Introduction
This project is a learning portfolio based on my learning contract whose aim is to research and compile a learning package on the medications used in Parkinson’ Disease. The learning package will carry investigated research in the negative drug interactions in people with Parkinson’s disease. Parkinson’s disease is the topic of this project because of the high prevalence of the disease among the world population (over 6 million people affected) and the fact that it is still an idiopathic disorder (its cause is yet to be found).
In this project, evidence of the outcome of the learning contract uses relevant internet literature search, PowerPoint presentation and videos. There will be a systematic review of literature relating 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.
Main content
a) Literature Review
There has been much research on Parkinson’s disease and particularly on the medication of the disease. Many journals and research studies have been published in the recent past reflecting one or moer the different medical interventions to the Parkinson’s 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 disease occurs naturally and external stimulus, such as trauma or virus, does not trigger it. Parkinson disease usually affects patients aged 50 years and older; however researchers have recently established that parkin gene, a mutated gene, can trigger the disease at much younger age (Aschenbrenner & Venable 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).
b) Topic
Medication of Parkinson’s disease
There are several different 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 not 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 if 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.
i) 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 or all of the body (alkinesia) and rigidity (Jankovic & Tolosa 2006, p.214). 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 that the dose has to be increased over time. It is also estimated that the drug does not work for about 25% of people with Parkinson’s disease.
Side effects of levodopa
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 in 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.
ii) 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 that they relay the same message to the nerve cells of the patient. They stimulate the dopamine receptors instead of replacing it as levodopa does (Jankovic & Tolosa 2006, p.89). It is the belief of many researchers that these drugs may contain a neuroprotective effect.
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 they used together with levodopa, patients require less of the levodopa and experience relatively fewer “on-off” or “wearing off” problems.
Side effects of Dopamine Agonists
However, 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 characteristic 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 drugs may result in suddenly falling asleep of the patient which may be a danger. Generally, people who do not respond to levodopa usually also 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, and are best taken with meals.
iii) 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 does breaking down 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 with fatigue that results from dyskinesias.
Side effects of COMT Inhibitors
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.
iv) MAO-Inhibitors
A fourth type of medicine for Parkinson’s disease is the MAO inhibitors. These drugs serve to help dopamine to last longer in the brain. They are at times used as a first drug treatment, but grow 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 of MAO-Inhibitors
Some physicians believe that these drugs are harmful when used over a long length of time.
v) Antiviral medications
Parkinson disease is also tackled using antiviral medication which decreases dsykinesia in some later stages of the disease. These drugs can be used in combination or alone as well as during early stages. Though effect of the drug wears off after several weeks, anti viral may be effective once more after discontinuing its use for a while.
Side effects of Antivirals
Anti-viral have side effects such as purple blotching of legs, swelling of legs, hallucinations, confusion, blurred vision, nightmares, and depression. In addition, doses of anti-viral need to be adjusted downward for patients with reduced kidney functions.
vi) Anticholinergic medications
Another drug type for Parkinson’s disease is the 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 with excess sweating and drooling (problem of excess saliva production). These drugs may be useful for younger patient during early stages of the Parkinson’s disease when symptoms are mild.
Side effects of Anticholinergic medications
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 these drug types include Artane or Cogentin. Primary anticholinergic agents currently in use are benztropine and trihwxyphenidyl. On the other hand, the drugs are less resourceful for balance, slowness, and walking problems.
vii) 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, 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 of Amantadine
Withdrawing of this drug suddenly may be tragic because it could result in a worsening of 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, Parkinson’s disease requires specialist Parkinson’s nurses and thus the need for professional training and development. A Parkinson’s disease nurse specialist is a specialist practitioner whose primary skills are in clinical leadership, development of nursing knowledge, research awareness, serving as consultant educator and change agent as well as 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, offer valuable advice and information about living with the condition. In addition, the specialist nurses are needed 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 the 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 continuing professional development. The main issue relates to compulsory post basic education for the specialist nurses (Tuite 2009, p.215)
c) 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’ 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 of best intervention for an individual.
When 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 throughout when the individual is both “on” and “off” his or her medication (Morris 2012, 2). By tabulating or graphing the patient’s response to medication basing on these variables, the physical therapist provides data about the positive or negative effects of medication to the person, medical practitioners or other health care professionals. This in turn allows for carefully 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 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. Through early planning for interventions through the course of PD, patients are able to participate in decision making pertaining to communication in the last stages of their lives.
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 which is 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 management of the disease across the world. This It is also the finding of this project 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 growing knowing of the 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 be holding of 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, and not dilution, is needed to the specialist nurse role that requires greater level of autonomy, discretion and decision-making, clinical judgment. There is 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, E. J. 2009. Parkinson’s Disease Treatment Guide for Physicians. UK: Oxford University Press.
Aschenvrenner, S. D., & Venable, J. S. 2008. Drug Therapy in Nursing. Philadelphia: Lippincott Williams & Wilkins.
Bunting-Perry, K. L. 2007. Comprehensive Nursing Care for Parkinson’s Disease. New York: Springer Publishing Company
Halllet, M., & Poewe, W. 2008. Therapeutics of Parkinson’s Disease and Other Movement Disorders. John Wiley & Sons.
Jankovic, J., & Tolosa, E. 2006. Parkinson’s Disease and Movement Disorders. Lippincott Williams & Wilkins.
McCall, B., Williams, A., & Oxtoby, M. 2007. Parkinson’s. England: Class Publishing Ltd.
Morris, E. M. 2012. Locomotor Training in People With Parkinson Disease. Retrieved from: http://physther.net/content/86/10/1426.full
Movement Disorders, 2002. Management of Parkinson’s Disease: An Evidence-Based Review. Retrieved from: http://www.movementdisorders.org/publications/ebm_reviews/managementofPD.pdf.
Tuite, P. 2009. Parkinson’s Disease: A Guide to Patient Care. New York: Springer Publishing Company.
Woodward, S., & Waterhouse, C. 2009. The Oxford Handbook of Neuroscience Nursing. UK: Oxford University Press.
