parkinsons disease Flashcards
motor symptoms include
hypokinesia, bradykinesia, rigidity, rest tremor, and postural instability, stiffness, slow movement
PD = hypokinetic movement disorder = decreased bodily movement
what is it and what does it result from
Progressive neurodegenerative condition resulting from the death of dopaminergic cells of the substantia nigra in the brain
non motor symptoms include
dementia, depression, sleep disturbances, bladder and bowel dysfunction, speech and language changes, swallowing problems and weight loss
suspected parkinsons disease - what do you do? and how often to review?
Suspected Parkinson’s disease should be referred to a specialist and reviewed every 6 to 12 months
driving?
When Parkinson’s disease diagnosis is confirmed, patients should be advised to inform the DVLA and their car insurer
curable?
no
non drug treatment (4)
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
drug treatment - if motor symptoms decrease QOL, give any one of the following
Levodopa + carbidopa (co-careldopa)
Levodopa + benserazide (co-bendelopa)
drug treatment - if motor symptoms DO NOT decrease QOL, give any of the following (3)
Levodopa OR
Non-ergot derived dopamine receptor agonist (pramipexole, ropinirole, rotigotine) OR
MAO-B inhibitors (rasagiline, selegiline)
name 3 non-ergot derives dopamine receptor agonists
pramipexole, ropinirole, rotigotine
name 2 MAO-B inhibitors
rasagiline, selegiline
risk of adverse effects from antiparkinsonian drugs - what are some of these SE and which drugs cause them? (4)
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)
levodopa treatment is associated with motor complications such as (3)
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
MR preps of levodopa can help with…
end of dose deterioration or nocturnal immobility
Why is it important for to take their doses at the correct time?
to prevent symptoms of PD
comparing drugs - overall improvement in motor performance is better with this drug than dopamine receptor agonists
levodopa
comparing drugs - motor complications less likely to occur with this drug class when use alone long term
dopamine receptor agonists
comparing drugs - Excessive sleepiness, hallucinations and impulse control disorders more likely to occur with these drugs than with levodopa
dopamine receptor agonists
poor absorption or abrupt withdrawal of antiparkinson is bad because…
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
if a patient develops dyskinesia (involuntary, uncontrolled movement) or motor fluctuations, can you modify their antiparkinosnian drug therapy
seek specialist advice before doing this
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)
Non ergot derived dopamine receptor agonists (e.g. pramipexole, rotigotine, ropinirole), OR
MAO-B inhibitor (rasagiline, selegiline)
COMT inhibitor (entacapone, tolcapone)
name 2 COMT inhibitors
entacapone, tolcapone
When can ergot derived dopamine receptor agonists be considered as adjunct to levodopa?
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
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
amantadine
If pt experiences daytime sleepiness and sudden onset sleep , what should happen with their PD Drug treatment
PD drug treatment should be adjusted under specialist medical guidance
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 …..
modafinil
review at least every 12 months
can patients with daytime sleepiness and sudden onset of sleep drive
These patients should also be advised not to drive, to inform DVLA about symptoms, and to think about any occupational hazards
treatment of nocturnal akinesia (akinesia = loss of ability to move muscles) - 1st and 2nd line
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)
what to do if pt with PD develops postural hypotension. + 1st line and alternative
Review drug treatment to address any pharmacological case
If drug therapy required, 1st line midodrine
Alternative: fludrocortisone (unlicenced)
do psychotic symptoms need treatment?
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
treatment of psychotic symptoms in PD pt with no cognitive impairment
Quetiapine (unlicensed) can be considered to treat hallucinations and delusions
If standard treatment ineffective, offer clozapine
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 ….
other antipsychotics (e.g. C1 phenothiazines and butyrophenones such as haloperidol, benperidol) can worsen the motor features of PD
once possible pharmacological causes have been addressed, the following two drugs can be considered to treat REM sleep behaviour disorder
clonazepam (unlicensed) or melatonin (unlicensed)
drooling of saliva - when would you consider drug treatment
Only consider if non-drug treatment such as SALT is not available or ineffective
drooling of saliva - 1st and 2nd line , other considerations
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
treatment of PD dementia
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)
patients with advanced PD can be offered the following
Apomorphine HCl intermittent injections or continuous SC infusions
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
domperidone (unlicensed in <35kg) to be started 2 days before apomorphine, then discontinued ASAP
what is the interaction between domperidone and apomorphine
QT interval prolongation
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)
Assess cardiac RF
ECG monitoring
Ensure benefits outweighs risk when initiating treatment
Levodopa-carbidpoa intestinal gel is used for treatment of….
advanced levodopa-responsive PD with severe motor fluctuations and hyperkinesia or dyskinesia
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 …
a portable pump directly into duodenum or upper jejunum
when can deep brain simulation be considered for pt with advanced PD
symptoms are not adequately controlled by best drug therapy
IMPULSE CONTROL DISORDERS e.g. compulsive gambling, hypersexuality, binge eating, obsessive shopping - these can develop in pt with PD who are on ….
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
