Parkinson s Disease. Gillian Sare

Transcription

1 Parkinson s Disease Gillian Sare

2 Outline Reminder about PD Parkinson s disease in the inpatient Surgical patients with PD Patients who cannot swallow End of life care

3 Parkinson s disease PD is the second most common neurodegenerative condition after Alzheimer s disease Lewy body inclusions accumulate in brain stem, substantia nigra and cortex Prevalence 160 per 100,000 in UK. Incidence ~ 13 per 100,000 per year but rises with age 2% of those over 80, 10% of people in nursing homes

4 Diagnosis Throughout history descriptions of the shaky palsy James Parkinson 1 st described cardinal features in 1817 Tremor Bradykinesia Stiffness Postural instability

5 Diagnosis Remains essentially clinical Patient present in a heterogeneous manner Tremor Gait problems Falls Stiffness/slowness

6 Non-motor manifestations of PD Depression (up to 60%) Dementia (up to 75%) Sleep disorders GI disturbance Restless legs Pain Postural hypotension Urinary problems

7 Drug therapies for PD

8 Standard Drug Therapies Levodopa (Madopar/Sinemet) Dopamine agonists (ropinerole, pramipexole, rotigotine) MAOB-inhibitors (selegiline, rasagiline) Amantadine COMT inhibitors (entacapone, tolcapone, Stalevo)

9 Drug therapies for late stage PD Apomorphine Short acting dopamine agonist given as rescue for sudden off periods or as continuous infusion Intrajenunal dopamine (Duodopa) Dopamine gel delivered by PEJ tube

10 Parkinson s in the inpatient

11 Why do patients with PD come into hospital Elective admissions for surgery Emergency admissions Relating to Parkinsons disease Relating to comorbidities Failure of social care Elective admissions for surgery

12 General advice Check what drugs they take and prescribe them at the correct time Never, ever, give metaclopramide or prochlorperizine (stemitil) domperidone and cyclizine Never give any antipsychotics (except quetiapine)

13 PD related admissions Falls Falls occur frequently in PD Can be caused by many factors Undertreatment - can be assessed by noting how much rigidity and bradykinesia there is falls may only occur in off state when were meds last increased how long disease duration Overtreatment relating to dyskinesia Relating to postural hypotension stop antihypertensives and consider hypertensives Related to late stage disease Unresponsive to medication physio - look to minimise harm

14 PD related admissions Cognitive decline Dementia occurs in 70% of people with PD in time Confusion, fluctuations, visual hallucinations Drugs which help movement exacerbate cognitive decline Concurrent illness unmasks underlying cognitive vulnerabilities

15 PD related admissions What to do with acute confused PD patient Exclude and treat concurrent illness Cut drugs (one at a time, agonists gradually, and the effect of reductions take time) Amantadine>selegiline>dopamine agonists>rasagiline>entacapone>l-dopa Rivastigime worth a go, but effects are often minimal and note GI side effects Consider quetiapine if extreme behaviour or cutting drugs not working not higher than 75mg/day without specialist advise start at 12.5mg DO NOT USE ANY OTHER ANTIPSYCHOTIC Lorazepam for PRN use Talk to family and involve SS

16 Admission with other health conditions PD will always be worse if there is another concurrent illness Not the best time to change around meds if the patient has had regular OP review by specialist Warn patient that recovery is longer and PD can take many weeks to return to baseline

17 Surgical patients Never, ever, withhold PD meds in a patient due for surgery Should be first on the list and have their morning meds with small sip of water Restart PD meds immediately after surgery even if not being fed (e.g. gut surgery) If malabsorption likely to be major issue convert to dispersible madopar and possibly increase dose However, dyskinesias are bad immediately post op and patient in bed. Start cautiously and increase

18 Patients who are unable to swallow Once again PD meds are essential meds Put down and NGT immediately and continue L-dopa dose in dispersible form If on an agonist convert to rotigotine patch at equivalent dose If vomiting profusely or NG cannot be passed then consider rotigotine patch in agonist naive patients in elderly be cautious 8mg and titrate little effect for first 48 hours NGT!!!

19 End of life issues

20 Advanced planning Where possible we should discuss this with patients we are variably good at doing this in clinic If patient is admitted with problems, when planning discharge, consider advance planning Involve patient and relatives Make sure GP is aware as community paperwork needs doing Make sure care home know

21 PD specific end of life issues DNAR - (always?) NG and RIG/PEG feeding Complex in PD Loss of swallow is usually and end stage development (unlike e.g. MND/PSP/HD) However, drugs for PD important in palliative care unless you think death is very imminent Lack of drugs leads to worsening swallow etc Individual assessment needed Antibiotics and repeat admission should be discussed Preferred place of death

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