parkinsons disease management in primary care. introduction progressive condition 1:500 whole...

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