Transcript Parkinson`s Disease

Parkinson’s Disease
Management in Primary Care
Introduction
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Progressive condition
1:500 whole population
1:50 of elderly
1:10 Nursing Home Residents
Recognition
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Slowness
Stiffness
Tremor
Loss of balance
First Diagnosis
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PCT priorities
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carer support
manage co-morbidity
nursing needs assessment
Patient concerns
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driving (DVLA, insurers)
inheritance (rare)
Management Aims
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Initial
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acceptance of diagnosis
control symptoms
reduce distress
improve outlook
Subsequent
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relieve morbidity
prevent complications
Maintenance
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PCT priorities
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complications
follow-up arrangements
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?shared care
Patient concerns
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work/finance/benefits
sexuality
Complex Parkinson’s
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PCT priorities
Aims
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maintain good health
manage drug regime
address disease/complication problems
support for patients/carers
Complications
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Deteriorating function
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Loss of drug effect
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immobility, slowness, loss of activity
end-dose, on-off effects
Involuntary movements (dyskinesia)
Confusion, depression, hallucination
Constipation, incontinence, wt loss,
hypotension
Referral
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Initial
Maintenance
Complex
Palliative
Referral: Initial
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Confirmation of diagnosis
Management
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multi-disciplinary team
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see later
drug treatment
Special Interest follow-up
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monitoring side effects
Referral: Maintenance
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Multi-disciplinary team
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Occupational Therapy
Physiotherapy
Dietician
Speech/Language therapy
Social Services
Podiatrist
Continence Advisor
Referral: Complex
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Specialist team in major role
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access to secondary care
neurosurgery
watch for complications
communication
Referral: Palliative
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Appropriate support
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palliative care services
social needs assessment
care in home, nursing home or hospice
Drug Treatment
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Progression
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Tachyphylaxis
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Levodopa only works for 4-5 years
More levodopa = late side effects
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PD inevitably progresses
50% of patients by 4-5 years
Polypharmacy
Drug Treatment
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Levodopa
Dopamine agonists
Selegiline (MAOI type B)
COMT inhibitors
Anticholinergics
Amantadine
Levodopa
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used since 1960’s
mixed with dopa decarboxylase inhibitor
good for rigidity/bradykinesia
not so good for tremor
Side Effects:
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confusion, hallucinations, mood
changes/swings
involuntary movements: on-off
Dopamine Agonists
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Bromocriptine, Pergolide, Ropinirole,
Cabergoline, Pramipexole
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single Rx
co-Rx with levodopa
Apomorphine
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subcutaneous injection in advanced
refractory disease
usually initiated in-patient (ADR)
Selegiline
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MAOI prevents Dopamine breakdown
co-Rx with levodopa
unexpectedly high mortality
(?autonomic ADR)
COMT inhibitors
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Inhibit alternative dopamine
degradation pathway
Allow reduction levodopa dose (3050%)
LFTs need to be monitored
Anticholinergics
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Benzhexol, orphenadrine
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useful in younger patients with tremor
avoid in elderly (ADR)
Amantadine
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Useful in younger/mildly-affected
patient
Loses effect quickly (months)
Good for mild akinesia/tremor
Drugs to avoid
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Phenothiazines
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Prochlorperazine, fluphenazine,
haloperidol, sulpiride
Metoclopramide
MAOIs: provoke ADR with levodopa
Atypical antipsychotics
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clozapine, olanzapine
Parkinson’s Disease Society
215 Vauxhall Bridge Road,
LONDON SW1V 1EJ
Tel 020 7931 8080
www.parkinsons.org.uk
Helpline 0808 800 0303