CURRENT PARKINSON’S DISEASE THINKING ON...Parkinson’s disease management. Clinical Pharmacist...
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TRAINING MATTERS NOVEMBER 2015 population over 65 years, rising to two per cent in people over 80 years. Of note, 50 to 80 per cent of people with PD may develop Parkinson’s disease dementia (PDD), although this seems more related to increasing age than PD itself. Causes During the disease process there is progressive loss of dopaminergic cells from the substantia nigra in the basal ganglia (midbrain). This cell loss results in decreased dopamine (as well as serotonin and GABA) in the striatum. The basal ganglia controls muscle tone and provides smooth muscle voluntary movements. PD symptoms present as impairment in carrying out learned voluntary actions (see table 1) when 80 per cent of dopaminergic cells are lost. Every person with PD has a different set of signs and symptoms (see table 2), so care and treatment needs to be individualised. The exact cause of PD is unknown and the vast majority of cases are idiopathic (unknown). PD is thought to be a complex interaction between genetic and environmental risk factors. A number of medicines can also produce Parkinson-like symptoms and account for seven per cent of people presenting with suspected PD (see table 3). These medication-induced effects respond poorly to levodopa therapy. Dependent on the particular agent, slow withdrawal is recommended, neurodegenerative diseases, it is second only to Alzheimer’s disease. In the UK, PD affects between 100 and 180 people per 100,000 population and each year there are between four and 20 new cases per 100,000 populating (region dependent), with more males affected then females and increasing prevalence with age. On average, there will be five to eight people on PD medication in every community pharmacy. PD is rare below the age of 50 years – such cases are known as juvenile PD and account for only five per cent of all PD cases – but it affects one per cent of the where it limits daily activities and also encompasses autonomic dysfunction (constipation, erectile and urinary dysfunction, hypotension and dizziness); neuropsychiatric conditions (depression, dementia, hallucinations and psychosis); pain; lethargy/fatigue, and impacts majorly on quality of life for the individual and their carer and families. Prevalence and incidence Parkinson’s disease is the fourth most common neurological condition in the UK behind stroke, all forms of dementia and epilepsy. However, in terms of progressive Parkinson’s disease (PD) is a progressive neurodegenerative disease caused by the death of dopamine producing cells in the substantia nigra in the brain. There is no diagnostic test for PD and a diagnosis is based on the presenting signs and symptoms and the history of onset. The current NICE Clinical Guideline 35 (2006) states that people who have PD present with symptoms including hypokinesia (movement that is lessened in power and strength) along with bradykinesia (slowness of movement), rigidity and a resting tremor. PD potentially affects all muscle groups to an extent www.tmmagazine.co.uk Contributing author: Dr Denise Taylor, senior lecturer in clinical pharmacy, Department of Pharmacy and Pharmacology, University of Bath. CPD MODULE Welcome to our CPD module series for community pharmacy technicians. Written in conjunction with the Pharmacy Magazine CPD series, it will mirror the magazine’s programme throughout the year. The series has been designed for you to use as part of your continuing professional development. Reflection exercises have been included to help start you off in the CPD learning cycle. CURRENT THINKING ON... PARKINSON’S DISEASE MODULE NUMBER: 62 AIM: To provide an overview of the pharmacy medicines management services for people with Parkinson’s disease (PD) and their carers. OBJECTIVES: After completing this module, you should be able to: l Recognise early signs and symptoms associated with possible PD and signpost appropriately l Identify medicines which may be harmful in PD. CPD SUPPORT R E F L E C T E V A L U A T E A C T P L A N 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
Transcript of CURRENT PARKINSON’S DISEASE THINKING ON...Parkinson’s disease management. Clinical Pharmacist...
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
www.tmmagazine.co.uk
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.
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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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