Transcript Parkinson`s Disease

Debra Vincent Scott
Clinical nurse specialist in
Parkinson's disease
Email [email protected]
MOBILE 07979005687
This presentation has been produced by GlaxoSmithKline
Aims
• Prevalence
• Diagnosing
• Non Motor symptoms
• Stages of PD
• Treatment
• Patients experience
Prevalance
• 1 in 500 UK resident have PD
• 1 in 100 > 60 yrs have PD
• 127000 Pt have formal PD diagnosis (GPRD database)
• 1 in 20 Pt; Develop symptoms under 40 yrs of age
• By 2020: PD no will rise- 162000
• 28% rise in PD cases
• Economic burden of PD is ~ £2 billion annually
(Imperial College) (1, 2)
Diagnosing PD
• A set of characteristic symptoms that affect
motor control:
• resting tremor,
• bradykinesia, and
• hypertonia.
• Resting tremor is an oscillating movement (4—6
Hrzd) that occurs when the patient is trying to be
still; disappears on action
• Essential Tremor: Persists on movement
• Cerebellar Tremor: Intentional tremor
• Bradykinesia means slowness of movement.
• Usually experienced as ‘weakness’ or ‘stiffness’ of limb
• Hypertonia means excessive muscle tone.
• Manifest itself as rigidity or stiffness.
• Other typical features: are
• a Stooped posture/ Slow, shuffling festinant gait/
Reduced arm swing/ Facial appearance (Masked like
‘hypomimia’)/ Low volume speech/ Excessive drooling
of saliva
The ‘Braak hypothesis’
Stage 5 and 6:
Changes spread to the
cortex
Stage 3 and 4:
Pathology spreads to the
midbrain and basal ganglia
Stage 1 and 2:
Pathology confined to certain
structures in the brain stem,
not yet the substantia nigra
Image adapted from The Professionals Guide to Parkinson’s Disease,
Non-motor symptoms of
PD
3
Neuropsychiatric
Autonomic
Sleep disturbance
Sensory symptoms
Dementia
REM sleep disorder
Depression
RLS
Apathy
Vivid dreams
Anxiety
Daytime somnolence
Loss of libido
Dystonia
Constipation
Urinary incontinence
Erectile dysfunction
Excessive sweating
Postural hypotension
Excessive salivation
Pain
Paraesthesia
Criteria for entry into staging categories
Parkinson's Disease
Diagnosis / early
Levodopa or
Dopamine agonists
Rasagiline.
selegiline
Maintenance
Entacapone
Stalevo
Knowledge of disease
Ideas and perceptions
Employment issues
Neuro rehab
Promote normal function
Regular reviews-red flags
Support
MDT input
Complex
Motor complications.
Neuropsychiatric complications
Reduction of drugs.
Carer support/respite/hospice
Palliative
Symptoms versus side effects
Advanced care needs
Amantadine.
Apomorphine
Duodopa
DBS
4 .MacMahon D.G Thomas.S Practical Approach to Parkinson’s Disease. Journal of Neurology (1998) 245
(SUPP1)S19.S22
TREATMENT
Begins with
Diagnosis
Patient education.MDT input
Discussion of when and which drug
Treatments. Bradykinesia dominated disease may need
earlier treatment than tremor dominated disease
People with suspected Parkinson’s should be
referred quickly and untreated to a specialist (NICE
2006)
Parkinson’s
Levodopa
DAs
Dopamine agonists
MAO-B inhibitors
Monoamine oxidase B
inhibitors
Anticholinergics
COMTs
Catechol-Omethyltransferase
inhibitors
Drugs to avoid
Generic name
Brand name
Usually
prescribed for
prochlorperazine
metoclopramide
Stemetil
Maxalon
Dizziness, nausea
and vomiting
fluphenazine
perphenazine
flupentixol
Motival
Triptafen
Fluanxol
Depixol
Depression
chlorpromazine
fluphenazine
haloperidol
Largactil
Moditen
Serenace
Haldol
Fentazin
Confusion,
hallucinations,
disorientation, or
disturbed thinking
perphenazine
Drug management
• As responses to drugs are variable, treatment
regimes differ from person to person
• The timing of drugs is important in order to
achieve continuous dopaminergic stimulation
• Nurses have a key role in helping the patients
manage complex drug regimes
• Sudden discontinuation of treatment should be
avoided as it can result in Neuroleptic Malignant
Syndrome.
• Get it on time campaign. NH homes to send in
medication with patient
End note
•
•
•
•
Start ‘slow and low’
Watch for side effects; low BP, Orthostatic hypotension, ICD
NMS are more common in older pts
NMS are often confusing & poorly recognised
• Insomnia: likely due to Akathisia (inner restlessness),
stiffness (rigidity), difficulty turning in bed, as well as tremor
• Anxiety: likely due to Akathisia
• Cramps: could be ‘dystonias’: inspect feet for inversion,
great toe
• Pain/ Paresthesia/ depression: may be levodopa
responsive
• Avoid hospitalisation
• The patient is the expert
References
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findley LJ The economic impact of Parkinson's disease. Parkinsonism Relat Disord. 2007 Sep;13 Suppl:S8-S12.
Epub 2007 Aug 16.
Oliver H.H. Gerlach, MD,* Ania Winogrodzka, MD, PhD, and Wim E.J. Weber, MD, PhD; Clinical Problems in
the Hospitalized Parkinson’s Disease Patient: Systematic Review Movement Disorders, Vol. 26, No. 2, 2011
Huse DM, Schulman K, Orsini L, Castelli-Haley J, Kennedy S, Lenhart G. Burden of illness in Parkinson’s disease.
Mov Disord 2005;20:1449–1454
Parkinson’s-UK. ‘‘Get It on Time.’’ www.parkinsons.org.uk.
Shulman LM, Taback RL, Rabinstein AA, Weiner WJ. Non-recognition of depression and other non-motor
symptoms in Parkinson’s disease. Parkinsonism Relat Disord. 2002;8(3): 193–197.
Miyasaki JM, Shannon K, Voon V, et al. Quality Standards Subcommittee of the American Academy of
Neurology. Practice Parameter: evaluation and treatment of depression, psychosis, and dementia in
Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the
American Academy of Neurology. Neurology. 2006;66(7):996–1002.
Poewe WH, Lees AJ, Stern GM. Low-dose L-dopa therapy in Parkinson’s disease: a 6-year follow-up study.
Neurology1986;36:1528-1530.
Kumar N, Van Gerpen JA, Bower JH, Ahlskog JE. Levodopa-dyskinesia incidence by age of Parkinson’s
disease onset. Mov Disord 2005; 20:342-344
Holloway RG, Shoulson I, Fahn S, Kieburtz K, Lang A, Marek K, et al. Pramipexole vs levodopa as initial
treatment for Parkinson disease: a 4-year randomized controlled trial. Arch Neurol 2004;61:1044-1053
Dodd, Klos KJ, Bower JH, Geda YE, Josephs KA, Ahlskog JE. Pathological gambling caused by drugs used to
treat Parkinson disease. Arch Neurol 2005;62:1377-1381.
Nirenberg MJ, Waters C. Compulsive eating and weight gain related to dopamine agonist use. Mov Disord
2006;21:524-529. 73.
Voon V, Hassan K, Zurowski M, de Souza M, Thomsen T, Fox S, et al. Prevalence of repetitive and rewardseeking behaviors in Parkinson disease. Neurology 2006;67:1254-1257
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Parkinson’s-UK. ‘‘Get It on Time.’’ www.parkinsons.org.uk.
Shulman LM, Taback RL, Rabinstein AA, Weiner WJ. Non-recognition of depression and other non-motor symptoms
in Parkinson’s disease. Parkinsonism Relat Disord. 2002;8(3): 193–197.
Miyasaki JM, Shannon K, Voon V, et al. Quality Standards Subcommittee of the American Academy of Neurology.
Practice Parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an
evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.
Neurology. 2006;66(7):996–1002.
Poewe WH, Lees AJ, Stern GM. Low-dose L-dopa therapy in Parkinson’s disease: a 6-year follow-up study.
Neurology1986;36:1528-1530.
Kumar N, Van Gerpen JA, Bower JH, Ahlskog JE. Levodopa-dyskinesia incidence by age of Parkinson’s disease
onset. Mov Disord 2005; 20:342-344
Holloway RG, Shoulson I, Fahn S, Kieburtz K, Lang A, Marek K, et al. Pramipexole vs levodopa as initial treatment for
Parkinson disease: a 4-year randomized controlled trial. Arch Neurol 2004;61:1044-1053
Dodd ML, Klos KJ, Bower JH, Geda YE, Josephs KA, Ahlskog JE. Pathological gambling caused by drugs used to
treat Parkinson disease. Arch Neurol 2005;62:1377-1381.
Nirenberg MJ, Waters C. Compulsive eating and weight gain related to dopamine agonist use. Mov Disord
2006;21:524-529. 73.
MacMahon D.G Thomas.S Practical Approach to Parkinson’s Disease. Journal of Neurology (1998) 245
(SUPP1)S19.S22
Voon V, Hassan K, Zurowski M, de Souza M, Thomsen T, Fox S, et al. Prevalence of repetitive and reward-seeking
behaviors in Parkinson disease. Neurology 2006;67:1254-1257