Casestudy 76 - case study 24 PDF

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Case Study 76 L.C. is a 78-year-old man with a 3 year history of Parkinson Disease (PD). He is a retired engineer, married, and living with his wife in a small farming community. He has 4 adult children who live close by. Since his last visit to the clinic 6 months ago, L.C. reports that his tremors are “about the same” as they were. However, further questioning reveals that he feels his gait is a little more unsteady and his fatigue is slightly more noticeable. L.C. is also concerned about increased drooling. Among the medications L.C. takes are carbidopa-levodopa 25/100 mg (Sinemet) and pramipexole (Mirapex) 0.5 mg, each three times daily. On the previous visit the Sinemet was increased from 2 to 3 times daily. He reports that he has become very somnolent with this regimen and that his dyskinetic movements appear to be worse just after taking his carbidopa-levodopa (Sinemet).

1. What is PD? (Include the pathophysiology)- (5 points) Parkinson Disease is a progressive neurodegenerative disorder that leads to tremors, muscle rigidity, bradykinesia, and postural instability. Since it is progressive, it is separated into stages; stage one is mild and stage 5 is completely dependent. Through this, the degeneration of the substantia nigra occurs which causes a decrease in dopamine levels.

2. What is parkinsonism? – (5 points) Parkinsonism is characterized by any condition that may cause muscle rigidity, bradykinesia, tremors, or postural instability. Parkinsonism can be a combination of these symptoms or include all of those mentioned. It is can be caused by different brain disorders, brain injuries, or other drugs or toxins that have Parkinsonism as a side effect or adverse effect.

3. What are the clinical manifestations of PD? Include 8 manifestations. (8 points) Underline the symptoms L.C. has mentioned. (2 points) Some symptoms that are commonly found in Parkinson’s patients include tremors and other involuntary movements, rigidity and stiffening of the muscles, slowed muscle movements or bradykinesia, trouble walking and poor postural stability and instability standing. L.C. exhibits many of these signs such as his tremors, unsteady gait, fatigue, and increased drooling.

4. L.C.’s wife asks you, “How do the doctors know he really has Parkinson disease? They never did a lot of tests on him.” How is PD diagnosed? Include 4 important points in your response. (8 points) Parkinson’s disease cannot be diagnosed with one test; however, tests are conducted to rule out other diseases that may present themselves with similar symptoms. Assessment findings and brain scans help to rule out those other possible diseases. Upon neurological and physical examination in conjunction with a detailed review of medical history helps physicians diagnose PD. Doctors may be able to detect a change in dopamine levels within the cerebrospinal fluid which may also help to diagnose Parkinson’s disease. It is impossible to truly know an individual has PD until an autopsy can be performed.

5. L.C. asks, “Why don’t they give me a dopamine pill? Wouldn’t that just fix everything?” Why is oral dopamine not a replacement therapy? Include 2 important points in your response (4 points) The treatment plan of Parkinson’s is to provide medications that would slow the progression of the disease. Dopamine replacement therapy would not be effective because it does not slow down that progression. It is unable to cross the blood brain barrier due to its polarity. Since it is so polar, this prevents it from entering the brain.

6. Why is levodopa given in combination with carbidopa? Include 3 important concepts in your response (6 points) Carbidopa enhances the levodopa so the level of levodopa remains high through treatment. Without Carbidopa, levodopa would be converted to dopamine in the bloodstream. This allows the maximum amount of levodopa to reach the brain. Carbidopa also eases the nausea and vomiting that levodopa tends to cause.

7. Why did L.C.’s dyskinetic movements appear to be worse just after taking carbidopalevodopa? (2 points) What changes to his medication therapy may be needed? Include 2 different options. (4 points) Dyskinesia is a side effect of levodopa and it may be due to a prolonged usage of the medication. It may also occur when levodopa is at its peak level within the body. Some changes that may help with the dyskinetic movements after taking carbidopa-levodopa may be to

decrease his dosage. By decreasing the dosage, the peak level of levodopa will also decrease which may result in a decrease of the dyskinetic movements. It may also help if he took his medication along with non-protein foods. Some individuals experience less benefits with this medication after they eat a meal that is high in protein.

8. Because L.C. takes Sinemet, what serious adverse effect should you assess for in him? (2 points) a. b. c. d.

Suicidal thoughts Permanent hearing loss Steven-Johnson syndrome Spontaneous tendon rupture

9. L.C.’s wife asks, “They can do surgery for everything else. Why can’t they do some kind of surgery to fix Parkinson disease?” (2 points) How would you describe the surgical treatments available for patients with PD? List and describe 3 surgical treatments (6 points) While surgery is an option, surgical managements are a last resort for Parkinson’s patients. Some surgical treatments include a stereotactic pallidotomy or thalamotomy, deep brain stimulation, and fetal tissue transplantation. Stereotactic pallidotomy or thalamotomy involves creating a whole in the skull to insert an electrode that will locate the spot in the brain that is responsible for the dyskinetic movements and burns the brain tissue to destroy it in an attempt to stop those movements. Deep brain stimulation is similar to a pacemaker, but located on the brain. It is placed on the brain and creates an electrical current to help stimulate the brain. Fetal tissue transplants are still an experimental treatment option that uses fetal pig or human brain tissue that is then transplanted into the patient's brain.

10. What interprofessional team members would be involved in L.C.’s care and how? List and describe the role of 4 team members (8 points) Social workers can help the patients and their families navigate the system of health care and work through the transition of a diagnosis, such as Parkinson disease. A physical therapist can perform regimented exercises with the patient to improve their mobility and strength. The physical therapist can also help L.C. improve his balance and gait to reduce the risk of falls.

An occupational therapist helps patients with Parkinson disease stay as active and independent as possible through daily living activities. This satisfaction of being able to perform daily living activities on his own which will improve his mental health. A home care nurse can visit his house daily or on an as needed basis to evaluate L.C. and his environment. This will also give his wife, or other caregiver for that day, a break so they can also take care of themselves.

11. What factors do you need to take into consideration when helping L.C. with these referrals? Include 4 important factors (4 points) There are many factors that need to be considered when referring a patient to another interprofessional team member. For example, it may be intimidating for a patient to talk to a social worker if they do not know what their job entails and how they are involved in their care to help them. Also, for older adults, it is important that when instructions are presented that they are clear and concise. It is also helpful for the individual to have a packet or brochure of what is to be done with large printed letters in order for them to read it. It is also important to determine the financial side of the situation and educate the patient on what insurance will cover. Also, if the patient needs to go to a physical therapy office, it is important to determine whether or not the patient has transportation to get to the office.

12. L.C. is reporting an increase in drooling, and you are concerned about his ability to swallow. What further assessment could you perform to determine whether L.C. is at immediate risk for aspirating? Describe 8 assessment points. (8 points) L.C.’s history should be reviewed to determine whether he has had any past history with difficulty swallowing or any bouts of choking. After this is determined, it should also be reviewed if he has any acid reflux or not because if it is severe enough, this may cause some dysphasia as well. Some severe dental problems may also make it difficult for a patient to swallow. If L.C. presents with drooping of the mouth or a swollen airway, this may also indicate that he may be at risk for aspirating. By assessing whether or not L.C. can cough will also determine whether he is at immediate risk for aspiration. It is also important to determine whether or not L.C. has a decreased level of consciousness.

13. What are 3 nutrition interventions that should be implemented for L.C.? (6 points) L.C. should consume a high-fiber diet with many whole foods such as fruits and vegetables and lean proteins to improve his general well-being. To maintain his independence, L.C. can use special utensils that are easier to use with dyskinetic movements. L.C. would also

benefit from drinking water through a straw as that would be easier to maintain control of the fluid through his dyskinetic movements as well.

14. Because L.C. is reporting that his gait is more unsteady, there is an increased risk for falls. Which suggestion could you offer to diminish this risk? (2 points) a. b. c. d.

Only use a wheelchair to get around Use a bag or backpack to carry objects Stand as upright as possible and use a walker Keep the feet close together while ambulating

15. What are 3 suggestions you can make to L.C. to help manage fatigue? (6 points) It is important to determine whether or not L.C. is consuming enough calories to fuel his body in conjunction with participating in light exercise. This exercise can be basic repetitive movements or with a light amount of weight in order to keep his muscles strong. It can also be suggested to the physician to prescribe a stimulant, such as Ridlin, that can lessen L.C.’s fatigue.

16. You are giving instructions to L.C. and his wife about ambulating safely. You determine that they understand the directions if they say that L.C. will: (2 points) a. b. c. d.

Schedule his PT appointments in the evening Sit on a large, soft sofa with supportive pillows Use a step stool to obtain difficult-to-reach items When rising from a seat, rock back and forth to start moving

17. As L.C.’s case manager, identify 5 things that you would need to assess to determine whether L.C. could be cared for in his home. (10 points) One thing that would need to be assessed is the environment of the home. The home should be free from loose carpets or throw rugs that may cause him to trip or fall, there should also be adequate lighting throughout the home, and there should be limited stairs, however the stairs should have handrails if present. The second thing that would need to be assessed is his social support system. His wife and his children should be supportive. His wife also should assess her mental and physical health in order to provide adequate care. His wife should also have resources to turn to for support.

The third thing that would need to be assessed is his access to meals. There should be assistance available during meal times, meal preparations. Meals can also be delivered to his home if cooking becomes increasingly difficult for L.C. The fourth thing that would need to be assessed would be transportation. L.C. should have transportation available to and from doctors visits, the grocery store, and other activities. The fifth thing that would need to be assessed is the risk for neglect. Elder abuse is common in Parkinson's patients, therefore the risk for neglect from the caregiver would need to be assessed....