My wife, who until recently had been my Principal Carer, has been very ill 
recently, including three days on life support, followed by two weeks intensive 
care. This necessitated us both entering nursing homes for respite care. I was 
resident for some weeks in one or the other of four nursing homes, and I was 
interested in the level and type of care for the other patients there.

The care was the same, more or less, whatever the reason for being there, While 
this may seem very democratic, and it does not fulfil
patient requirements. So I have decided to pen this little piece on the 
particular care of PWP.

---------------------------

THE CARE OF PWP (PEOPLE WITH PARKINSONISM) IN NURSING HOMES

PWP (People/Person With Parkinsonism) have a number of side effects, some 
arising from the disorder itself, some from medication. Any one person may 
encounter some, or all, or none of these, in the course of a single day. I have 
lumped together all varieties of PS (Parkinson Syndrome] as the practicalities 
of caring for PWP are more or less the same, at least )so far as caring for 
them, except for medication and treatment, which I am not qualified to comment 
on.

There is plenty of literature out there on the major symptoms of tremor, 
rigidity, and postural instability. (Would that were the sum
total of it). So this paper is about how one may recognise and treat some of the 
several secondary symptoms.

It is essential that a correct diagnosis be made from a physical examination of 
the PWP, and not just judged by appearance. The more
one sees of PS,  the more one come to realise that PS turns the normal order of 
things upside down. For example, a Babinski sign instead of a normal plantar 
reflex: an abnormal response to heat and cold, i.e. being cold when the 
surroundings are hot, and vice versa.

Motor symptoms include:

Gait and posture disturbances:

Shuffling - The gait is characterized by short steps, with feet barely leaving 
the ground, producing an audible shuffling noise. Small
obstacles tend to cause the patient to trip.

Gait freezing - A manifestation of akinesia (an inability to move) characterized 
by an inability to move the feet which may worsen
in tight, cluttered spaces or when attempting to initiate gait. This 
necessitates a strategy being developed to counteract the situation,
such as having the PWP step over a broom. The addition of a “task” to the 
process of walking seems to concentrate the mind on the job at hand.

Decreased arm-swing - Has some effect on lateral stability.

Turning “en bloc” - Rather than the usual twisting of the neck and trunk and 
pivoting on the toes, PWP keep their neck and trunk
rigid, requiring multiple small steps to accomplish a turn. May necessitate 
holding the arms out to maintain balance. Can lead to
falls.

Stooped, forward-flexed posture - In severe forms, the head and upper shoulders 
may be bent at a right-angle relative to the trunk
(camptocormia). This leads to the PWP being unstable, and prone to fall. Also, 
the PWP may suffer mild to severe lower back pain
Forward tilt to the head: In extreme cases, the head may be carried with the 
chin on the chest. This is more often due to contraction in the 
sternocleidomastoid pair of muscles (running from the sternum [breastbone] to 
the clavical [collarbone], to the mastoid process [under and behind the ear] to 
the occiput [back of the skull]), rather than to any weakness in the trapezius 
muscles at the top of the spine. The posture interferes with eating, drinking, 
breathing, and talking.

Festination -  A combination of stooped posture, imbalance, and short steps. It 
leads to a gait that gets progressively faster and
faster, often ending in a fall. Commonly, the PWP will rise from a chair, and 
initiate walking. The upper body will move, but the feet
will seem stuck to the floor. The PWP will then start to fall forward, often 
“measuring” themselves full length on the floor.

Dystonia [in about 20% of cases] - Abnormal, sustained, painful twisting muscle 
contractions, often affecting the foot and ankle
(mainly toe flexion and foot inversion) which often interferes with gait.

Speech and swallowing disturbances :

Hypophonia - Soft speech. Speech quality tends to be soft, hoarse, and 
monotonous. Some people with Parkinson’s disease claim
that their tongue is “heavy” or have cluttered speech. May add to an impression 
that the PWP is slow-witted.

Monotonic speech -  The organs of speech are often stiff. May give the 
impression that the PWP feels no emotion.

Festinating speech - excessively rapid, soft, barely-intelligible speech. This 
often occurs during an “on” period, when the dopamine replacement medication is 
over active. May give a false impression of dementia.

Drooling - Most often caused by a weak, infrequent swallow and stooped posture. 
May add to an impression that the PWP is slow-witted, and/or not in control of 
bodily functions.

Dysphagia: Impaired ability to swallow. Can lead to aspiration pneumonia.

Other motor symptoms:

Fatigue (up to 50% of cases): May be mistaken for laziness.

Masked faces: (A mask-like face also known as hypomimia) with infrequent 
blinking. May lead to an impression that the PWP is
emotionally “detached”.

Other movement difficulties

Difficulty rolling in bed or rising from a seated position

Micrographia (small, cramped handwriting)

Impaired fine motor dexterity and motor coordination

Impaired gross motor coordination

Akathisia, the inability to sit still

This symptomology can easily lead to misdiagnoses of dementia, 
simple-mindedness, Alzheimer’s, recalcitrance, unmanageableness, etc. if only 
judged by appearances.

Dr, J, F, Slattery, PhD Soc Sc
-------------------------------------
This is not medical advice, merely the opinion of the writer, whose
doctorate is not in medicine, 

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