Effects of psychological nursing in Parkinson's related depression patients undergoing functional magnetic resonance imaging: A randomized controlled trial

Abstract

BACKGROUND

Patients with Parkinson’s disease (PD) often experience depression, and some may require magnetic resonance imaging (MRI) for diagnosis, which can lead to MRI failure due to claustrophobia.

AIM

To explore the value of psychological interventions in successfully completing functional MRI scans of the brain for PD-related depression.

METHODS

Ninety-six patients with PD were randomly divided into two groups. The control group (47 patients) received general care, and the experimental group (49 patients) received general care combined with psychological care. The Unified Parkinson's Disease Assessment Scale (UPDRS), Hamilton Depression Scale (HAMD), and Geriatric Depression Scale (GDS)-15 scores, heart rate, systolic blood pressure, and MRI-Anxiety Questionnaire (MRI-AQ) scores before and after the scan were recorded. The completion rate of magnetic resonance (MR) scanning, scanning duration, and image quality scores were recorded.

RESULTS

Before scanning, no statistically significant difference was observed between the two groups in terms of heart rate, systolic blood pressure, and UPDRS, HAMD, GDS-15, and MRI-AQ scores. After scanning, systolic blood pressure, MRI-AQ score, and scan time in the experimental group were significantly lower than those in the control group, whereas the scan completion rate and image quality score were significantly higher than those in the control group.

CONCLUSION

Psychological nursing interventions are helpful in alleviating PD-related depression and assessing MR depression scores and may be helpful in the successful completion of functional MRI scans of the patient's brain.

Key Words: Magnetic resonance imaging; Psychological nursing; Parkinson's disease; Depression; Claustrophobia

Core Tip: This study investigates the prevalence of depression among Parkinson’s disease (PD) patients, highlighting its significant impact on psychological well-being. Functional magnetic resonance imaging (MRI) plays a crucial role in PD diagnosis, yet patients often experience anxiety during scans due to unfamiliarity and discomfort. Psychological nursing interventions can alleviate anxiety, enhancing patients' ability to undergo MRI scans successfully. The study reveals correlations between anxiety levels, PD severity, and MRI-related depression scores. Psychological nursing significantly reduces blood pressure spikes post-scan and improves completion rates and image quality. Despite limitations like small sample sizes, multi-center studies are proposed for future validation of findings.

INTRODUCTION

Parkinson's disease (PD) is a common chronic degenerative disease of the nervous system in the elderly and is characterized by motor dysfunctions, such as static tremor, motor retardation, muscle rigidity, and postural gait abnormalities[1,2]. Research shows that PD not only manifests as a movement disorder but is also accompanied by anxiety, depression, insomnia, cognitive dysfunction, and other non-movement symptoms[3]. Among these, depression and cognitive impairment are the most common, with incidence rates of 40% and 15%–64%, respectively[4,5]. Depressive symptoms may present in the early stages of PD, even before movement disorder, and persist throughout the course of the disease[6].

Currently, the main clinical diagnosis of PD depends on clinical symptoms and physical examination, and the commonly used method involves the Movement Disorder Society-Unified PD Rating Scale scale[7]. However, subjective bias among different raters may affect the scoring consistency. Researchers have found that before clinical symptoms appear in patients, damage to 70%–80% of dopamine neurons in striatal nerve endings and 50%–60% of dopamine neurons in the substantia nigra compacta occurs[8]. The application of new magnetic resonance imaging (MRI) techniques for the early diagnosis, differential diagnosis, and condition evaluation of PD offers high specificity and sensitivity, enhancing diagnostic accuracy and providing crucial information for early treatment and efficacy evaluation[9]. However, due to patients’ lack of familiarity with magnetic resonance (MR) scanning and the enclosed nature of the examination, individuals with PD-related depression tend to experience increased anxiety and fear, leading to symptoms such as an accelerated heart rate, elevated blood pressure, and accelerated breathing. In severe cases, symptoms such as drowning and asphyxia can occur, causing some patients to struggle with the successful completion of the examination or are forced to discontinue MR scans[10].

For patients to successfully complete MR scanning, effective psychological intervention measures during examinations should be implemented. An important part of psychological nursing interventions is the establishment of harmonious interpersonal relationships between nursing staff and patients. Nurses should engage in proactive communication with patients before the examination, explain basic knowledge of MR scanning and related precautions, and dispel patients' fears and concerns, thereby helping patients relax physically and mentally and alleviating adverse emotions. Nurses should also cooperate with inspectors to ensure a successful completion of the functional MRI examination. This study aimed to explore the value of implementing psychological interventions to help patients with PD-related depression in completing MRI scans and to provide guidance for patients with PD to successfully navigate the MRI scanning process.

MATERIALS AND METHODS

General information

A total of 96 patients with PD admitted to our hospital between March 2017 and July 2021 were divided into two groups using a random-number generator. The control group consisted of 47 patients (female/male = 21/26) aged 54-73 years, while the experimental group consisted of 49 patients (female/male = 20/29) aged 58-71 years. This study was conducted after review and approval by the hospital’s medical ethics committee.

The inclusion criteria were as follows: (1) Compliance with the diagnostic criteria for PD-related depression and use of the Unified Parkinson's Disease Assessment Scale (UPDRS), Hamilton Depression Scale (HAMD), and 15 items of the Geriatric Depression Scale (GDS-15) to make a diagnosis; (2) undergoing magnetic resonance examination for the first time; and (3) voluntarily participation in the study and cooperation in completing various questionnaires. Exclusion criteria were as follows: (1) Mental and cognitive abnormalities hindering normal communication; (2) presence of foreign bodies in the body incompatible with MRI examination (e.g., cardiac pacemakers, hearing aids, cochlear implants, middle ear grafts, intraocular metal foreign bodies, artificial eyes, removable dentures, dental brackets, and implants on the head and face); and (3) refusal to participate.

Magnetic resonance scanning

All patients were treated using the same GE Signa EXCIE1.5T superconducting MR machine with an 8-channel head coil. The magnet's dimensions were 172 cm in length, 244 cm in longitudinal movement range, with a 60 cm aperture. The room was illuminated with warm-colored lighting to ensure ventilation, maintaining a temperature range of 20–25℃. The MRI machine was equipped with light lamps, head coils with mirrors, air-conduction earphones, and alarm balloons. Transverse-axis ESWAN and DTI images were obtained for each patient. The normal scanning duration was 14 min 22 s (3D FSPGR: 3 min 12 s; DTI: 4 min 57 s; ESWAN: 5 min 49 s; positioning image and uniform field correction: 24 s)[11,12]. The control group received routine nursing care, whereas the observation group received psychological care based on routine nursing care.

Nursing process

Routine care: The scanning room was equipped with adjustable lighting, ventilation fans, mirrors, alarm balloons, and air-conduction earphones, and the operating room was equipped with a music player, scanning rack, and speaker. MRI was performed using a GE 1.5T superconducting magnetic resonance imaging instrument. The control group received only routine care which involved informing patients about the need to remove gold and silver accessories and metal objects before the examination, asking patients if they had dentures, and explaining the examination process and precautions to the patients. During the examination, patients are assisted with the adjustment of their posture, guided on how to correctly hold their breath, and administered oral anxiolytic medications.

Psychological care: His involved actively contacting the patients before the examination, avoiding the use of professional terminology when communicating with the patient, maintaining an easygoing communication with the patient, familiarizing the patient with the scanning area, detailing the MRI process, encouraging deep breathing and short rests before the examination, encouraging the patients to eat and drink a small amount of water, addressing questions from the patient and their families, and alleviating fear, anxiety and other psychological concerns to establish a closer relationship between nurses and patients[13]. Understanding the experience of patients suffering from claustrophobia will help them identify the causes of their condition and understand that it is possible to overcome claustrophobia. With the help of text, pictures, videos, and other methods, patients can acquire pathological knowledge related to claustrophobia and be informed of points to note during the examination process, thereby improving patient compliance and confidence in treatment[14]. The light in the operation area was checked and adjusted to soften it, preventing irritation to the patient's eyes. Demonstration of the use of a calling device was provided, and patients were monitored to increase their sense of security[14]. During the examination process, Chinese medical personnel provided verbal support and encouragement to patients, guiding them to relax their whole body and take deep breaths to divert their attention and improve their psychological state. The patients’ eyes were shielded to prevent discomfort, and the patient held an alarm balloon. When they could not tolerate the discomfort, they pressed the balloon to trigger an alarm. Soundproof earphones were provided to mitigate the effect of operating noise, and patients were informed that they could communicate with medical personnel through a microphone. When patients felt unwell, they used their pagers to summon medical personnel and express their physical and mental discomfort. Patients' families were also informed that they could accompany them during examinations to increase their sense of security[15].

Data collection

Vital signs: Heart rate and systolic blood pressure of both patient groups were recorded before and after the MRI examination.

UPDRS, HAMD, GDS, and MRI Anxiety Questionnaire scores were recorded before and after the scan in both patient groups[16].

The number of patients in both groups that underwent MRI examinations, the scan success rate, and the time required for the patients to complete the scans were recorded. Image quality was assessed using a Likert Scale 5-level scoring method. A score of 1 indicates poor image quality, whereas a score of 5 indicates excellent image quality. The specific ratings were as follows: (1) 5 points, excellent image quality, very satisfied; (2) 4 points, good image quality, satisfactory; (3) 3 points, the image quality is defective and does not affect diagnosis, average; (4) 2 points, poor image quality, affecting diagnosis, unsatisfactory; and (5) 1 point, poor image quality, inability to diagnose, and dissatisfaction.

Statistical methods

Statistical analysis was performed using SPSS 22 software. Measurement data were expressed as mean ± SD. Independent- or paired-sample t-tests were performed. Chi-square tests were used to compare the categorical variable. Differences were considered statistically significant at P < 0.05.

RESULTS

Comparison of basic information between the two groups of patients

The results of age comparison between the two groups showed no significant difference (control group: 65.06 ± 5.02 vs experimental group: 63.78 ± 4.24, t = 1.347, P = 0.181). Gender composition ratio also showed no statistical difference (χ² = 0.146, P = 0.702).

Comparison results of vital signs before and after scanning

There was no statistically significant difference in heart rate and systolic blood pressure between the two groups before scanning (control group: 84.24 ± 9.88 vs experimental group: 85.37 ± 10.17, t = 0.542, P = 0.589), (control group: 141.89 ± 11.98 vs experimental group: 142.31 ± 13.02, t = 0.160, P = 0.874). After scanning, there was no statistically significant difference in heart rate between the two groups (control group: 84.33 ± 10.46 vs experimental group: 86.53 ± 10.90, t = 0.994, P = 0.323); however, the systolic blood pressure in the control group was significantly higher than that in the experimental group, with a statistically significant difference of (153.98 ± 10.06 vs 149.22 ± 12.10, t = 2.053, P = 0.043).

The intragroup comparison showed no statistical difference in heart rate before and after scanning between the experimental and control groups. However, both groups exhibited significantly higher systolic blood pressure after scanning than before scanning, with significant differences, as shown in Figure 1. The incidence of a 20 mmHg increase in systolic blood pressure in the control group was 34.04% (16/47), significantly higher than the 4.08% (2/49) incidence of a 20 mmHg increase in systolic blood pressure in the experimental group, with a statistically significant difference (χ² = 14.135, P < 0.001).

Figure 1 Comparison of changes in heart rate and blood pressure before and after magnetic resonance imaging scanning. A: Comparison of heart rate before and after magnetic resonance (MR) scanning. No statistical difference was observed between the both patient groups; B: Comparison of systolic blood pressure before and after MR scanning. Systolic blood pressure of both patients after scanning is higher than that before scanning, with a statistically significant difference.

Comparison of scores between the two groups before scanning

The results showed that there was no statistical difference in the UPDRS, HAMD, GDS - 15, and MRI-anxiety questionnaire (MRI-AQ) (pre) scores between the two groups. After magnetic resonance scanning, the MRI-AQ (post) score in the experimental group was significantly lower than that in the control group, with a statistically significant difference. Further details are listed in Table 1. The intragroup comparison showed that the post-scan MRI-AQ score in the experimental group was significantly lower than the pre-scan MRI AQ score, with a statistically significant difference. No statistically significant difference was observed in MRI-AQ scores before and after scanning in the control group (Figure 2).

Figure 2 Comparison results of magnetic resonance imaging anxiety questionnaire before and after magnetic resonance scanning. No statistically significant differences were observed between the control and experimental groups. After scanning, the magnetic resonance imaging anxiety questionnaire score in the experimental group was significantly lower than before scanning. MRI: Magnetic resonance imaging; MRI-AQ: Magnetic resonance imaging anxiety questionnaire.

Table 1 Details of the results of comparing the two groups of related depression scores.

Scores	Control	Experiment	t	P value
UPDRS III	32.340 ± 3.252	32.265 ± 3.696	0.106	0.916
HAMD	15.915 ± 5.111	14.878 ± 4.952	1.01	0.315
GDS-15	8.809 ± 1.393	9.102 ± 1.342	-1.051	0.296
MRI-AQ (pre)	39.596 ± 3.616	39.245 ± 4.121	0.443	0.659
MRI-AQ (post)	40.340 ± 3.447	29.449 ± 4.505	13.263	< 0.001

MRI: Magnetic resonance imaging; MRI-AQ: Magnetic resonance imaging anxiety questionnaire; GDS: Geriatric Depression Scale; HAMD: Hamilton Depression Scale; UPDRS: The Unified Parkinson's Disease Assessment Scale.

Correlation analysis between various scores

The MRI-AQ (pre) was positively correlated with the UPDRS and HAMD scores, with correlation coefficients of 0.86 and 0.80, respectively. The correlation with the GDS-15 was poor (r = 0.64), as shown in Figure 3.

Figure 3 Correlation between various anxiety scores. MRI: Magnetic resonance imaging; MRI-AQ: Magnetic resonance imaging anxiety questionnaire; GDS: Geriatric Depression Scale; HAMD: Hamilton Depression Scale; UPDRS: The Unified Parkinson's Disease Assessment Scale.

Comparison of MRI completion rate, examination time, and image quality scores

The completion rate of magnetic resonance scanning in the control group was 76.60% (36/47), whereas, in the experimental group, it was significantly higher at 93.88% (46/49), indicating a statistically significant difference (χ² = 5.752, P = 0.016). The MRI scanning duration of the control group was significantly higher than that of the experimental group, while the image quality score of the control group was significantly lower than that of the experimental group, with statistically significant differences, as shown in Figure 4.

Figure 4 Difference in scanning time and image quality scores between both patient groups. A: The scanning time of the experimental group patients was significantly shorter than that of the control group, and the difference was statistically significant; B: The image quality score of the experimental group patients was significantly higher than that of the control group, and the difference was statistically significant.

DISCUSSION

Among the clinical symptoms of patients with PD, depression is more common and has a serious impact on psychological status and quality of life. Functional MRI is a particularly important method for diagnosing and evaluating the severity of PD. Currently, there are many studies on functional MR for PD-related depression[17-20]. However, patients with PD may feel uncomfortable and anxious due to unfamiliar equipment, sounds, and examinations. In addition, functional MR scans often take longer[21,22], and during the examination process, patients may feel "buried alive" or "abandoned.” This results in involuntary motion, motion artifacts, decreased image quality, prolonged image post-processing time, and an inability to provide effective coordination.

Regarding the factors that cause anxiety during MR scanning, it is considered that the first factor is related to the patient's PD condition, leading to PD-related depression. The higher the anxiety score of patients with PD, the more likely they were to experience anxiety during MR scanning. Our research results also show that MRI-AQ (pre) is positively correlated with both UPDRS and HAMD. It was also confirmed that the more severe the PD and the higher the HAMD score, the higher the MR-related depression score. However, the slightly poor correlation between MRI-AQ (pre) and GDS-15 may be related to lower GDS-15 discrimination, resulting in a poor correlation between GDS-15 and MRI-AQ (pre), UPDRS, and HAMD. In addition, during the MR scanning process, examination equipment and environment are important factors that cause anxiety in patients with PD. The MRI examination equipment and the examination environment are relatively special, and factors such as tight space, long examination time, radiofrequency noise during examination, and injection of enhancers can lead to varying degrees of anxiety in the receiving patient. Tazegul et al[23] found that patients' concerns about test results contribute to anxiety. Patients undergoing MRI for the first time are unfamiliar with the examination environment, procedures, and equipment. van Minde et al[24] pointed out that patients undergoing head scans were more anxious before the MRI examination than those undergoing dual-foot scans. Additionally, Thu et al[25] found a correlation between high anxiety levels and longer waiting times.

To alleviate patient anxiety, it is crucial to first address PD-related depression. Psychological care can significantly improve the anxiety levels of patients undergoing MR scanning. The psychological nursing intervention in our study involved improving cognitive and situational stimuli and family support, establishing harmonious interpersonal relationships between nurses and patients, actively communicating with patients, explaining some basic knowledge of enhanced MRI and related precautions, dispelling patients' fears and concerns, facilitating patient understanding and acceptance of imaging examinations, minimizing or eliminating patients' fear during the examination process, reducing sensitivity to stimuli, encouraging patients to bravely face reality, establishing confidence in the examination, and improving patient self-control. In addition, providing patients with gentle care can effectively enhance their trust in nurses, and skilled nursing practices can effectively improve treatment compliance, thereby ensuring the smooth progression of enhanced MRI scans.

This study found that there was no statistically significant difference between the heart rate before and after examination in both the control and experimental groups, while the systolic blood pressure after examination was significantly higher in both groups, with a statistically significant difference. This is because long-term high-field strength and strong noise can cause patients to experience claustrophobia, anxiety, psychological disorders, and tension, leading to elevated blood pressure[26]. Although the blood pressure after examination in both groups was significantly higher than before, the proportion of patients whose systolic blood pressure increased by > 20 mmHg after examination in the experimental group was significantly lower than that in the control group, and the systolic blood pressure after examination in the experimental group was also significantly lower than that in the control group. Considering that psychological nursing interventions can significantly reduce blood pressure spikes in patients, it suggests that such interventions can successfully mitigate anxiety and psychological disorders.

In addition, through the application of psychological nursing adjustment, the patients’ MRI-AQ score was significantly lower after the examination than before the examination. It was also confirmed that psychological nursing could help alleviate the anxiety state of patients with PD during magnetic resonance examination, alleviate the pressure on patients during MR scanning, and help patients smoothly complete the magnetic resonance examination. Our results also showed that the completion rate of MR scanning was significantly higher in the experimental group than in the control group. Another result also confirmed that after psychological care, the MR scanning time was significantly shortened, and the MR image quality score increased. On the other hand, it confirmed that psychological care contributed to the smooth completion of functional MRI examinations.

Our study had certain limitations. First, this was a single-center, small-sample size study, potentially limiting the generalizability of the findings. Additionally, the data primarily relied on patient-reported questionnaire responses, which could introduce certain cognitive biases and consequently affect the scoring data. However, in the future, we plan to carry out multi-center and large-sample studies to obtain more robust data.

CONCLUSION

In summary, the use of the MRI-AQ to score PD-related depression on MR scans was effective. Psychological care can help patients with PD-related depression successfully complete MR scans, shorten examination time, and improve MRI scores.