Parkinson s s disease: diagnosis and long-term management Dr Richard Grunewald Consultant Neurologist Sheffield Teaching Hospitals NHS Trust
How do we move? We need constantly to process a vast amount of joint position afferent information from muscle spindles QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
What are the basal ganglia doing? processing all that afferent information This allows us to stay upright, predict where our limbs will be just ahead of movement, adjust for fatigue and load. Disorders of the basal ganglia involve failure of this (i.e. movement disorders) QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
What is PD anyway? Neurodegenerative disease fairly specific for dopaminergic neurones in the brain.but there are several other things that look rather similar!
Vascular Parkinsonism/NPH Brain is unique in being enclosed in a rigid container You can t get blood in unless something comes out at the same time QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
Vascular Parkinsonism/NPH Gait apraxia is common in the elderly Lower half parkinsonism is the more severe end of the spectrum Ubiquitous in the elderly Blood supply to the brain is difficult as the brain is enclosed in a rigid box (the skull) Mismatch of blood flow into the skull with venous drainage during the cardiac cycle is usually compensated by flow of CSF in and out of the skull Failure of bi-directional CSF flow down the acqueduct occurs as we get older, as blood supply to the brain becomes more pulsatile (atherosclerosis) Global brain ischaemia results - effects basal ganglia early Ventriculoperitoneal shunt helps some (normal pressure hydrocephalus QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
Idiopathic Parkinson s s disease Neurodegenerative condition associated with loss of dopaminergic neurones Cause(s) obscure, but a very small number of cases inherited QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
Progression of IPD Predictable At first one or two doses of l-dopa sufficient to control symptoms throughout the day Then early wearing off peak dose dyskinesia On-off fluctuations Drug-induced psychosis Dementia
Progression of IPD Early wearing off Patients notice effect of drug wanes before next dose is due Increase frequency of dosing Try controlled release medication
Progression of IPD Peak dose dyskinesia Involuntary fidgeting movements when l-dopa in bloodstream is at peak level Manage by using direct-acting dopaminergic agonist drugs
Progression of IPD On-off fluctuations Progression of predictable end-of-dose wearing off of l-dopa to increasingly random fluctuation between off state (immobile) and on state with or without dyskinesia Management as for peak dose dyskinesia
Progression of IPD Drug-induced psychosis Starts with illusions Hallucinations (mainly visual) in the evening Delusions (spouse infidelity) Paranoia Try to reduce dopaminergic agonist Cautious use of atypical neuroleptics Dementia
Progression of IPD Hypersexuality Compulsive ideation Gambling others
Complications of PD Result of two processes: Presynaptic neurone loss Postsynaptic receptor supersensitivity QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
Other problems Sleep - multifactorial Mood Salivation - botulinum toxin injections Pain Twitching
Complications of PD Early wearing off caused by reducing storage capacity for dopamine On-off fluctuations, dyskinesia and psychosis caused by postsynaptic changes QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
What else is going wrong in Parkinson s s disease? Pathology extends outside basal ganglia Dementia, autonomic instability QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
What else is going wrong in Parkinson s s disease? Increasing sensitivity to the side effects of the drugs Increasingly difficult balance between symptom control and adverse effects QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
I have a patient who I think has PD. Do I start treatment straight away or refer, and if so to whom? Referral is recommended fo r confirmation of diagnosis, planning managemen t, counselling and edu cation and initiation of therapy. Younge r patients shou ld be referred to the Mo vement Disorder Clinic, Department of Neu rology, the Ro yal Hallamshire Hospital, telephone 0114 2712306, fax 0114 271368 4 Older patients with more complex co-morbidity and rehabilitation needs to Dr J Liddle, Department of Hea lthcare of the Elderly, Brearley Wing, Northern General Hospital, fax 0114 2715981, te lephone 0114 271 4970 or Dr N Samaniego, Department of HealthCare of the Elderly, Royal Hallamshire Hospital, fax 2711389, te lephone 0114 2711773 or 2712430.
Do I start treatment? NICE recommends prompt referral for assessment (but this is not funded) No evidence for adverse effect of early treatment Treatment can mask symptoms making expert assessment problematic Expert follow up essential Patient and family need support
But I ve I heard L-dopa L is toxic and we should avoid using it until we have to. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. it isn t!
My patient has come back from Dr Grunewald s clinic telling me she has been started on a drug called pramipexole and is asking for a repeat prescription. I have never heard of this drug. Why is he asking me to prescribe this? Shouldn t t the dose be adjusted by his team, not me? Pramipexole is one of the range of dopaminergic agonist drugs Safe as any Titration takes many months and as the disease progresses further adjustment necessary How to provide backup and continuity? With 500 patients with PD alone on our books we can t see everyone even every year. Our nurses can!
Quick guide to dopaminergic agonist drugs: Continuous dopaminergic stimulation? improves prognosis Effective in reducing on-off swings, dyskinesia if dose maximised and l-dopa minimised Bromocriptine original and best, but you need to use enough Cabergoline less potent, long half life (3days) Ropinirole non ergot drug, less potent, makes patients sleepy Pramipexole like Ropinirole but more potent and more sleepy Rotigotine like ropinirole but in a patch
Magic recipe for PD Treats 90% of patients optimally L-dopa plus peripheral decarboxylase inhibitor five times daily (e.g. co-beneldopa, co-careldopa 125) Full dose direct acting agonist five times daily (e.g. bromocriptine 20mg, pramipexole 0.7mg, ropinirole 5mg)
My patient did not seem to respond to l- dopa or the other more expensive drugs and is getting increasingly immobile. What do I do? Is the diagnosis sound? Consider vascular parkinsonism Normal pressure hydrocephalus Parkinson s plus syndromes Cervical myelopathy Refer for Consultant opinion In Sheffield younger patients to Royal Hallamshire (Neurology) Those with complex problems benefit from MDT assessment at ARC or Northern General
What is apomorphine? Produced from morphine, but chemically unrelated Given parenterally (subcutaneous) Boluses for unpredictable offs Continuous infusion for refractory psychosis or fluctuations Very irritant Also used to stimulate libido Expensive ( 10,000 per annum) QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
What is Duodopa? Duodenal dopa infusion gel Continuous infusion 30,000 per annum Little evidence on effectiveness QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
My patient has come to me with a cutting from the Daily Mirror saying that Stalevo is a wonder drug. Should she be taking it? Mixture of l-dopa, peripheral dopa decarboxylase inhibitor and entacapone Increases delivery of l-dopa to the brain (but so does an increased dose of l-dopa, cheaper) No particular advantage in most patients.
My patient has come to me with a cutting from the Daily Mirror saying that Rasagaline is a wonder drug. Should she be taking it? Me too version of selegeline In clinical trials as effective as selegeline (!) No particular advantage in most patients. Why use selegeline anyway? Small symptomatic effect Well tolerated Antidepressant No prognostic advantage demonstrated
My patient has come to me with a cutting from the Daily Mirror saying that Rotigotine is a wonder drug. Should she be having it? Dopamine agonist patch In clinical trials more effective than placebo (!) Not very potent Advantage that you can stop treatment quickly, and that patient does not need to swallow tablets? Less likely to precipitate hallucinations
My patient with PD is getting increasingly difficult at home - paranoid and sexually demanding. What should I do? Dopaminergic drugs stimulate libido Hallucinations and delusions are common druginduced complications of advanced PD Reduce dopaminergic drugs Direct acting agonists first Antidepressants, amantidine, selegeline L-dopa Refer to specialist service or if things are nearing crisis direct to on-call team.
My patient with PD has recently been started on clozapine.. I know this is a dangerous drug. Why is this and what do I have to do to monitor him? Clozapine has a unique place in management of drug-induced psychosis Patients are registered with the Clozaril patient monitoring service You arrange to have the blood taken, we do the rest.
My patient with PD has recently been started on a drug called tolcapone.. I know there is a perfectly good drug in this class called entacapone.. The patient now needs regular blood tests. Why? Tolcapone is a COMT inhibitor, like entacapone Tolcapone is much more effective in reducing on-off swings and dyskinesia 1 in 20,000 patients have liver failure on the drug..
My patient is not satisfied with the opinion on his condition - he has heard there is a scan which makes the diagnosis. Can he have it? DAT scans distinguish between groups of patients with essential tremor and those with IPD. So does l-dopa challenge! 750
My patient has asked me about surgery for his PD - he has heard that people are having treatment with stem cells, infusions of growth factors, radiosurgery and lasers. Can he have these too? DBS for PD available in Sheffield Surgical treatment for other movement disorders also available here For stem cells, growth factors needs another planet.
I am quite interested in PD but also have a day job. Is there a quick and easy source of information for me to help me with common PD associated problems? PD nurses have an invaluable role in providing continuity of care, advice and cost-effective timely intervention Multidisciplinary teams including physio, OT, speech therapy required to optimise care Open access to specialist Consultant advice
Why do we need a shared care protocol? Inform about the disorder and its treatments Define standard of care, e.g. what the patient can expect of us Document the services available Define who does what Prevent disputes!
Conclusions Parkinsonism is a complex group of degenerative conditions Multi-disciplinary input required to get the best out of the patient Effective, quick crisis management required Communication, communication, communication.