Parkinson's Disease: Problem and Solution

Abstract

Parkinson’s disease is a life-threatening condition in which dopamine and acetylcholine are imbalanced in the body. This condition has many exacerbated sequela’s including but not limited to Acute Akinetic Crisis. It is estimated that approximately seven to 10 million individuals currently have the disease and around 60,000 are newly diagnosed each year. With this disease condition rising, many new studies have begun to be researched to identify the likelihood and risk factors associated with the disease. Two of the biggest contributors are biological sex and age. The studies revealed that the average population range of a patient with Parkinson’s disease is of the age from 65 to 85 years. This category or what can be considered “the ideal patient” range makes up a huge portion of our population, and with the baby boomers getting older, it is likely to see a large spike in the near future. Current patients do not receive quick access to their health care professionals, resulting in tragedy and life-taking events for some affected by Parkinson’s disease. The key to improving, understanding, and treating individuals with this disease is more direct and followed through patient-centered care. This care is ideal and can be broken down into a 5-step process to handle the disease. This process if initiated, and followed, and initiated can continue to ensure proper management of the disease.

Parkinson’s A Spiraling Condition

Parkinson’s is a disease with a cause that can be contributed to the degeneration of neurotransmitters in the brain. The most common neurotransmitter affected being dopamine. As more dopamine degenerates, the disease begins to further and progresses resulting in signs and symptoms worsening. These symptoms and aggravated manifestations occur as the disease causes more and more damage to the brain, impairing motor and cognitive functions. According to the Journal of Neuroscience and Neuropharmacological Medicine dopamine has a few functions in the body including; improving contraction strength of the heart, improving blood circulation to vital organs (i.e. kidneys, liver, brain), and acting as a want and reward neurochemical transmitter. When dopamine levels decrease, it causes abnormal brain activity, and in contrast, stimulates an increase in the release of acetylcholine which is another neurochemical transmitter that gets affected due to the disease. The production and maintenance of acetylcholine are very relevant in this disease as it plays a role in body functioning; contractions of smooth muscle, dilation of blood vessels (which controls blood pressure in veins and arteries), increases body secretions (saliva, hydrochloric acid found in the stomach, and fluid that lubricates joints and lining of other organs), and slowing of the heart. Parkinson’s pathophysiology of the decreased dopamine and imbalanced acetylcholine results in drastic manifestations of signs and symptoms which include, “tremors, stiffness of muscles, poor balance/coordination, speech difficulty, fatigue, increased secretions...” (Non-motor signs and symptoms in Parkinson’s disease). With Parkinson’s, over time these manifestations that start out as a little shakiness in your hands or feeling fatigued and tired progress and can become so advanced that it affects how individuals function on a day-to-day basis. This alteration and advancement alter the lives of all involved with the disease. Examples of this concession of symptoms are; stiffening of muscles that can cause individuals to lose range of motion in the trunk and extremities impeding on one’s ability to move and function without assisted devices, the communication pathways in the brain being altered, and how our facial muscles move to communicate being refashioned resulting in hindering social connections and limiting an individual’s ability to vocalize needs or wants dyer to maintaining essentials of life.

What Health Care Team Means

Healthcare is a team effort. What makes a health care team is everyone involved with the care, management, and overall aspects of care. It can be a physical, a nurse, a speech therapist, a certified nursing assistant, a home health worker, or a family member with the power to do so, and so on. Every member of the team is vital to the treatment and success of the patient. If there is a weakness in one aspect of the team, it affects the while team and the patient. It is vital that as we currently are or will take care of patients in the future, we understand our role and the roles of every healthcare team member. Understanding and participating in this will further the care of our patients and will ultimately help with outcomes.

The Problem

Many Parkinson’s patients struggle with acquiring quick access to neurologists specializing in their medication regimen and intended therapeutic goals of medication and treatment. Consequences generated from the lack of access to health care teams include; therapeutic goals not being reached, an increase in symptoms of functional brain network degrading similar to that seen in HIV/AIDS, and a life-threatening sequela condition known as Acute Akinesia Crisis.

One risk factor that dramatically increases the likelihood of Acute Akinetic Crisis is when neurochemical transmitter dysfunctions are not being managed appropriately by pharmaceuticals and/or alternative treatment options. According to the article Acute akinesia or akinetic crisis in Parkinson’s disease, the acute crisis is characterized by worsening motor and non-motor symptoms and unresponsiveness to medication and treatments. This means that an Acute Akinetic crisis is a highly amplified, untreatable motor and cognitive defect, that will progress and worsen. Another article Acute Akinesia, an unusual complication in Parkinson’s Disease: a case report which describes these features as a “sudden onset of severe and sustained hypertonic akinetic state with frequent cognitive and/or psychotic disturbances, dysphagia, dysphonia, and increases in body temperature and serum creatine phosphokinase (CPK) values… and, in the most severe forms, leads to death”. These articles estimate that the annual incidence of Acute Akinetic Crisis is about 0.3% and a death rate of 15%. When we assess these numbers, we see that 0.3% of 10 million reported is three million, and 15% of three million is 450,000 deaths per year related to Parkinson’s and its worsened condition Acute Akinetic Crisis. With Parkinson’s having such a worldwide and centralized presence in the US it is imperative that patients are to get healthcare access that is beneficial to their health specifying in their disease process.

The Affected

According to an article published by Parkinson’s News Today Parkinson’s disease is the second most common, age-related neurodegenerative disorder, affecting about 3% of the population by the age of 65 and up to 5% of the population over the age of 85. That is an estimated of approximately seven to 10 million people worldwide have that have the disease. The article continues and reveals statics regarding the amount of diagnoses per year, which is about 60,000. The Parkinson’s foundation has an estimated prevalence projection of individuals broken down by state who are affected by the disease see.

Parkinson's disease does not discriminate, the disease process does not care what sex you claim, what religion you are a part of, or whether you are a good person or a bad one. It affects many of our loved ones, people we know, and their loved ones. Risk factors in acquiring the disease can be a combination and contributed to aging, genetics, environmental and immune status, and biological sex. Aging is one of the biggest contributing factors. The article Ageing and Parkinson's disease: Why is advancing age the biggest risk factor? discusses how age-related decline leads to the loss of neurons within this disease. It summarizes that as we age, our brain continues to build new pathways, and our cells are working hard for biological reasons and for our everyday situations and tasks. This causes neurodegeneration of our vital cells as a result of aging and overworking. Just like our bodies, the use and abuse we put it through have serious and permanent consequences. Another risk factor as listed is biological sex. Biological sex has an important factor in the development of Parkinson’s and has been widely discussed in the past few decades.

There are clear sex-related differences in epidemiological and clinical features of the disease, and according to Parkinson’s Disease in Women and Men: What’s the Difference? Parkinson’s “affects men twice more often than women” however, “women have a higher mortality rate and faster progression of the disease”. With these two reports, we understand that the ideal patient or individual to have and be affected by Parkinson’s and its Acute Crisis is likely to be someone who is usually male and over the age of 65. This category or what can be considered “the ideal patient” range makes up a huge portion of our population. Something we all regardless of the profession need to consider is who our loved ones are and if they fit or are going to fit this ideal range in the coming future. According to Pew Research Center, Baby Boomers which are all individuals that fall between 55-75 have always had an outsize presence compared with other generation population size, reporting an estimated 74.1 million Boomers in 2016. This large generation is getting older and it is likely to see Parkinson’s Disease as well as many other conditions having a large spike in the coming near future. This individual for some of us could be a grandparent, an uncle, a father, and people in and around our lives that have influence.

Testing and Current Treatments

Some might peruse, with such a life-threatening disease, how we can stay ahead of our care and treatment. Well, the answer is it all starts with a diagnosis. Currently, there is no specific test that exists to diagnose Parkinson's disease; however, providers are trained in nervous system conditions (neurologists) and will diagnose Parkinson's disease based on medical history, a review of signs and symptoms, and a neurological and physical examination. Additional findings can be obtained through a specific single-photon emission computerized tomography SPECT scan called a dopamine transporter (DAT) scan. According to the article The impact of DaTscan on the diagnosis and management of movement disorders: A retrospective study “The imaging technique, DaTscan, can be used to visualize dopamine degeneration in the Nigro-striatum…”. Parkinson's disease can't be cured, but medications can help control your symptoms, often dramatically. Mayo Clinic presents a list of common medications your provider may prescribe which include:

1. I“Carbidopa-levodopa-the most effective Parkinson’s disease medication is a natural chemical that passes into your brain and is converted to dopamine. 1Levodopa is combined with carbidopa (Lodosyn), which protects levodopa from early conversion to dopamine outside your brain. This prevents or lessens side effects such as nausea.
2. IDuopa is for patients with more-advanced Parkinson's who still respond to carbidopa-levodopa, but who have a lot of fluctuations in their response. Because Duopa is continually infused, blood levels of the two drugs remain constant.
3. Dopamine agonists- which mimic dopamine effects in your brain.
4. MAO B inhibitors- these medications help prevent the breakdown of brain dopamine by inhibiting the brain enzyme monoamine oxidase B (MAO B). This enzyme metabolizes brain dopamine.
5. Anticholinergics. These medications were used for many years to help control the tremor associated with Parkinson's disease.
6. Amantadine. Doctors may prescribe amantadine alone to provide short-term relief of symptoms of mild, early-stage Parkinson's disease. It may also be given with carbidopa-levodopa therapy during the later stages of Parkinson's disease to control involuntary movements (dyskinesia) induced by carbidopa-levodopa.”

5-Step Disease Plan: Management of Diseases

Other management of chronic diseases like Parkinson’ Disease requires consistent care and communication between a patient and care team members. The article Patient and physician perceptions of disease management in Parkinson’s disease: results from a US-based multicenter survey composes a five-step vital plan that is to be shared between patients, individuals involved in patient care, and specifically physicians and health care providers. It is as followed; patient identification, diagnosis, choice of therapy, disease/drug information, and patient monitoring.

Where the inconsistency and disruption occur in this five-step process are usually in the last step which is patient monitoring. Many patients do not have a consistent and timely follow-up with their care providers due to limitability, hours, location, and provider demand, which results in many Parkinson’s symptoms manifesting into worsening and altering patient states, and long-term hindering on their activities of daily living. Clinical care for patients with Parkinson’s disease like many other diseases is complex, the disconnect does exist between patient and physician perceptions and realities of care. Unfortunately for patients and others involved in the lives and care of these patients has a large impact on the overall quality of life.

Health Care Team’s Duties

Due to Parkinson’s having such a high rate of people affected and their likelihood of the consequential worsening conditions and manifestations, it is an ethical duty and virtue for patients to have access to reliable, quick, and necessary care. The article Beyond patient-centered care: person-centered care for Parkinson’s disease states this virtue best; “Care, comfort, compassion, and consolation are as important as finding a cure for Parkinson’s disease.” Constructions of the use of this collaborative patient-centered care approach should obligate physicians to put the overall health and care of patients first by directly serving their patients’ best interests. To truly do this means putting the welfare of the patient first. To ensure they have access to their care providers and guarantee that secondary providers are informed of current and previous treatment plans. This holistic collaboration to ensure the best outcomes will further the effective management of Parkinson’s Disease.

Patient Duties

Now with clear and consistent management from the health care team, the patient has a responsibility in the fourth step (disease and drug information) and in the fifth step (monitoring/follow up) that was previously discussed. Patients need to take responsibility, accountability, and commitment in their disease and the health care process. Part of doing this requires the patient to be well-rounded and educated with their diagnosis, medication, and plan of treatment. To accomplish this requires involvement and compliance with care plans, scheduling and showing up to frequent in-person medication and treatment evaluations, and a reliable communication establishment for when potential complications arise. With Health care and patient duties fulfilling their ends of these 5 steps process the possibility and options for management of the disease are vastly broadened.

My First Parkinson’s Patient

As a new LVN in an Assisted Living facility, approximately 55 patients were shared between 3 nurses, myself, and two others. There was a particular patient who was diagnosed with Parkinson’s Disease and demonstrated very advanced signs and symptoms. This patient had lost a large amount of function in his trunk and extremities requiring a lift to place him into a motorized wheelchair, had severe dysphagia resulting in assistance with feeding and a specialized mechanical soft diet, and had a severe language and communication due to brain degeneration limiting his ability to communicate to staff and loved ones. This patient on average was seen by a neurologist every 6 months and was seen by his Primary care provider about every 3 months. Unfortunately, what we later found out after the patient had developed Acute Akinetic Crisis was that the multidisciplinary communication was not occurring.

Treatment plans and care actions were not being communicated directly or agreed upon, and the patient's Power of attorney was relaying the information between the two providers. With this lack of communication and teamwork, the patient was ultimately being treated with two different plans of care and two different medications that interacted with each other and in a similar pharma kinetically in the body. This patient's condition spiraled very rapidly. He was unable to maintain any level of consciousness, lost all ability to communicate, and secretions built up so fast and drastically in the body he experienced shortness of breath and difficulty breathing. After being admitted for a few days in the ICU, the patient passed away. The death record showed death was caused by Acute Akinetic Crisis and communicated to us nurses that his body had stiffened to the point of his lungs not being able to expand and the amount of secretions building up so much, it turned fatal. A horrific story, one that will stick with all of the nurses forever. This story is not the only of its kind. Many individuals with Parkinson’s disease are not having their care managed appropriately by health care teams. Many patients are being seen by multiple providers, being treated with different approaches, and are being mistreated due to this problem.

The Solution

The solution and preventative action that can be taken to mediate this disease, the extreme sequela accompanied with it, and many other disease processes are; collaborative healthcare meetings, interdisciplinary communication, frequent in-person medication and treatment evaluations, and care plan compliance both from the providers and the patients. It is our responsibility as future and/or current healthcare professionals to provide the best care both preventative and active to alleviate and attenuate manifestations of illness and disease and signs and symptoms of current diseases for our patients. If this action plan is taken and fully embraced by patients and by health care teams, we could see fewer complications of Parkinson’s disease, less Acute akinetic crisis, an increase in quality of life for patients, and a decreased mortality rate among this diagnosis and many others.