Parkinsonism Part 2 Flashcards
what is the difference between vascular parkinsonism and idiopathic PD?
vascular parkinsonism:
- usually bilateral vs asymmetric (unilateral) in IPD
- usually no resting tremor vs resting tremor in IPD
- usually stepwise in progression (stepwise = every time there is a CNS insult) vs continuous progression in IPD
- vascular risk factors are usually present (factors affecting heart disease, DM)
- increasing age is a risk factor
- -> those w VP tend to be older than those w PD
- mostly NOT caused by infarct/lesions in the basal ganglia (not at the dopaminergic neurons at the basal ganglia)
vascular parkinsonism is also known as
vascular Parkinson’s disease
- PD due to vasculature in the brain
- cerebrovascular disease
are drug-induced parkinsonism reversible?
depends
may not be completely reversible
response to the drug withdrawal is variable - may or may not be reversible
do drug-induced parkinsonism respond to levodopa?
no
how do we distinguish between drug-induced parkinsonism from idiopathic PD?
usually difficult to distinguish from PD but:
- symptoms tend to occur bilaterally
- withdrawal of the drug usually leads to improvement in symptoms in 80% of patients in 8 weeks (but also depends on how long the drug was used)
- treatment should be withdrawal of offending drug
in which gender drug-induced parkinsonism can be observed greatly?
female/ women
in which gender all types of parkinsonism (including idiopathic PD) can be observed greatly
male
which drugs are most likely to cause drug-induced parkinsonism?
high risk:
- dopamine D2 receptor blockers
which: typical antipsychotics (haloperidol, *prochlorperazine*, thioxanthene, amisulpride, flupentixol, fluphenazine, sulpride, zuclopenthixol)
atypical antipsychotics at higher doses (risperidone, olanzapine, aripiprazole)
- Calcium channel antagonist:
- flunarizine, cinnarizine
which drugs are least likely to cause drug-induced parkinsonism?
- SSRIs (fluoxetine, sertraline)
how can drug-induced parkinsonism be treated?
- not always reversible
- best ‘treatment’ = prevention
- anticholinergics and amantadine may be used (but not as effective compared in use in idiopathic PD) (levodopa not effective)
DIP can unmask
existing PD; as bring PD sx earlier, prodromal
when does the drug-induced parkinsonism appears?
course is variable - onset ~3months within exposure to the offending agent
what can cause Parkinson hyperpyrexia syndrome (PHS)
- changes in dopaminergic treatment
- provoked by trauma, surgery, and pulmonary, GI, and UTI
- may have no apparent trigger
what can be a severe case seen in parkinson hyperpyrexia syndrome (PHS)
- no response to dopaminergic rescue medications –> sx deteriorate rapidly, patient becomes progressively more immobile and rigid
what are the systemic complications of PHS?
- decrease consciousness –> aspiration pneumonia
- rhabdomyolysis –> acute renal failure
- immobility –> DVT, PE
- DIVC (disseminated intravascular coagulation)
what is the management of PHS?
- if cause of PHS is due to the decrease of dopaminergic meds, reinstate prev treatment (increase back the dose) and increase dose of levodopa gradually
- if PO route cannot be used, options are:
- rotigotine patch
- amantadine injection (but not available in SG)
- dantrolene (injectable/PO), bromocriptine
What are the usual reason PD patients are admitted into acute care?
- chest infection (due to pneumonia; dysphagia - prone to aspiration –> risk of chest/lung infection)
- general medical problems (activities of daily living (ADL) is affected/reduced)
who are the different HC professionals that need to care for people with PD
- physiotherapist = as skeletal muscles prone to atrophy with little movement - help maintain balance
- OT: help them work around their disability, to ensure their environment at home and at work is safe
- speech therapist: to help project voice - maintain social connection
- medical social worker: direct them to services
- nutritionist: changes in diet to avoid muscle loss
what should be done to patients being admitted with Parkinsonian features but without known PD (i.e. new diagnosis)
- accurate diagnosis impt but may be difficult to do so in acute care due to concurrent illness
- differential diagnoses: drug-induced Parkinsonism, essential tremor
- Specialist advice recommended
what should be done for patients with known PD, admitted for an unrelated problem
- Most of these pts not admitted to a neurological or geriatric unit
- thus, review meds
- AVOID anti-dopaminergics
- AVOID anticholinergics
- to avoid SE such as confusion
3. screen for possibly related problems (problems from PD that are that look like unrelated problem?) - drooling - aspiration - constipation - faecal loading
- arrange for specialist input
what should be done for patients who are admitted for specific complications of PD?
- aspiration pneumonia
- dopamine agonist withdrawal
- psychosis (excess dopamine)
- dyskinesias (from the drug levodopa)
why do patients not get their medications on time?
- serving of medication in hospitals are different from what they did when they were at home
- international patients
- formulary may not have that preparation/not stocked
- is there support from the family to give med on time
what are the different levodopa preparations that need to be looked at when doing medication review?
- controlled vs regular release
- sinemet 1:10 (10/100 or 25/250) vs 1:4
- Madopar vs Madopar HBS vs Madopar dispersible
(1: 4)
what is the role of pharmacists in the management of PD?
- ensure correct levodopa preparation
- can patients swallow the pills whole
- e.g. madopar HBS has to be swallowed whole
drugs to be swallowed whole as well:
a. Alpha blockers (CR) for PD man with BPH
b. dysphagia
c. bisphosphonate
d. nifedipine LA for HTN
- Drug interactions
- dopamine antagonists
- common anti-emetics
- SSRIs - drug-food interactions
- Madopar with protein diet - Comorbidities
- Drug-disease interactions
e. g. depression - SSRIs
e. g. BPH - alpha blockers (hypotension)
- increased hypotension developed due to autonomic dysfunction in PD patients + alpha blockers
- timing
- entacapone must be taken at the same time as levodopa
what was the important points from the community pharmacy PD project?
objective: aim was to help patients patient a greater understanding of their conditions and how to manage it more effectively
- many believed their medication to be working
- after the project more patients knew more about their treatment
what is ISMP recommendation to ensure hospitalised PD patients are not at risk?
- dont delay adminstration; allow creation of administration schedules
- prevent CI drugs to be used; avoid non-formulary drugs
- manage nil by mouth (NBM) status
- report adverse events
- ensure other meds don’t worsen PD symptoms
when are PD patients not compliant with their medications?
- no access to med
- med are not updated
- the adminstration timing not followed
what is the pharmacist’s impact on PD-related care in the emergency department (ED)
- they can prevent any anti-PD medication omission in the ED
- this ensure patients dont have a deterioration related to the PD sx
what is so bad about missing doses of PD meds?
- prolong length of stay in hospitalised PD patients
- could due to increased aspiration risk, or minor accidents
