Parkinson's Disease - Management

  • Created by: LBCW0502
  • Created on: 24-11-18 15:32
Which observations did James Parkinson note about the shaking palsy?
Involuntary tremulous motion, a propensity to bend forwards, the senses and intellect are intact
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The presence of which proteins indicates Parkinson's disease?
Lewy bodies - mechanism also involves basal ganglia
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Describe the mechanism for normal movement
Dopamine release from nerve terminals. Passes through striatal dopamine receptors into the striatal neurone to produce a response
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Describe the mechanism for a patient with Parkinson's disease
Fewer nerve terminals release dopamine. Passes through fewer striatal dopamine receptors leads to limited movement as a response
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Outline the process for the mechanism for movement
Input from motor cortex, basal ganglia, output to motor cortex via thalamus, impulse sent to spinal cord resulting in movement of skeletal muscle (in PD there are issues with the impulse from the basal ganglia to the thalamus)
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Which are the symptoms of PD? (1)
Tremor (draw smaller pictures), postural instability, bradykinesia, rigidity of limbs, pain, fatigue, insomnia etc.
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Which are the symptoms of PD? (2)
Facial expressions change, speech monotonous/hypophonic, movement (decreased manual dexterity, rigid hands/arms, frozen shoulder), bulbar symptoms, dysarthia, dysphagia
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Describe features of differential diagnosis
Essential tremor, drug induced PD symptoms e.g. antipsychotics, anti-emetics (metoclopramide), anti-histamines (cinnarizine), methyldopa
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What are the causes of PD
Idiopathic, elderly, personality, environmental factors, pesticides, genetics (family history) etc.
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What are the aims of drug therapy?
To control symptoms with lowest therapeutic dose for that individual. Simple regime with minimal or no side effects
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What are the therapeutic drug strategies? (1)
Increase dopamine levels in the brain (levodopa, co-careldopa, co-beneldopa). Decrease metabolism of dopamine in brain (MAOBIs - selegiline, rasagaline, safinamide, COMT inhibitors - entacapone, tolcapone, opicapone)
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What are the therapeutic drug strategies? (2)
Stimulate dopamine receptors (dopamine agonists - pramipexole, ropinirole, rotigotine, apomorphine) - affect dopamine pathway in the brain
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What are the guiding principles?
Patient factors (age, lifestyle), symptoms, stage of disease, current therapy, previously tried therapy
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Describe features of levodopa
Most effective drug in PD (symptom control). Sinemet (co-careldopa). Madopar (co-beneldopa) - L-DOPA and dopa decarboxylase inhibitor (prevent metabolism of L-DOPA/dopamine)
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What are the long term challenges when using L-DOPA?
Risks of dyskinesia (decreased gap between dyskinesia threshold and response threshold)
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Describe features for optimising L-DOPA therapy
Improve consistency of absorption (treatments improve GE, review medicines with slow GE, treat constipation with laxative). Take doses one hour before/after meals. Use smaller doses more frequently. Consider use of MR preparations
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Describe features of dopamine agonists
Non-ergot (ropinirole, pramipexole, rotigotine patch, apomorphine). Ergot (bromocriptine, lisuride, carbergoline, pergolide). Ergots not used due to fibrotic reactions (retroperitoneal, pleuropulmonary, cardiac)
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What are the long term challenges of dopamine agonists?
Neuropsychiatric symptoms (impulse control disorders, punding). Sudden onset sleep (excessive daytime sleepiness and sudden onset sleep - might not be for all dopamine agonists)
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Describe features of MAO-B and COMT inhibitors
Slow the metabolism of dopamine in the body and keep levels of dopamine in the blood at more constant levels
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Describe features of anticholinergics
Reduce effects of central cholinergic excess that occurs as a result of dopamine deficiency. Used in drug induced Parkinsonism but are less effective than dopaminergic drugs in idiopathic PD e.g. benzatropine/orphenadrine/procyclidine/trihexyphenidyl
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What are the non-motor symptoms of PD?
Depression, anxiety, sleep dysfunction, urinary/bladder, constipation, pain
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What are the medicines to avoid?
Certain anti-sickness tablets (prochlorperazine, metoclopramide). OTC cough/decongestant remedies (pseudoephedrine). Herbal medicines (St. John's Wort)
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What are the advancing strategies?
Continuous delivery of medication for continuous, stable blood levels and effect e,g. rotigotine patch, L-DOPA intestinal gel, CR preparations
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What are the complications of missed doses?
Ability to manage symptoms may be lost (reduced mobility, increased risk of aspiration). Can be as serious as neuroleptic malignant syndrome (fevers, confusion). Always need to get dose on time
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Further resources
PD in NICE guidelines - application of case studies (lecture)
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Card 2

Front

The presence of which proteins indicates Parkinson's disease?

Back

Lewy bodies - mechanism also involves basal ganglia

Card 3

Front

Describe the mechanism for normal movement

Back

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Card 4

Front

Describe the mechanism for a patient with Parkinson's disease

Back

Preview of the front of card 4

Card 5

Front

Outline the process for the mechanism for movement

Back

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