1. Mobility: Rigidity and slowness of movement are the two most frustrating aspects.
Common difficulties are:
- to help initiate walking gently rock the patient from side to side and then ask to step forward
- encourage to step over an object when freezing occurs
- counting while marching is helpful
- encourage arm-swinging to improve balanceb) Turning
- encourage to turn in a wide circle rather than pivoting on the spotc) Rising from a chair
- use a high chair with arm rests
- move to the front of the chair, place feet on the floor 8 - 10 inches apart, put hands on arms of chair, lean forward and push up
- if unsuccessful rock forward and re-tryd) Turning in bed - may need regular turning
- use Tri-Turn Sheets, bed poles, other aidse) Tremor
- writing, eating and dressing are difficult
- keep elbow pressed close to side
- use eating utensils from Occupational Therapist
- velcro tabs easier than zips and buttons
2. Eating and Drinking:
- assistance with eating may be necessary
- alter the diet if necessary
- frequent sips of cold water to prevent food sticking
- encourage coughing to prevent aspiration
- watch posture while eating
- due to poverty of movement and slowing of bowel action
- also decreasing fluid intake and anticholinergics
4. Urinary Incontinence:
- due to difficulty getting to the toilet, and inability to undress and prepare when there
- monitor for constipation -- do not allow impaction to occur- night time is more difficult due to turning and moving
- patients may be unable to initiate voiding -- frustration for nurse and patient
- Parkinson's affects the control of muscle co-ordination and therefore a person's ability to communicate. The symptoms of tremor, stiffness and slowness can also impact upon the person's verbal and non-verbal methods of communicating with others.
a) Verbal Communication Speech:
- approximately 50% of people with Parkinson's experience difficulties with speech
- the voice becomes softer due to a decreased ability to vocalise during exhalation
- slurring due to decreased tongue control
- difficulty initiating speech or unwanted hesitations due to akinesia
- uncontrollable repetitions of words
- speech may become monotonous and flat
- sounding, with no variation in the pitch and quality.
- referral to a speech pathologist
- increase use of non-verbal communication
- shorter sentences, more frequent pauses
- deep breathing and vocal exercises
- practice making sounds i.e. vowels
- don't let others talk for you- use amplifiers etc if neededb)
Non-Verbal Communication Facial Expression:
- due to reduced movement it becomes expressionless and "mask-like"
- smiling, frowning, grinning and the ability to express anger, fear and joy require a conscious effort
- the listener may become confused and unable to respond appropriately
- facial exercises involving the brow, eyes, cheeks and lips to increase mobility
- may be restricted or "frozen" therefore limited non-verbal communication
- tremor of the hands most common
- general range of motion exercises to stretch the muscles of the limbs
- the tremor occurs at rest and decreases with purposeful movement therefore ensure the hand is doing something e.g. play with a coin, bead, or pen etc.
- arrest the tremor by immobilising the limb e.g. thumb tucked into belt, sit on hand, grab hold of structure, tuck elbow into side
- due to difficulty with fine motor movements, the handwriting becomes smaller (micrographia)
- the shape of the letters remains the same but the size is smaller
- the smallness is exacerbated when writing a long paragraph compared to a short sentence, or when doing another task at the same time e.g. writing a message while on the phone
- changes may be noticed when signing cheques
- tremor can impede writing
- if writing becomes small STOP. Think about what you are writing and rehearse the movement in your mind
- write only small sections at a time
- use lined paper to act as a visual cue
- avoid doing other tasks while writing
- printing instead of writing may be easier
- use a non-slip foam grip on the pen
- use other methods e.g. typewriter or computer
Parkinson's can cause considerable difficulties in a person's ability to communicate with others. Speech can be affected in volume, tone, inflection and pace. Facial expression may become mask-like and limb movement restricted. Handwriting can become smaller and smaller until it is indiscernible.
These problems however, can be overcome by understanding the complexities of the illness. Concentrate on every movement and one movement only. Regular exercise of everyday movements provides valuable practice and precision. Reduce stress by using relaxation and preparation. Maintain independence and dignity by refusing to allow others to speak for you.
There are a number of factors in relation to Parkinson's Disease which can contribute to the social withdrawal of the sufferer. As Parkinson's Disease is a chronic illness, the potential for these factors influencing the individual become greater over a very long period.
1. Communication Difficulties:
As explained previously, there are a number of physical restrictions which can impede the person's ability to communicate with others. The person with Parkinson's must be given time and not rushed when asked to respond. An empathic attitude will reduce stress and greatly facilitate their ability to communicate. People with Parkinson's should have social interaction incorporated into their daily activities programme. Education for others, as well as family members etc, will reduce embarrassment for the person with Parkinson's
2. Physical Symptoms:
The most obvious symptom is tremor. Many people with Parkinson's are extremely embarrassed and attempt to hide the offending limb. Dyskinesias, or abnormal wriggling movements, may also cause distress. In both cases, it is important to reduce the amount of stress the person experiences as this will exacerbate the condition. We encourage people with Parkinson's to minimize the effect of the movement by stabilising the limb. The tremor is reduced if the limb is involved in purposeful movement, so playing with coins etc. is useful. Dyskinesias may be reduced with a reduction in levodopa intake, though this may cause Parkinson's symptoms to return
3. Decreased Mobility:
As the illness progresses this becomes the largest factor in contributing to the individual's social isolation. Their ability to physically walk from their home to other areas decreases as symptoms become more severe and medication less effective. Tasks such as, climbing stairs, using escalators, and generally moving around busy areas such as shopping centres becomes nearly impossible. Regular medication reviews to ensure pharmacological treatment is optimally effective and side effects are kept to a minimum, coupled with the use of external cues and other movement strategies can address the problems of decreased mobility
4. Decreased Ability to use Transport:
As well as a decrease in the person's functional mobility, they will also experience difficulty in using various forms of transport eg. driving a motor vehicle. The decrease in reaction time, ability to navigate, fine motor co-ordination, and general limb mobility make it increasingly difficult for the person to have full control of the motor vehicle. Some people with Parkinson's may require limitations on their licence, or even cancellation. It is advisable to refer people to occupational therapy for a full driving assessment
5. Cognitive Difficulties:
People with Parkinson's may also be experiencing concurrent cognitive impairment, which will impede their ability to follow simple instructions or utilise aids such as cue cards, diaries etc. Difficulty with storing and recalling items from memory is commonly reported and thus the use of a diary or personal messages is recommended. Distraction whilst performing tasks can cause further complications. Encourage the person to break complex tasks into single steps, mentally rehearse each step, concentrate fully on each step and not be distracted by environmental factors
All people with Parkinson's report lethargy to some degree. This should be reduced with effective pharmacological management. Encouraging the person to identify factors which increase/decrease lethargy will help them maintain independence and optimal level of functioning. Other family members should be told about this phenomenon. The person should be encouraged to take regular rest periods to establish stable sleep patterns
At some stage, up to 90% of people with Parkinson's may experience depression to some degree. Anti-depressant medication may be necessary for more severe cases, for others supportive counselling and education may be appropriate. Depression can result from the grief process at being diagnosed with Parkinson's, loss of mobility, loss of independence, and a loss of general control over one's life. This symptom may also be due to other chemical changes occuring within the brain
8. Myths about Parkinson's Disease:
The greatest factor at present which contributes to the social isolation of people with Parkinson's is their preconceived ideas or myths about the condition. Many people worry that Parkinson's will either kill them, be inherited by their children, make them totally physically incapacitated, or directly result in dementia.
These of course are all untrue. Education at the time of diagnosis is vital in dispelling myths and enlisting the participation of the person and their family in the ongoing management of Parkinson's Disease. Supportive counselling to allow the individual and their family the opportunity to express emotions such as anger, frustration, fear etc. within a safe environment is extremely therapeutic.
Most people worry about what others will think and therefore attempt to hide their Parkinson's. Acceptance of the illness and participation in management decisions through education will encourage the person to maintain independence and optimal functioning. As well as individual education, broader public awareness campaigns and specific inservice education sessions for health providers will improve understanding of the illness and how we can lessen the stigma associated with Parkinson's Disease.