Parkinson's Flashcards
1
Q
Impact of PD
A
- Financial burden. need for care, changes in cognition/psychology of patient
- Affects speech and tremor
- Mean duration of illness: 15 years
2
Q
PD Presentation
A
- Resting tremor: most common first symptom, usually asymmetric
- Rigidity: muscle tone increase in flexor and extensor muscles (resistance to passive movements)
- Bradykinesia: difficulty with daily activities like writing, shaving, eating, dressing
- Postural instability: loss of postural reflexes
“TRAP” = primary criteria for diagnosis
3
Q
Essential Tremor
A
- Not a sign of Parkinson’s
- Symmetric
- Tremulous hand action along with head and voice tremor
- Large tremulous handwriting
4
Q
Other PD Features
A
- Masked facies
- Hypophonia
- Drooling
- Depression
- Fatigue
- Slow gait
- Difficulty with ADLs
- Pain
5
Q
PD Advanced Symptoms
A
- Dysphagia
- Falls
- Freezes in gaits
- Dementia
- Psychosis
- Postural hypotension
- Bladder and anal dysfunction
6
Q
PD Non-Pharm
A
- Patient/caregiver education
- Support/counseling: peers, professional, legal, occupational
- Exercise
- Nutrition
- Surgery
7
Q
Psychological Support + PD
A
- Depression
- Limited social functioning
- Poor QoL (severe disease)
8
Q
PD + Safety Devices
A
- Grab bars
- Bath seats
- Emergency alert systems
9
Q
PD Pharmacotherapy Approach
A
- Plan for short and long term relief/management
- Manage potential SE
- Provide symptom control for daily living
- Timing of inital therapy based on patient functional ability
- Titrate treatment over time to maximize therapeutic response
10
Q
PD Treatment Mechanisms
A
- Increase endogenous DA: inhibit peripheral metabolism, COMT, or central/peripheral MAO-B metabolism
- DA agonists: D1, D2, D3, partial agonists
- Adenosine A2a
- Anticholinergic: helps with tremor and rigidity (often not preferred in geriatrics)
11
Q
Surgical Therapy + PD
A
- Deep Brain Stimulation (DBS)
- Most commonly performed PD surgery in America
- Implant electrode connected to a pulse generator that delivers current to thalamus, globus pallidus interna, or subthalamic nucleus
- Adjust amplitude, frequency, and pulse width
12
Q
PD + Psychosis
A
- 15-40% experience psychosis
- DA or ACh drug induced possibility
- Look for triggers and minimize polypharmacy
- Reduce anti-PD medications, add atypical antipsychotics (Seroquel)
- Add cholinesterase inhibitor (dementia)
- May consider pimavanserin
13
Q
Atypical Antipsychotics
A
- Tight binding to DA antagonists could worsen condition
- Quetiapine (sedation), clozapine, pimvanserin (titrate as tolerated)
- Black box: dementia
- Acetyl-cholinesterase inhibitors: Donepezil, rivastigmine also options
14
Q
Depression + PD
A
- Occurs in 25-40% of population
- Difficult to diagnose (symptom overlap)
- Insomnia, fatigue, psychomotor slowing, decreased libido
- Evaluate electrolytes, thyroid, hypogonadism
- SSRI therapy if depression is significant
15
Q
MAO-B Inhibitors
A
- May delay the need to begin levodopa therapy by 9 mo
- Inconclusive on if selegiline slows PD progression
- Use in patients with intact cognition and experiencing “wearing-off” with L-dopa
16
Q
Selegiline
A
- Dose: 10 mg/day
- Use with L-dopa to reduce its dose by ~50%
- AE: Minimal, insomnia and jitters
- Rare 5HT syndrome with use with SSRIs
17
Q
Rasagiline
A
- Azilect
- Selective MAO-B inhibitor
- 5x more potent than selegiline
- 0.5-1mg/day when used with levodopa
- CYP1A2 metabolization
- Approved for early PD patients monotherapy
18
Q
Levodopa
A
- Starting Dose: 200-300 mg/day, Max: 800-1600 mg/day
- Titrate 100mg/week
- Carbidopa: 75 mg/day to prevent peripheral AE
- Several combination products available in various formulations
19
Q
Carbidopa/Levodopa
A
- Most common prescription for PD symptoms
- Virtually all PD patients experience a clinical benefit with the medication
- After sustained usage, effects usually wear off between doses
20
Q
Carbidopa/L-dopa Complications
A
- Motor flunctuations: “on-off”
- Non-motor fluctuations: sensory, cognitive, psychiatric
- Diminishing efficacy
- Refractory loss of balance
- Cognitive deficiency
- Episodic vs continual dosing
21
Q
“Wearing-Off”
A
- Benefits from each L-dopa dose gets shorter over time and symptoms return between doses
- Disease could be worsening or more frequent dosing could be needed
- Seen with prolonged usage (4-5+ years)
22
Q
Wearing-Off Strategies
A
- Increase L-dopa dose or number of doses
- Add DA-agonist or increase its dose
- Use COMT-I
23
Q
DDA
A
- Direct DA Agonists
- Use alone or in conjunction with carbidopa/levodopa
- Pramipexole or ropinirole are most commonly used
24
Q
DA Agonists Benefits
A
- Less risk of motor complications and dyskinesias compared to carbidopa/levodopa
- Improve effects and durations when used in combination with levodopa/carbidopa
- May be beneficial as a monotherapy in a early disease patient
- Potentially neuroprotective compared with levodopa/carbidopa
25
DA Side Effects
- N/V
- Orthostasis
- Psychosis
- Narcolepsy
* *Occurs in higher doses or rapid titrations**
- Often a limiting factor for the use of these medications
26
Pramipexole (D2)
- Dose: 0.125 mg TID, titrate every 5-7 days as toelrated
- 1.5mg/day is as effective as higher doses and has less SE
- Adjust for renal insufficiency
27
Ropinirole
- D3 > D2 > D4
- Dose: 0.25 TID and titrate by 0.25 every week
- Max: 25 mg/day
- Metabolized by CYP1A2
28
Transdermal DA
- Rotigotine (Neupro)
- More continuous DA stimulation
- Less possibility of motor fluctuation and dyskinesias
- AE: application site rxn, nausea, somnolence, narcolepsy
- Allows for lower L-dopa doses
29
COMT-I
- ONLY use as adjunct to carbidopa/levodopa
- NO ROLE MONOTHERAPY
- Indicated for those experiencing wearing off
- Comtan (entacapone) or Tasmar (tolcapone)
* *Latter has LFT issues, don't really use**
- Increase L-dopa levels in brain and reduce its burden for more consistent and continuous levels
30
Entacapone
- Dopaminergic effects most common
- Allows for reduced doses of L-dopa
- Brown/orange fluid discoloration is common
- No hepatotoxicity evidence
- SE: diarrhea, orthostasis
- Dose: 200mg up to 8x a day used with Carbidopa/levodopa
31
Amantadine
- Monotherapy for newly diagnosed patients for mild tremor
- Exact MoA unknown
- Limit use with elderly due to neuropsychiatric effects (confusion, nightmares, hallucinations)
- Withdrawal slowly to avoid worsening PD symptoms
32
Anticholinergics
- Option for younger patients with mainly resting tremor
- Options: Trihexyphenidyl (Artane), Benztropine (Cogentin)
- AE: memory impairment, agitation, confusion, hallucination, antimuscarinic effects, dysphoria
- AE limit its use
