Week 5- Holistic Care of the Parkinson's Disease Patient Flashcards
what is the first line treatment for parkinsons for when motor symptoms affect their life?
• Offer levodopa to people with early Parkinson’s disease whose motor symptoms
affect their quality of life
what is the first line treatment for parkinsons for when motor symptoms are not affect their life?
• Consider a choice of dopamine agonists, levodopa, or monoamine oxidase B
inhibitors for people with early Parkinson’s disease whose motor symptoms do not
affect their quality of life
when should adjuvant therapy be added on for treatment of motor symptoms in parkinsons?
-first line should be optimised first
When?
• When dyskinesia or motor fluctuations develop (including “wearing off” episodes)
What?
• Offer a choice of dopamine agonists, monoamine oxidase B inhibitors, or catecholO-methyl transferase inhibitors as an adjunct to levodopa
• If dyskinesia is not adequately managed by modifying existing therapy, consider
amantadine
what is levodopa? what it helps with? effectiveness
• First line agent
• Dramatically improves motor function
• Palliative treatment – no effect on disease progression
• Effectiveness decreases with time, must escalate dose
• receptor down-regulation
• disease progression
-can increase life expectancy in patient
whare are some unwanted affects for levodopa?
1. Dyskinesia (involuntary movements) • from 2 years (50% of patients by year 5) • face and limbs 2. Fluctuations in Clinical State • “on-off” phenomena • wearing off effect (end of dose deterioration) • freezing • Entacapone (COMT inhibitor) may help 3. Acute Side Effects • Nausea and anorexia • Hypotension • Sleep disturbances including sudden onset of sleep – implications for driving • Psychological effects
what is levodopa always giving with? and why?
Dopadecarboxylase Inhibitors:
• Carbidopa
• Benserazide
- Levodopa is given as a combination product with either carbidopa or benserazide
- These reduce peripheral metabolism of levodopa and improve absorption of levodopa
- Reduce peripheral side effects
- They do not cross the BBB
what can be giving as a dd on therpay?
COMT Inhibitors : • Entacapone • Tolcapone • Entacapone is given as an adjuvant to co-careldopa/co-beneldopa or as a combination product with co-careldopa • Potentiates the effects of levodopa • Helps counteract fluctuations in plasma concentration of levodopa • Add on therapy – not useful alone
how is levodopa administered?dose? prescribing?
• Max of 800mg Levodopa per day
• titrate benefit vs side-effects
• Small doses of Levodopa at increased frequencies to
reduce ‘peaks and troughs’ and dyskinesia
• Proteins inhibit absorption. Wait 30-60 minutes after
medication before eating
• Brand specific prescribing
• Manage underlying issues which may affect absorption
e.g. constipation, drug interactions
• Iron supplements
how are dopamine receptor agonists used?
- Monotherapy (vs L-DOPA to delay starting it)
- reduced (+ increase time to) motor complications (less dyskinesias)
- slightly poorer improvement in motor function
- possibly greater neuro-psychiatric side effects
- can delay introduction of L-DOPA
- Combined with L-DOPA
- reduced “off” time
- improved motor impairment
- reduced L-DOPA dosage
- increased side effects
what can all dopaergic drugs cause?
impulse control disorder
-can be as log as 4-5 years most likely in men and ppl with smoking/alcohol abuse
what action should happen if someone has impulse control disorder?
• Gradually reduce any dopamine agonist. Monitor whether the impulse control disorder improves and
whether the person has any symptoms of dopamine receptor agonist withdrawal
• Offer specialist cognitive behavioural therapy targeted at ICD behaviours if modification of dopaminergic
therapy is not effective
what is amantadine? side effects
-can be used alone or as combination
• MOA not fully understood
• Increases dopamine levels (possibly by increasing dopamine release)
• Mild benefit to symptoms
• Only used as an adjuvant
• Efficacy diminishes within a few months of continuous treatment - slowly withdrawing and
reintroducing the drug may prolong effectiveness
• Side effects:
• Psychological – hallucinations, delusions, paranoia, anxiety, impulse control disorders
• Sleep disturbances
• GI- nausea, vomiting, anorexia, weight loss, dry mouth
• Hypotension
• Palpitations
between levadopa and dopamine receptor agonists and MAO-b INHIBITORS which one will have more complications with SE but most improvement in symptoms and activities of daily living
levodopa
what is the significance of missing a dose?
• Acute akinesia (the inability to initiate movement)
• Unable to communicate and become more physically dependant on others
• Loss of the ability to swallow, which increases the risk of aspiration
• Increased risk of falls, and a higher risk of fractures
• Neuroleptic-like malignant syndrome (very rare) :
• fever, marked rigidity (including respiratory causing hypoventilation), altered
consciousness, leucocytosis and elevated creatine kinase
• It is caused by a sudden, marked reduction in dopamine activity, either from withdrawal of
dopaminergic agents or from blockade of dopamine receptors
• More common in those with more severe PD symptoms or on high doses of levodopa
what is the treatment for non-motor symptoms of parkinsons?
- Mental Health: • Depression, anxiety, and apathy • Dementia and cognitive impairment • Impulse control and psychotic symptoms - Autonomic dysfunction: • Constipation • Orthostatic (postural) hypotension • Dysphagia → weight loss, aspiration pneumonia • Excessive salivation and sweating • Bladder and sexual dysfunction Nausea and vomiting - Pain - Sleep disturbance and daytime sleepiness - Pressure sores
what needs to be considered for treatment?
-patients choice
-Parkinson’s, complications,
or adverse effects of antiParkinsonian medication
-will they compromise using a different medication in order to have the desired symptom resolved
how does mental health affect parkinsons as a symptom and how is it managed?
Depression – SSRIs
• Dementia- consider Rivastigmine (licensed) or off-label use of donepezil, galantamine
• Confusion and hallucinations – quetiapine (1st line) or clozapine (2nd line)
• Impulse control and psychotic symptoms- optimise drug therapy
how does autonomic dysfunction affect parkinsons as a symptom and how is it managed?
- Constipation- stimulant + softener
- Postural hypotension – midodrine/fludrocortisone
- Dysphagia- medicines optimisation
- Salivation/drooling - glycopyrronium
- Bladder dysfunction – antimuscarinics
- Sexual dysfunction- PDE5 inhibitors SLS e.g. sildenafil etc.
how does nausea and vomiting affect parkinsons as a symptom and how is it managed?
-first line Domperidone
• Consider cyclizine or ondansetron
• Protein-free snacks with Levodopa doses to reduce side effects
how does pain affect parkinsons as a symptom and how is it managed?
- Follow pain ladder
- Consider side effects
- Physiotherapy
how does affect Sleep disturbances & Daytime sleepiness parkinsons as a symptom and how is it managed?
Sedatives
• Daytime sleepiness- modafinil
how does pressure sores parkinsons as a symptom and how is it managed?
- Barrier creams
- Change position every 2 hours
- Pressure relieving mattresses and cusions
when shold reviwes be done and what is medicine management used for?
• Review of all aspects of their care every 6-12 months
• Normally only start or alter anti-parkinsonian medications on the advice of a
specialist
• Drugs may need to be titrated to optimise
• Drug changes need to be actioned promptly
• Prioritise medicines reconciliation for Parkinson’s patients
• Sudden drug cessation may precipitate acute akinesia or neuroleptic malignant
syndrome
what are the specifics for medicines management for levodopa?
• Small doses of Levodopa at increased frequencies to reduce ‘peaks and troughs’ and dyskinesia
• Proteins inhibit absorption. Wait 30-60 minutes after medication before eating
• Brand specific prescribing
• Print medication timings on pharmacy labels
• Manage underlying issues which may affect absorption e.g. constipation, drug interactions
• Avoid medications which worsen symptoms
- OTC avoid sympathomimetics (e.g. pseudoephedrine) with MAO-B inhibitors
- OTC antihistamines
- Calcium channel blockers – occasional EPSE, frequency unknown
what multidisciplinary care can help with parkinsons?
• SALT, physio, OT, dietetics, social care, community nursing, continence, psychology,
mental health services, specialist nurses, consultants
what are some other considerations for patients with parkinsons?
• DVLA must be informed
• Awareness of communication difficulties – quiet voice, slurred speech, reduced
facial expressions and body language
• Encourage self-administration and independence
• Recommend Vit D colecalciferol
