parkinsons disease management in primary care. introduction progressive condition 1:500 whole...
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Parkinson’s Disease
Management in Primary Care
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Introduction Progressive condition 1:500 whole population 1:50 of elderly 1:10 Nursing Home Residents
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Recognition Slowness Stiffness Tremor Loss of balance
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First Diagnosis PCT priorities
carer support manage co-morbidity nursing needs assessment
Patient concerns driving (DVLA, insurers) inheritance (rare)
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Management Aims Initial
acceptance of diagnosis control symptoms reduce distress improve outlook
Subsequent relieve morbidity prevent complications
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Maintenance PCT priorities
complications follow-up arrangements
?shared care
Patient concerns work/finance/benefits sexuality
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Complex Parkinson’s PCT priorities Aims
maintain good health manage drug regime address disease/complication
problems support for patients/carers
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Complications Deteriorating function
immobility, slowness, loss of activity Loss of drug effect
end-dose, on-off effects Involuntary movements (dyskinesia) Confusion, depression, hallucination Constipation, incontinence, wt loss,
hypotension
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Referral Initial Maintenance Complex Palliative
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Referral: Initial Confirmation of diagnosis Management
multi-disciplinary team see later
drug treatment Special Interest follow-up
monitoring side effects
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Referral: Maintenance Multi-disciplinary team
Occupational Therapy Physiotherapy Dietician Speech/Language therapy Social Services Podiatrist Continence Advisor
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Referral: Complex Specialist team in major role
access to secondary care neurosurgery watch for complications communication
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Referral: Palliative Appropriate support
palliative care services social needs assessment care in home, nursing home or
hospice
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Drug Treatment Progression
PD inevitably progresses Tachyphylaxis
Levodopa only works for 4-5 years More levodopa = late side effects
50% of patients by 4-5 years Polypharmacy
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Drug Treatment Levodopa Dopamine agonists Selegiline (MAOI type B) COMT inhibitors Anticholinergics Amantadine
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Levodopa used since 1960’s mixed with dopa decarboxylase
inhibitor good for rigidity/bradykinesia not so good for tremor Side Effects:
confusion, hallucinations, mood changes/swings
involuntary movements: on-off
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Dopamine Agonists Bromocriptine, Pergolide,
Ropinirole, Cabergoline, Pramipexole single Rx co-Rx with levodopa
Apomorphine subcutaneous injection in advanced
refractory disease usually initiated in-patient (ADR)
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Selegiline MAOI prevents Dopamine
breakdown co-Rx with levodopa unexpectedly high mortality (?
autonomic ADR)
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COMT inhibitors Inhibit alternative dopamine
degradation pathway Allow reduction levodopa dose (30-
50%) LFTs need to be monitored
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Anticholinergics Benzhexol, orphenadrine
useful in younger patients with tremor
avoid in elderly (ADR)
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Amantadine Useful in younger/mildly-affected
patient Loses effect quickly (months) Good for mild akinesia/tremor
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Drugs to avoid Phenothiazines
Prochlorperazine, fluphenazine, haloperidol, sulpiride
Metoclopramide MAOIs: provoke ADR with levodopa Atypical antipsychotics
clozapine, olanzapine
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Parkinson’s Disease Society
215 Vauxhall Bridge Road,LONDON SW1V 1EJTel 020 7931 8080www.parkinsons.org.uk
Helpline 0808 800 0303