Parkinson s Disease - A Junior Doctor s Survival Guide

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1 Parkinson s Disease - A Junior Doctor s Survival Guide Professor Richard Walker Consultant Geriatrician Hon. Professor of Ageing & Interna<onal Health Northumbria Healthcare NHS Founda<on Trust

2 Geriatricians ideally suited to care for Parkinson s disease Ø Many patients elderly Ø Multiple co-morbidity Ø Multi-system disease Ø Requires multidisciplinary team

3 North Tyneside Prevalence Ø Population of 110,000. Ø Case finding hospital records, GP records (diagnostic lists and drug treatment), other hospitals (eg Neurology). Ø Age-standardised prevalence = 160/100,000. Comparable with previous studies (Porter et al 2006).

4 Aetiological theory for PD

5 What causes Parkinson s? Ageing Genes Environment Parkinson s disease Possible protective effect: smoking and caffeine

6 When do clinical signs of Parkinson's develop? Striatal dopamine levels Reduced by 80% Cell loss in the substantia nigra Reaches 50%

7 The Braak hypothesis Stage 5 and 6: Changes spread to the cortex Stage 3 and 4: Pathology spreads to the midbrain and basal ganglia Stage 1 and 2: Pathology confined to certain structures in the brain stem, not yet the substantia nigra Image adapted from The Professionals Guide to Parkinson s Disease

8 DIAGNOSIS

9 Differential Diagnoses Ø Drug induced parkinsonism Ø Cerebrovascular parkinsonism Ø Lewy body dementia Ø Alzheimers disease Ø Multi system atrophy Ø Progressive supranuclear palsy Ø Benign essential tremor Ø Other weird and wonderful conditions

10 Brain Bank Criteria Ø Developed by PD society brain bank study Ø Retrospectively Ø Sensitivity 96% Ø Specificity 82% Ø Tool now used in epidemiological studies in PD

11 Diagnosis of Parkinsonism - signs Ø BRADYKINESIA and one of: Ø Muscular rigidity Ø 4-6Hz rest tremor Ø Postural instability

12 Probable most important diagnostic criteria Ø Asymmetrical onset Ø Progressive condition Ø Responsive to levodopa

13 Speech Hypomimia Reduced arm swing Posture Tremor Arising from a chair Bradykinesia Rigidity Motor symptoms of Parkinson s Motor symptoms of Parkinson's Postural instability Micrographia Turning in bed Turning Freezing Gait festination Shuffling gait Falls

14 Investigations Ø Routine blood investigations Ø DAT Scan normal in essential tremor and drug-induced Parkinsonism Ø +/- MRI Scan Ø?Dopamine challenge reasonable dose for reasonable length of time Ø Sniffin sticks objective change in sense of smell at diagnosis in over 70%

15 Partnerships in PD PDS Service Users Carers Age Concern Voluntary Bodies Family Health Visitor Consultant Social Worker Person with PD Friends Physiotherapy PD Nurse OT Dietician Psychiatrist GP District Nurse SALT Psychologist

16 The most important partnership Person with PD Person who knows about PD

17 Drug classes in Parkinson s Levodopa MAO-B inhibitors Monoamine oxidase B inhibitors Anticholinergics DAs Dopamine agonists COMTs Catechol-Omethyltransferase inhibitors

18 L-dopa Benefits Disadvantages Most effective symptomatic therapy Good response for morbidity and probably mortality Benefits may be enhanced by: Ø dopamine agonists Ø CR preparations Ø COMT inhibitors Short and long term side effects Complications with longterm use include motor fluctuations and dyskinesias Do not stop disease progression Free radical formation?

19 Specifics of L dopa prescribing Ø Sinemet 110, 125, 275 Halfs etc etc Ø Start low go slow Ø What dose do you go to? Ø CR preparations Ø Dispersible madopar

20 Typical pattern of wearingoff during the day

21 Dopamine agonists Benefits Disadvantages Proven antiparkinsonian activity, although less than levodopa Motor fluctuations and dyskinesias are encountered less if monotherapy Do not produce free radicals Initiation of treatment requires careful dose titration Limited evidence for add on therapy Non-ergolines (ropinirole/ pramipexole) can cause confusion (particularly in the elderly), nausea, dizziness, fainting and daytime sleepiness Ergot-derived agonists (cabergoline, bromocriptine and pergolide) can cause additional, lung and peritoneal fibrosis now not used

22 Impulse Control Disorder A person s inability to resist a temptation or impulse More likely to happen in those with a previous history of novelty seeking or risk taking behaviours Compulsive behaviours have been reported as a side effect with levodopa and dopamine agonists Behaviours can include: l Pathological gambling l Hypersexuality l Compulsive eating l Compulsive shopping l Punding

23 Ø Thalamotomy l Surgery drug-resistant unilateral tremor Ø Pallidotomy l drug-induced dyskinesias Ø Sub-thalamotomy - experimental Ø Stimulation - bilateral l l l thalamic (tremor) bilateral subthalamic nucleus (parkinsonism, tremor, dystonia) pallidal (dyskinesias)

24 Non-motor symptoms Neuropsychiatric Autonomic Sleep disturbance Sensory symptoms Dementia Depression Apathy Anxiety Loss of libido REM sleep disorder RLS Vivid dreams Daytime somnolence Dystonia Constipation Urinary incontinence Erectile dysfunction Excessive sweating Postural hypotension Excessive salivation Pain Paraesthesia

25 Sleep Disorders Ø Two thirds of patients Ø Insomnia l l Initial Sleep maintenance (sleep fragmentation) Parasomnias l l REM sleep behaviour disorder Vivid dreams Ø Excessive daytime sleepiness and sleep attacks Ø Obstructive sleep apnoea and stridor (NB MSA)

26 NEUROPSYCHIATRIC COMPLICATIONS

27 Ø Depression Ø Anxiety and agitation Ø Sleep disturbances Ø Vivid dreams Ø Hallucinations Ø Delirium Ø Dementia

28 Confused patient Ø Delirium screen Ø Decrease PD medication in following order l Anticholinergic, Amantadine, MAOIB, DA, COMT-I, LD Ø Consider atypical neuroleptic, eg Quetiapine (Clozapine) start at low dose of 12.5mgs Ø Cholinesterase inhibitors, eg Donepezil, Rivastigmine (NB patch) may improve cognition and hallucinations

29 Swallowing problems Ø Look for reversible cause Ø Get PD medication into patient l NG tube l Rotigotine patch l Apomorphine subcutaneously (NB Domperidone) Ø Don t consider for end of life care unless adequate dopaminergic replacement, or on advice from PD specialist team

30 General tips for inpatients Ø Make sure they get medication on time Ø Know how to contact PD specialist team, eg PD nurse specialist will often know patients well Ø Ask about hallucinations Ø Any illness will often make PD symptoms worse, and it takes PD patients longer to recover

31 Useful Contacts for PD Ø Parkinson s UK Ø BGS movement disorders section Ø [email protected]