parkinsons

Question 1

what is parkinson’s disease

Answer 1

a progressive neurodegenerative disease which leads to the death of dopaminergic cells in substantia nigra part of the brain

Question 2

describe the motor symptoms of parkinson’s disease

Answer 2

• hypokinesia (decreased muscle movement)
• bradykinesia (slow movement)
• rigidity
• rest tremor
• postural instability

Question 3

describe the non-motor symptoms of parkinson’s disease

Answer 3

• dementia
• depression
• sleep disturbances
• bladder and bowel dysfunction
• speech and language changes
• swallowing problems and weight loss

Question 4

TRUE OR FALSE

patients with parkinson’s disease should inform the DVLA and car insurer when they are diagnosed

Answer 4

TRUE

Question 5

what is the aim of parkinson’s disease treatment

Answer 5

to control symptoms and improve quality of life (it is incurable)

Question 6

what non-drug treatment can be offered to patients with parkinson’s disease

Answer 6

• physiotherapy if balance or motor function problems are present
• speech and language therapy if they develop communication
• swallowing or saliva problems, occupational therapy if they experience difficulties with their daily activities.
• Dietitian referral should be considered.

Question 7

what is the first line treatment for the motor symptoms of parkinson’s disease

Answer 7

• if motor symptoms decrease quality of life: levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa)
• if motor symptoms DO NOT affect quality of life: choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride)

Question 8

name some of the adverse reactions from antiparkinsonian drugs

Answer 8

• psychotic symptoms
• excessive sleepiness and sudden onset of sleep with dopamine-receptor agonists
• impulse control disorders with all dopaminergic therapy (especially dopamine-receptor agonists)

Question 9

why may the use of the levodopa in parkinson’s disease be associated with motor complications

Answer 9

motor complications= fluctuations and dyskinesias (involuntary muscle movements)

• the patient may have a large variation in their motor performance due to “on” and “off” periods whilst taking levodopa. “on” period= normal motor function, “off” period= weakness + restricted mobility.
• the patient’s motor skills may also deteriorate near the end of their dose known as “end-of-dose” deterioration. modified release preparations help to reduce this and nocturnal immobility

Question 10

compare the advantages + disadvantages of levodopa vs non-ergot dopamine-receptor agonists (pramipexole, ropinirole or rotigotine)

Answer 10

advantages levodopa:
- provides more noticeable improvement in motor skills

disadvantage of levodopa:
- causes motor complication (fluctuations in motor ability during “on” and “off” period)

advantages of non-ergot dopamine-receptor agonists (pramipexole, ropinirole or rotigotine):
- motor complications are less likely to occur when used alone long-term

disadvantages of non-ergot dopamine-receptor agonists (pramipexole, ropinirole or rotigotine):
- excessive sleepiness, hallucinations, and impulse control disorders are more likely to occur with dopamine-receptor agonists than with levodopa

Question 11

what do you do if a patient with Parkinson’s disease develops dyskinesia or motor fluctuations, despite being on optimal treatment with levodopa

Answer 11

add on another drug. choice of:

• non-ergotic dopamine-receptor agonists (pramipexole, ropinirole, rotigotine)
• monoamine oxidase B inhibitors (rasagiline or selegiline hydrochloride)
• COMT inhibitors (entacapone or tolcapone)

Question 12

what is the only time you would use ergot dopamine-receptor agonists

name some examples of them

Answer 12

ergot-derived dopamine-receptor agonist should only be considered as an adjunct to levodopa if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist.

examples of ergot-derived dopamine-receptor agonist:
bromocriptine, cabergoline or pergolide

Question 13

how do you manage Daytime sleepiness and sudden onset of sleep in parkinson’s disease

Answer 13

• adjust parkinson’s drug under specialist treatment. If reversible pharmacological and physical causes have been excluded, modafinil should be considered
• note review this every 12 months*

Question 14

how do you manage Nocturnal akinesia in parkinson’s disease

Answer 14

nocturnal akinesia = difficulty turning in bed + getting up to pass urine

• levodopa or oral dopamine-receptor agonists should be considered as first-line options
• rotigotine as second-line (if both levodopa or oral dopamine-receptor agonists are ineffective).

Question 15

how do you manage Postural hypotension in parkinson’s disease

Answer 15

• review drug treatment to check if there’s a pharmacological cause. if you need drug therapy:
• midodrine hydrochloride should be considered as the first option
• fludrocortisone acetate [unlicensed indication] as an alternative

Question 16

how do you manage psychotic symptoms of parkinson’s

Answer 16

if hallucinations + delusions are well tolerated, do not treat. otherwise:

• reduce dose of drug that may be causing hallucinations + delusions (specialist advice)
• patients with no cognitive impairment, quetiapine [unlicensed indication] can be considered to treat hallucinations and delusions. clozapine as an alternative if not tolerated

Question 17

which symptoms of parkinson’s disease can some antipsychotics worsen

Answer 17

• can worsen motor symptoms

antipsychotic medicines (such as phenothiazines and butyrophenones)

Question 18

how to manage Rapid eye movement sleep behaviour disorder in parkinson’s disease

Answer 18

first address any pharmacological causes then

• Clonazepam [unlicensed indication] or melatonin [unlicensed indication]

Question 19

how do you manage Drooling of saliva in parkinson’s disease

Answer 19

• first try speech and language therapy. if ineffective or not available, then:
• Glycopyrronium bromide [unlicensed indication] should be considered as first-line treatment and botulinum toxin type A as second-line

Question 20

how do you manage Parkinson’s disease dementia

Answer 20

in mild/moderate/severe dementia:

• offer a acetylcholinesterase inhibitor (donepezil, rivastigmine and galantamine)

Question 21

how do you treat advanced parkinson’s disease

what is the MHRA recommendation for this

Answer 21

• Apomorphine hydrochloride as intermittent injections or continuous subcutaneous infusions. Add Domperidone whilst taking this to reduce nausea + vomiting associated with taking Apomorphine

MHRA recommendation:

• assessment of cardiac risk factors and ECG monitoring because risk of serious arrhythmia due to QT prolongation when taking domperidone + apomorphine hydrochloride
• do not use Domperidone in those weighing less than 35 kg

note advanced parkinson’s disease is when symptoms become more complex + antiparkinsonian drugs become less effective

Question 22

how do you manage Impulse control disorders in patients with parkinson’s disease

name some examples of Impulse control disorders

Answer 22

• inform patients about the different types of impulse control disorders so they know what to look out for
• dopamine-receptor agonist therapy may be reduced or stopped if problematic impulse control disorders develop. This would be done gradually

examples of Impulse control disorders:

• compulsive gambling
• hypersexuality
• binge eating
• obsessive shopping

Question 23

how do COMT inhibitors help to manage parkinson’s disease

name a few examples

Answer 23

They are a new class of antiparkinsons medication.

work by inhibiting the enzyme catechol-o-methyl-transferase (COMT), they prevent peripheral degradation of levodopa, allowing a higher concentration to cross the blood-brain barrier

examples:
Comtan® (entacapone)
Tasmar® (tolcapone)
Ongentys® (opicapone)