Susan M. Calne

The late stage of Parkinson's disease (PD) can be protracted with inexorable changes in physical and mental health, loss of autonomy and self-esteem, altered relationships, and social isolation. Severely affected patients (Hoehn & Yahr stage 4-5) present a challenge to nurses who care for them; addressing their needs takes time and patience. Changes in mental status have profound implications for the welfare of the late-stage PD patient as well as of the caregiver(s). Depression and dementia in patients with PD are two factors that interfere with the ability to deliver effective care in late-stage PD as they lead to loss of initiative and cooperation. Primary caregivers often have their own medical problems, with limited stamina and support; relationships may change, leading to sadness or conflict. Nurses can be powerful advocates for the physical and mental health of both the patient with late-stage Parkinson's disease and the primary caregiver.

Patients in the late stages of Parkinson's disease may be significantly disabled for many years, often because of their increasing inability to tolerate therapeutic doses of antiparkinson drugs. Their status and management have been overlooked in the literature. Few current healthcare professionals have cared for patients with Parkinson's disease in the prelevodopa era and do not understand how severe and protracted the illness can be without effective treatment. This article describes a practical approach to the nursing management of severely affected patients (i.e., Hoehn and Yahr Stage 4-5) who no longer derive consistent, therapeutic benefit from their drugs. Specific problems these patients face are adverse drug reactions such as postural hypotension, psychosis, and confusion, as well as difficulties with nutrition, elimination, mobility and falling, communication, sexuality, memory, and mood. Nursing interventions can help minimize the effect of these problems on the patient.