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The Team Approach: Caring for Elders with Parkinson's Disease. Pamela Willson, PhD, RN, FNP, BC, CNE Wednesday , October 10, 2012 Prairie View A&M University College of Nursing 1-2 p.m. 12th floor Board Room. Objectives. Review PD clinical features - PowerPoint PPT Presentation
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The Team Approach:
Caring for Elders with Parkinson's
Disease
Pamela Willson, PhD, RN, FNP, BC, CNEWednesday, October 10, 2012 Prairie View A&M University College of Nursing1-2 p.m. 12th floor Board Room
ObjectivesReview PD clinical featuresDescribe PD implications of managing
healthcare within federal healthcare system Integrate recent clinical data & evidence-based
strategies into treatment strategiesDescribe telehealth methods for improving PD
patients access to careDiscuss a chronic disease self-management
educational intervention
Parkinson Disease (PD)PD is the 2nd most common
neurodegerative disease40,000 – 59,000 new cases annually in the
USMore common in older individuals;
increases after age 601.5 million Americans
About 80,000 are Veterans
PD Classical Clinical FeaturesResting TremorCogwheel RigidityBradykinesiaPostural Instability
PD Associated Clinical FeaturesMicrographiaHypophoniaShuffling gait/festinationDrooling
DysphagiaDepressionAutonomic
dysfunctionDementia
Progressive Chronic DiseaseLoss of dopaminergic neurons
Classic movement abnormalities and tremor Rigidity and muscle stiffness – back & neck pain,
cramping, soreness and heaviness feelings of the muscles, inflexibility
Freezing or motor block – start hesitation, mid-motion, worsens with stress
Motor fluctuation – sudden wearing-off, dyskinesia, or no response to meds, dysarthria
Rigidity & incoordination of muscles – dysphagia, aspiration
Progressive Chronic DiseaseProgresses to a multicentric disorder
affecting many systemsNeuropsychiatric changes – depression,
hallucination, delirium, anxiety, panic attack, & agitation
Cognitive impairment – PD dementiaSleep disturbances – insomnia, REM behavior
disorder, sleep apnea, excessive daytime sleepiness, & sleep attack
Autonomic dysfunction – constipation, urinary problems, incontinence, orthostatic hypotension, & sexual dysfunction
Etiologies & Risk FactorsGenetic defects – 10% of cases
First-degree relative with PD – RR is 1.6 to 10.4
Environmental factors Pesticides, herbicides, & heavy metals
Rodent model Twin study – exposure to cleaning solvent
trichloroethylene; 6-fold increased risk Agent Orange – exposure to about 2.6 million
soldiers Living in a rural area Drinking well water
Department of Veterans Affairs (VA)PD added to list of presumed to be
service-related illness for veterans who served in combat in Vietnam
IOM evidence suggesting that exposure to Agent Orange & other herbicides may be a risk factor for PD
The policy provides treatment & disability assistance
Six PADRECCsParkinson’s Disease Research Education
and Clinical Centers (PADRECCs)Established in 2001Expanded to include 51 consortium
community care facilitiesGoal to improve the long term functional
outcome of veterans through innovative research, clinical care and educational programsModeled after the GRECC and MIRECC
PADRECC Resourceshttp://www.parkinsons.va.govPADRECC/Consortium Hotline at 1-800-
949-1001 x 5769 Resources & educational materials
PatientsProviders
Who’s on the Team?
Team Members Patient & Caregiver Primary Care Provider Neurologist Neurosurgeon Physical Medicine &
Rehabilitation Physical Therapist Occupational Therapist
Speech Pathologist Psychiatrist Psychologist Social Worker Pharmacist Neuroscience Nurse Educator
MEDVAMC Team
MEDVAMC Team
Aliya I. Sarwar, MD - Interim Director J. Gabriel Hou, MD,PhD - Associate Director of Research & Interim Co-Director Linda Fincher, BSN, RN - Assistant Clinical Director Pamela Willson, PhD, RN, FNP-BC, CNE - Associate Director of Education Shawna Johnson, BSN, RN - Clinical Care Coordinator Michele York, PhD - Clinical Neuropsychologist Arnold (Herb) Love - Administrative Officer Farah Atassi, MD, MPH - Research Health Science Specialist Suzanne Moore, MS - Research Health Science Specialist
Managing the Complexities of Parkinson Disease: Practical Strategies for the Federal Healthcare Professional (U.S. Medicine, 2012)
1.0 CME – management of PD
Treatment Guidelines VA Algorithm for Treatment of Early PD
www.parkinsons.va.gov/cfiles/PocketCardFront.pdf
American Academy of Neurology (2006) Early & late-stage PD treatment
European Federation of Neurological Sciences & the United Kingdom’s National Institute for Health and Clinical Excellence (2006)
Canadian Neurological Sciences Federation (2012)
PADRECC OutcomesDoes a multidisciplinary treatment approach
improve PD patients functional outcomes? N= 43; No DBS or thalamotomy patients Average age 71.5; 31 white 12 African-American
Unified Parkinson’s Disease Rating Scale (UPDRS) on one year follow-up Overall, mean improvement of -5.4 30 patients (68.8%) improved by -11.28 points 2 unchanged; 11 (25.6%) worsened by 9.82 points
Diaz & Bronstein (2005) NeuroRehabilitation 20, 161-167
PADRECC Outcomes Team members seen and visit types:
Neurology physician – 2.84 visits (100%) Neurology nurse – 1.74 (88.4%) Medication change – 26 (60.5%) Referrals
Rehabilitation therapy were most common – 62.8% Neuropsychological testing – 41.9% Functional diagnostic testing – 16.3% Support group – 9.3%
Education Home exercise programs – 86% Health wellness – 83.7%
PD Assessment Measures Unified Parkinson’s Disease Rating Scale (UPDRS)
Measures clinical course of PD over time Subscales: mentation, behavior & mood; ADLs, & motor
skills Hoehn and Yahr
Scale classifies PD’s six stages – severity of disease 0= no involvement; 1=unilateral involvement only
through 5=confinement to bed or wheelchair
PDQ-39 Quality of Life; 39 items & 8 subscales
Mobility, ADL, emotional well-being, stigma, social support, cognitions, communication & bodily discomfort
Karon Cook, PhD, 2003
Physical TherapyPatients with a Hoehn & Yahr disability scale
score of 3 or higher (0-5 scale) Compromised postural righting reflexes Unable to recover balance on a pull test
Falls are a recurring problem; patient’s have difficulty walking sideways or backwards; gait is slow & shuffling Safety training; rearrange furniture; flexibility
exercise to improve axial mobility; cueing strategies
Elizabeth J. Protas, PT, PhD, FACSM, 2003
Model of Care for Physical & Occupational Therapy Task specific training regimes
Taught to do one thing at a time; avoid dual activities
Long movement sequences should be broken into steps; focus on learning one at a time
Exercise and activity training should be undertaken at peak medication dose
Begin therapies early in disease process: Preserve flexibility Prevent deconditioning Minimalize mental decline Find solutions to functional problems
Trail & Warkentin, 2003
Depression 50% of PD patients suffer from depression
Decreased energy & motivation; feelings of sadness, helplessness, hopelessness; changes in weight, sleep & appetite; irritability, & thoughts of suicide
May co-exist with cognitive decline symptoms Nonpharmacological strategies:
Walking, tai chi, yoga and water therapy Community education/support groups Behavioral/cognitive counseling of individuals or
familiesNaomi Nelson, PhD, 2003
Communicative NeedsMost eventually exhibit hypokinetic dysarthria
with associated respiratory, laryngeal, and articulatory dysfunction
Aim is to strengthen muscles involved with volume production & articulation
Augmentative communication devices – amplification systems for reduced loudness
Nonelectronic communication boards or notebooks or computers
Reevaluate with changing patient needsJean Whitehead, MA, CCC/SLP, 2003
Access to CareTelemedicine/Telehealth Is there a difference between office-based vs
home web-based clinical assessments for PD?Random crossover design; 42 PD patients were
evaluated at baseline and 6- & 12-weeks Correlation coefficient between web and office were:
0.67 (first visit) to 0.75 (last visit) Doctor vs patient scores of 0.81 & 0.82
No difference in responsiveness and data precision Fewer missing values for web-based assessments
Cubo, et al., 2012, Movement Disorder, 27(2),308-311.
Telehealth EducationUsefulness & usability of follow-up telehealth
medication counseling of community-based PD patients RCT for in-person, videophone, or telephone
standardized medication educational session – 20-30 minutes (N=75)
Patients were more satisfied with videophone equipment & counseling than telephone or in-person sessions Nurses found visualization via videophone significantly more useful for medication and self-management interactions
Telehealth has the potential to facilitate patient-provider communication and partnerships in chronic disease preventive health care
Fincher, Ward, Dawkins, Magee, & Willson, 2009, Jl of Gerontological Nursing, 35(2), 16-24.
Telehealth Increased AccessPilot RCT of telemedicine for PD
patients in a community settingTelemedicine vs usual care; 3 telemedicine
visits over 6-months (N=10)UPDRS motor subscale was improved (p =
0.03) relative to baseline for telehealth nursing home patients vs usual care patients
QOL PDQ-39 and patient satisfaction were higher for telemedicine patients
Implementation cost was low; about $250 per site
Dorsey, et al, 2010
Telehealth Access
Telehealth Access
Dorsey, et al, 2010
Telehealth Access
Dorsey, et al, 2010
Chronic Disease Self-Management Counseling (CDSM) Program
CDSM trainers (faculty & students) delivered workshops: Techniques to deal with problems such as
frustration, fatigue, pain and isolation Exercise for maintaining and improving strength,
flexibility, and endurance Medications Nutrition Communicating effectively with family, friends, and
health professionals
CDSM Program
Course ProductsStudents participated in CDSM patient
counseling in 6-week (2.5 hours per session) course
Students developed theory-based patient educational handouts for multiple chronic conditions (e.g., Parkinson’s Disease, Stroke, Diabetes, Heart Failure, Kidney Disease)
Theory AssignmentsSocial Cognitive TheoryTheory of Reasoned Action & Belief
ModelTranstheoretical Model of Behavior
ChangeHealth Promotion ModelLiterature search for Theoretical
underpinnings of CDSM
Evidence Based Practice StrategiesEvaluated an EB SM research article
Determining the evidence for patient SM support programs
Journal Club format for presentationSummative evaluation paper
Impact of SM intervention on Pt outcomesApply to Pt education & SM Experience as a facilitator & future practice
Students were highly motivated & engaged
Met course objectives
Demonstrated SM and clinical competencies
Student Reflective Evaluations“It [CDSM Program] took the mystery
out of action planning for me”
[Implementation of SM classes & clinical] “actually seeing the program in action cemented this skill in my brain…I will feel confident in using this skill in my practice”
Students Reflective Evaluations[I got to] “witnessed SM in action”
“This experience [CDSM Program] helped me see the big picture of holistic care”
[I] “appreciate the importance of formulating an action plan to motivate our patients to change behavior”
Patient Evaluation CDSM Program
Identify personal risk factorsUnderstand stroke
Stay on track managing risk factorsIncrease my physical activity
Complete my action planAppreciate relaxation exercisesSupport my self-management
Establish self-management at homeI direct my self management activities
My overall satisfacion with course
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 54.54.5
4.24.5
4.34.54.5
4.34.54.7
ConclusionsLinking two courses facilitated a higher
level demonstration of independent student skills and the use of National Guidelines in the management of complex patients
The Chronic Disease Self-Management course added to the students skill sets, demonstrating theoretical based (self-efficacy, health prevention) patient education methods & materials
Future ???CDSM program for patients with PDVideoconference delivery mode Pilot study:
The Chronic Disease Self-Management course for patients at Beaumont and Richmond Community Based Outreach Clinics (CBOCs)
Feasible, acceptable, improved patient QOL indices
Anderson, et al., 2012
SummaryMost patients with PD are older than 60 yearsAccess to specialty care improves patient
outcomes and quality of lifeThe specialty skills of a multidisciplinary team
improves patient carePD is a progressive chronic disease that needs
frequent monitoring as symptoms progress and fluctuate
Telemedicine/telehealth provides increased patient access and high patient satisfaction
Questions ?