parkinsons disease

Question 1

motor symptoms include

Answer 1

hypokinesia, bradykinesia, rigidity, rest tremor, and postural instability, stiffness, slow movement

PD = hypokinetic movement disorder = decreased bodily movement

Question 2

what is it and what does it result from

Answer 2

Progressive neurodegenerative condition resulting from the death of dopaminergic cells of the substantia nigra in the brain

Question 3

non motor symptoms include

Answer 3

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

Question 4

suspected parkinsons disease - what do you do? and how often to review?

Answer 4

Suspected Parkinson’s disease should be referred to a specialist and reviewed every 6 to 12 months

Question 5

driving?

Answer 5

When Parkinson’s disease diagnosis is confirmed, patients should be advised to inform the DVLA and their car insurer

Question 6

curable?

Answer 6

no

Question 7

non drug treatment (4)

Answer 7

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 8

drug treatment - if motor symptoms decrease QOL, give any one of the following

Answer 8

Levodopa + carbidopa (co-careldopa)
Levodopa + benserazide (co-bendelopa)

Question 9

drug treatment - if motor symptoms DO NOT decrease QOL, give any of the following (3)

Answer 9

Levodopa OR
Non-ergot derived dopamine receptor agonist (pramipexole, ropinirole, rotigotine) OR
MAO-B inhibitors (rasagiline, selegiline)

Question 10

name 3 non-ergot derives dopamine receptor agonists

Answer 10

pramipexole, ropinirole, rotigotine

Question 11

name 2 MAO-B inhibitors

Answer 11

rasagiline, selegiline

Question 12

risk of adverse effects from antiparkinsonian drugs - what are some of these SE and which drugs cause them? (4)

Answer 12

Psychotic symptoms (dopamine receptor agonists)
Excessive sleepiness (dopamine receptor agonists)
Sudden onset sleep (dopamine receptor agonists)
Impulse control disorders with all dopaminergic therapy (esp dopamine receptor agonists)

Question 13

levodopa treatment is associated with motor complications such as (3)

Answer 13

Response fluctuations and dyskinesias (uncontrollable muscle movements)
Response fluctuations characterised by large variations in motor performance, with normal function during ‘on’ period and weakness and restricted mobility during ‘off’ period
End of dose deterioration with progressively shorter duration of benefit can also occur

Question 14

MR preps of levodopa can help with…

Answer 14

end of dose deterioration or nocturnal immobility

Question 15

Why is it important for to take their doses at the correct time?

Answer 15

to prevent symptoms of PD

Question 16

comparing drugs - overall improvement in motor performance is better with this drug than dopamine receptor agonists

Answer 16

levodopa

Question 17

comparing drugs - motor complications less likely to occur with this drug class when use alone long term

Answer 17

dopamine receptor agonists

Question 18

comparing drugs - Excessive sleepiness, hallucinations and impulse control disorders more likely to occur with these drugs than with levodopa

Answer 18

dopamine receptor agonists

Question 19

poor absorption or abrupt withdrawal of antiparkinson is bad because…

Answer 19

To avoid potential for acute akinesia (loss of ability to move muscles) or neuroleptic malignant syndrome, antiparkinsonian drug concentrations should not be allowed to fall suddenly due to poor absorption or abrupt withdrawal

Question 20

if a patient develops dyskinesia (involuntary, uncontrolled movement) or motor fluctuations, can you modify their antiparkinosnian drug therapy

Answer 20

seek specialist advice before doing this

Question 21

Pt who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered a choice of one of the following as an adjunct to levodopa (3)

Answer 21

Non ergot derived dopamine receptor agonists (e.g. pramipexole, rotigotine, ropinirole), OR
MAO-B inhibitor (rasagiline, selegiline)
COMT inhibitor (entacapone, tolcapone)

Question 22

name 2 COMT inhibitors

Answer 22

entacapone, tolcapone

Question 23

When can ergot derived dopamine receptor agonists be considered as adjunct to levodopa?

Answer 23

An ergot-derives dopamine-receptor agonist (cabergoline, pergolide, bromocriptine) should ONLY be considered as adjunct to levodopa if symptoms not adequately controlled with non-ergot derived dopamine receptor agonist

Question 24

If dyskinesia not adequately managed by modifying existing therapy (e.g. with non-ergot derived dopamine receptor agonists, MAO-B inhibitor, or COMT inhibitor), consider the following drug

Answer 24

amantadine

Question 25

If pt experiences daytime sleepiness and sudden onset sleep , what should happen with their PD Drug treatment

Answer 25

PD drug treatment should be adjusted under specialist medical guidance

Question 26

If reversible pharmacological and physical cases of daytime sleepiness and sudden onset of sleep have been excluded, consider this drug to treat excessive daytime sleepiness. review every …..

Answer 26

modafinil
review at least every 12 months

Question 27

can patients with daytime sleepiness and sudden onset of sleep drive

Answer 27

These patients should also be advised not to drive, to inform DVLA about symptoms, and to think about any occupational hazards

Question 28

treatment of nocturnal akinesia (akinesia = loss of ability to move muscles) - 1st and 2nd line

Answer 28

When treating nocturnal akinesia in pt with PD, levodopa or oral dopamine receptor agonist’s should be considered 1st line
2nd line if the above ineffective: rotigotine (DRA, patch)

Question 29

what to do if pt with PD develops postural hypotension. + 1st line and alternative

Answer 29

Review drug treatment to address any pharmacological case
If drug therapy required, 1st line midodrine
Alternative: fludrocortisone (unlicenced)

Question 30

do psychotic symptoms need treatment?

Answer 30

Hallucinations and delusions need not be treated if well tolerated
otherwise, reduce dose of any antiparkinsonism drugs that might have triggered them, taking into account severity of symptoms and possible withdrawal effects
seek specialist advice before modifying drug treatment

Question 31

treatment of psychotic symptoms in PD pt with no cognitive impairment

Answer 31

Quetiapine (unlicensed) can be considered to treat hallucinations and delusions
If standard treatment ineffective, offer clozapine

Question 32

in PD pt with no cognitive impairment, you can consider quetiapine to treat hallucinations and delusions. alternative is clozapine. it is important to acknowledge that other antipsychotics can ….

Answer 32

other antipsychotics (e.g. C1 phenothiazines and butyrophenones such as haloperidol, benperidol) can worsen the motor features of PD

Question 33

once possible pharmacological causes have been addressed, the following two drugs can be considered to treat REM sleep behaviour disorder

Answer 33

clonazepam (unlicensed) or melatonin (unlicensed)

Question 34

drooling of saliva - when would you consider drug treatment

Answer 34

Only consider if non-drug treatment such as SALT is not available or ineffective

Question 35

drooling of saliva - 1st and 2nd line , other considerations

Answer 35

1st line: Glycopyrroidium bromide (unlicensed indication)
2nd line: botulinum toxin type A
Other antimuscarinic drug should only be considered if the risk of cognitive adverse effects is thought to be minimal
Topical preparations such as atropine (unlicensed indication) should be used if possible to reduce risk adverse events

Question 36

treatment of PD dementia

Answer 36

AChE inhibitor (e.g. rivastigmine, galantamine, donepezil) should be offered to pt with mild-moderate PD dementia
Consider for pt with severe PD dementia (unlicensed indications apart from rivastigmine caps and oral solution for treatment of mild to moderate dementia in pt with PD)
If AChE inhibitors not tolerated or contraindicated, consider memantine (unlicensed)

Question 37

patients with advanced PD can be offered the following

Answer 37

Apomorphine HCl intermittent injections or continuous SC infusions

Question 38

patients with advanced PD can be offered apomorphine HCl intermittent injections or continuous SC infusions. to control n+v associated with apomorphine, manufacturers recommend the administration of this antiemetic

Answer 38

domperidone (unlicensed in <35kg) to be started 2 days before apomorphine, then discontinued ASAP

Question 39

what is the interaction between domperidone and apomorphine

Answer 39

QT interval prolongation

Question 40

to reduce the risk of serious arrhythmia due to QT prolongation associated to concomitant use of domperidone and apomorphine (this is used in advanced PD), MHRA recommends the following (3)

Answer 40

Assess cardiac RF
ECG monitoring
Ensure benefits outweighs risk when initiating treatment

Question 41

Levodopa-carbidpoa intestinal gel is used for treatment of….

Answer 41

advanced levodopa-responsive PD with severe motor fluctuations and hyperkinesia or dyskinesia

Question 42

Levodopa-carbidpoa intestinal gel is used for treatment of advanced levodopa-responsive PD with severe motor fluctuations and hyperkinesia or dyskinesia. the gel is administered with …

Answer 42

a portable pump directly into duodenum or upper jejunum

Question 43

when can deep brain simulation be considered for pt with advanced PD

Answer 43

symptoms are not adequately controlled by best drug therapy

Question 44

IMPULSE CONTROL DISORDERS e.g. compulsive gambling, hypersexuality, binge eating, obsessive shopping - these can develop in pt with PD who are on ….

Answer 44

any dopaminergic therapy at any stage in the disease
Particularly if pt has Hx previous impulsive behaviours, alcohol consumption, or smoking
Pt should be informed of the different types of impulse control disorders and that DRA may be reduced or stopped if problematic impulse control disorders develop
When managing impulse control disorders, DRA doses should be reduced gradually and pt should be monitored for symptoms of dopamine agonist withdrawal
Specialist CBT should be offered if modifying dopaminergic therapy is not effective