Parkinson's disease Flashcards
5 pharm therapies for patients with dyskinesias or motor fluctuations despite optimal levodopa therapy
- COMT Inhibitors (prolong LDopa) ex. entacapone
- MAO-B inhibitors (motor sx) ex. rasagiline, selegiline
- Dopamine agonists (motor sx) ex. rotigotine patch, ropinirole, pramipexole
- Controlled release levodopa
- Intrajejunal levodopa-carbidopa enteric gel through perc gastrostomy
- Amantadine (dyskinesias, anticholinergic)
REM SBD can be a precursor to what 4 ND conditions? Less commonly seen in other 3 conditions?
- Idiopathic Parkinson’s disease
- Levy body dementia
- Multisystem atrophy (MSA)
- MCI non-amnestic
Less Common - PSP
- FTD
- ALS
- Huntington disease
- Alzheimer’s disease
Management of REM SBD
- Decrease/discontinue SSRI/antidepressant
- Melatonin 3-12 mg
- Clonazepam 0.25-2 mg
Medications that can cause hallucinations in PD patient
- Sinemet (DA)
- Tolterodine (anticholinergic)
- Amantadine (DA, anticholinergic)
- Pramipexole (DA)
Management for hallucinations in Parkinson’s disease
- Discontinue/decrease offending drug (anticholinergics, anxiolytics/sedatives, amantadine, DA, MAO-B, COMTi, levodopa)
- Start antipsychotic - in Parkinsonism can only safely use quetiapine, alternative is clozapine but requires monitoring
Management of constipation in PD
- Increase fluid and fibre intake
- Mobilize as able
- Discontinue anticholinergics
- Bulk forming laxative - Metamucil, psyllium
- PEG (osmotic)
- Senna (stimulant)
- Add domperidone
PD Palliative care recommendations
- Offer discussion of prognosis
- Provide information on progression, med sfx, end of life, advanced care planning, options for future tx, support services
- Recognize family and patient may need different information
- Consider palliative care team referral at any stage of PD
- Palliative care requirements (including the option of medical assistance in dying) should be considered throughout all phases of the disease
MDS Criteria - 2 features of a dramatic and significant response to levodopa therapy
- Marked improvement with dose increases or marked worsening with dose decreases
a. Objectively >30% UPDRS III
b. Subjectively - documented hx from reliable source - Unequivocal and marked on/off fluctuations which must have at some point included predictable end of dose wearing off
PD Diagnostic Criteria (clinically established)
- Need bradykinesia PLUS tremor OR rigidity
Then: - Absence of absolute exclusion criteria
- At least 2 supportive criteria
- No red flags
Supportive criteria for PD
- Clear and dramatic response to dopaminergic therapy
- Presence of levodopa induced dyskinesia
- Rest tremor of limb
- Olfactory loss OR cardiac sympathetic denervation on MIBG scintigraphy
PD absolute exclusion criteria (9)
- Unequivocal cerebellar abnormalities (gait, limb ataxia, oculomotor)
- Downward vertical supra nuclear gaze palsy
- Dx of probable bvFTD or PPA within first 5 yrs of disease
- Parkinsonian features only in lower limbs for >3 years
- Tx with dopamine blocker or depleting agent (drug induced)
- No observable response to high dose LD despite at least moderate severity of disease
- Unequivocal cortical sensory loss (grapesthesia, stereognosis), limb ideomotor apraxia or progressive aphasia
- Normal functional neuroimaging of presynaptic dopaminergic system
- Documented alternate condition known to produce Parkinsonism
PD red flags (10)
- Rapid progression of gait, regular wheelchair within 5 yrs
- Complete absence of progression of motor sx over 5+ years (unless due to tx)
- Early bulbar dysfunction (sev dysphonia or dysarthria, sev dysphagia) within 5 yrs
- Severe autonomic failure in first 5 years (orthostasis, urinary retention or incontinence)
- Inspiratory respiratory dysfunction
- > 1 fall per year due to impaired balance within 3 years
- Disproportionate anterocollis or contractures of hand or feet in 10 yrs
- Absence common non motor symptoms in 5 yrs
- Pyramidal tract signs (weakness or hyperreflexia)
- Bilateral symmetric Parkinsonism
Non-oral treatment for patient on Sinemet, entacapone, selegiline and DA with wearing off and dyskinesias
Rotigotine patch (if stopping other DA) OR
Intrajejunal levodopa carbidopa gel via perc gastrostomy
Fluctuating non-motor symptoms in advanced PD (6)
- Neuropsychiatric (Hallucinations, cognition, depression, anxiety)
- Constipation
- Orthostasis HOTN
- Excessive drooling
- Urinary incontinence
- Sleep disturbance
Criteria for absence of response to levodopa
Item is: absence of observable response to high dose levodopa despite at least moderate severity of disease
1. Must have received 600+mg/day
2. Absence clearly reported by patient/witness or confirmed objectively (improvement <=3 pts on UPDRS)
3. Patient must have at least moderate severity Parkinsonism (UPDRS >2 of rigidity or bradykinesia)
