Holistic care of Parkinson's patients

Question 1

What can the non-motor symptoms associated with Parkinson’s disease be caused by?

Answer 1

Either by symptoms of the disease itself, complications or adverse effects of anti-Parkinsonian medication.

Question 2

What considerations do we need to make regarding prescribing decisions for non-motor symptoms?

Answer 2

Are we treating a symptom or a side effect of the medication
Can introducing an additional medication be avoided by optimisation of another therapy
Establishing the patient’s priority- which symptoms have the greatest impact, ultimately it is their priority

Question 3

State the mental health conditions that can be associated with Parkinson’s disease.

Answer 3

Depression
Dementia
Confusion and hallucinations
Impulse control and psychotic symptoms

Question 4

What is the appropriate management if a patient with Parkinson’s is experiencing depression?

Answer 4

Referral to specialist mental health clinic, where the patient can be assessed.
First line therapy is usually SSRIs (Citalopram, Escitalopram, Sertraline, Fluoxetine)

Question 5

Which dementia medications are available for Parkinson’s patients?

Answer 5

Rivastigmine is licensed for dementia in Parkinson’s patients
However Donepezil and Galantamine can be considered but are off licensed
Memantine although not routinely recommended and is off licensed, NICE states it can be used if other therapies are not tolerated or contraindicated

Question 6

What is the appropriate treatment for confusion and hallucinations in Parkinson’s patients?

Answer 6

Pharmacological management should only be provided if symptoms are severe and problematic.
First line: Quetiapine
Second line: Clozapine, specialist initiation only and requires monitoring (in the BNF states psychosis in Parkinson’s)

Question 7

Which medications related to mental health conditions should be avoided in Parkinson’s patients?

Answer 7

Anti-psychotics due to the potential to cause extra-pyramidal side effects, worsening the disease. These side effects are commonly associated with both Quetiapine and Clozapine and therefore should be used with extreme caution.

Question 8

What is the appropriate management for impulse control and psychotic symptoms?

Answer 8

As previously, highest risk is associated with dopamine receptor agonists and therefore may involve cessation of treatment or CBT if no approvement is shown.

Question 9

State the potential autonomic dysfunction side effects associated with Parkinson’s.

Answer 9

Constipation
Postural hypotension
Dysphagia
Salivation/drooling
Bladder dysfunction
Sexual dysfunction

Question 10

What is the first line management for constipation in Parkinson’s?

Answer 10

Stimulant and a stool softener
(Avoid repeated doses of stimulant laxative as it can then cause a lazy bowel)

Therefore if needed regularly ideally issue the stool softener on repeat and the stimulant as required, sometimes in chronic or severe constipation however this cannot be avoided.

Question 11

What is the appropriate management of postural hypotension?

Answer 11

Prescribing midodrine first line if severe Second line management is fludrocortisone due to cardiac risk factors and extensive interactions

Question 12

What considerations should be made for a patient with Parkinson’s that has dysphagia?

Answer 12

No specific pharmacological management
Ensure formulation of other medication is optimised - ideally patches or dispersible formulation
May require referral to dietician for build up drinks or supplementary feeds and fluid thickener to prevent aspiration pneumonia

This is a symptom of declining Parkinson’s so may want to optimise anti-Parkinson’s medications

Question 13

Which medication can be prescribed to help with hypersalivation?

Answer 13

Glycopyrronium can be considered as first line drug therapy if non-pharmacological management such as speech and language therapy has not been effective or not available

If Glycopyrronium is ineffective, contra-indicated or not tolerated consider referral to consider referral to a specialist service for botulinum toxin A.

Anticholinergics can only be considered if the risk of cognitive adverse effects are thought to be minimal. Be cautious of anti-cholinergic burden.

Question 14

Which medication can be prescribed to help with bladder dysfunction?

Answer 14

Antimuscarinics

Question 15

Which medication can be prescribed to help with sexual dysfunction?

Answer 15

PDE-5 inhibitors, these patients also qualify for SLS use so more options are available.
e.g. Sildenafil

Question 16

Which anti-emetics are appropriate for management of nausea and vomiting in Parkinson’s patients?

Answer 16

First line: Domperidone
Consider: Cyclizine and Ondansetron

Remember to also manage N&V a protein free snack can be given alongside Levodopa medication.

Question 17

Which anti-emetics are not appropriate for management of nausea and vomiting in Parkinson’s patients?

Answer 17

Metoclopramide and Prochlorperazine

Question 18

How should pain be managed in Parkinson’s disease?

Answer 18

In accordance to the pain ladder, with consideration to potential side effects.
For example:
- Opioids are addictive, dependence can worsen drowsiness
- NSAIDs if used long-term require GI protection (PPIs) which can worsen fracture risk

Physiotherapy may be a good non-pharmacological strategy for overcoming aches and pains as seen in Parkinson’s.

Question 19

What is the appropriate management for sleep disturbances in Parkinson’s?

Answer 19

Sedatives can be used but they can cause cognitive side effects and increase fall risks.
However these medications are addictive so need to be monitored closely.

Question 20

What medication can be used to manage day time sleepiness?

Answer 20

Modafinil can be considered o treat excessive daytime sleepiness in people with Parkinson’s disease, only if a detailed sleep history has excluded reversible pharmacological and physical causes.
This medication is not used frequently.

Question 21

How do you manage pressure sores in Parkinson’s disease?

Answer 21

Provide and apply barrier creams
If patients are particularly sedentary - including stays in care homes and on the wards
Also consider using pressure relieving mattresses and cushions

Question 22

What is the appropriate management for rapid eye movement sleep behaviour disorder?

Answer 22

Consider clonazepam or melatonin (off licensed use) to treat rapid eye movement sleep behaviour disorder if a medicines review has addressed possible pharmacological causes.

Question 23

What is the appropriate management for nocturnal akinesia?

Answer 23

Consider levodopa or oral dopamine agonists to treat nocturnal akinesia in people with Parkinson’s disease. If the selected option is not effective or not tolerated, offer the other instead.

Consider rotigotine if levodopa and/or oral dopamine agonists are not effective in treating nocturnal akinesia.

Question 24

How often should the medicine management for Parkinson’s be reviewed?

Answer 24

The medication should be reviewed of all aspects of care every 6-12 months

Question 25

What is the Pharmacist’s role in the management of Parkinson’s medication?

Answer 25

Any initiation or alteration of Parkinson’s medications should be done on the advice of the specialist
Pharmacist can recognise when doses of Parkinson’s medications may need to be optimised (either up or down titrated to the patients symptoms and tolerability).
Any drug changes should be actioned promptly
Pharmacists should also prioritise these patients for medicine reconciliations to ensure their medication is administered on time, every time.

Question 26

What is the generalised dosing regimen for Levodopa?

Answer 26

Patients will taken four/five tablets of Levodopa daily to avoid peaks/troughs in plasma levels associated with infrequent dosing.
Modified release preparations are usually used overnight to ensure there is no significant off period.
Pharmacists may be involved in counselling patient in the medication management of Parkinson’s due to the high tablet burden and co-prescribed medication to treat associated side effects.
As proteins inhibit absorption of Levodopa, it must be taken 30-60 minutes before or after meals and not within 2-3 hours of taking iron supplements.

Question 27

How can Pharmacists ensure adequate management of Parkinson’s control?

Answer 27

Clearly printing the times the medication should be taken on the dispensing label in addition to ensuring brand specific prescribing to ensure API and excipient consistency.
Also addressing any issues that may affect the absorption of the medication including constipation and drug interactions and promote sitting upright with dysphagia.

Question 28

Which medications should Pharmacists advise Parkinson’s patients to avoid?

Answer 28

Due to the potential for worsening symptoms, Pharmacists should advise patients to avoid:
OTC sympathomimetics such as pseudoephedrine with MAO-B inhibitors
OTC antihistamines
Calcium channel blockers - low blood pressure is more common in Parkinson’s rather than high blood pressure

Question 29

Who are the MDT involved in Parkinson’s care?

Answer 29

SALT
Physiotherapy
Occupational therapies, help promote the patient’s independence
Social care
Community nursing
Continence
Psychology
Nurses
Consultants

Question 30

What other considerations should be made regarding Parkinson’s patients?

Answer 30

DVLA need to be informed of the diagnosis
Awareness of communication difficulties - quiet voice, slurred speech, reduced facial expressions and body language
Encourage self-administration and independence
Recommend cholecalciferol as a vitamin D supplement to reduce fracture risk with falls