VOL: 97, ISSUE: 20, PAGE NO: 65
Deborah Rigby, MSc, RGN, is continence adviser, Bath and West Community NHS Trust
Liz Whelan, RGN, is Parkinson’s nurse specialist, Bath and West Community NHS Trust
Lower urinary tract symptoms are often reported in people with Parkinson’s disease. Urological symptoms can appear in the early stages and may progress regardless of the status of the disease (Shimizu et al, 1997). Continence problems may be associated with bladder or bowel function or result from functional disabilities.
Martignoni et al (1995) suggest that between 37-71% of patients with idiopathic Parkinson’s disease could present with urinary symptoms. Assessment of continence is therefore a fundamental part of nursing care.
Continence problems have implications for patients’ quality of life and carers’ ability to cope, and may ultimately influence admission to care in an institutionalised setting (Thom et al, 1997).
What is Parkinson’s disease?
Parkinson’s disease is caused by loss of the dopamine-producing cells in the substantia nigra, which is part of the basal ganglia of the brain. The cause is unknown. The basal ganglia help to control learnt voluntary movements.
The term Parkinsonism encompasses conditions that share some of the signs and symptoms of idiopathic Parkinson’s disease and are of more widespread pathology, including multiple system atrophy, Lewy body disease, progressive supranuclear palsy and striatonigral degeneration.
When assessing patients with bladder dysfunction, it is important to consider the affects of all medication currently being taken. In the elderly client group, comorbidity may give rise to polypharmacy, which may interact with both medication for Parkinson’s disease and bladder disturbance. Compliance may also vary because of complicated drug regimes.
A nursing assessment of a patient with Parkinson’s disease or Parkinsonism should include the activities of daily living. A continence problem is not solely a nursing problem, and involvement of the interdisciplinary team is mandatory to effect the best possible outcome to improve quality of life (Morris and Iansek, 1997).
No two people with Parkinson’s disease will present and progress in the same way. Assessment therefore needs to be flexible and ongoing.
Mobility in Parkinson’s disease is affected by bradykinesia, gait initiation difficulties, ‘freezing’ and postural reflex changes. When assessing a patient with bladder disturbances the following questions need to be asked:
- Can he or she go to the toilet independently?
- Is he or she able to access the toilet without ‘freezing’ in the hall or doorways?
- Can he or she adjust clothing?
- Is he or she able to turn over and get out of bed at night?
- Has he or she seen a physiotherapist experienced in Parkinsonism for assessment of movement strategy education?
- Would he or she benefit from visual, auditory or verbal cues to help overcome gait difficulties?
Morris (2000) argues that physiotherapy programmes needed to identify core elements specific to Parkinson’s disease as well as focusing on personal problems and needs.
To the less independent person with Parkinson’s disease, the ability to ask to go to the toilet at the appropriate time may be hampered by a dysphonic voice, resulting in quiet speech. This, combined with reduced facial expression, which is a common sign in Parkinson’s disease, may make the patient appear disinterested or unfriendly.
Thought processes may also be slowed and impatient staff may not give patients with Parkinson’s disease sufficient time to express their needs. On a busy, noisy ward or in a residential setting these difficulties may be intensified and cause unnecessary continence problems.
Assessment should take this into account, and the advice of a speech and language therapist may be appropriate. Loss of hearing is common in elderly patients and, if not assessed, may lead to misunderstanding between the patient and nurse or carer.
A decrease in cognitive function is more common in patients with Parkinsonism than in the general population (Biggins et al, 1992), and depression can affect up to 50% of those with the disease. Assessment should include a validated measurement scale of the patient’s ability to understand and retain the advice and information given. If nocturia is a persistent problem sleep deprivation may occur, which can exacerbate depression and impair cognitive function.
Where poor cognitive function is present, assessment should take into account the patient’s behaviour when wishing to use the toilet. Restlessness can be a sign of wanting to urinate and, if not acted on by carers or nurses, may result in continence problems or falls.
Manual dexterity is poor in people with Parkinson’s disease and Parkinsonism because they have difficulty planning and executing automatic movement sequences. This can lead to problems getting on or off the toilet and adjusting clothing in an appropriate manner, increasing dependency on carers and staff. An occupational therapist can help to assess such difficulties, providing adaptive aids and cognitive strategies to help overcome some of them.
Where dysphagia is a problem, even if the patient does not have coughing or choking episodes, referral to a speech and language therapist for assessment and advice is necessary. Adequate bladder function depends on an average fluid intake of seven to eight cups of liquid a day.
Bladder symptom history
In older people, a number of commonly occurring physiological changes may affect the ability to maintain continence. Careful assessment using a recognised continence care pathway or assessment tool, with an understanding of age and disease-related changes, should enable the assessor to determine the type of continence problem.
Quality of life
Recognised quality-of-life indices can be used to measure symptoms. The PDQ-39, a specific, validated tool (Peto et al, 1998), is becoming a recognised index for this client group. Research has shown that patients are more concerned about quality-of-life issues than clinical ones.
This is an essential part of the assessment. It enables a clear picture of bladder habit and volumes to be assessed.
The average person goes to the toilet between six and eight times a day, and nocturia twice a night is normal in people aged over 70. Bladder volumes will vary depending on fluid intake; an average voided volume should be 200-400ml.
Advice on fluid intake
There is much debate about how much we should drink and what type of fluids this should include. There is a consensus of opinion in the fluid matrix (fluid intake guide) which offers a validated research-based approach (Abrams and Klevmark, 1996). As a guide the matrix suggests intake based on bodyweight - for example, a person weighing 76kg should aim to drink 2.3L a day.
A routine urine test will be able to identify nitrites and leucocytes in the urine. A positive urine test is indicative of a urinary tract infection and a urine sample should be sent for culture.
A common problem in men aged over 55 is prostate enlargement. There has been considerable discussion in recent years over whether men with Parkinson’s disease have unnecessary prostatectomies.
Gray et al (1995) concluded that lower urinary tract dysfunction in people with Parkinson’s disease related to age rather than the disease. The study found that bladder capacity was reduced in both men and women with Parkinson’s disease but that there was no evidence of increased obstruction.
Flow studies can be performed using simple flowmetery and provide essential information to support assessment.
A normal post-void residual is less than 100ml (Fowler, 1993). The monitoring of renal function is essential before embarking on a catheterisation programme.
Constipation may be caused by reduced mobility and medication. The gut transit time may also be slower in Parkinson’s disease and, if appetite is poor, it may be unrealistic to expect a daily bowel action.
The second article in this two-part series, examining the diagnosis and management of continence problems associated with Parkinson’s disease, will be published in the next issue of NTplus Continence on July 26.