapidly changing environment, self-directed learning was an essential tool for enabling the researcher (as a nursing student) to develop independent learning skills, assertiveness and responsibility, and a sense of accountability …which are essential attributes to the nursing career.
However, the exercise presented the researcher with various challenges. Given that the medical curricula largely emphasizes on mastering of large volume of information as opposed to development of independent knowledge assimilation for learners, the researcher found it rather challenging to fulfill the learning contract. The researcher, as a product of prior pedagogical/teacher learning experiences, was not well prepared to for the SDL which resulted in difficulty in adapting. As such, the researcher experienced problems dealing with the study in the absence of a lecturer to offer direction and assistance.
In view of the above, the learner feels the need for future adjustments to learning contracts in order to better the outcomes of the self-directed learning. This implies that there should be adequate student-teacher preparation by ensuring balance between student-directed and teacher-directed learning.
Conclusion
Summary
In summary, this project has therefore explored the medication options available for treatment of Parkinson’s disease. There has been explanation of the less potent drugs for PD such as the anticholinergic agents (Artane), and amantadine (symmetrel). Discussion on medications with more substantial potency has dealt with direct action of dopamine agonists. However, it has been established that levodopa, combined with carbidopa still remains the most efficacious medication for treatment of Parkinson’s disease (Adler & Ahlskog 2000, p. 116). This project has found that the rapid expansion of study on the growing availability of medical and surgical treatment options for PD has improved the management of the disease across the world. Also, the finding of this project suggests that chronic use of drugs able to block dopamine receptors often causes Parkinsonism (Ahlskog 2009, p. 184).
Possible Future Directions for Learning
Going forth, there are a few possible future directions for the medication of Parkinson’s disease. The rapid pace of research provides optimism, for instance, there is increasing understanding of the organization of the human basal ganglia both in normal people and those with PD conditions. This would enable the design of more improved strategies of treatment that would help in reducing the risk of developing motor complications (McCall et al 2007, p. 223). In addition, there is a growing knowledge of mechanisms that result in cell death in PD patients which promises to inspire the development if putative neuroproctective drugs that may slow or halt disease progression altogether (Ahlskog 2009, p. 155). These areas among others provide possible future directions for exploration on this subject.
Dissemination of Knowledge Gained
A simple process shall be adopted in the effort to disseminate the valuable knowledge gained from this project. Participation in the Parkinson’s Awareness Week will provide a wonderful chance to educate others on the medicine currently available for PD and their respective appropriate usage. Furthermore, there will workshops to enlighten those living with the condition and their families.
Comments
This project recommends that it is necessary to monitor and maintain the quality role of specialist Parkinson’s nurses. More development is needed to the specialist nurses for them to have greater level of autonomy, discretion, decision-making, and clinical judgment. There is a need for health professionals to collaborate and work together in a multidisciplinary team so as to contribute more in helping patients with PD to lead healthy lifestyles.
References
Ahlskog, EJ 2009, Parkinson’s disease treatment guide for physicians, Oxford University, UK. Press.
Aschenvrenner, SD & Venable JS 2008, Drug therapy in nursing, Lippincott Williams & Wilkins, Philadelphia.
Bunting-Perry, KL 2007, Comprehensive nursing care for Parkinson’s disease, Springer Publishing Company, New York.
Halllet, M & Poewe W 2008, Therapeutics of Parkinson’s disease and other movement disorders. John Wiley & Sons, Ltd, Chichester, UK.
Jankovic, J & Tolosa E 2006, Parkinson’s disease and movement disorders, Lippincott Williams & Wilkins, Philadelphia, PA.
McCall, B, Williams A & Oxtoby, M 2007, Parkinson’s. Class Publishing, Ltd, England.
Morris, EM 2012, Locomotor training in people with Parkinson disease [Online], Available at: http://physther.net/content/86/10/1426.full Accessed 9th September 2012].
Movement Disorders 2002, Management of Parkinson’s disease: An evidence-based review [Online], Available at: http://www.movementdisorders.org/publications/ebm_reviews/managementofPD.pdf. Accessed 9th September 2012].
Tuite, P 2009, Parkinson’s disease: A guide to patient care. Springer Publishing Company, New York.
Woodward, S & Waterhouse, C 2009, The Oxford handbook of neuroscience nursing. Oxford University Press, UK.
