MDS Alert

Published on Mon Apr 26, 2010 PDF

Experts share inside tips for combating dysphagia, pain, falls, and more.

Parkinson's disease can be a difficult foe, but the right combo of strategies can improve clinical outcomes and quality of life for people with the condition.

Case in point: Swallowing problems are a big issue in Parkinson's, relayed Ron Benner, BSN, RN, MBHA, LNHA, director of nursing at the Lieberman Geriatric Center in Skokie, Ill., in a presentation at  he March 2010 American Medical Directors Association annual meeting. One solution is to time administration of Parkinson's drugs so the person is "on" rather than in an "off" period when he eats, Benner said. "If you give the medication about 30 minutes before meals, it will kick in so the person can swallow better as he's eating," instructs Brian J. Gates, PharmD, at Washington State University.

There's another reason to give the Parkinson's med before the meal: "Protein can affect absorption of levodopa," Gates tells MDS Alert. Separating medication administration from meals is "most critical in the later stages of Parkinson's."

To reduce saliva secretions that accumulate because the person can't swallow them well, clinicians sometimesorder anticholinergics, Gates notes. Yet elderly patients can develop a lot of side effects from these drugs, which are known to cause confusion and worsen dementia. The anticholinergic glycopyrrolate (Robinul) doesn't cause confusion as often as some of the other medications do, he adds.

"Some people will administer atropine eye drops to patients orally --" just drop them in the mouth --" to way, the patient doesn't develop as many systemic effects from the [anticholinergic effect]."

Another option: Administering botulinum toxin to paralyze the person's salivary glands can also help but is usually reserved for the more extreme cases, adds Gates.

The SNF team at Lieberman also focuses on Parkinson's diseaserelated effects on a resident's voice, Benner noted. (For tips on how speech therapists and nursing facility caregivers can help residents with this problem, see the sidebar on page 54.)

Pain seen in people with Parkinson's disease can be due to dyskinesia, Parkinson's medication-related"on and off periods," and comorbid conditions, Benner noted. "Pain in the Parkinson's disease patient usually occurs in the legs or in the largemuscles of the arms and legs."

"People with PD can generally take most of the common pain medications, such as opioids for severe pain," says Gates. "Muscle relaxants can sometimes help contracted muscles, although sometimes not."

You also should evaluate whether the Parkinson's medications are working properly or if the clinician needs to make an adjustment, he stresses.

Tip: "When you get into the narcotic utilization with this population, depending on the age group, constipation becomes a severe problem," as does maintaining "strong hydration to counter the constipation," Benner said.

Incorporate this: The Lieberman team has found that nonpharmacological remedies, such as music and biofeedback therapy, work quite well in treating pain in people with PD. Use of active and passive range-of-motion is very effective in controlling pain in the large muscles of the arms and legs, Benner noted.

To help prevent falls, the team at Lieberman assesses the patient for stiffness and weakness, as well as freezing and balance problems.

To ease patients' walking problems, a full-time music therapist at Lieberman works with a physical therapist to help patients with PD walk to the beat of music. "God Bless America" appears to be a favorite. There's "something about the beat of that song that helps [the patients] move well," Benner relayed. The music therapist plays the guitar while the patient sings aloud with the physical therapist by his side as he walks down the hall. "Sometimes we repeat the song depending on how long the hallway is."

The right walker can also help residents stay on their feet. Options include a U-step walker, which is a lot heavier than the standard walker and turns very smoothly, said Benner. The walker also has a "laser light component" to help the person see the entry points of doorways. The devices run about $450, which Medicare Part B doesn't cover, although Medicaid in some states "will contribute a percentage and the rest can be applied to a person's spend down or yearly allowance." (For more information on the walker, go to www.ustep.com/walker.htm.)

As for unique exercise programs: Lieberman offers yoga for people in wheelchairs. The team hasn't figured out how to do wheelchair Pilates yet. But Benner predicted that someone in his group will come up with a way to pull that off. (For more information on Pilates, go to www.pilates.com.)