Debra Vincent Scott Clinical nurse specialist in Parkinson’s

Debra Vincent Scott Clinical nurse specialist in Parkinson's disease Email [email protected] MOBILE 07979005687 This presentation has been produced by GlaxoSmithKline

Aims Prevalence Diagnosing Non Motor symptoms Stages of PD Treatment Patients experience

Prevalance 1 in 500 UK resident have PD 1 in 100 60 yrs have PD 127000 Pt have formal PD diagnosis (GPRD database) 1 in 20 Pt; Develop symptoms under 40 yrs of age By 2020: PD no will rise- 162000 28% rise in PD cases Economic burden of PD is 2 billion annually (Imperial College) (1, 2)

Diagnosing PD A set of characteristic symptoms that affect motor control: resting tremor, bradykinesia, and hypertonia. Resting tremor is an oscillating movement (4— 6 Hrzd) that occurs when the patient is trying to be still; disappears on action Essential Tremor: Persists on movement Cerebellar Tremor: Intentional tremor

Bradykinesia means slowness of movement. Usually experienced as ‘weakness’ or ‘stiffness’ of limb Hypertonia means excessive muscle tone. Manifest itself as rigidity or stiffness. Other typical features: are a Stooped posture/ Slow, shuffling festinant gait/ Reduced arm swing/ Facial appearance (Masked like ‘hypomimia’)/ Low volume speech/ Excessive drooling of saliva

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,

Non-motor symptoms of PD 3 Neuropsychiatric Autonomic Sleep disturbance Sensory symptoms Dementia REM sleep disorder Depression RLS Apathy Vivid dreams Anxiety Daytime somnolence Loss of libido Dystonia Constipation Urinary incontinence Erectile dysfunction Excessive sweating Postural hypotension Excessive salivation Pain Paraesthesia

Criteria for entry into staging categories Parkinson's Disease Diagnosis / early Levodopa or Dopamine agonists Rasagiline. selegiline Maintenance Entacapone Stalevo Complex Amantadine. Apomorphine Duodopa Palliative DBS Knowledge of disease Ideas and perceptions Employment issues Neuro rehab Promote normal function Regular reviews-red flags Support MDT input Motor complications. Neuropsychiatric complications Reduction of drugs. Carer support/respite/hospice Symptoms versus side effects Advanced care needs 4 .MacMahon D.G Thomas.S Practical Approach to Parkinson’s Disease. Journal of Neurology (1998) 245 (SUPP1)S19.S22

TREATMENT Begins with Diagnosis Patient education.MDT input Discussion of when and which drug Treatments. Bradykinesia dominated disease may need earlier treatment than tremor dominated disease People with suspected Parkinson’s should be referred quickly and untreated to a specialist (NICE 2006)

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

Drugs to avoid Generic name Brand name Usually prescribed for prochlorperazine metoclopramide Stemetil Maxalon Dizziness, nausea and vomiting fluphenazine perphenazine flupentixol Motival Triptafen Fluanxol Depixol Depression chlorpromazine fluphenazine haloperidol Largactil Moditen Serenace Haldol Fentazin Confusion, hallucinations, disorientation, or disturbed thinking perphenazine

Drug management As responses to drugs are variable, treatment regimes differ from person to person The timing of drugs is important in order to achieve continuous dopaminergic stimulation Nurses have a key role in helping the patients manage complex drug regimes Sudden discontinuation of treatment should be avoided as it can result in Neuroleptic Malignant Syndrome. Get it on time campaign. NH homes to send in medication with patient

End note Start ‘slow and low’ Watch for side effects; low BP, Orthostatic hypotension, ICD NMS are more common in older pts NMS are often confusing & poorly recognised Insomnia: likely due to Akathisia (inner restlessness), stiffness (rigidity), difficulty turning in bed, as well as tremor Anxiety: likely due to Akathisia Cramps: could be ‘dystonias’: inspect feet for inversion, great toe Pain/ Paresthesia/ depression: may be levodopa responsive Avoid hospitalisation The patient is the expert

References findley LJ The economic impact of Parkinson's disease. Parkinsonism Relat Disord. 2007 Sep;13 Suppl:S8-S12. Epub 2007 Aug 16. Oliver H.H. Gerlach, MD,* Ania Winogrodzka, MD, PhD, and Wim E.J. Weber, MD, PhD; Clinical Problems in the Hospitalized Parkinson’s Disease Patient: Systematic Review Movement Disorders, Vol. 26, No. 2, 2011 Huse DM, Schulman K, Orsini L, Castelli-Haley J, Kennedy S, Lenhart G. Burden of illness in Parkinson’s disease. Mov Disord 2005;20:1449–1454 Parkinson’s-UK. ‘‘Get It on Time.’’ www.parkinsons.org.uk. Shulman LM, Taback RL, Rabinstein AA, Weiner WJ. Non-recognition of depression and other non-motor symptoms in Parkinson’s disease. Parkinsonism Relat Disord. 2002;8(3): 193–197. Miyasaki JM, Shannon K, Voon V, et al. Quality Standards Subcommittee of the American Academy of Neurology. Practice Parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;66(7):996–1002. Poewe WH, Lees AJ, Stern GM. Low-dose L-dopa therapy in Parkinson’s disease: a 6-year follow-up study. Neurology1986;36:1528-1530. Kumar N, Van Gerpen JA, Bower JH, Ahlskog JE. Levodopa-dyskinesia incidence by age of Parkinson’s disease onset. Mov Disord 2005; 20:342-344 Holloway RG, Shoulson I, Fahn S, Kieburtz K, Lang A, Marek K, et al. Pramipexole vs levodopa as initial treatment for Parkinson disease: a 4-year randomized controlled trial. Arch Neurol 2004;61:1044-1053 Dodd, Klos KJ, Bower JH, Geda YE, Josephs KA, Ahlskog JE. Pathological gambling caused by drugs used to treat Parkinson disease. Arch Neurol 2005;62:1377-1381. Nirenberg MJ, Waters C. Compulsive eating and weight gain related to dopamine agonist use. Mov Disord 2006;21:524-529. 73. Voon V, Hassan K, Zurowski M, de Souza M, Thomsen T, Fox S, et al. Prevalence of repetitive and reward-seeking behaviors in Parkinson disease. Neurology 2006;67:1254-1257

Parkinson’s-UK. ‘‘Get It on Time.’’ www.parkinsons.org.uk. Shulman LM, Taback RL, Rabinstein AA, Weiner WJ. Non-recognition of depression and other non-motor symptoms in Parkinson’s disease. Parkinsonism Relat Disord. 2002;8(3): 193–197. Miyasaki JM, Shannon K, Voon V, et al. Quality Standards Subcommittee of the American Academy of Neurology. Practice Parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;66(7):996–1002. Poewe WH, Lees AJ, Stern GM. Low-dose L-dopa therapy in Parkinson’s disease: a 6-year follow-up study. Neurology1986;36:1528-1530. Kumar N, Van Gerpen JA, Bower JH, Ahlskog JE. Levodopa-dyskinesia incidence by age of Parkinson’s disease onset. Mov Disord 2005; 20:342-344 Holloway RG, Shoulson I, Fahn S, Kieburtz K, Lang A, Marek K, et al. Pramipexole vs levodopa as initial treatment for Parkinson disease: a 4-year randomized controlled trial. Arch Neurol 2004;61:1044-1053 Dodd ML, Klos KJ, Bower JH, Geda YE, Josephs KA, Ahlskog JE. Pathological gambling caused by drugs used to treat Parkinson disease. Arch Neurol 2005;62:1377-1381. Nirenberg MJ, Waters C. Compulsive eating and weight gain related to dopamine agonist use. Mov Disord 2006;21:524-529. 73. MacMahon D.G Thomas.S Practical Approach to Parkinson’s Disease. Journal of Neurology (1998) 245 (SUPP1)S19.S22 Voon V, Hassan K, Zurowski M, de Souza M, Thomsen T, Fox S, et al. Prevalence of repetitive and rewardseeking behaviors in Parkinson disease. Neurology 2006;67:1254-1257