parkinsons disease management in primary care. introduction progressive condition 1:500 whole...
TRANSCRIPT
Parkinson’s Disease
Management in Primary Care
Introduction Progressive condition 1:500 whole population 1:50 of elderly 1:10 Nursing Home Residents
Recognition Slowness Stiffness Tremor Loss of balance
First Diagnosis PCT priorities
carer support manage co-morbidity nursing needs assessment
Patient concerns driving (DVLA, insurers) inheritance (rare)
Management Aims Initial
acceptance of diagnosis control symptoms reduce distress improve outlook
Subsequent relieve morbidity prevent complications
Maintenance PCT priorities
complications follow-up arrangements
?shared care
Patient concerns work/finance/benefits sexuality
Complex Parkinson’s PCT priorities Aims
maintain good health manage drug regime address disease/complication
problems support for patients/carers
Complications Deteriorating function
immobility, slowness, loss of activity Loss of drug effect
end-dose, on-off effects Involuntary movements (dyskinesia) Confusion, depression, hallucination Constipation, incontinence, wt loss,
hypotension
Referral Initial Maintenance Complex Palliative
Referral: Initial Confirmation of diagnosis Management
multi-disciplinary team see later
drug treatment Special Interest follow-up
monitoring side effects
Referral: Maintenance Multi-disciplinary team
Occupational Therapy Physiotherapy Dietician Speech/Language therapy Social Services Podiatrist Continence Advisor
Referral: Complex Specialist team in major role
access to secondary care neurosurgery watch for complications communication
Referral: Palliative Appropriate support
palliative care services social needs assessment care in home, nursing home or
hospice
Drug Treatment Progression
PD inevitably progresses Tachyphylaxis
Levodopa only works for 4-5 years More levodopa = late side effects
50% of patients by 4-5 years Polypharmacy
Drug Treatment Levodopa Dopamine agonists Selegiline (MAOI type B) COMT inhibitors Anticholinergics Amantadine
Levodopa used since 1960’s mixed with dopa decarboxylase
inhibitor good for rigidity/bradykinesia not so good for tremor Side Effects:
confusion, hallucinations, mood changes/swings
involuntary movements: on-off
Dopamine Agonists Bromocriptine, Pergolide,
Ropinirole, Cabergoline, Pramipexole single Rx co-Rx with levodopa
Apomorphine subcutaneous injection in advanced
refractory disease usually initiated in-patient (ADR)
Selegiline MAOI prevents Dopamine
breakdown co-Rx with levodopa unexpectedly high mortality (?
autonomic ADR)
COMT inhibitors Inhibit alternative dopamine
degradation pathway Allow reduction levodopa dose (30-
50%) LFTs need to be monitored
Anticholinergics Benzhexol, orphenadrine
useful in younger patients with tremor
avoid in elderly (ADR)
Amantadine Useful in younger/mildly-affected
patient Loses effect quickly (months) Good for mild akinesia/tremor
Drugs to avoid Phenothiazines
Prochlorperazine, fluphenazine, haloperidol, sulpiride
Metoclopramide MAOIs: provoke ADR with levodopa Atypical antipsychotics
clozapine, olanzapine
Parkinson’s Disease Society
215 Vauxhall Bridge Road,LONDON SW1V 1EJTel 020 7931 8080www.parkinsons.org.uk
Helpline 0808 800 0303