Parkinson's disease Flashcards
What are the clinical features of Parkinson’s other than bradykinesia, rigidity & tremor? (3 categories)
Motor symptoms: tremor, stiffness (difficulty using limbs, trouble turning in bed), difficulty walking, falls, poor balance, dysphagia
Non-motor: cognitive impairment, depression/psychosis, REM sleep behavior disorders (insomnia, RLS), olfactory loss
Autonomic: postural hypotension, bladder issues, constipation, sexual dysfunction
Resulting in: falling, not eating, not sleeping, in poor mood.
Parkinson’s PRICMCP?
P: dx date, initial symptoms + progression, exact timing of PD medications (and relationship to means - should be taken 1h before to 30min after to maximise absorption), ON + OFF times
R: FH, pesticide/heavy metal exposure
I: none
C: results from both disease + medication: dyskinesia (uncontrolled/involuntary movements), depression/psychosis, cognitive impairment, sleep disorders, RLS, disability, GIT*** (dysphagia, poor gastric motility, constipation), falls/#, sexual dysfunction, urinary difficulties. Anticholinergics (dry mouth, blurred vision, constipation, urinary retention), DAs (impulse control***)
M: current & previous regime. Has it made a difference? Compliance (especially with timing), appropriate home setup.
C: current symptoms. How is patient affected - jobs, ADLs, driving. Carer burden/stress!!
P: insight into progressive + disabling nature of the disease.
What pharmacological options for PD? (what is your spiel)
No therapy slows progression: aim = symptom control + QOL.
Start low, go slow
Firstline = MAO-B, DAs or L-dopa
MAO-Bi (Rasagiline): well-tolerated, no titration. Can be used first if mild disability.
DAs: delays motor fluctuations (compared with L-dopa) but impulse control disorder is a big problem
L-Dopa: most potent but highest risk of dyskinesia & fluctuations
Add COMT inhibitor (entacapone) after 1st 3.
Others: anticholinergics/amantadine.
How common is GIT dysfunction in PD, what is its impact on PD management, and what is your strategy for managing that? (5)
Very common
Causes Dysphagia, reduced gastric motility, constipation
Affects swallowing + absorption of medications → significant contributor to motor fluctuations
Strategies:
- Take meds 45m prior to 2h after meals
- Move largest, protein-rich meal to the evening
- Treat constipation
- Domperidone (ECG prior)
- Bypass GIT (transdermal Rotigotine - Neupro)
What are the differential diagnoses of PD? (with brief description of how they are different)
PSP (more symmetrical, early falls, difficulty looking down)
MSA (cerebellar + autonomic)
CBD (alien limb, cortical sensory loss, myoclonus, apraxia)
Secondary Parkinson’s (drug, CVD, structural lesions)
What are the management options for PD when oral drug therapies failed with poor symptom control with unpredictable fluctuations?
GIT dysfunction is common and affects drug absorption. There are several ways to manage this, but requires a specialised MDT.
Ideal candidates: Levodopa responsive (otherwise no point), poor symptom control despite medication adjustments but cognitively/psych sound with good social support.
- Apomorphine (oral/SC): very potent dopamine agonist, can be given as continuous pump or intermittent rescue SC injections
- Deep brain stimulation
- Intestinal gel (Levodopa-carbidopa) via jejunal tube (percutaneous endoscopic gastrostomy needed)
What is your approach to managing this patient with Parkinson’s disease?
Goal: minimize symptoms, prevent complications
Confirm dx + A: clinical but review MRI (r/o structural lesions, stroke, MS affecting basal ganglia), pharmacy record (antipsychotics, maxalon, prochlorperazine)
Screen for complications:
- review symptom diary/collaterals (on-off, dyskinesia, times)
- depression, MMSE
- SGA
- stool chart, bladder scan.
T: non-pharm
- Educate: progressive/non-reversible nature, taking meds at the right time***, provide written information. PD symptom chart***
- Life-style: moderate exercise 30min 5d/wk, good sleep hygiene, smoking cessation, moderation of alcohol (Falls)
- Diet: frequent water (6 glasses/d), fiber/protein-rich food, healthy fats (nuts, avocado)
- Falls prevention: walking aids, home mods, exercise programs with PT, vital calls, night lights
T: pharm
- MAO-B, DA, L-Dopa +/- COMT: again, educate on taking tabs at appropriate time (45m prior to 2h post meals) - fix this first
- Consider advanced therapies if still L-dopa responsive but yet poor symptom control with unpredictable fluctuations - S/C pump, S/C injections, intestinal gel, deep brain stimulation
Involve
- Allied Health + PD nurses
- Neuropsychiatrist/Psychology + Neurologist
- Groups + societies + carer support
Ensure follow-up and monitor for complications of therapies & disease
- E.g. impulse control, postural hypotension, cognitive effects. Screen as above.
Falls are a major cause of morbidity in PD. Why?
Rigidity and freezing when ‘off’
Dyskinesias when ‘on’
Postural hypotension due to autonomic failure and dopamine therapy
What is your approach to postural hypotension in PD? (4)
This is a difficult and important issue. Falls risk is the biggest concern, which is increased by both undertreatment and overtreatment
The approach is:
- Non-pharmacologic measures first - falls prevention measures
- Reduce antihypertensives next
- Consider fludrocortisone and/or midodrine next
- Try to avoid changing dopamine therapy if possible as reductions in postural drops will be offset by reduced mobility and falls risk may be higher
What non-pharmacologic measures should be tried to optimise postural BP in PD? (4)
- Postural precautions
- Compression stockings
- Take anti-hypertensives at night
- Exercise - horizontal positions (e.g. swimming)
- Increase salt + fluid intake
- Sleep with the head of the bed up
Why is nutrition such a prominent issue in PD?
Increased BMR due to tremor and dyskinesias
Reduced intake due to dysphagia symptoms in advanced disease
Reduced appetite (and nausea) due to dopamine therapy
What is your approach to low mood in PD?
Consider alternative diagnosis
- Cognitive impairment, delirium
- Undertreated PD (“blunted effect”)
- Thyroid, B12 deficiency, infection
Non-pharm & pharm as for usual depression management.
What is your approach to psychosis/hallucinations in PD?
Difficult Mx issue as psychosis maybe due to side effect of the drug vs. progression of disease
- If hallucinations are distressing, it is more likely to be delirium or drug-induced; hallucinations due to progressive disease are often non-distressing****
If thought to be due to the side effect of medications
- Stop anticholinergic medications first
- Reduce or cease dopamine agonists next
- Reduce L-dopa doses next if possible – consider smaller, more frequent doses if Sx are temporally related to doses
- Consider antipsychotics – clozapine is most effective but quetiapine is preferred due to less severe AEs
What is your approach to cognitive decline in PD?
- Consider alternative diagnoses such as depression, undertreatment, B12 deficiency or hypothyroidism
- Educate the patient and their care-givers about the prognosis (progressive and incurable), non-pharmacologic strategies and drug treatment
- Avoid unnecessary exacerbants such as elective surgery and infection
- Consider cholinesterase inhibitors (e.g. Donepezil) early
What is your approach to bladder dysfunction in PD?
- Educate Pt and family about the condition (usually detrusor overactivity, causing urge incontinence) and the risk of falls as a result
- Screen for and treat infection
- Use non-pharmacologic strategies, including regular voiding (NOT fluid restriction) and incontinence pads
- Avoid anticholinergics
