parkinsons Flashcards
what is parkinson’s disease
a progressive neurodegenerative disease which leads to the death of dopaminergic cells in substantia nigra part of the brain
describe the motor symptoms of parkinson’s disease
- hypokinesia (decreased muscle movement)
- bradykinesia (slow movement)
- rigidity
- rest tremor
- postural instability
describe the non-motor symptoms of parkinson’s disease
- dementia
- depression
- sleep disturbances
- bladder and bowel dysfunction
- speech and language changes
- swallowing problems and weight loss
TRUE OR FALSE
patients with parkinson’s disease should inform the DVLA and car insurer when they are diagnosed
TRUE
what is the aim of parkinson’s disease treatment
to control symptoms and improve quality of life (it is incurable)
what non-drug treatment can be offered to patients with parkinson’s disease
- 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.
what is the first line treatment for the motor symptoms of parkinson’s disease
- 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)
name some of the adverse reactions from antiparkinsonian drugs
- psychotic symptoms
- excessive sleepiness and sudden onset of sleep with dopamine-receptor agonists
- impulse control disorders with all dopaminergic therapy (especially dopamine-receptor agonists)
why may the use of the levodopa in parkinson’s disease be associated with motor complications
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
compare the advantages + disadvantages of levodopa vs non-ergot dopamine-receptor agonists (pramipexole, ropinirole or rotigotine)
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
what do you do if a patient with Parkinson’s disease develops dyskinesia or motor fluctuations, despite being on optimal treatment with levodopa
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)
what is the only time you would use ergot dopamine-receptor agonists
name some examples of them
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
how do you manage Daytime sleepiness and sudden onset of sleep in parkinson’s disease
- 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*
how do you manage Nocturnal akinesia in parkinson’s disease
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).
how do you manage Postural hypotension in parkinson’s disease
- 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
how do you manage psychotic symptoms of parkinson’s
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
which symptoms of parkinson’s disease can some antipsychotics worsen
- can worsen motor symptoms
antipsychotic medicines (such as phenothiazines and butyrophenones)
how to manage Rapid eye movement sleep behaviour disorder in parkinson’s disease
first address any pharmacological causes then
- Clonazepam [unlicensed indication] or melatonin [unlicensed indication]
how do you manage Drooling of saliva in parkinson’s disease
- 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
how do you manage Parkinson’s disease dementia
in mild/moderate/severe dementia:
- offer a acetylcholinesterase inhibitor (donepezil, rivastigmine and galantamine)
how do you treat advanced parkinson’s disease
what is the MHRA recommendation for this
- 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
how do you manage Impulse control disorders in patients with parkinson’s disease
name some examples of Impulse control disorders
- 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
how do COMT inhibitors help to manage parkinson’s disease
name a few examples
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)
