Parkinson s Disease Management in Primary Care Introduction

Parkinson’s Disease Management in Primary Care

Introduction n n Progressive condition 1: 500 whole population 1: 50 of elderly 1: 10 Nursing Home Residents

Recognition n n Slowness Stiffness Tremor Loss of balance

First Diagnosis n PCT priorities n n carer support manage co-morbidity nursing needs assessment Patient concerns n n driving (DVLA, insurers) inheritance (rare)

Management Aims n Initial n n n acceptance of diagnosis control symptoms reduce distress improve outlook Subsequent n n relieve morbidity prevent complications

Maintenance n PCT priorities n n complications follow-up arrangements n n ? shared care Patient concerns n n work/finance/benefits sexuality

Complex Parkinson’s n n PCT priorities Aims n n maintain good health manage drug regime address disease/complication problems support for patients/carers

Complications n Deteriorating function n n Loss of drug effect n n immobility, slowness, loss of activity end-dose, on-off effects Involuntary movements (dyskinesia) Confusion, depression, hallucination Constipation, incontinence, wt loss, hypotension

Referral n n Initial Maintenance Complex Palliative

Referral: Initial n n Confirmation of diagnosis Management n multi-disciplinary team n n n see later drug treatment Special Interest follow-up n monitoring side effects

Referral: Maintenance n Multi-disciplinary team n n n n Occupational Therapy Physiotherapy Dietician Speech/Language therapy Social Services Podiatrist Continence Advisor

Referral: Complex n Specialist team in major role n n access to secondary care neurosurgery watch for complications communication

Referral: Palliative n Appropriate support n n n palliative care services social needs assessment care in home, nursing home or hospice

Drug Treatment n Progression n n Tachyphylaxis n n Levodopa only works for 4 -5 years More levodopa = late side effects n n PD inevitably progresses 50% of patients by 4 -5 years Polypharmacy

Drug Treatment n n n Levodopa Dopamine agonists Selegiline (MAOI type B) COMT inhibitors Anticholinergics Amantadine

Levodopa n n n used since 1960’s mixed with dopa decarboxylase inhibitor good for rigidity/bradykinesia not so good for tremor Side Effects: n n confusion, hallucinations, mood changes/swings involuntary movements: on-off

Dopamine Agonists n Bromocriptine, Pergolide, Ropinirole, Cabergoline, Pramipexole n n n single Rx co-Rx with levodopa Apomorphine n n subcutaneous injection in advanced refractory disease usually initiated in-patient (ADR)

Selegiline n n n MAOI prevents Dopamine breakdown co-Rx with levodopa unexpectedly high mortality (? autonomic ADR)

COMT inhibitors n n n Inhibit alternative dopamine degradation pathway Allow reduction levodopa dose (3050%) LFTs need to be monitored

Anticholinergics n Benzhexol, orphenadrine n n useful in younger patients with tremor avoid in elderly (ADR)

Amantadine n n n Useful in younger/mildly-affected patient Loses effect quickly (months) Good for mild akinesia/tremor

Drugs to avoid n Phenothiazines n n Prochlorperazine, fluphenazine, haloperidol, sulpiride Metoclopramide MAOIs: provoke ADR with levodopa Atypical antipsychotics n clozapine, olanzapine

Parkinson’s Disease Society 215 Vauxhall Bridge Road, LONDON SW 1 V 1 EJ Tel 020 7931 8080 www. parkinsons. org. uk Helpline 0808 800 0303