Movement Disorders,motor Neurone And Parkinsons

Question 1

Motor neurone disease

Answer 1

• neurodegenerative condition which affects brain and spinal cord
• degeneration of motor neurones to lead to ( muscle weakness,muscle cramps, wasting and stiffness, loss of dexterity,reduced respiratory and cognitive function)
• refer all patients to a neurologist without delay

Question 2

What is the aim of treatment?

Answer 2

There is no cure, treatment will focus on maintaining functional ability and managing symptoms

Question 3

Non drug treatment is what?

Answer 3

Includes - nutrition,psycho ill support,physio, expertise programmes and the use of immobility aids and special equipment

Question 4

Management if symptoms - muscular symptoms

Answer 4

• quinine (unlicensed as 1st line) for muscle cramps, 2nd line is baclofen, other options are tizanidine,dantrolene sodium or gabapentin (all unlicensed)

Question 5

Management of symptoms - muscle stiffness

Answer 5

Muscle stiffness - baclofen,tizanidine,dantrolene and gabapentin - all unlicensed

Question 6

Saliva problems?

Answer 6

Antimuscarinic - unlicensed, glycopyrronium bromide (for patients with cognitive impairment) - if ineffective, specialist referral for botulinum toxin type A

Question 7

Thick tenacious saliva

Answer 7

Humidification (moisture),nebulisers and carbocistine

Question 8

Respiratory problems

Answer 8

Treat patients with breathlessness with opioids (unlicensed) and benzos if symptoms are exacerbated by anxiety

Question 9

Amyotrophic lateral sclerosis aka motor neurones disease

Answer 9

Riluzole used as treatment to extend life

Question 10

Parkinson’s disease is what?

Answer 10

Progressive neurodegenerative condition
Results from death of dopamine cells in the brain
Patients will present with motor and non motor symptoms

Question 11

Motor symptoms of Parkinson

Answer 11

• Hypokinesia (small movements)
• Bradykinesia(slow movements)
• rigidity
• rest tremor
• postural instability

Question 12

Non motor symptoms

Answer 12

Dementia
Depression
Sleep disturbance
Bladder and bowel
Speech and language
Swallowing
Weight loss

Question 13

Non drug treatment

Answer 13

Physiotherapy
Speech and language therapy
Occupational therapy
Dietician

Question 14

Examples of drugs used in Parkinson’s

Answer 14

• entacapone
• opicapone
• tolcapone
• co- beneldopa
• co- carledopa
• amantidine
• apomorphine
• bromocripine
• carbergoline

Question 15

Classes of anti Parkinson meds

Answer 15

1) antimuscarinic
2) dopaminergic drugs

Question 17

Examples of antimuscarinic drugs

Answer 17

Orphenadrine,procyclidine and trihexyphenidyl

Question 18

Examples of dopaminergic drugs

Answer 18

• Catechol-o-methyltransferase inhibitors (entaccapone,topicapone and tolcapone)
• Dopamine precursors - levadopa (co- benaldopa,co-carledopa) - for more major complications

Dopamine receptor agonists - mimic cation of dopamine (amantadine,apomorphine,bromocriptine,cabergoline,pergolide,pramipexole,ropinirole,rotigotine)
Monoamine-oxidase B inhibitors - rasagiline,selegilline,safinamide)

Question 19

Parkinson’s drug treatment

Answer 19

1st line = management of motor symptoms which decrease quality of life
- levaadopa + carbidopa (co-carledopa) or benserazide (co- benaldopa)

2) Management of motor symptoms which do not affect quality of life- you can prescribe any of the following - levodopa, Non ergot derived dopamine receptor agonists (pramipexol,ropinirole or rotigotine)
- monamine oxidasase B inhibitors (rasagilline or selegilline)

Avoid abrupt withdrawal of parkinsonian drugs to prevent side effects

Question 20

Patient and carer advice

Answer 20

Inform patients of risk of adverse reactions from anti parkinsonian drugs including;
- psychotic symptoms
- sudden onset of sleep with dopamine agonists (pramipexole,ropinirole or rotigotine)
- impulse control disorders with dopaminergic therapy (Esp dopamine agonists)- pramipexole,ropinirole or rotigotine)
- above symptoms are less likely with levadopas but levadopa is associated with more motor complications(dyskinesias)

Question 21

Parkinson’s adjuvant therapy

Answer 21

Patients who develop dyskinesia or motor fluctuations despite optimal levodopa
Should be offered a choice of non-ergotic dopamine agonists (pramipexole,ropinirole,rotigotine),monoamine oxidase B inhibitors(rasaligine, selegilline) or COMT inhibitors (entacapone or tolcapone) as ajunct

NB:
Only consider an ergot derived dopamine agonist(eg. Bromocriptine,cabergoline or peroglide) as adjunct to levodopa of not ergot are not adequate

Amantadine - used if dyskinesia is not adequately managed by modifying existing therapy

Question 22

Parkinson’s drug management of non motor symptoms

Answer 22

1) excessive daytime sleepiness and sudden onset of sleep :
- give modafinil
- review treatment at least every 12 months
- advice patient not to drive and inform DVLA and think of any occupational hazards

2) nocturnal amines is (inability to turn in bed or side to pass urine at night)
- levodopa or oral dopamine receptor(1st line)
- Rootigotine (2nd line )

Question 23

More non motor symptom treatments

Answer 23

3) postural hypotension
- midorine hydrochloride (1st line)
- fludrocortisone (alternative)

4) depression
5) psychotic symptoms
- hallucinations and delusions(treatment not needed if well tolerated,consider reducing dose, but specialist advice must to sort first)
- quetiapine (clozapine as alternative)- used in patients with NO cognitive impairment
- other antipsychotics eg.phenothiazines and Butyrophenones) worsen the motor symptoms of Parkinson’s

6) Rapid eye movement - sleep behaviour disorder - clonazepam or melatonin

7) Drooling saliva
- Drug treatment only considered if non drug treatment such us speech and language therapy is not available or ineffective
- glycopyronium bromine - 1st line
- Botulinium type A (2nd line)
Other antimuscarinics should only be considered if the risk of cognitive effects is minimal and topical preparations like atropine should be used to reduce the risk of adverse events

8) Parkinson’s disease dementia
- offer a cholinesterase inhibitor c.i to patients with mil to moderate Parkinson’s disease
- offer memantibe if C.I is contraindicated

9) Advanced Parkinson’s disease
- offer apomorphine hydrochloride injections or infusions
- give dopamine to counte n/v side effects from apomorphine

Question 24

Drug management of impulse disorders

Answer 24

• examples - gambling, hyper sexuality, eating or obsessive shopping
• can develop in Parkinson’s patients on dopaminergic therapy
• high risk if history of impulsive behaviours,alcohol consumption or smoking
• reduce dose of dopamine receptor agonists gradually and monitor withdrawal symptoms
• offer CBT if dose reduction is not effective

Question 25

Important safety advice for anti Parkinson’s drugs

Answer 25

1) impulse control disorders can develop dopaminergic therapy especially if patient has previous history of impulsive behaviours, alcohol consumption (levadopa,apomorphine,bromocriptine,carbergoline, pergolide, pramipexole, ropinirole and rotigotine) 2) fibrotic reactions - monitor for dyspnoea (laboured breathing),persistent cough,chest pain,cardiac failure and abdominal pain (bromocriptine,cabergoline, pergolide)

Question 26

Parkinson’s treatment cessation

Answer 26

- never stop abruptly or decrease dose suddenly, increases risk of neuroleptic malignant syndrome (NMS,high fever,confusion,rigid muscles, sweating and fast heart rate) - Nausea and vomitting - domperidone (drug of choice in Parkinson’s) - AVOID Metoclopramine - increases EPSE,Exacerbates Parkinson’s disease and antagonises effects of anti Parkinson drugs - Apomorphine (dopamine- receptor agonists) (sc injections/infusion) - causes n/v side effects- start domperiode 2 days before apomorphine treatment and discontinue asap - domperidone increases risk of qt PROLONGATION When given with apomorphine. Cause serious arrhythmia (monitor ECG and cardiac risk factor)

Question 27

COMT Inhibitors

Answer 27

Use adjunct to levadopa eg.tolacapone and entacapone Tolcapone - patient carer advice = liver toxicity - advise patient to recognise signs and seek immediate attention- anorexia,n/v,fatigue,abdominal pain,dark urine or pruritus - entacapone - patient carer advice - urine may be reddish brown

Question 28

Patient and carer advice for most Parkinson’s drugs

Answer 28

Sudden onset of sleep - excessive daytime sleepiness and sudden onset of sleep can occur with dopamine receptor agonists - caution when driving and operating machinery - counsel patient on improving sleep behaviour 2) hyposensitive reaction - especially during first few days of treatment - care when driving or operating machines 3) colour of urine - majority of anti Parkinson’s drugs colour urine - label 14 - medicine may colour urine - this is harmless