30 sec sit to stand - Oregon Geriatrics...

The Care & Managemend of PD 10/23/2014

1

Interdisciplinary Care in the

Chronically Ill Patient:

Parkinson’s Disease Model

Lisa Mann, RN, BSN, MA

Jennifer Wilhelm, PT, DPT, NCS

Aimee Mooney, MS,CCC-SLP

30 sec sit to stand

• Normal values:

• 30 y/o = 30 reps

• 40 y/o = 25 reps

• 50 y/o = 20 reps

• 60 y/o = 15 reps

• 70 y/o = 13 reps

• 80 y/o = 12 reps

• 90 y/o = 10 reps


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Objectives

LEARN…

• the unique issues surrounding best practices

in Parkinson’s disease (PD)

• what each discipline can offer in managing the

disease

• how this team model of care could be applied

to other neurodegenerative or geriatric

illnesses

Application Goals

• What:

Disciplines to utilize based on subjective and

objective examination

• When:

Anticipate degenerative progression

• Where:

Challenges in different care environments

• Results:

Maximize quality of life through team care.


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The Challenge of Treating Parkinson’s DiseaseChronic Illness Poster Child

• Individualized

• Complex

– Primary Symptoms: Motor

– Secondary Symptoms: Non-Motor

• Progressive

• Multifaceted

• Unpredictable

• Caregiver/family impact

Motor Symptoms

• Tremor

• Rigidity

• Bradykinesia

• Postural Instability

• Masked facies

• Cramped handwriting

• Swallowing

• Speech

With progression:

• Motor Complications

– Motor fluctuations

– Freezing

– Dyskinesia


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Non-Motor Symptoms & Rx

• Long list of potential non-motor symptoms

- Cardiac - Respiratory

- Gastrointestinal - Sensory (smell, vision , pain , skin)

- Urinary - Thermoregulatory

- Sleep - Cognitive

- Psychological

• Note if PD medications help relieve problem

• Therapies (PT, OT, ST, RD) beneficial

Multi-Disciplinary Team CareEmpowering PCP to Empower Patient

Patient/Care partner

Provider

Physical Therapy

Occupational Therapy

Speech Therapy

Registered Dietician

Social Worker /

Nurse

Variables:

• Patient problem

• Staging

• Co-morbidities


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Treatment by Stage: When & What?

Individualized, symptomatic responsive

Hoehn & Yahr Staging

• Stage 1 Unilateral Involvement

• Stage 2 Bilateral involvement

• Stage 2.5 Mild bilateral disease with recovery on pull test.

• Stage 3 Mild/moderate disease withimpaired balance.

• Stage 4 Severe disease; marked disability

• Stage 5 Confinement to bed or WC


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PD Medications: Polypharmacy

• MAO-B Inhibitors: selegiline, rasagaline

• Anti-viral: amantadine

• Anticholinergics (tremor): trihexiphenidyl

• Dopamine Agonists: ropinirole, pramipexole,

apomorphine (injectable), rotigotine (patch)

• LEVODOPA: carbidopa-levodopa

• COMT Inhibitors: entacapone, tolcapone

Motor Symptoms Video


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Early Stage Tx: Medication…

• Delay starting medications?

• Under ~65 years:

– MAO-B Inhibitor (protective?)

– Anti-viral

– Dopamine (DA) agonists

• Over ~65 years:

– Physiologic age?

– Levodopa

• Exercise Rx


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Early Stage Tx: …Empowerment

• Information/resources:

– National organization materials (free)

– OHSU Parkinson Center Newly Diagnosed

Education Session (1x) = HOPE – www.ohsubrain.com/pco

– PRO – www.parkinsonsresources.org

• Therapy Referrals

– Baseline

– Prevention

– Education

Team care for …

• Communication difficulties

• Vision changes / driving

• Falls

• Swallowing impaired

• Incontinence

• Cognitive changes

• Orthostatic hypotension

Locations

• Outpatient/home

• Hospital

• Long Term Care


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Communication & Voice

Patient

• I have a hard time being

heard in restaurants.

• At work I have trouble

getting through all my

emails and typing up

reports.

Family

• I always have to ask him

to repeat what he said.

• He thinks I’m going

deaf. No else

understands him either.

Communication / voiceOT SLP PT

Voice volume Diaphragmatic

breathing

exercises

Lee Silverman Voice

Treatment (LVST)

Vocal Hygiene

Posture

Computer skills Accessibility

Computer

training

Speech

production

Introduction to voice

amplification and

AAC

Dysarthria

management


10

Vision & Driving

Patient

• I have a hard time

telling where one stair

ends and the other

begins.

• I can’t parallel park as

quickly as I used to.

Family

• Some times he bounces

off the wall as he is

walking.

• I’m concerned about

mom’s driving. Is she

safe to drive?

Vision & Driving

OT SLP PT

Vision:

Contrast

sensitivity

Education

Lighting

Home

adaptations

Assess impact

on reading, use

of memory

compensations

Vision:

Depth

perception

Vision exercises Stairs

Driving Objective

testing

Trails A & B

(visual scanning)

Cognitive

assessment

Axial mobility


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Middle Stage, HY 2-3

• Treatment for PD motor symptoms:

– Medications: Levodopa + COMT Inhibitors

– Surgery (DBS)? > Indicators

– Exercise

• Treatment for non-motor symptoms

– Medications, referrals

• Referrals

– Rehab therapists, social worker, counselor, dietitian

Increased risk for hospitalization

Hospitalization Complicationswww.awareincare.org

• PD med admin key problem

– 75% do not receive medication on time

• 61% of those experience serious complications

– 41% contraindicated medications prescribed

• 69% complications

– Neuropsychiatric most common

• Comorbidities high

– Non motor symptoms


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Hospitalization: Vital Elements

• Timing of C/L critical

– Individualized medication schedule with home

times (15 min admin window)

• Ensure contraindicated meds not used

– Especially: anti-emetics, anti-psychotics

• Rehab referrals w/ on-off evals

• SW consult for d/c

– consider caregiver capacity

Balance / Falls

Patient

• I was turning around in

the kitchen and fell.

• I often freeze when

getting up from a chair

to walk or going into an

elevator.

Family

• If my husband falls again, I don’t know how I will get him up off the floor.

• He forgets to use his walker.

• Sometime she can’t keep up with her walker; it goes to fast.


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Falls

OT SLP PT

Freezing Home

adaptations

Cognitive: use

of Spaced

Retrieval (SR)

to train

consistent use

of cuing

strategies

Freezing

strategies:

auditory,

visual, tactile

Balance

Festination

Home safety

evaluation

Cognitive:

Use of

environmental

cues

U-Step walker;

fall

assessment;

exercises for

balance

Swallowing

Patient

• No, I don’t have any

swallowing problems.

Family

• She is always choking

when she takes her

pills.

• Why does he seem to

cough so much?

Especially after he has

eaten?


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Swallowing

OT SLP PT

Eating and

Swallowing

Meal time

manage-

ment;

adaptive

aids

Assessment: Modified

barium or FEES (ENT)

Treatment: Training in

compensatory swallowing

techniques

Education:

Coordinate eating with

medications

Small, frequent, highly

nutritious meals

Diet Modification:

Switch to soft diet

Unique

cases: neck

flexibility

Advanced Stage, HY4-5

• Managing fluctuations of L-dopa therapy

– Documentation & communication with M.D.

– COMT inhibitors

– Amantadine to help control dyskinesia

– Anti-psychotics for hallucinations (only two options)

• Referred to PT, OT, ST

– Common issues: home safety, falls, assistive

equipment, cognitive management, augmentative

and alternative communication support


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Advanced Stage, HY4-5

• Referral to Social Worker – caregiver support

Options for…

– In-home care support

– Respite

– Community resources

– Placement

– Etc.

• Counseling – patient and spouse grieving

Long Term Care: Multiple EnvironmentsSNF, ALF, AFC, Hospice

• Mismanagement by LTC care teams

– Med timing, food, fluctuations in fxn

– Caregiver turnover

• Education in PD (e.g. NPF Medications)

• Specific orders

– med timing, observation diary, etc.

• Rehab for function, comfort, caregiver training


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OHSU Parkinson Centerwww.ohsubrain.com/pco

Orthostasis

Patient

• I passed out two times

this morning.

Family

• He gets up and then

slumps to the floor and

won’t respond. A few

minutes later he’s fine.


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Orthostasis

OT SLP PT

Position

changes

Bed position;

Compression

stockings

Environmental cues

to support recall of

safety

recommendations

Supine resisted

exercises;

Sequencing,

slow

Cognition

Patient

• My wife moves things

around on me. I can’t

find anything.

• The boy scouts are in

the basement, so I can’t

close the door.

Family

• He can’t find anything

in the bathroom.

• I have to remind to do

EVERYTHING, he cannot

get started and he

cannot stick with a task

to completion (getting

dressed) .


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Cognition

OT SLP PT

Cognition Contrast

sensitivity.

“Figure

ground”

Careprovider

education:

daily routines.

Training on

initiation

strategies:

Development

of routine task

checklist paired

with initation

alarm.

Aerobic

exercise

program

Long term care: Incontinence

Patient

• I’m so tired. I get up 4-

5x a night to go to the

bathroom.

• I can’t go to the exercise

classes here because I

have to go to the

bathroom in the middle

of class.

Family

• He’s always having

accidents during the day.

Sometimes they have to

change his bedding in the

middle of the night.

• She keeps having

recurrent UTIs which

causes her to be confused

more.


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Incontinence

OT SLP PT

Leakage /

Hygiene

Voiding diary Cognitive:

spaced

retrieval

Pelvic floor PT

Mobility Pants management Improve bed

and sit to stand

mobility

Bathroom Equipment: instruction

and determine

appropriate.

Make certain path is

visible.

Forming a Team

• Local support group

• Local rehab therapists

– Neuro specialty

– Exposure to special PD training

• Statewide PD support organization

• Statewide PD medical center

– OHSU TEAM-PD Network


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Resources

• Statewide:

– OHSU Parkinson Center

– Parkinson’s Resources of Oregon

– Brian Grant Foundation

• National:

– National Parkinson Foundation

– American Parkinson’s Disease Association

– Parkinson Disease Foundation

– American Physical Therapy Association

– American Speech & Hearing Association

• Aging & Disability Resources Connection of Oregon

Summary Take-Home Tips

• Medication: timing, never stop abruptly,

protein interaction, contraindicated meds

• Sudden change? Probably not PD. Consider

complicating factors.

• Early referrals for team care

• Routine follow-up with rehab team

• Realistic therapy goals and education

• Patient centered care based on active

participation


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Questions?

INVITATION

Allied Team Training in PD (ATTP)

Nov 13-15, 2014 – San Diego, CA

30 sec sit to stand - Oregon Geriatrics...

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