Definition

Parkinsons disease is the second most common neurodegenerative disease.

PD is a chronic, slow, progressive disorder caused by loss of dopaminergic neurons in the substantia nigra of the basal ganglia.

Risk factors of PD

Age - the most important risk factor

Positive family history Male gender Environmental exposure: Herbicide and pesticide exposure, metals (manganese, iron), well water, farming,

rural residence, wood pulp mills; and steel alloy

industries

Race Life experiences (trauma, emotional stress, personality traits such as shyness and depressiveness)?

An inverse correlation between cigarette smoking and caffeine intake in case-control

studies.

PATHOGENESIS
Inherited Lewy bodies & nerve cell loss in the substantia nigra

Pathophysiology
Loss of nerve cells in the pigmented nigra pars compacta Depletion of dopaminergic neurons Reduction of dopamine Reduced thalamic excitation of the motor cortex

Major sign & symptoms

T Tremors(resting tremors) R - Rigidity A - Akinesia / Bradycardia P - Postural deformity

Tremors
Resting tremors in the limb, most commonly in one hand, which disappears with voluntary movement. Tremors occur in distal portions of extremities & especially in hands. Pill rolling motion in hands.

Rigidity of muscles
Slowness of voluntary movement Stiffness associated with vague aching & discomfort of a limb Difficulty in initiating movement

Pt.s move minimally when sitting, edema can develop

in the feet , legs , hands & arms Cogwheel rigidity is characterized by ratchet-like rhythmic contractions, especially in hand, on passive stretching.

Akinesia / bradycardia

Gait is slowed with dragging of the foot & decreased arm swing on the affected side.

Postural disturbance
Stooped over posture with small, shuffling steps & often a broad base on turns. Forearms are semiflexed & fingers are flexed at metacarpophalangeal joints. Pt may fall forward (propulsion) or backward (retropulsion)

Secondary manifestations
Fine motor deficits

Handwriting becomes
small & more difficult

to read.
Clumsiness & difficulty

with ADLs such as

buttoning clothing.

 Monotonic voice: soft to whisper like,

monotonic & muffled.

Mask like face: expressionless & eyes stare

straight ahead; blinking is less frequent.

 General weakness & muscle fatigue Muscle cramps of legs, neck & trunk Cognitive changes Dementia

Other common manifestations

Drooling Seborrhea Dysphagia

Excessive perspiration
Constipation Orthostatic hypotension Urinary hesitation & frequency

Diagnosis
History Physical examination MRI SPECT

EEG

MEDICAL MANAGEMENT
Neuroprotective therapies Selegiline Symptomatic supportive approach Speech therapy Physiotherapy gait training, balance maintenance, exercise Occupational therapy

Recommendations for patient

Encourage regular exercise Stretching exercise Low protein diet

Dietary supplements
Calcium intake of 1200 mg for men & 1500mg for postmenopausal women Wearing elastic stockings will help to ovoid orthostatic hypotension

Pharmacologic treatment
Five drugs

Levadopa
Dopamine antagonists Anticholinergics Antivirals Selective monamine oxidase B inhibitors

Combination therapy
Carbidopa 10-25 mg
Levadopa 100-250 mg Stalevo combination Carbidopa Levadopa Entacapone

Anticholinergic drugs
Trihexyphenidyl hydrochloride (Artane) 2-5 mg 4 times daily. Benzotropine mesylate (cogentin) 0.5 6mg daily.

Surgical management
High frequency subthalamic stimulation using an implanted electrode & pulse generator is used to control tremors.

Nursing management
Impaired physical mobility r/t rigidity, bradykinesia & weakness. High risk injury from falls r/t rigidity, bradykinesia & weakness. Body image disturbance r/t signs & symptoms of illness. Impaired communication r/t change in voice & difficulty in writing.