Parkinsons or pain?

[anashenwrath, ASN, RN]

Hello all! I float between 7-3 and 3-11 shifts, and the staff for each shift are about to have an all-out war with each other over one of our patients. As the pacifist of the Dementia Unit, I am trying to find an answer.

Our patient is a 71-year old male w a primary dx of Parkinsons and associated dementia.

On the 7-3 shift, he is pretty alert, with minor delusions and baseline forgetfulness. He talks and jokes with staff. He can stand and ambulate with a two-person assist for short distances, and is otherwise is a high-back wheelchair with a seatbelt. He will alert staff when he needs toileting, and he has a decent PO intake (feeds self). He still presents with some Parkinsonian dyskinesias, but it's limited to leaning, writhing in his chair a bit, and getting a kung-fu grip on things and not letting go.

On 3-11, right around dinnertime, his whole demeanor changes. He starts grimacing and really leaning hard to the left, until he's literally doubled over in his chair (he gets transferred to a Broda at this point). Absolutely refuses to eat, turning his head away violently. He grits his teeth and squeezes his eyes shut. Breathing becomes deep and a little rapid, but otherwise vitals are stable. Skin gets sweaty. Trying to transfer him becomes a 5-person job, as he's rigid and resistant. Trying to communicate with him is next to impossible. Anything he says (which is very little) seems to center on hallucinations and delusions.

Usually, once he goes to bed, he sleeps soundly. If he's not tired though, he'll have OOB behaviors

The issue is, 7-3 isn't seeing him on evenings, and 3-11 isn't seeing him on days, and god forbid two shifts communicate with each other like adults. Evening staff keeps insisting he's in pain and we need to increase his pain medication (he was on a 5mg vicodin trial x7 days, with the result being "unassessable." Still pending response from MD). Meanwhile the day shift is insisting that it's just his Parkinsons worsening at night.

I've been trying to research Parkinsons a bit more, and I can't find any real evidence that it worsens at night. But I also personally find the signs more Parkinsonian than pain, especially bcs once he falls asleep, he seems comfortable. One time I asked him as he was just starting to have an episode if he was experiencing pain, and his response (which took a while) was, "I'm always in pain."

So is it common for Parkinsons to worsen so significantly in the evenings? Or does this sound like something else?

[psychgeribuff]

Is the patient on sinemet or another antiparkinson medication? Mabe he is in pain bc his medication needs adjustment and at dinner/toward the evening his muscle ridgitiy is more significant.

[amoLucia]

Maybe he's just plain old tired after sitting up all day. Can he nap after lunch and then get up again for dinnertime?

And as PP said, maybe a med adjustment is in order.

[anashenwrath, ASN, RN]

He gets sinemet three times a day. I can't remember the exact dose... but AM dose is higher than the PM doses. So maybe that could help if we adjust so he's getting a higher dose in the evening. I'll have to check his other meds tomorrow to see what else he has that could be relevant.

I don't know if he'd stay down for a nap after lunch; he's pretty alert all day. We could try offering it though. But if we try to put him down for a nap just at the start of the symptoms (when he's still awake), he just thrashes and climbs out of bed. It's only once he falls asleep that the symptoms clear.

[amoLucia]

They usually are fussy after lunchtime. And if they know they'll get up for dinner, they are sometimes more coop.

You might want to try it before you have to go to some kind of med change. Used to work for some of my pts.

Can't remember - can you draw sinemet level for lab?

[4boysmama]

it sounds like pretty classic sundowning to me. While yes, parkinson's doesn't exacerbate at night per se, the associated dementia certainly does. I doubt that pain meds will help (other than to sedate him, I guess). I've seen several sundowners have good management of symptoms with antipsychotics (mainly seroquel), but that's tricky with parkinson's d/t the potential motor issues.