T R A I N I N G M AT T E R S NOVEMBER 2015

population over 65 years,rising to two per cent inpeople over 80 years. Of note,50 to 80 per cent of peoplewith PD may developParkinson’s disease dementia(PDD), although this seemsmore related to increasingage than PD itself.

CausesDuring the disease processthere is progressive loss ofdopaminergic cells from thesubstantia nigra in the basalganglia (midbrain). This cellloss results in decreaseddopamine (as well asserotonin and GABA) in the striatum.

The basal ganglia controlsmuscle tone and providessmooth muscle voluntarymovements. PD symptomspresent as impairment incarrying out learned voluntary

actions (see table 1) when 80per cent of dopaminergic cellsare lost.

Every person with PD has a different set of signs andsymptoms (see table 2), socare and treatment needs to be individualised.

The exact cause of PD is unknown and the vastmajority of cases areidiopathic (unknown). PD is thought to be a complexinteraction between geneticand environmental riskfactors. A number ofmedicines can also produceParkinson-like symptoms andaccount for seven per cent ofpeople presenting withsuspected PD (see table 3).These medication-inducedeffects respond poorly tolevodopa therapy. Dependenton the particular agent, slowwithdrawal is recommended,

neurodegenerative diseases,it is second only toAlzheimer’s disease.

In the UK, PD affectsbetween 100 and 180 peopleper 100,000 population andeach year there are betweenfour and 20 new cases per100,000 populating (regiondependent), with more malesaffected then females andincreasing prevalence withage. On average, there will be five to eight people on PD medication in everycommunity pharmacy.

PD is rare below the age of 50 years – such cases areknown as juvenile PD andaccount for only five per centof all PD cases – but it affectsone per cent of the

where it limits daily activitiesand also encompassesautonomic dysfunction(constipation, erectile andurinary dysfunction,hypotension and dizziness);neuropsychiatric conditions(depression, dementia,hallucinations and psychosis);pain; lethargy/fatigue, andimpacts majorly on quality of life for the individual andtheir carer and families.

Prevalence andincidenceParkinson’s disease is the fourthmost common neurologicalcondition in the UK behindstroke, all forms of dementiaand epilepsy. However, interms of progressive

Parkinson’s disease (PD) is aprogressive neurodegenerativedisease caused by the death of dopamine producing cellsin the substantia nigra in thebrain. There is no diagnostictest for PD and a diagnosis isbased on the presenting signsand symptoms and the historyof onset.

The current NICE ClinicalGuideline 35 (2006) states thatpeople who have PD presentwith symptoms includinghypokinesia (movement that is lessened in power andstrength) along withbradykinesia (slowness ofmovement), rigidity and aresting tremor.

PD potentially affects allmuscle groups to an extent

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Contributing author: Dr Denise Taylor, senior lecturer in clinical pharmacy, Department of Pharmacy and Pharmacology, University of Bath.

C P D M O D U L E

Welcome to our CPD module series for community pharmacytechnicians. Written in conjunction with the PharmacyMagazine CPD series, it will mirror the magazine’sprogramme throughout the year. The series has beendesigned for you to use as part of your continuingprofessional development. Reflection exercises have beenincluded to help start you off in the CPD learning cycle.

CURRENT THINKING ON... PARKINSON’S DISEASE

MODULE NUMBER: 62AIM: To provide an overview of the pharmacymedicines management services for people withParkinson’s disease (PD) and their carers.

OBJECTIVES: Aftercompleting this module,you should be able to:l Recognise earlysigns andsymptomsassociated withpossible PD andsignpostappropriatelyl Identifymedicines which maybe harmful in PD.

CPDSUPPORT

REFL

ECT

EVALUAT

E

ACT

PLAN

44

Walking

Washing

Household chores

Bathing

Answering the phone

Driving

Dancing

Enjoying hobbies

Rising from a chair

Eating

Talking

Dressing

Shopping

Gardening

Working

Having sex

Turning over in bed

Getting out of bed

Cooking

Climbing stairs

Using public transport

Going to the toilet

Cleaning teeth

Playing sport

Writing

Socialising

Fine movement activities

Table 1: Examples of learned voluntary actions

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with 60 per cent recovering intwo months, but others maytake up to two years.

Staging There are four stages to PD:• Establishing the diagnosis• Early or maintenance of PD• Complex or later PD• Palliation.

Treatments do not cure orhalt the progression of PD, butthey do improve quality of life.

Non-pharmacologicaltreatments Non-pharmacologicaltreatments and supportservices are extremelyimportant for people with PDat any stage of their disease.There is a need formultidisciplinary teamworkwith the person with PD andtheir carer at the centre.

There is no one packagethat fits all – pharmacologicaland non-pharmacologicaltreatments are tailored to theindividual need. For example,physiotherapy aids retentionof muscle strength andmobility; occupational therapysupports maintenance of dailyactivities (washing, dressing,tips for un-freezing); speechand language therapy enablescommunication, swallowing(eating and drinking), andsocial services are necessaryfor access to disability andfinancial support.

There are numerous otherssuch as community psychiatricnurses, psychiatrists,

chiropodists and you, thepharmacy technician.

Treatments in early PD In early PD (E-PD) the aim is to preserve dopaminergicfunction for as long aspossible by using dopaminesupplementations. Levodopapreparations, non-ergotderived dopamine agonistsand MAO-B inhibitors are allfirst line options in early PD.The choice is dependent on

the individual circumstancesof the person with PD. Forexample, age, preference,tolerability and once theshort- and long-term benefitsand drawbacks of eachmedicine have been explainedto the patient.

Historically, levodopa witha decarboxylase inhibitor (DCI)has been the gold standard oftreatment, but tolerance tolevodopa occurs over time(estimated at 10 per cent yearon year tolerance), making itinappropriate to use first-linein younger patients as it willbe ineffective within 10 years.

Anticholinergic agents,amantadine and beta-blockers

are not recommended in E-PDdue to lack of evidence orlimited efficacy.

Treatments in complex or later PD After five to 10 years of taking a levodopapreparation, between 50 and 70 per cent of peopleexperience ON or OFFepisodes. An ‘ON’ is whenthey can perform activities of daily living as normal forthem while an ‘OFF’ is whenthey completely freeze andvoluntary movement isdifficult or impossible. Thiscan be extremely frighteningand may cause a great degreeof anxiety and concern for theperson with PD and theirfamilies. These fluctuations in symptom control may notnecessarily be related to

timing of medicinesadministration.

Some 85 per cent of peoplewith PD who take levodopaexperience the agent’s efficacy‘wearing off’, while 37 percent experience a suddenON/OFF and 34 per cent adelayed response to usualtreatment.

At this stage, an adjuvantagent is required to reducecomplications and improvequality of life. There is nosingle adjuvant agent ofchoice and selection is basedon patient preference afterthe short- and long-termbenefits and drawbacks ofeach class of medicine havebeen explained to them.

If a person has been on alevodopa preparation firstline, either a COMT inhibitoror a non-ergot deriveddopamine agonist could beintroduced. In the latterscenario, the dose of levodopamust be lowered to preventdyskinesia (difficulty ordistortion in performingvoluntary movements) andneuropsychiatric effects such

as hallucinations and psychosis. Conversely, if a person had

been on a non-ergot deriveddopamine agonist first linethen either a levodopapreparation or a COMTinhibitor could be added.

Importantconsiderations It is extremely important toremember that Parkinson’smedication should never bewithdrawn abruptly orallowed to fail suddenly dueto lack of absorption (e.g. ingastroenteritis or abdominalsurgery) due to the risk ofacute akinesia (total loss orimpairment of the power ofvoluntary movement for theperson – akin to paralysis) orneuroleptic malignantsyndrome occurring.

People with PD who arehospitalised, awaiting surgicalprocedures or admitted tocare homes should have theirmedication given to them atthe times appropriate to themand not the local organisation(self medication should be apreferred option).

Parkinson’s UK haspublished guidance forcommunity and hospitalpharmacists on the mostappropriate use of PD

medicines. For details, see:www.parkinsons.org.uk/professionals/resources/key-information-community-pharmacists-booklet.

PD is a fluctuating anddebilitating disease; theefficacy of pharmacologicaltreatments fluctuates as wellas the response to treatment.The person with PD needssupport and understanding.Remember that trappedwithin an uncooperative bodyis a cognitively intact person.

Useful resources1. NICE Pathways forParkinson’s disease:pathways.nice.org.uk/pathways/parkinsons-disease2. Kearney D; Dunsmure L.Parkinson’s diseasemanagement. ClinicalPharmacist 2011(3) 368-3733. Blochberger A; Jones S.Parkinson’s disease clinicalfeatures and diagnosis. ClinicalPharmacist. Vol 3 December2011 pages 361-366.4. NICE Clinical KnowledgeSummaries for PD: cks.nice.org.uk/parkinsons-disease5. Parkinson’s UK Get it ontime: www.parkinsons.org.uk/professionals/resources/get-it-time-medicine-management-patients-parkinsons-film.

NOVEMBER 2015 T R A I N I N G M AT T E R S 45

C P D M O D U L E

reflectionexercise

Could you signpost a person newly diagnosed withParkinson’s disease to local support groups for peoplewith Parkinson’s disease and their families? Visit theParkinson’s UK website (www.parkinsons.corg.uk) andNHS Choices (www.nhs.uk/conditions/Parkinsons-disease/pages/introduction.aspx). Use these to createyour local list. Patient access to carer support and socialservices may need a GP referral.

Go to www.tmmagazine.co.uk to answer the CPD questions. When you pass, you’ll be able to download a certificate to showcase yourlearning. You can also add this to your online, personalised learning log.

“Remember that trapped within an

uncooperative body is a cognitively

intact person”

www.tmmagazine.co.uk

Communicating with patientsThe clinical features of PD profoundly affect theindividual’s ability to communicate and can alsoprejudice how people communicate with them. This is because the altered body language and facialexpressions of people with PD can seem threatening toothers. Remember that 55 per cent of communication isvia body language, 38 per cent dependent on tone andvolume and only seven per cent on the words spoken. As a pharmacy professional it is important that youadapt your communication skills to help the personcommunicate effectively with you. Due to reducedspeech volume, conversations may be better in a quietconsultation room rather than at the front counter.

Table 3: Medicines associated with Parkinsonism

Table 2: Possible associated symptoms of PDDribbling/ droolingSwallowingIncontinenceConstipation Pain (muscle spasm)FreezingDepressionSlowness

AnxietyTremorInsomniaBehaviourConfusionNightmaresMemoryHallucinations

Medication classAnti-emetic

Antipsychotics

Anti-hypertensives

Causality unproven

ExampleMetoclopramide, prochlorperazine,cinnarizine

First generation: dose dependent, avoidhaloperidolSecond generation: dose dependenteffects, avoid. Clozapine least associationwith movement abnormalities

Calcium channel blockers

NSAIDs, captopril, amiodarone,phenytoin, valproate, lithium, oralcontraceptives, SSRIs

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