Kristen Mauk

Background

Parkinson’s disease (PD) is one of the most common neurological diseases, affecting at least 1.5 million people in the United States (American Parkinson Disease Association {APDA}, 2010). The average age of onset is about 59 years of age (APDA, 2010), and the likelihood of developing PD increases with age (National Institute of Neurological Disorders, 2008). It affects both men and women, particularly those over the age of 60 years (American Parkinson Disease Foundation, 2012). Parkinson’s disease was first described by Dr. James Parkinson as the “shaking palsy,” so named to describe the motor tremors witnessed in those experiencing this condition.

Parkinson’s disease is a degenerative, chronic disorder of the central nervous system in which nerve cells in the basal ganglia degenerate. A loss of neurons in the substantia nigra of the brainstem causes a decrease in the production of the neurotransmitter dopamine, which is responsible for fine motor movement. Dopamine is needed for smooth movement and also plays a role in feelings and emotions. One specific pathological marker is called the Lewy body, which under a microscope appears as a round, dying neuron.

Signs and Symptoms

Parkinson’s disease has no known etiology, though several causes are suspected. There is a family history in 15% of cases. Some believe a virus or environmental factors play a significant role in the development of the disease. A higher risk of PD has been noted in teachers, medical workers, loggers, and miners, suggesting the possibility of a respiratory virus being to blame. More recent theories blame herbicides or pesticides. An emerging theory discusses PD as an injury related to an event or exposure to a toxin versus a disease. Interestingly, coffee drinking and cigarettes are thought to have a protective effect in the development of PD (Films for the Humanities and Sciences, 2004).

The signs and symptoms of PD are many; however, there are four cardinal signs: bradykinesia (slowness of movement), rigidity, tremor, and gait changes such as imbalance or incoordination. A typical patient with PD symptoms will have some distinctive movement characteristics with the components of stiffness, shuffling gait, arms at the side when walking, incoordination, and a tendency to fall backward. Not all patients exhibit resting tremor, but most have problems with movement, such as difficulty starting movement, increased stiffness with passive resistance, and rigidity, as well as freezing during motion (NINDS, 2012). Advanced PD may result in Parkinson’s dementia.

Diagnosis

Diagnosis of PD is made primarily on the clinician’s physical examination and thorough history taken from the patient and/or family. Several other conditions may cause symptoms similar to PD, such as the neurological effects of tremor and movement disorders. These may be attributed to the effects of drugs or toxins, Alzheimer’s disease, vascular diseases, or normal pressure hydrocephalus, and not be true PD. There is no one specific test to diagnose PD, and labs or X-rays rarely help with diagnosis.

Treatment

Management of PD is generally done through medications. Levodopa, a synthetic dopamine, is an amino acid that converts to dopamine when it crosses the blood–brain barrier. Levodopa helps lessen most of the serious signs and symptoms of PD. The drug helps at least 75% of persons with PD, mainly with the symptoms of bradykinesia and rigidity (NINDS, 2008). One important side effect to note is hallucinations. A more common treatment, and generally the drug of choice, involves a medication that combines levodopa and carbidopa (Sinemet), resulting in a decrease in the side effect of nausea seen with levodopa therapy alone, but with the same positive control of symptoms, particularly with relation to movement. Patients should not be taken off of Sinemet precipitously, so it is important to report all of a patient’s medications if they are admitted to either acute or long-term care. Dopamine agnoists trick the brain into thinking it is getting dopamine. This class of medications is less effective than Sinemet, but may be beneficial for certain patients. The most commonly prescribed dopamine agonists are pramipexole (Mirapex) and ropinirole (Requip) (Parkinson’s Disease Foundation, 2012). Medications such as Sinemet show a wearing-off effect, generally over a 2-year period. During this time, the person must take larger doses of the medication to achieve the same relief of symptoms that a smaller dose used to bring. For an unknown reason, if the medication is stopped for about a week to 10 days, the body will reset itself and the person will be able to restart the medication at the lower dose again until tolerance is again reached. This time off from the medication is called a “drug holiday” and is a time when the person and family need extra support, because the person’s symptoms will be greatly exacerbated without the medication. The earliest drugs used for PD symptom management were anticholinergics such as Artane and Cogentin, and these medications are still used for tremors and dystonias associated with wearing-off and peak dose effects (Parkinson’s Disease Foundation, 2012).

There are many other treatments for Parkinson’s disease being explored. These include deep brain stimulation (DBS), with electrode-like implants that act much like a pacemaker to control PD tremors and other movement problems. The person using this therapy will still have the disease and generally uses medications in combination with this treatment, but may require lower doses of medication (NINDS, 2012). Thalamotomy, or surgical removal of a group of cells in the thalamus, is used in severe cases of tremor. This will manage the tremors for a period of time, but is a symptomatic treatment, not a cure. Similarly, pallidotomy involves destruction of a group of cells in the internal globus pallidus, an area where information leaves the basal ganglia. In this procedure, nerve cells in the brain are permanently destroyed.

Fetal tissue transplants have been done experimentally in Sweden with mild success in older adults and more success among patients whose PD symptoms were a result of toxins. Stem cell transplant uses primitive nerve cells harvested from a surplus of embryos and fetuses from fertility clinics. This practice, of course, poses an ethical dilemma and has been the source of much controversy and political discussion.

A more recent development includes the use of adult stem cells, a theory that is promising but not yet well researched. Cells may be taken from the back of the eyes of organ donors. These epithelial cells from the retina are micro-carriers of gelatin that may have enough cells in a single retina to treat 10,000 patients (Films for the Humanities and Sciences, 2004). In addition, cells modified from the skin of patients with PD can be engineered to behave like stem cells (NINDS, 2012). Both of these alternatives present a more practical and ethically pleasing source of stem cells than embryos.
Other research includes areas include those related to alternative therapies. For example, Tai Chi has been shown to be effective in improving balance and reducing falls for PD patients (NINDS, 2012). Rehabilitation units have been using Tai Chi for similar benefits in other patients with neurological deficits. Simple interventions such as using Wii games to promote activity and exercise may be explored. The role of caffeine in PD is also being examined. In a small randomized control study of 61 patients with PD, caffeine equivalent to 2–3 cups of coffee per day was given to subjects and compared with a control group of those taking a placebo. Those patients receiving the caffeine intervention showed little improvement in daytime sleepiness, but modest improvement in PD severity scores related to speed of movement and stiffness (Postuma et al., 2012). Further study with larger groups was recommended by the researchers.

Much of the nursing care in PD is related to education. Because PD is a generally chronic and slowly progressing disorder, patients and family members will need much instruction regarding the course of the disease and what to anticipate. Instruction in the areas of medications, safety promotion, prevention of falls, disease progression, mobility, bowel and bladder, potential swallowing problems, sleep promotion, and communication is important. Most of the problems seen as compli¬cations of PD are handled via the physician as an outpatient, but certainly complications such as swal¬lowing disorders as the disease progresses may require periods of hospitalization. When persons suffer related dementia in the final phases of the disease, they are often cared for in long-term care facilities that are equipped to handle the challenges and safety issues related to PD dementia. In ¬addition, access to resources and support groups is essential.

Adapted from Mauk, K. L., Hanson, P., & Hain, D. (2014). Review of the management of common illnesses, diseases, or health conditions. In K. L. Mauk’s (Ed.) Gerontological Nursing: Competencies for Care. Burlington, MA: Jones and Bartlett Publishers. Used with permission.

Guest Blog: Lindsay Munden, DNP, RN, FNP-BC

Psoriasis

Psoriasis is a lifelong disease that causes scaling and inflammation of the skin. The condition starts beneath the skin’s surface and is triggered by an overactive immune system, which causes skin cells to be over-produced and accumulate on the skin’s surface faster than normal. This process is called cell turnover, and in psoriasis may take a few days instead of weeks. This causes the formation of thick, red, itchy, flaky patches with silvery scales known as plaques. While any part of your body can be affected, psoriasis most often occurs on the elbows, knees, scalp, back, face, palms, and feet.

Risks

According to the American Academy of Dermatology (2015) about 7.5 million people in the United States have psoriasis. Anyone can get the disease, but it occurs more often in adults.

• Age: Adult men and women are affected equally. The two peak ages at onset are during the late teens to early 20s and in the late 50s to early 60s.
• Genetics: Psoriasis has a strong genetic influence, with one-third of patients with psoriasis reporting having a family member with the disease.
• Environmental Factors: Trauma to normal skin, repeated friction, infections, stress, fatigue, warm humid climates, changes in weather that dry the skin, and certain medications may trigger psoriasis flare-ups.

Causes

The primary cause of psoriasis remains unknown. Research has indicated that psoriasis is caused by genetic influences and a dysfunction of the immune system. Although, psoriasis plaques may look contagious, you cannot get the condition from someone that has the disease.

Symptoms

Symptoms can range from mild to severe and are often recurring. Itchy, red, inflamed and dry scaly plaques distributed symmetrically over areas of bony prominences such as the elbows and knees are characteristic of the disease. The joints, nails and scalp may also be affected. As with other chronic conditions, symptoms may flare or worsen for a few months and then subside for a period of time.

Diagnosis

Psoriasis may be hard to diagnose because it can be confused with other skin diseases. Usually your healthcare provider will make a diagnosis based on a thorough skin examination. Biopsy is seldom necessary because the clinical features of psoriasis are so distinctive. Plaque psoriasis is the most common form, but patients typically have one or more types.

Treatment

The goal of therapy is to control the symptoms and clear the plaque lesions.

For mild to moderate psoriasis, topical medications (those applied directly to the skin) and phototherapy (light therapy) are the mainstays of treatment.  For severe psoriasis, systemic treatments are recommended. Sometimes, combining topical, light and systemic treatments leads to the best results.

Topical Medication Options:

• Topical steroids are widely used because they help reduce inflammation. Generally, a very potent topical corticosteroid preparation is applied two to three times daily for 2 weeks and then decreased to a lesser potency for maintenance therapy long term.
• Coal tar works by causing the skin to shed dead cells from its top layer and slow down the growth of new skin cells. This effect decreases scaling and dryness. Coal tar is applied once or twice daily and is not well favored due to the potential for staining of the clothes and skin.
• Anthralin works by slowing down the production of skin cells. This type of medication is applied to the skin for a prescribed period of time and then rinsed away, with increased increments until the skin is healed which may take a couple of weeks.
• Topical immunomodulators are medications which work by decreasing the body’s immune system to help slow down the growth of the psoriasis plaques.
• Vitamin D3 derivatives regulate cell growth and decrease lymphocyte (cells which play a role in the regulation of the immune system) activity. The medicine comes in a form of an ointment which is typically applied twice daily.

Phototherapy:

Phototherapy with ultraviolet-B (UVB) light is effective in the treatment of psoriasis lesions. This type of treatment reduces DNA synthesis of skin cells. Phototherapy can produce symptom-free periods of up to 2-4 months. UVB therapy units are often available at dermatologist offices and the use of commercial tanning beds (with both UVA and UVB lights) is not recommended. Dermatologists may recommend consistent light therapy 3-5 days a week for 2 to 3 months.

Systemic Medications:

Systemic therapy is reserved for patients that have severe or incapacitating disease. These medications are prescribed by expert specialists such as dermatologists or rheumatologists because they have a risk for serious side effects.

More Information:

National Psoriasis Foundation   www.psoriasis.org

National Institute of Arthritis and Musculoskeletal and Skin Diseases www.niams.nih.gov

American Academy of Dermatology https://www.aad.org/

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With the birth of my daughter’s second child, I began to reflect on the important role that grandparents can play in the lives of their grandchildren. Here are five essential tips for older adults who want to have a lasting influence in the lives of their children and grandchildren.

Visit often. For those of us fortunate enough to live near our children and grandchildren, it is easy to see them often. Grandparents may even be the caregivers while parents are working. Visits don’t always have to be planned. Sometimes the best family time is a spontaneous invitation to dinner and a movie. However, sometimes distance can prevent regular visits. Some grandparents make it a goal to see their distant grandchildren once every 6 weeks or every few months. Be sure to take advantage of technology for your time together. Set a regular time to Skype or do Face-time. Don’t miss out on the subtle changes in those early years while babies are growing. Exchanging pictures may help, but they don’t replace the in-person experience. You may even think of relocating to be closer to family. For older grandchildren, be sure to have their cellphone number. Text them often and exchange pictures to stay involved in their lives and let them know you are available to them. Even small connections throughout the week (but without being annoying to teenagers of course) can make a difference in your relationship with your grandchildren.

Offer to help in practical ways. Working parents with young children will need a break at times. Ask how you can best help. Offer to keep the children for an overnight while mom and dad have a special dinner or weekend getaway. Many grandparents like to take their grandchildren on trips without the parents. Places like amusement parks, the zoo, or day trips to the water park or national forest all provide good diversion and quality time with Grandma and Grandpa while giving parents a rest. For even more quality time, take the older grandchildren on a cruise, camping in the mountains, or to a resort without their parents. For the mom with a newborn, take meals to the house (if you live close), do her grocery shopping or laundry, or send her a new bathrobe to show you are thinking of her. A favorite role model of mine sends the grandchildren a “baby shower in a box” with all sorts of goodies when she can’t be present due to distance or health concerns.

Plan special activities. Special activities need not be expensive. This could mean a trip to the park with Grandma or a special morning walk each week with Grandpa. My father used to take every grandson on a bow-hunting trip when they turned 12 years old. This was a rite of passage for every boy in the family. Grandpa would mount their first deer head for them and buy them a special hunting knife to commemorate the occasion. The girls in the family would take a trip to a Disney resort while the men were hunting. Grandchildren remember these events forever.

Attend special events. How fortunate are the kids whose grandparents are able to attend basketball and volleyball games, swimming tournaments, and Grandparent’s Day at school! Take advantage of being able to attend those dance recitals and school plays. If you live far, plan your visits to be able to attend some significant events like graduations, wedding showers, or school performances. This makes lasting memories with your family.

Be a constant in their lives. My parents divorced when I was 9 years old, and my paternal grandparents were the one constant in my life at that time. When a child’s world is jolted by change, grandparents can be that steadying influence that doesn’t change. They provide stability and security in an unsteady world for a child. The most important thing to remember is to be there. You don’t have to be the all-star parent or grandparent, but your children will remember that you were there for them when it counted the most.

I remember when my father retired at the age of 62 from a busy career as a pediatric surgeon. I thought he would be bored, but he had already compiled a notebook full of chores to do around the house, places he wanted to go, and a bucket list of other accomplishments that had been put on hold. Shortly after his retirement, my Mom confided in me that it was a bit of an adjustment having Dad home all the time. Suddenly, Mom said she seemed to no longer be able to cook right after about 40 years of doing this on her own. Dad had a better way to do things, after all. Once I saw Mom trying to wrap a gift and the wrapping paper seemed too small for the size of present. Dad was trying to give her step by step instructions and after snapping at her, Mom let him wrap the gift himself. Now, while I do concede that Dad was able to wrap the gift absolutely perfectly with the allotted paper, Mom and I gave each other a knowing glance and smiled. Ah, retirement.

So, when my own husband announced that he was going to retire and sell his share of the business at the age of 51, I knew I had to take some action to give our marriage the best chance to survive and thrive against this new challenge. After all, when my father-in-law retired, my mother-in-law had to encourage him to get a part-time job so she could have some “peace”. Even she was a bit concerned when my husband decided to take early retirement. Here I offer my short bit of wisdom, gleaned not only from my own experience but also from many wise women who gave me their sage advice to prepare for this season of life: when your husband retires.

Set the ground rules. I had fortunately learned during a brief period when my husband was working from home that there were certain things that would have to be agreed upon before he ever retired if we were to live peaceably. For example, he was not allowed to take over any of my former responsibilities unless I asked him to. Driving the kids around to activities can be helpful, but trying to wash the shrinkable clothes was not. Taking us out to eat after I worked all day was fine, but trying to take over the kitchen was off limits. Helping the kids with business math (not my area of expertise) was great, but trying to be the full-time homeschool Dad was not going to work for any of us.

Have separate work spaces. Jim and I cannot share a computer. I teach partially online and spend lots of time working from home with consulting. We agreed early on that he would set up a separate place in a different part of the house for his computer and desk. This has created much harmony over sharing the work space.

Allow everyone time to adjust to the change. I must admit that it took me several weeks, maybe even months, to realize that my husband was truly going to retire. Once he was home all the time, the reality gradually set in, but I kept reminding myself to give us all an adaptation period as if we were starting a new job orientation, because things were definitely going to change. Our two teenagers were the most leery of Dad being home all the time. For them, the ground rules (i.e. “please just let us do our work and don’t change our routine”) were particularly essential.

Accept your differences. My husband is a problem-solver and savior. He likes a challenge and wants to fix everything for everyone if he can. While I admire this about him, I didn’t want him to fix the nice structure and functionality by which our home was already running. I learned to embrace his strengths and encourage him to accept my weaknesses (like overindulging in carbs and worrying about things I can’t control). He likes to exercise every day, watch sports, and spend time on the landscaping. I would rather take the kids to the movies and go shopping. And that had to be ok.

Embrace the positives. While I was a bit skeptical about how our lives would change with my husband retiring so soon, there are so many things to celebrate that I am daily embracing the wonderful opportunities and blessings that his retirement has brought to our family. We are free to travel more. He accompanies me on business trips, even to China twice! He is much more relaxed and pleasant. It makes our family happy to see him have the time and resources to do what he enjoys. Jim keeps busy all of the time and yet does not have the daily pressure of work-related stress. We spend more time with family and have plans to move nearer to the grandchildren and to a better climate.

For all the women who are warily facing their husband’s retirement, take heart. I can honestly say that with some forward and deliberate planning, my husband’s retirement is one of the best things that has ever happened to us!