Parkinsons Disease

1
Parkinsons Disease

• Management in Primary Care

2
Introduction

• Progressive condition
• 1500 whole population
• 150 of elderly
• 110 Nursing Home Residents

3
Recognition

• Slowness
• Stiffness
• Tremor
• Loss of balance

4
First Diagnosis

• PCT priorities
• carer support
• manage co-morbidity
• nursing needs assessment
• Patient concerns
• driving (DVLA, insurers)
• inheritance (rare)

5
Management Aims

• Initial
• acceptance of diagnosis
• control symptoms
• reduce distress
• improve outlook
• Subsequent
• relieve morbidity
• prevent complications

6
Maintenance

• PCT priorities
• complications
• follow-up arrangements
• ?shared care
• Patient concerns
• work/finance/benefits
• sexuality

7
Complex Parkinsons

• PCT priorities
• Aims
• maintain good health
• manage drug regime
• address disease/complication problems
• support for patients/carers

8
Complications

• Deteriorating function
• immobility, slowness, loss of activity
• Loss of drug effect
• end-dose, on-off effects
• Involuntary movements (dyskinesia)
• Confusion, depression, hallucination
• Constipation, incontinence, wt loss, hypotension

9
Referral

• Initial
• Maintenance
• Complex
• Palliative

10
Referral Initial

• Confirmation of diagnosis
• Management
• multi-disciplinary team
• see later
• drug treatment
• Special Interest follow-up
• monitoring side effects

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Referral Maintenance

• Multi-disciplinary team
• Occupational Therapy
• Physiotherapy
• Dietician
• Speech/Language therapy
• Social Services
• Podiatrist
• Continence Advisor

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Referral Complex

• Specialist team in major role
• access to secondary care
• neurosurgery
• watch for complications
• communication

13
Referral Palliative

• Appropriate support
• palliative care services
• social needs assessment
• care in home, nursing home or hospice

14
Drug Treatment

• Progression
• PD inevitably progresses
• Tachyphylaxis
• Levodopa only works for 4-5 years
• More levodopa late side effects
• 50 of patients by 4-5 years
• Polypharmacy

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Drug Treatment

• Levodopa
• Dopamine agonists
• Selegiline (MAOI type B)
• COMT inhibitors
• Anticholinergics
• Amantadine

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Levodopa

• used since 1960s
• mixed with dopa decarboxylase inhibitor
• good for rigidity/bradykinesia
• not so good for tremor
• Side Effects
• confusion, hallucinations, mood changes/swings
• involuntary movements on-off

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Dopamine Agonists

• Bromocriptine, Pergolide, Ropinirole,
  Cabergoline, Pramipexole
• single Rx
• co-Rx with levodopa
• Apomorphine
• subcutaneous injection in advanced refractory
  disease
• usually initiated in-patient (ADR)

18
Selegiline

• MAOI prevents Dopamine breakdown
• co-Rx with levodopa
• unexpectedly high mortality (?autonomic ADR)

19
COMT inhibitors

• Inhibit alternative dopamine degradation pathway
• Allow reduction levodopa dose (30-50)
• LFTs need to be monitored

20
Anticholinergics

• Benzhexol, orphenadrine
• useful in younger patients with tremor
• avoid in elderly (ADR)

21
Amantadine

• Useful in younger/mildly-affected patient
• Loses effect quickly (months)
• Good for mild akinesia/tremor

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Drugs to avoid

• Phenothiazines
• Prochlorperazine, fluphenazine, haloperidol,
  sulpiride
• Metoclopramide
• MAOIs provoke ADR with levodopa
• Atypical antipsychotics
• clozapine, olanzapine

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Parkinsons Disease Society

• 215 Vauxhall Bridge Road,
• LONDON SW1V 1EJ
• Tel [phone]
• www.parkinsons.org.uk
• Helpline 0808 800 0303