Transcript Parkinson`s Disease – An Overview

Parkinson’s Disease
on AMU and the wards
Dr Sally Jones
Consultant Geriatrician
Birmingham Heartlands Hospital
Overview
• Parkinson’s Disease – a reminder
– Terminology, the Basal Ganglia and Dopamine
• Signs and symptoms in PD
• Emergency presentations in PD
– PD related presentations
– PD complicating other non –related problems
Parkinsonism or Parkinson’s Disease?
Parkinsonism = signs/symptoms which may be caused by:
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Parkinson’s Disease
Lewy Body Dementia
PSP
MSA
Corticobasilar degeneration
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Cerebrovascular Disease/basal ganglia infarct
Drug induced
NPH
Functional/psychogenic
Severe depression (causes psychomotor retardation)
true dopamine deficiency
The Basal Ganglia
• Group of subcortical
nuclei interconnected
with cerebral cortex,
thalamus and brainstem
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Subthalamic Nucleus
Substantia Nigra
Caudate Nucleus
Putamen
Globus Pallidus
The Basal Ganglia
• Originally thought to be associated purely with motor
control
• We now know that there is more to it...
– Motor
– Associate (cognitive)
– Limbic (emotional)
• Progressive cell loss in basal ganglia depletes dopamine
• Dopamine loss explains many of the symptoms
Patients with
Parkinson’s Disease
produce less dopamine
Some PD
medications
replace L-dopa
L–Dopa
Dopamine
Some PD medications stop
dopamine breakdown
Some PD medications
mimic action of dopamine
Dopamine receptors
The message is passed on
Some medications
CAUSE parkinsonsism
by blocking dopamine
receptors
Patients with Parkinson’s Disease produce less dopamine
Some PD medications
replace L-dopa:
- co-careldopa (sinemet)
- co-beneldopa (madopar)
- duodopa
Both levodopa combined with
decarboxylase inhibitor.
L–Dopa
Dopamine
Some medications
CAUSE parkinsonsism “Dopamine Antagonists”
- Phenothiazines
- Stemetil
- Metoclopramide
- Some anti-histamines
- most anti-psychotics
Some PD medications stop
dopamine breakdown
- COMT inhibitors
(entacapone)
- MAO-B inhibitors
(selegeline, rasagaline)
Some PD medications mimic
action of dopamine
- Dopamine Agonists
(ropinirole, pramipexole,
rotigotine, apomorphine,
amantadine)
Avoid!!!
Dopamine receptors
The message is passed on
It’s not just a tremor!
Motor Symptoms
• Triad of tremor, rigidity and bradykinesia
• May manifest as:
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Postural instability
Postural change (disproportionate antecolis)
Reduced facial expression (hypomimia)
Difficulty initiating movements
Difficulty turning corners
Drooling & swallow problems
Quiet mumbling speech
• Other commonly used motor terms:
– Freezing, on/off, dyskinesia, dystonia, end of dose deterioration
Non-motor symptoms
• Neuropsychiatric
– Hallucinations & perceptual problems, REM sleep disorder,
impulse control disorder, apathy, depression, anxiety, dementia
• Autonomic
– Postural hypotension, urinary problems, erectile dysfunction
• Sensory
– Anosmia, diplopia
• Speech & Swallow
– Drooling, Dysphagia, Quiet mumbling speech
• Gastroenterology
– Nausea, constipation (severe → impaction, volvulus)
Staging
Traditionally:
• Hoehn & Yahr 1-5
Or more clinically useful:
• Diagnostic phase
• Maintenance phase
• Complex phase
• Palliative phase
Reflection
How might
understanding this
help when seeing
these patients in
ED/AMU?
Emergency Presentations in PD
1. So how might PD present as an emergency?
2. How might PD complicate non-related
emergencies/acute admissions?
Drug related problems & emergencies
Cause
Complication
What to do
PD medication side effect
Postural hypotension
Nausea
Hallucinations/delirium
Diarrhoea with entacapone
Motor fluctuations
Quickly exclude other
causes. Domperidone for
nausea +/- postural
hypotension (can also given
fludrocortisone for this).
DON’T CHANGE PD DRUGS –
let PD team know – can
usually be sorted as
outpatient unless v unwell
Missed/delayed PD
medication
Deteriorating swallow
Deteriorating mobility
Deteriorating speech
Deteriorating consciousness
Aspiration pneumonia
Falls
Pressure ulcers
Neuroleptic Malignant Synd.
GIVE THE PD MEDICATION
OR
PD patient given a
dopamine antagonist
(eg stemetil,
metoclopramide,
risperidone, haloperidol)
ITU/HDU support may be
needed if appropriate, esp in
neuroleptic malignant
syndrome
Neuroleptic Malignant Syndrome
• In non-PD patients NMS is typically caused by
neuroleptics or other dopamine blocking agents
• In PD patients, the same thing can occur when their
dopamine is (abruptly) stopped/reduced
– usually precipitated by abrupt withdrawal or malabsorption of
PD medication (or if PD patient is given neuroleptics!)
– can be triggered by infection/other acute illness
– sometimes called parkinsonism-hyperpyrexia syndrome
– characterised by rigidity, hyperpyrexia and stupor, usually with
raised CK
Neuroleptic Malignant Syndrome in PD
History
Recent abrupt discontinuation of PD medication
Recently given dopamine antagonists (neuroleptics, stemetil etc)
Recent infection/physiological insult?
Signs
Rigidity
Hyperpyrexia
Stupor
Autonomic problems
Dysphagia
Lab findings
Raised CK
Metabolic Acidosis
Raised WCC
LFTs may be deranged
Management
GIVE THEIR PD MEDICATION (convert to NG if needed)
Critical care – IV hydration, anti-pyretics, cooling, dialysis if needed
Dantrolene for severe refractory rigidity
Observe closely for
Aspiration pneumonia, DIC, thromboembolism, Renal failure
Falls & PD
• Often multi-factorial:
– PD + contributing co-morbidities +/- acute illness
• PD falls risk factors:
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Postural instability
Postural hypotension
Difficulty with gait initiation
Freezing
Festination
Perceptual problems
Diplopia
GI problems & emergencies in PD
• Nausea & Vomiting
– Common s/e of PD meds
– Domperidone is anti-emetic of
choice in PD
• Constipation
• Impaction & pseudo-obstruction
• SIGMOID VOLVULUS
– Some PD patients get this
recurrently
• Don’t forget D&V will impair
absorption of PD meds
Respiratory problems & emergencies in PD
Aspiration
Pneumonia
Swallow
worsens
NBM
PD control
worsens
Swallowing problems & NBM in PD
NEVER miss/delay PD medications – if the patient cannot swallow or
is planned to be NBM (eg for theatre), need URGENT alternative:
• Plan A
– Take PD meds as usual even if NBM for everything else
• Plan B
– Dispersible madopar oral or NG
– Convert any sinement/madopar/stalevo to dispersible madopar and give at
same doses and times
– Will dissolve in 5-10ml water, thicken if needed – usually safer to swallow
this than to miss/delay PD meds (risk/benefit)
• Plan C
– Rotigotine patch (but ensure correct conversion – call PD team if needed)
Flowchart - NBM & swallowing problems in Parkinson’s
Is the gut working and can the patient swallow small
10ml amounts of (thickened) fluid/yoghurt/custard?
Yes
No
Is the gut working and can you pass an NG tube?
Either:
Give usual PD meds with 10ml of
water, yoghurt, custard, even if
NBM for everything else
Yes
Urgent NG Tube
Or:
Contact doctor urgently to convert
usual PD medication to dispersible
Madopar and give in 10ml of
(thickened) fluid, even if NBM for
everything else.
Contact doctor urgently to
convert usual PD medication to
dispersible Madopar.
A stat dose of dispersible
Madopar can be given if
medication already delayed.
No
Rotigotine Patch
Contact doctor urgently to
prescribe: Rotigotine Patch
4mg as a stat dose.
Before next dose due, contact
doctor/pharmacist to: convert
PD medication to daily
rotigotine patch (dose will
vary between patients)
Medicines not available in department?
In hours: Contact ward pharmacist/pharmacy to obtain medication
Out of hours: Check ward stock list or source medication via emergency medicines cupboard
Surgical patients with PD
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Parkinson’s patients MUST continue to take some form of PD medication
Place 1st on operating lists
If timing of PD medication is going to clash with surgery, the regimen MUST be
altered – call PD team if necessary
Patients can still receive PD medication with a small amount of water up to 1-2
hours pre-op, even if they are nil by mouth for everything else
If the surgery is expected to last more than 3 hours, or if there is likely to be a
NBM period >6hours, an alternative route of drug administration MUST be
arranged – eg NG tube or rotigotine patch (get specialist advice from PD team
if necessary)
If there is a non-functioning gut (eg ileus), convert PD drugs to rotigotine
(follow NBM flowchart and contact PD team asap)
PD team – Dr Sally Jones (BHH), Elderly Care SpR/Cons (all 3 sites),
PD CNS - Maggie Johnson (via switchboard/ext 43768)
Psychiatric problems & emergencies in PD
Problem
Note
Action in ED/AMU
Hallucinations
Very common in PD (& in PD
dementia). Often “normal for
them”, but worse if unwell or if
recent PD medication change
Quickly exclude acute medical
issue (eg infection, electrolytes).
Let PD team know - can usually be
managed as outpatient unless v
disturbed. NEVER adjust the PD
drugs or give anti-psychotic unless
the PD team instruct to do so.
Dopamine
Dysregulation Syndrome
(& impulse control
disorders)
Unusual to present as
emergency but may “shop”
round different hospitals in
attempt to obtain more PD
drugs.
Let PD team know of any concerns.
Can usually be managed as
outpatient.
Mood disorders
Very common
Involve RAID/CMHT if concerns
PD dementia
Lewy Body Dementia
Often hallucinate and have
perceptual problems
Delirium
PD patients are susceptible
Exclude reversible contributers.
Involve PD &RAID teams if
concerns. NEVER give haloperidol
or risperidone.
Summary of Emergencies in PD
PD related problem
PD complicating other problems
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Neuroleptic Malignant Syndrome
Aspiration pneumonia
Postural hypotension
Falls
Volvulus
Constipation/pseudo-obstruction
Psychosis
Severe motor fluctuations
PD medication side effects
Nil by mouth
Iatrogenic medication issues
Autonomic instability
Mobility issues
Delirium
Nausea/vomiting
Diarrhoea
Golden Rule 1
Parkinson’s is a gradually progressive condition
and does NOT get worse overnight, so if a PD
patient suddenly deteriorates:
• Either it’s not the PD
• Or they’ve missed their medication
Golden Rule 2
Never ever miss or delay PD medication
• Stat dose if already late when you see them
• NG tube if needed
• Dispersible madopar (instead of their usual L-dopa
preparation) at same time/dose equivalent if needed
• Rotigotine patch if NG really not an option (but make
sure its the correct dose and let the PD team know)
• All PD meds are in the emergency drugs cupboard in
pharmacy
Golden Rule 3
NEVER prescribe metoclopramide, stemetil,
haloperidol or risperidone for a PD patient or I
will hunt you down and shoot you!!
• Most anti-emetics and anti-psychotics:
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Make Parkinson’s Disease WORSE
CAUSE drug induced parkinsonsim
Can cause life threatening complications
• Anti-emetic of choice in PD = Domperidone
• Drug of choice if severely agitated = Lorazepam
Thank you 
Questions?