Parkinson s Disease Duncan Gerry. 5/12/12 All drugs are poison
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1 Parkinson s Disease Duncan Gerry 5/12/12 All drugs are poison
2 Order of the Day Current and future of PD service in Hillingdon Case history highlighting the complexity of management, presentation and some of the common medications used Focus on one group of medications and a serious consequence
3 Learning objectives To be aware of the present and future of the PD service in the Hillingdon area Increased awareness of a relatively common and potentially very serious side effect of a commonly used drug group in Parkinson s Disease.
4 Service Details and some changes afoot Parkinson s Disease clinic run in the MVH Elderly Day Hospital Consultant and SpR for training Staff Grade with Parkinson s disease specialist training Parkinson s disease specialist nurse Parkinson s UK Hayley Cole, Parkinson s Disease specialist nurse In post now for over a year Covers the whole of the Hillingdon area (needs to have a Hillingdon GP) Sees referrals from all sources and liaises with the local PD specialists. Part of the Community Rehabilitation team Referrals to be sent to Eastcote Health Centre She is also to be found on the Hillingdon Community Health website Yen Tai Recently appointed Neurologist with an interest in Movement Disorder Will be taking over the PD service from February 2013.
5 Mr DL - History Idiopathic Parkinson s Disease first presented to Neurology in Symptoms and signs at presentation Progressively stooped posture Shortening of stride length Soft voice diminished arm swing on the right with Right sided bradykinseia and increased tone. No tremor noted Medication started Pramepixole
6 Progression May 2007 Immediate effect with Pramepixole Writing improved Mouse control improved Now minimal bradykinesia Dose doubled Pramepixole 250mcg bd as salt
7 April 2008 Progressive symptoms related mainly to his voice (soft and difficult to understand) New symptom associated with Parkinson s Disease Urinary hesitancy and urgency Additional symptom of day time somnlescence Recognised side effect of DA drugs but can also be a side effect of IPD. May be a group effect but may be specific. Management - Change DA to new drug in the same group, Ropinirole.
8 April 2008-September 2009 Ropinrole increased to the maximum 24mg as once daily XL. Increasingly symptomatic L-Dopa added in (Madopar 62.5mg tds)
9 Up to April 2011 Progressive Parkinsonian symptoms despite increasing doses of DA, L-Dopa, COMPT inhibitors and MAOB-I. Still walking a mile a day but has had falls (two in the past 4 months) Other problems documented Drooling Poor sleep Falls Day time somnlescence Obsessive behaviour.
10 Medication as of April 2011 Ropinirole 24mg XL od Stalevo 100 (Levodopa 100mg, Carbidopa 25mg and Entacapone 200mg) tds Half Sinemet CR 25/100 tds Rasagiline 1mg od Doxazocin 2mg od Omeprazole 20mg
11 December 2011 Increasing problems with on/off phenomena. Falls Freezing Cognition reported as intact Rasagiline (an MAOB-I) discontinued as no perceived benefit but other medication remain the same Referred to me for on going care
12 Admission - December 2011 Falls Multiple Memorable fall 2 weeks ago with a head injury (he managed to distort the metal bathroom door handle simply by using his head) Confusion AMT documented as 10/10 Hallucinations Visual and auditory Rash Widespread itchy erythematous patches with occasional blisters.
13 Medication on admission None documented None prescribed
14 New Diagnoses Acute on chronic subdural Bullous pemphigoid Transferred to MVH for rehabilitation
15 Ward round Hallucinations Drowsy at times Requiring sedation (lorazepam) particularly at night Mobile now only with a Zimmer frame and assistance of 2.
16 Medication Ropinirole 24mg XL od Stalevo 100 (Levodopa 100mg, Carbidopa 25mg and Entacapone 200mg) tds Half Sinemet CR 25/100 tds Tolterodine 4mg XL (discontinued on ward round) Omeprazole 20mg
17 Collateral history from wife Hallucinations are new and started shortly prior to admission Was an accountant but has been struggling with finances for the past year Has been staying up all night using the computer (going back a few years) For two years has been placing peaces of paper around the house saying that he is sorting things out but his wife can t see any logic to it. Has become fixated on the idea of an international web based scam.
18 New diagnosis Punding Related to impulse control disorders n. A human activity characterized by compulsive fascination with and performance of repetitive, mechanical tasks, such as assembling and disassembling, collecting, or sorting household objects. Origins of the term come from complex prolonged, purposeless, and stereotyped behaviour in chronic amphetamine users.
19 Impulse control disorders Can be associated with all groups of PD drugs Dopamine agonists particularly in the spotlight. Odds ration of 2.72 (CI ) DA vs non DA treated Parkinson s Disease (DOMINION study) A spectrum of disease covering addictive gambling obsessive shopping binge eating Hypersexuality which overlaps with Punding (compulsive hobbyism) Dopamine dysregulation disorder.
20 29 th November 2012 Loving husband who claimed Parkinson's drug turned him into a 'gay sex addict' wins 160,000 compensation in a French court Didier Jambart, of Nantes, France, was an upstanding member of the community before he started taking Requip But it soon turned him into a gambler and sex addict who sold his children's toys for cash His wife, who has stood by him throughout, was with him as he wept with relief in court after the ruling
21 Parkinson's UK information sheet I thought I would be immune to impulsive and compulsive behaviour, but soon after starting on medication in August 2006, something made me try internet gambling. Unfortunately, almost without realising what was happening, I spent hours in front of my computer and ran up debts on credit cards and loans of more than 40,000. I am no longer taking dopamine agonists and am spending less, but have managed to agree repayment plans with all my creditors and have avoided bankruptcy. It is a nightmare. At the time, however, I enjoyed the sound of the slots and genuinely believed I was going to win. JC, diagnosed in 2006
22 Frequency Dominion study One ICD 13.4% Two or more ICDs 3.9% Frequency of single ICDs Compulsive buying 5.7% Pathological gambling 5% Binge eating 4.3% Compulsive sexual behaviour 3.4%
23 Risk factors for ICDs male younger person with Parkinson s single person who lives alone smoker someone with a history of addictive behaviour someone who has a family history of gambling History of alcohol abuse
24 What to do? Warn all patients and relatives prior to starting to be aware of the common/ important side effects of medication Review and ask the right questions to look out for side effects. If it happens - Maybe nothing MICLO Depends on the degree of impact on quality of life. Generally first line is to gradually withdraw the Dopamine agonist there may be a threshold effect. Other drugs antidepressants, mood stabilisers, atypical antpsychotics or anticonvulsants (I start asking for help about now) Psychological support
25 MR DL Gradual reduction in Dopamine Agonist to 8mg XL od Punding behaviour has now stopped.
26 Take home messages All drugs have consequences Specific side effects of Dopamine Agonists are recognised and the side effects are not isolated to Parkinson's Disease patients Education Active monitoring Intervention when necessary
27 Any Questions?
28 THE END
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