The management of advanced Parkinson’s disease Dr J Paul Milnes Consultant Physician Airedale NHS...
-
Upload
betty-gaines -
Category
Documents
-
view
218 -
download
1
Transcript of The management of advanced Parkinson’s disease Dr J Paul Milnes Consultant Physician Airedale NHS...
The management of advanced The management of advanced Parkinson’s diseaseParkinson’s disease
Dr J Paul MilnesDr J Paul Milnes
Consultant PhysicianConsultant Physician
Airedale NHS TrustAiredale NHS Trust
Outline of the lectureOutline of the lecture
A few facts about Parkinson’s A few facts about Parkinson’s diseasedisease
The problems encountered as the The problems encountered as the disease progressesdisease progresses
Highlight important management Highlight important management pointspoints
Epidemiology of Epidemiology of Parkinson’s diseaseParkinson’s disease
Approximately 1% of the population Approximately 1% of the population over 60 years has Parkinson’s diseaseover 60 years has Parkinson’s disease
The number of cases increase with ageThe number of cases increase with age The ageing population is expected to The ageing population is expected to
dramatically increase the number of dramatically increase the number of casescases
Parkinson’s disease may affect Parkinson’s disease may affect between 5 and 10% of the nursing between 5 and 10% of the nursing home populationhome population
Changes in the brain in Changes in the brain in Parkinson’s diseaseParkinson’s disease
Loss of dopaminergic neurones from Loss of dopaminergic neurones from the substantia nigra is an essential the substantia nigra is an essential feature of Parkinson’s diseasefeature of Parkinson’s disease
The presence of Lewy bodiesThe presence of Lewy bodies
Changes in the brain in Changes in the brain in Parkinson’s diseaseParkinson’s disease
There’s more to Parkinson’s disease There’s more to Parkinson’s disease than the substantia nigra than the substantia nigra involvementinvolvement
Braak has demonstrated the Braak has demonstrated the progression of abnormalities in the progression of abnormalities in the brain as Parkinson’s disease brain as Parkinson’s disease progresses progresses Mov Disord 2006; 21: Mov Disord 2006; 21: 20422042
The diagnosis of The diagnosis of Parkinson’s diseaseParkinson’s disease
Don’t be afraid to question the Don’t be afraid to question the diagnosis even at a relatively late diagnosis even at a relatively late stagestage
Do all people with Do all people with Parkinson’s disease have Parkinson’s disease have
tremor?tremor? Up to 20% of cases never develop Up to 20% of cases never develop
tremor at any stage of the illnesstremor at any stage of the illness
Do all people with Do all people with Parkinson’s disease have Parkinson’s disease have reduction and slowness of reduction and slowness of
movement?movement?
Hypokinesia and Hypokinesia and bradykinesiabradykinesia
Poverty and slowness of movement Poverty and slowness of movement Must be present to make the diagnosisMust be present to make the diagnosis
Reduced facial expressionReduced facial expression Slow shuffling gaitSlow shuffling gait Reduced arm swingReduced arm swing Reduced swallowingReduced swallowing Difficulty turningDifficulty turning Small handwritingSmall handwriting Difficulty with fine movements affecting the whole Difficulty with fine movements affecting the whole
range of activities of daily livingrange of activities of daily living Usually asymmetricalUsually asymmetrical
UKPDS Brain Bank UKPDS Brain Bank CriteriaCriteria
Step1 Diagnosis of a parkinsonian syndromeStep1 Diagnosis of a parkinsonian syndrome Bradykinesia (slowness of movement) and at Bradykinesia (slowness of movement) and at
least one of the followingleast one of the following Muscular rigidityMuscular rigidity Rest tremor Rest tremor Postural instability unrelated to primary visual, Postural instability unrelated to primary visual,
vestibular or proprioceptive dysfunctionvestibular or proprioceptive dysfunction
Step2 Exclusion criteria for Parkinson’s Step2 Exclusion criteria for Parkinson’s DiseaseDisease
Step3 Supportive criteria for Parkinson’s Step3 Supportive criteria for Parkinson’s DiseaseDisease
Differential diagnosis of Differential diagnosis of Parkinson’s DiseaseParkinson’s Disease
Essential tremorEssential tremor Diffuse Lewy Body Disease Diffuse Lewy Body Disease Cerebrovascular diseaseCerebrovascular disease Progressive supranuclear palsyProgressive supranuclear palsy Multiple system atrophyMultiple system atrophy Trauma or toxin relatedTrauma or toxin related Drug inducedDrug induced OthersOthers
The diagnosis of The diagnosis of Parkinson’s diseaseParkinson’s disease
Don’t be afraid to question the diagnosis Don’t be afraid to question the diagnosis because it can be difficultbecause it can be difficult
Has a specialist been involved?Has a specialist been involved? Up to 25% error rate for non specialist hospital Up to 25% error rate for non specialist hospital
doctorsdoctors
““The diagnosis of Parkinson’s disease The diagnosis of Parkinson’s disease should be reviewed regularly and should be reviewed regularly and reconsidered if atypical features reconsidered if atypical features develop” develop” NICE 2006NICE 2006
The management of the The management of the disease can be planned in disease can be planned in
four stagesfour stagesNursing Older People 2004; Nursing Older People 2004;
16:116:1 DiagnosisDiagnosis
MaintenanceMaintenance
ComplexComplex
PalliativePalliative
Audit of 73 cases in Audit of 73 cases in CornwallCornwall
Parkinsonism and related disorders 1999; Parkinsonism and related disorders 1999; 5(S53)5(S53)
Mean duration of the disease 14.6 Mean duration of the disease 14.6 yearsyears
Average duration of the four stagesAverage duration of the four stages Diagnosis 1.5 yearsDiagnosis 1.5 years Maintenance 6 yearsMaintenance 6 years Complex 5 yearsComplex 5 years Palliative 2.2 yearsPalliative 2.2 years
The palliative phase of The palliative phase of Parkinson’s diseaseParkinson’s disease
Patients become increasingly Patients become increasingly disabled and dependantdisabled and dependant
The palliative phase of Parkinson’s The palliative phase of Parkinson’s disease has been defined bydisease has been defined by
Inability to tolerate adequate dopaminergic Inability to tolerate adequate dopaminergic therapytherapy
Unsuitability for surgeryUnsuitability for surgery The presence of advanced co-morbidity The presence of advanced co-morbidity
which is life threatening or disablingwhich is life threatening or disabling
The palliative phase of The palliative phase of Parkinson’s disease Parkinson’s disease
NICE Guidance 2006NICE Guidance 2006 Palliative care does not correlate Palliative care does not correlate
with imminent death in Parkinson’s with imminent death in Parkinson’s diseasedisease
Shift from a therapeutic Shift from a therapeutic pharmacological approach to one pharmacological approach to one which places a greater emphasis on which places a greater emphasis on quality of life issuesquality of life issues
The palliative phase of The palliative phase of Parkinson’s disease Parkinson’s disease
NICE Guidance 2006NICE Guidance 2006 It should be possible to seek advice It should be possible to seek advice
from specialist palliative care teams, from specialist palliative care teams, not just at the end of life, but at any not just at the end of life, but at any stage after diagnosisstage after diagnosis
Recognising the needs of carers at an Recognising the needs of carers at an early stage will enable people to stay at early stage will enable people to stay at home for as long as possiblehome for as long as possible
Many carers will have become “experts Many carers will have become “experts in Parkinson’s disease” themselvesin Parkinson’s disease” themselves
Palliative care and Palliative care and specialist care for PD specialist care for PD
patients in nursing homespatients in nursing homes Between 5 and 10% of nursing home Between 5 and 10% of nursing home
residents have Parkinson’s diseaseresidents have Parkinson’s disease
Many may remain undiagnosed Many may remain undiagnosed
The support from specialist services is The support from specialist services is inadequate and inconsistentinadequate and inconsistent
This population poses huge challenges to us This population poses huge challenges to us allall
NICE Guidance 2006NICE Guidance 2006
The care of people with Parkinson’s The care of people with Parkinson’s disease is best undertaken in a disease is best undertaken in a multidisciplinary way throughout multidisciplinary way throughout each stage of the diseaseeach stage of the disease
Advanced Parkinson’s Advanced Parkinson’s diseasedisease
Motor problemsMotor problems
Non-motor problemsNon-motor problems
Motor problems in Motor problems in advanced disease includeadvanced disease include
Failing mobility and fallsFailing mobility and falls Deterioration in the whole range of Deterioration in the whole range of
activities of daily livingactivities of daily living More frequent “off” periodsMore frequent “off” periods Speech impairmentSpeech impairment Swallowing difficultySwallowing difficulty Dyskinesias – abnormal movements Dyskinesias – abnormal movements
related to drugsrelated to drugs Less predictable response to medicationLess predictable response to medication
Motor problems in Motor problems in advanced disease advanced disease
The delicate balance between the The delicate balance between the benefits and side effects of drug benefits and side effects of drug treatmenttreatment
The crucial role of other The crucial role of other professionals and carersprofessionals and carers
The importance of ensuring the The importance of ensuring the correct timing of medication - correct timing of medication - especially in hospital and care especially in hospital and care homes homes
The crucial role of other The crucial role of other professionals and carersprofessionals and carers
Levodopa (madopar & Levodopa (madopar & sinemet)sinemet)
Levodopa is the most important treatment Levodopa is the most important treatment of the later stages of Parkinson’s diseaseof the later stages of Parkinson’s disease
It is the most effective drug for treating It is the most effective drug for treating motor problemsmotor problems
The side effects are not as extreme as The side effects are not as extreme as some of the other medications some of the other medications
Diet can influence its effect in advanced Diet can influence its effect in advanced Parkinson’s diseaseParkinson’s disease
Protein intake interferes with levodopa therapyProtein intake interferes with levodopa therapy
Levodopa and some amino acids, in protein rich Levodopa and some amino acids, in protein rich foods, compete for the same carriers in the foods, compete for the same carriers in the intestinal mucosa and blood brain barrier intestinal mucosa and blood brain barrier
The data suggest that patients with advanced The data suggest that patients with advanced Parkinson’s disease should adjust daily protein Parkinson’s disease should adjust daily protein intake and shift protein intake to the eveningintake and shift protein intake to the evening
The use of low protein foods to reduce off periods after mealThe use of low protein foods to reduce off periods after mealMov Disord 2006; 21(10): 1682Mov Disord 2006; 21(10): 1682
Beware of an unexpected Beware of an unexpected change in the speed of a change in the speed of a patient’s deteriorationpatient’s deterioration
Beware of an unexpected Beware of an unexpected change in the speed of a change in the speed of a patient’s deteriorationpatient’s deterioration
Consider other contributory factorsConsider other contributory factors
Reassess for intercurrent physical or Reassess for intercurrent physical or mental health problemsmental health problems
Common precipitants includeCommon precipitants include InfectionInfection DepressionDepression Drug side effectsDrug side effects
Case studyCase study
80 year old man with advanced 80 year old man with advanced Parkinson’s diseaseParkinson’s disease
Marked deterioration in his mobility Marked deterioration in his mobility over a 6 week periodover a 6 week period
Recurrent falls and more drowsyRecurrent falls and more drowsy No recent changes in drug treatment No recent changes in drug treatment
or signs of infectionor signs of infection Specialist review and further Specialist review and further
investigationinvestigation
Non-motor features in Non-motor features in advanced Parkinson’s advanced Parkinson’s
diseasedisease Are they important?Are they important?
YesYes
Sydney Multicentre Study Sydney Multicentre Study of Parkinson’s Disease of Parkinson’s Disease Hely et al. Hely et al.
Mov Dis 2005; 20(2): 190Mov Dis 2005; 20(2): 190
Report on people with PD who Report on people with PD who survive 15 years from diagnosissurvive 15 years from diagnosis
One third of the 149 people One third of the 149 people recruited had survivedrecruited had survived
Sydney Multicentre StudySydney Multicentre StudyPD survivors at 15 yearsPD survivors at 15 years
81% Falls81% Falls 84% cognitive decline84% cognitive decline 50% hallucinations and depression50% hallucinations and depression 50% choking50% choking 41% urinary incontinence41% urinary incontinence 35% symptomatic postural 35% symptomatic postural
hypotensionhypotension
Sydney Multicentre StudySydney Multicentre StudyPD survivors at 15 yearsPD survivors at 15 years
40% were living in an aged care facility40% were living in an aged care facility
95% experienced L-dopa induced 95% experienced L-dopa induced dyskinesia and end of dose failure of dyskinesia and end of dose failure of medication medication
““The most disabling long-term problems The most disabling long-term problems of Parkinson’s Disease relate to of Parkinson’s Disease relate to symptoms not improved by L-dopa” symptoms not improved by L-dopa”
The non-motor problemsThe non-motor problems
Non-motor features in Non-motor features in advanced Parkinson’s advanced Parkinson’s
diseasedisease NeuropsychiatricNeuropsychiatric Sleep disordersSleep disorders Autonomic symptomsAutonomic symptoms Gastrointestinal symptomsGastrointestinal symptoms Sensory symptomsSensory symptoms OthersOthers
Non-motor features in Non-motor features in advanced Parkinson’s advanced Parkinson’s
diseasedisease NeuropsychiatricNeuropsychiatric
DepressionDepression AnxietyAnxiety HallucinationsHallucinations DelusionsDelusions DementiaDementia
Non-motor features in Non-motor features in advanced Parkinson’s advanced Parkinson’s
diseasedisease Sleep disorders includeSleep disorders include
Restless legsRestless legs REM sleep behaviour disorderREM sleep behaviour disorder Excessive daytime sleepinessExcessive daytime sleepiness Vivid dreams Vivid dreams InsomniaInsomnia
Non-motor features in Non-motor features in advanced Parkinson’s advanced Parkinson’s
diseasedisease Autonomic symptomsAutonomic symptoms
Bladder disturbancesBladder disturbances SweatingSweating Orthostatic hypotensionOrthostatic hypotension Sexual dysfunctionSexual dysfunction
Non-motor features in Non-motor features in advanced Parkinson’s advanced Parkinson’s
diseasedisease Gastrointestinal symptomsGastrointestinal symptoms
Dribbling of salivaDribbling of saliva Difficulty with swallowingDifficulty with swallowing Acid refluxAcid reflux Nausea and vomitingNausea and vomiting ConstipationConstipation
Non-motor features in Non-motor features in advanced Parkinson’s advanced Parkinson’s
diseasedisease Other symptomsOther symptoms
PainPain Loss of smellLoss of smell FatigueFatigue Double visionDouble vision
Screening for non-motor Screening for non-motor symptomssymptoms
A questionnaire has been developedA questionnaire has been developed
This can be downloaded from the This can be downloaded from the Parkinson’s Disease Society websiteParkinson’s Disease Society website
The NMS Quest Study The NMS Quest Study Mov Disord 2006; 21(7): 916Mov Disord 2006; 21(7): 916
International multidisciplinary group of International multidisciplinary group of expertsexperts
Development of a non-motor symptom Development of a non-motor symptom screening tool comprising of 30 itemsscreening tool comprising of 30 items
The number of symptoms correlated closely The number of symptoms correlated closely with advancing age and duration of diseasewith advancing age and duration of disease
Problems previously unknown to health Problems previously unknown to health professionals were frequently highlightedprofessionals were frequently highlighted
Management points for Management points for some common non-motor some common non-motor
symptomssymptoms DepressionDepression
DementiaDementia
HallucinationsHallucinations
Sleep problemsSleep problems
Depression in Parkinson’s Depression in Parkinson’s disease is common and disease is common and easily overlookedeasily overlooked
DepressionDepression
Affects up to 50% of patients with Affects up to 50% of patients with Parkinson’s DiseaseParkinson’s Disease
Low threshold for diagnosing depression Low threshold for diagnosing depression in Parkinson’s diseasein Parkinson’s disease
The strongest predictor of PD quality of The strongest predictor of PD quality of life in several surveyslife in several surveys
J Neurol Neurosurg Psychiatry 1999; 66: 431J Neurol Neurosurg Psychiatry 1999; 66: 431 J Neurol Neurosurg Psychiatry 2000; 69: 308J Neurol Neurosurg Psychiatry 2000; 69: 308
DepressionDepression
Features of depression and Features of depression and Parkinson’s disease overlapParkinson’s disease overlap
The diagnosis can be overlookedThe diagnosis can be overlooked If untreated can affect motor If untreated can affect motor
functionfunction
ManagementManagement
Holistic - multi-disciplinary team Holistic - multi-disciplinary team input input
Liaison with mental health servicesLiaison with mental health services
MedicationMedication
Medication for Medication for depressiondepression
Factors to considerFactors to consider Ensure optimal treatment of the Ensure optimal treatment of the
motor problems motor problems Side effects limit the value of the Side effects limit the value of the
older antidepressant drugsolder antidepressant drugs The presence of anxietyThe presence of anxiety
Treatment of depression - Treatment of depression - NICE Guidance 2006NICE Guidance 2006
There is insufficient evidence from There is insufficient evidence from clinical trials of the efficacy or safety clinical trials of the efficacy or safety of any antidepressant therapy in of any antidepressant therapy in Parkinson’s diseaseParkinson’s disease
There is an urgent need for further There is an urgent need for further research to establish safe and research to establish safe and effective treatments for depression effective treatments for depression in Parkinson’s diseasein Parkinson’s disease
Hallucinations in Hallucinations in Parkinson’s diseaseParkinson’s disease
May begin as visual hallucinations May begin as visual hallucinations which are non-frightening which are non-frightening
As the disease progresses the As the disease progresses the hallucinations may become more hallucinations may become more distressing and paranoid delusions distressing and paranoid delusions may developmay develop
Hallucinations in Hallucinations in Parkinson’s diseaseParkinson’s disease
May be a direct effect of the diseaseMay be a direct effect of the disease
Could be related to drug treatment Could be related to drug treatment
Consider intercurrent illnessConsider intercurrent illness
Impaired vision and environmentImpaired vision and environment
Consider depressionConsider depression
Significant risk of dementiaSignificant risk of dementia
Dementia in Parkinson’s Dementia in Parkinson’s diseasedisease
Dementia is the progressive loss of global Dementia is the progressive loss of global cognitive functioncognitive function
At least half the patients with Parkinson’s At least half the patients with Parkinson’s disease will ultimately develop dementiadisease will ultimately develop dementia
Typically PD dementia affects visuospatial Typically PD dementia affects visuospatial abilities, learning, verbal fluency, working abilities, learning, verbal fluency, working memory and mental flexibilitymemory and mental flexibility
Memory loss is less prominent than in other Memory loss is less prominent than in other common dementiascommon dementias
Management of PD Management of PD dementiadementia
Non-drug strategies – education and Non-drug strategies – education and practical support for patient and carerspractical support for patient and carers
Withdrawal of medication – ultimately Withdrawal of medication – ultimately leaving levodopaleaving levodopa
Treat depressionTreat depression
Use of atypical antipsychotic drugsUse of atypical antipsychotic drugs
Use of cholinesterase inhibitorsUse of cholinesterase inhibitors
Stepwise reduction in drug Stepwise reduction in drug treatmenttreatment
Focus treatment on the most effective Focus treatment on the most effective PD drugs with the least side effects PD drugs with the least side effects
Reduce from the topReduce from the top AnticholinergicsAnticholinergics SelegilineSelegiline AmantadineAmantadine Dopamine agonists (eg ropinirole/ Dopamine agonists (eg ropinirole/
pramipexole)pramipexole) COMT (eg entacapone)COMT (eg entacapone) ApomorphineApomorphine L-dopaL-dopa
Antipsychotic drugsAntipsychotic drugs
Older drugs – “Typical antipsychotic” Older drugs – “Typical antipsychotic” drugs should be avoideddrugs should be avoided
Atypical antipsychotic drugs may helpAtypical antipsychotic drugs may help Quetiapine is often used but little hard dataQuetiapine is often used but little hard data Clozapine is of benefit but rarely used in the UKClozapine is of benefit but rarely used in the UK Caution with Olanzapine and Risperidone in Caution with Olanzapine and Risperidone in
people at risk of strokepeople at risk of stroke
Cholinesterase inhibitorsCholinesterase inhibitors The group of drugs originally introduced The group of drugs originally introduced
to treat Alzheimer’s diseaseto treat Alzheimer’s disease
NICE Guidance 2006NICE Guidance 2006 Used successfully in patients with PD Used successfully in patients with PD
dementiadementia Further research is recommended to identify Further research is recommended to identify
those patients who will benefitthose patients who will benefit
Rivastigmine is currently licensed for the Rivastigmine is currently licensed for the treatment of PD dementiatreatment of PD dementia
Sleep related problems of Sleep related problems of Parkinson’s diseaseParkinson’s disease
Take an accurate historyTake an accurate history
Sleep related problems of Sleep related problems of Parkinson’s disease Parkinson’s disease
Age Ageing 2006; 35: 220Age Ageing 2006; 35: 220 Insomnia directly due to the effects Insomnia directly due to the effects
of Parkinson’s disease on central of Parkinson’s disease on central sleep regulation centres in the brainsleep regulation centres in the brain
Motor function relatedMotor function related Urinary difficultiesUrinary difficulties Neuropsychiatric problemsNeuropsychiatric problems
Management of sleep Management of sleep disordersdisorders
General measuresGeneral measures
Treatment of specific problemsTreatment of specific problems
General measures to cope General measures to cope with insomniawith insomnia
A warm bath 2 hours before bedtimeA warm bath 2 hours before bedtime
Hot milk or a light snack at bedtimeHot milk or a light snack at bedtime
Handrails or satin sheets to help turningHandrails or satin sheets to help turning
Avoid stimulants such as tea and coffee at Avoid stimulants such as tea and coffee at bedtimebedtime
Review other tabletsReview other tablets
Care with hypnotic drugs but sometimes helpfulCare with hypnotic drugs but sometimes helpful
Motor function relatedMotor function related
Restless legsRestless legs Abnormal leg movementsAbnormal leg movements Difficulty turning in bedDifficulty turning in bed
Medication changes may helpMedication changes may help
Urinary problems at night Urinary problems at night include -include -
Nocturia – frequent micturition at Nocturia – frequent micturition at night - is commonnight - is common Is it related to Parkinson’s disease or Is it related to Parkinson’s disease or
another problem?another problem? Exclude active infection and incomplete Exclude active infection and incomplete
bladder emptyingbladder emptying Incontinence related to poor mobilityIncontinence related to poor mobility
Neuropsychiatric causes of Neuropsychiatric causes of sleep disturbancesleep disturbance
Depression is common and treatableDepression is common and treatable
Panic attacksPanic attacks Treatment determined by time of occurrenceTreatment determined by time of occurrence
Cognitive problemsCognitive problems
Distressing dreams and hallucinationsDistressing dreams and hallucinations Review drug treatmentReview drug treatment Consider quetiapine Consider quetiapine
REM Sleep behaviour disorderREM Sleep behaviour disorder
REM Sleep Behaviour REM Sleep Behaviour DisorderDisorder
People enact their dreamsPeople enact their dreams TalkingTalking Shouting Shouting Falling out of bedFalling out of bed Even attacking their partnerEven attacking their partner
Drugs can helpDrugs can help ClonazepamClonazepam OthersOthers
Useful sources of Useful sources of informationinformation
Parkinson’s Disease Society Parkinson’s Disease Society www.parkinsons.org.ukwww.parkinsons.org.uk
2006 NICE Guidance2006 NICE Guidancewww.nice.org.ukwww.nice.org.uk
SummarySummary Parkinson’s disease affects 1% of the population over Parkinson’s disease affects 1% of the population over
60 years old60 years old Specialist support at diagnosis and throughout the Specialist support at diagnosis and throughout the
disease is essentialdisease is essential There is inadequate support for PD patients in There is inadequate support for PD patients in
nursing homesnursing homes The management becomes increasingly complex and The management becomes increasingly complex and
needs input from the whole range of carers and needs input from the whole range of carers and clinical staffclinical staff
Think of other contributory causes if there is an Think of other contributory causes if there is an unexpected deterioration in symptom controlunexpected deterioration in symptom control
The importance of the non-motor symptoms in The importance of the non-motor symptoms in advanced Parkinson’s disease has only recently advanced Parkinson’s disease has only recently received significant attentionreceived significant attention