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MO1 > Parkinson's disease > Flashcards

Parkinson's disease Flashcards

1
Q

what is PD?

A

A progressive neurodegenerative condition
resulting from the death of the dopamine-containing cells of the substantia nigra

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2
Q

what is the most common type of PD?

A

Idiopathic PD (85%)

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3
Q

what are the two main types of idiopathic PD?

A

PIGD – Postural instability gait disorder
– Tremor dominant PD

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4
Q

what genes can be linked with PD?

A

Parkin gene, DJ-1

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5
Q

what can cause secondary parkinsonism?

A
  • Drugs – Induce Parkinsonian syndrome
  • Toxins - MPTP
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6
Q

what can cause vascular parkinsonism?

A

restrictive blood supply to the brain eg stroke
cerebral infarction

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7
Q

what causes parkinson’s plus syndrome?

A
  • Multiple system atrophy
  • Progressive supra-nuclear palsy
  • Lewy Body Dementia
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8
Q

how do drugs cause parkinsonian syndrome?

A

Any drug that blocks the action of dopamine- Stop drug

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9
Q

give examples of drugs that causes parkinsonian syndrome?

A

– Neuroleptics
– Anti-psychotics (e.g. haloperidol, chlorpromazine )
– Anti-depressants
– Anti-emetics: (e.g. metoclopramide, prochlorperazine)
– Others: (e.g. cinnarizine, CCB, lithium, donepezil

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10
Q

what are the signs/ symptoms of PD?

A
  • Tremor (most common PC)
    – Rest
    – ‘pill – rolling’
    – 7/10 patients only
  • Rigidity
    – Increased tone – stooping posture
    – ‘cog wheeling’
  • Hypokinesia (akinesia, bradykinesia)
    – Slowness of movement
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11
Q

what autonomic dynsunctions may a person with PD have?

A

– Constipation
– Excess sweating
– Saliva pooling and drool
– Dysphagia
– Weight loss
– Urinary dysfunction
– Aphasia and speech/volume changes
– Postural instability/Postural hypotension
– Sleeping issues

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12
Q

what other symptom may a person with PD have?

A

– Mask like face
– Shuffling gait
– Flexed postures of neck, trunk, limbs
– Cognitive decline
– Dementia (8/10)
– Anxiety (4/10)
– Pain/dystonia
– Restless Leg Syndrome
– Depression
– REM sleep disorder ( common- but not all patients)

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13
Q

how do you diagnose PD?

A
  • Diagnosis is made predominantly on clinical
    presentation
  • Review diagnosis on a 6 – 12 monthly basis in
    case of an inaccurate diagnosis
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14
Q

what is the aim of treatment?

A

improve symptom control, medication does
not alter the progression of the disease

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15
Q

what are the agents available to treat?

A
  • Levodopa
  • Dopamine Agonists
  • MAO-B Inhibitors (Monoamine oxidase B)
  • Amantadine
  • COMT Inhibitors (catechol-O-methyl
    transferase)
  • Anticholinergics (rarely used
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16
Q

when is levodopa used?

A

used in all stages of PD

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17
Q

what and why is levodopa given with?

A
  • Given with a dopa-decarboxylase inhibitor
    (benserazide or carbidopa)
    – To reduce the peripheral conversion of levodopa to dopamine
    – Limits side-effects experienced by the patient
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18
Q

how should you dose levodopa?

A
  • Start with a low dose and increase gradually
  • Keep dose as low as possible to maintain good function in order to reduce the development of motor complications
  • Usually commenced BD or TDS
  • Increased as per clinician preference
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19
Q

when should you be cautious with levodopa?

A

– Severe pulmonary and cardiovascular disease
– Psychiatric illness
– Dyskinesia

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20
Q

what are the side effects of levodopa?

A
  • Impulse Control
    Disorder
  • Nausea and vomiting
  • Taste disturbances
  • Dry mouth
  • Postural hypotension
  • Drowsiness
  • Fatigue
  • Confusion
  • Psychosis
  • Dystonia
  • Dyskinesia
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21
Q

what dose should you avoid with levodopa?

A

Try and keep to 800mgs or less where possible
but less than 2g daily

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22
Q

what are the different preparations of levodopa?

A
  • Madopar (Co-beneldopa)
  • Capsules (62.5mg, 125mg, 250mg)
  • Dispersible tablets (62.5mg, 125mg)
  • MR capsules (125mg)
  • Sinemet (Co-careldopa)
  • Tablets (62.5mg, 110mg, 125mg, 275mg)
  • MR Tablets
    – Half Sinemet CR 125mg
    – Sinemet CR 250m
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23
Q

what are the counselling points surrounding levodopa?

A
  • May discolour the urine
  • Take with or just after food or a meal
  • Driving: care as can cause sudden onset of sleep and
    hypotensive reactions
  • Explain differences in name
  • MR: swallow whole; don’t take indigestion remedies
    2 hours before or after
  • Dispersible: can be dispersed in water or orange
    squash or swallowed whole
  • Will always leave a little white residue
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24
Q

what should you do when switching from MR levodopa to dispersible co-beneldopa?

A

reduce by aprox 30%

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25
Q

how do dopamine agonists work?

A
  • Direct action on the dopamine receptors
  • Can be used alone in early stages of PD and in
    combination with levodopa in advanced PD
  • Low doses and titrat
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26
Q

what are the two different types of dopamine agonists? give examples

A
  • Ergot derived: bromocriptine, pergolide,
    cabergoline – Not first line
    – Rarely used
  • Non-ergot derived: apomorphine,
    pramipexole, ropinorole, rotigotine
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27
Q

what are the side effects of ergot derived dopamine agonists?

A

– Fibrotic reactions
– Exclude cardiac valvuopathy

28
Q

what are the side effects of dopamine agonists?

A

– Psychiatric
– Impulse control disorders
– Sudden onset of sleep
– Hypotensive reactions
– Nausea and vomiting
– Constipation
– Dyspepsia
– Hallucinations/delusions/confusion
– Most common in younger men, particularly those
on levodopa

29
Q

what cautions are there with non-ergot dertived dopamine agonists?

A

psychiatric disorders, regular eye
tests, cardiovascular disease

30
Q

what is the counselling surrounding dopamine agonists?

A

– Impulse control disorders
– Driving
– Take with or just after food or a meal
– Cabergoline: dispense in original container
– Patch: apply to dry, non-irritated skin on torso, thigh,
or upper arm, removing after 24 hours
– Put replacement patch on a different area
– Do not cut

31
Q

how should you initiate a rotigotine patch?

A
  • Monotherapy: 2mg/24 hour patch
  • Adjunct: 4mg/24 hour patch
32
Q

if you are switching from levodopa /dopamine agonist to a rotigotine patch what conversion needs to be made?

A

– Find differences in practice
– Consider – side-effects especially hallucinations
and ensuring PD symptoms are adequately
controlled eg
– Madopar 62.5mg BD = 2mg/24 hours
– Madopar 62.5mg TDS = 4mg/24 hours
– For every 100mg levodopa mr = 2mg/24hours

33
Q

how do MAO-B inhibitors work? give example

A
  • Prevent the breakdown of dopamine
  • Can use alone or in combination with other
    agents
    Rasagiline (tablets)
    – Selegiline
34
Q

what cautions are there with MAO-B inhibitors?

A
  • Selegiline: gastric and duodenal ulcers,
    uncontrolled hypertension, side-effects of
    levodopa can be increased
35
Q

what are the side effects of MAO-B inhibitors?

A

– Nausea
– Constipation
– Dry mouth
– Selegiline: mouth ulcers, hypertension, bradycardia,
psychosis, impaired balance, sedation
– Rasagiline- headache, dizziness ( in practice reports)

36
Q

what counselling should you give with MAO-B inhibitors?

A
  • Avoid food with too much tyramine as can
    raise BP
    – Aged cheese, sour cream, yoghurt, dry meats
  • Selegiline disp: place on the tongue and allow
    to dissolve. Do not drink, rinse mouth out for
    5 minutes after taking
37
Q

how do COMT inhibitors work? give examples

A
  • Prevent the peripheral breakdown of levodopa by inhibiting catechol-O-methyltransferse
  • Adjunct agents to co-beneldopa and co-careldopa for patients with end dose deterioration
    – Entacapone
    – Tolcapone
    – Opicapone
38
Q

what cautions are there with COMT inhibitors?

A

IHD, levodopa dose may need to be
reduced (10-30%)
* Avoid in hepatic impairment

39
Q

what side effects do COMT inhibitors have?

A

– Nausea and vomiting
– Abdominal pain
– Constipation
– Urine – reddish/brown

40
Q

where can COMT inhibitors be found?

A

in a product containing
levodopa, Stalevo:
– Carbidopa
– Levodopa
– Entacapone

41
Q

what counselling should be given with COMT inhibitors?

A

– Alter colour of urine
– Driving
– Avoid iron containing products at the same time of day
– Diarrhoea when starting, and a few months later

42
Q

who can tolcapone be started by? why?

A

tolcapone- Only started by a specialist
* Caution: hepatotoxicity
* Side-effects:
– Constipation
– Dyspepsia
– Nausea and vomiting

43
Q

how should you counsel someone on tolcapone?

A

How to recognise signs of liver disorders
and seek medical attention if they develop anorexia, nausea, vomiting, fatigue, abdominal pain, dark urine or pruritus
* Reinforce need to attend regular blood monitoring

44
Q

what cautions/ side effects are there with opicapone?

A
  • Caution: hepatic impairment, concurrent
    levodopa dose, elderly over 85 years
  • Side-effects: constipation, dizziness,
    drowsiness, dry mouth, hypotension,
    movement disorders
  • Counselling:
    – Take at bedtime, at least ONE hour before or after levodopa combinations
45
Q

what is amantadine? when is it used?

A

Glutamate antagonist
* Used infrequently, usually for dyskinesia in
long term patients
* Use in combination with other agents
* Stimulatory effect: useful for tiredness
* Tolerance can occur

46
Q

what cautions, c/i and side effects are there with amantadine?

A
  • Cautions: CHF
  • Contra-indicated: Epilepsy, Gastric ulceration
  • Side-effects
    – GI disturbances
    – Anorexia
    – Dry mouth
    – Confusion
    – Hallucinations
47
Q

why are anticholinergics not first line?

A
  • Not first choice due to limited efficacy and
    propensity to cause neuropsychiatric side-effects
    – Procyclidine
    – Orphenadrine Hydrochloride
    – Trihexyphenidyl Hydrochloride
48
Q

when are anticholinergics useful?

A
  • Useful in reducing symptoms caused by
    antipsychotic drugs
49
Q

what cautions, side effects and counselling is there for anticholinergic drugs?

A

Cautions: cardiovascular disease, hypertension
and psychiatric disorders
* Side-effects
– Confusion
– Dry mouth
– Constipation
– Blurred vision
* Counselling
– Driving

50
Q

what counselling points should be given generally about PD meds?

A
  • Take medication on time
    – At home, in hospital
  • Avoid abrupt withdrawal
    – Life-threatening
    – Risk of neuroleptic malignant syndrome
    (NMS)
  • Altered consciousness, fever, autonomic instability,
    raised CK level
  • Should have CK level taken if abrupt withdrawal
51
Q

how can food affect PD meds?

A
  • Take medication on time
    – At home, in hospital
  • Avoid abrupt withdrawal
    – Life-threatening– Risk of neuroleptic malignant syndrome (NMS)
  • Altered consciousness, fever, autonomic instability, raised CK level
  • Should have CK level taken if abrupt withdrawal
  • If this occurs
    – Levodopa 30 minutes before meals, ideally with a carbohydrate food like a cracker or biscuit
52
Q

what should be told about impulse control disorder?

A

– Occurs with all dopaminergic therapy
– Can occur at any stage of the disease
– Must record this has been discussed with the
patient
– Provided with a contact in case this happens
– Patient can conceal the behaviour
– Different types: gambling, hypersexuality, binge
eating and obsessive shopping

53
Q

what should be told about excessive sleepiness and sudden onset of sleep?

A

–– Inform patients not to drive if they suffer from
this/operate heavy machinery
– Inform DVLA of symptoms

54
Q

what should be given in early PD?

A

– Early stage of PD where motor symptoms impact QOL:
* Levodopa
– If motor symptoms do not impact QOL:
* Levodopa
* Dopamine agonists
* MAO-B inhibitors

55
Q

what adjuvant therapy can be given for motor symptoms?

A
  • Adjuvant therapy for motor symptoms
    –Dopamine agonists
    – COMT inhibitors
    – MAO-B inhibitors
56
Q

what adjuvant therapy can be given with carbidopa/levodopa to aid off periods?

A

– Safinamide (Xadago; 2017)
– Levodopa inhalation powder (Inbrija; 2018)
– Istradefylline (Nourianz; 2019)
– Sublingual apomorphine (Kynmobi; 2020)
– Opicapone

57
Q

how should you manage postural hypotension?

A

Review existing medication
– Consider midodrine
– Consider fludrocortisone if midodrine not
tolerated or contra-indicated

58
Q

how should you initiate, monitor and what side effects does midorine have?

A

– Initiate at 2.5mg TDS and titrate to usual
maintenance of 10mg TDS
– Monitor
* Renal and hepatic function before and during treatment
– Side-effects
* Supine hypertension
* Administer last daily dose at least 4 hours before bedtime

59
Q

how should you initiate. monitor and what side effects does fludrocortisone have ?

A

– Use lowest effective dose, usually between 100 – 400
micrograms daily
– Monitor
* Hepatic function
– Side-effects
* Weight gain, oedema, headache

60
Q

how do you manage hallucinations/ dellusions?

A

– Review potential cause
* Treat underlying cause
* Review PD medication
– Reduce doses
– Consider quetiapine if there is no cognitive
impairment
– Clozapine if standard treatment fails
Do not treat if well tolerated by the
patient/family/carers

61
Q

how should you manage constipation?

A

– Increase dietary fibre and fluid intake as well as exercise levels
– Consider laxatives

62
Q

how should you manage nausea and vomiting?

A

– Mild: often related to levodopa or dopamine
agonist therapy
– Severe/persistent: low dose domperidone for
shortest time possible
* N.B. cardiovascular risks associated with domperidone
– Review P.D medication

63
Q

how should you manage daytime sleepiness?

A

– Can consider modafinil

64
Q

what are the alt formulations if dysphagia is present?

A

– Madopar capsules can be switch to dispersible
tablets- only where swallowing issues
– Switch Sinemet to Madopar dispersible where
swallowing issues
– Madopar MR capsules can be switched to
dispersible tablets
– Pramipexole – disperse in water (MR switch to IR
tablets and give a TDS regimen
– Rotigotine Patch- may be best option for long
term

65
Q

what lifestyle advice should be given to someone with PD?

A
  • Exercise
    – Helps maintain your ability, strengthen muscles
    and increase mobility in your joints
    – Research: protects the dopamine producing nerve
    cells that are lost in PD
  • Diet
    – Take extra time when eating and drinking
    – Balanced diet

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