Care of an Older Person with Parkinson’s Disease: Case Study

Introduction

This case will look at a resident of an aged care facility and their medical condition and associated comorbidities. The pathophysiology of their conditions will be discussed, and we will look at how their condition is related to the theories of ageing. Models of care also will be discussed, and we will see how this condition affect resident’s day to day life. This case study is about Mr A who is a resident of ABC aged care facility. Mr A is 78 years old who has lived with Parkinson’s disease for the past 18 years and is at constant risk of falls, has a suprapubic catheter, constipation problem. According to Mr A he first felt the symptoms of his disease when he was 60 years old and these symptoms got worse when as he aged. He has difficulty walking and doing his daily activities as he needs constant help and supervision. Mr A’s wife, who used to look after him died a few years ago and he decided to come to the aged care facility as he was not able to manage things by himself. He has a son who works and live interstate. Mr A says that it was not as big of a shock for him when he was diagnosed with this condition as his father had Parkinson’s. Mr A’s condition has changed his life dramatically as he has to make various changes in his day to day life to better manage his conditions and associated comorbidities.

Pathophysiology

Magrinelli et al., (2016) explain that traditionally, Parkinson’s has been considered a disorder purely related to movements which has a relation with degeneration of dopaminergic neurons, but, in recent years, clinical definition has changed and defines Parkinson’s disease as a multisystem neurodegenerative disorder featured by non-motor and motor features. Motor sign and symptoms, including tremor, bradykinesia and rigidity are attributed to the loss of dopamine neurons and problems related to gait and balance are related to degeneration of dopamine pathway. Non motor features include depression and delusions, constipation, urinary and genital disturbances, memory, olfactory disfunctions and sleep disturbances and these are a result of multiple neurotransmitter deficiencies in the peripheral and central nervous system. Any of these symptoms either alone or together contribute towards reduced quality of life and patient’s disabilities. The Australian brain foundation explains that Parkinson’s occur due to low levels of dopamine production which is due to death of nerve cells that produce them (Brain Foundation, 2019). Dopamine is the chemical which helps convey messages between brain and the body. DeMaagd & Philip (2015) explain that progressive degeneration of dopamine producing neurons in the pars compacta (located in mid brain), which project signals to the striatum (governs the voluntary motor controls in the body), results in the loss of motor functions in people suffering from Parkinson’s. They further explain that two types of dopamine receptors, D1 and D2, influence the motor activity in the extrapyramidal system, which includes globus pallidal segment and substantia nigra (SN). These components are further connected to thalamus and cortex and loss of dopamine results in decreased ability of thalamus to activate frontal cortex leading to reduced motor activity characteristic of Parkinson’s. However, the non-motor symptoms associated with Parkinson’s are due to progressive and widespread alpha-synuclein aggregation in specific nuclei of the peripheral nervous system and central nervous system and these changes could become visible to the eyes years before the motor symptoms start to show up.

Risk Factors

Age

Ageing remains the biggest risk factor for developing Parkinson’s disease as with advancing age a number of processes crucial for the proper functioning of substantia nigra starts to decline. In a study conducted in 2016 to find the relation of age and Parkinson’s disease, it was found that Parkinson’s disease was rare in people less than 40 years old but the frequency tend to increase thereafter. Another study concluded that men are 1.5 times more likely to develop the condition compared to women. Rodriguez et al; (2015) explains that Parkinson’s is a neurodegenerative disorder with ageing being the biggest risk factor and incidence of condition increasing exponentially in people over 60.

Genetic factors

Having a family history of Parkinson’s increases the risk by nearly 10% and a key factor in the disease is alpha synuclein and mutation of a genes SNCA, LRRK2 and DJ 1, PINK1 and are a common cause of Parkinson’s disease and these mutations can pass down from family members and increases likelihood of person developing Parkinson’s. Another similar study aimed to find the major risk factors for Parkinson’s disease found that having a family history of Parkinson’s disease increases the risk severely.

Environmental factors

Certain environmental factors can significantly increase the risk of Parkinson’s including exposure to pesticides, certain heavy metals, head injuries and number of medications have also been associated with Parkinson’s including calcium channel blocker, non-steroidal anti-inflammatories and statins. Chen & Ritz (2018) says risk factors of Parkinson’s disease increases as a result of genetic and environmental factors including pesticide exposure, traumatic brain injury.

Theory of ageing

Theories of ageing have been proposed in an attempt to explain why we age and what is the process of ageing and the two major categories of modern theories are based on programmed theories and damage and error theory. Jin (2010) explains that the programmed cell death theory has further subcategories including programmed longevity, endocrine theory and immunological theory and damage & error theory is divided into five categories. Venderova & Park, (2012) says that cells can decide and control their fate by using several functions and mechanisms and these functions are generally genetically programmed leading to Programmed Cell Death (PCD). They further say that these cell deaths requires the use of energy in form of ATP and genetical changes and are generally of two types namely apoptosis, autophagic and these processes have high significance in Parkinson’s disease due similarity of gene involvement.

Apoptosis, the most common form of cell death is highly linked to Parkinson’s disease and in this process membrane of the cell remains intact, while various bodies start to die within the cell and they are not released into the extracellular fluid. Levy, Malagelada, & Greene (2009) says that overproduction of certain mutated alpha synuclein causes apoptotic cell death. Venderova & Park (2012) says that over expression of certain genes including SNCA, PINK1, certain DJ1, LRRK2, are a major trigger of apoptosis and increases sensitivity to apoptotic cell death and these genes are common in Parkinson’s disease pathogenesis as well.

Autophagy, as define by Glick, Barth, & Macleod, (2010), is an important process for balancing energy sources in response to nutrient stress and it also plays a role in removing aggregated proteins and damaged cellular organelles. The pathogenesis of Parkinson’s share some common themes including oxidative stress, mitochondrial dysfunction and protein aggregation and all of these themes are closely linked with autophagy. Michel, Hirsch, & Hunot (2016) explain autophagy as an adaptive response when body is low on nutrients and say that several Parkinson’s related genes namely DJ-1, alpha-synuclein and LC3 are linked with dysregulation of autophagy which can to neurodegeneration and Parkinson’s.

Impact on person and ethical consideration

Parkinson’s has changed Mr A’s life drastically as evidenced by his deteriorating physical functioning. Rizek, Kumar, & Jog (2016) explain that some of the classic symptoms of Parkinson’s include tremor, soft voice, expression less face with reduced eye blinking, bladder or bowel problems, muscle stiffness. These symptoms can be seen in Mr A and they affect his life very much. Due to tremors, he needs constant supervision with all of his activities of daily living and mobility as well. He is at high falls risk. His eyes do not blink and need regular eye drops as they are always red and water keeps running from them. Mr A feels isolated as his social interaction has drastically reduced due to his speech and expression related problems. Mr A has a suprapubic catheter due to his lost bladder control. He says that as his symptoms started to worsen with his age, he lost voluntary control over his bladder and doctor suggested him the catheter.

Mr A, in the presence of his doctor, son and nurses, wrote his Advance Care Plan (ACP) a few years ago. Carr & Luth (2017) define Advance Care Plan (ACP) as a tool that enable patients to convey their treatment preferences and is a way to respect and achieve patient’s and family members priorities. He neither want to have any surgeries in case of any injury or fall nor he wants to be resuscitated. He has appointed his son as his primary decision maker when he is not able to communicate his needs in future. His ACP clearly mentions his care priorities in an event of a mis happening and provides the aged care, doctor and care attendants a clear vision of his care needs and, hence respecting his autonomy.

Model of care

Agency for Clinical Innovation-NSW Ministry of Health (2014) explain that a model of care should be person centered, efficient with utilization of resources, support safe and quality care for patients at the right time and that it has two types, financial model of care and clinical care. The financial model of care can either be consumer directed or residential care. Bally & Jung (2015) say that people living in residential communities have better access to doctor and other healthcare teams and they face lower risk of hospitalization and hence increasing their access to healthcare. Mr A is living in aged care facility and it has been very helpful for him since his wife has passed away. Mr A has care staff that regularly assist him with his needs including ADLs and ambulation. Nurses are available for him throughout the day and night to constantly give him his medications and other relevant care and doctors can make visits if needed. Mr A is always encouraged to participate in the activities with other residents in the facility to increase his social interaction. Hence the residential model of care is the best option for Mr A in terms of his health and safety.

Conclusion

Mr A’s current health condition was discussed in this paper. We discussed how Parkinson’s is linked with the programmed theory of ageing and what genes are commonly involved in them. Parkinson’s has impacted his life to a great extent, and he has to face many problems in his daily life due to this. With his advancing age, it was getting difficult for him to manage and after death of his wife, it was nearly impossible to live at home alone. The various co morbidities associated with his disease also adds to the difficulties. After moving to care facility, Mr A has been able to better manage his life due to the constant medical and care support available to him.

References

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