1. Management of Parkinson’s disease (in the acute medical ward) C. M. James MD FRCP FAcadMEd Consultant Physician Withybush Hospital, Pembrokeshire

2. QUESTION - 1

3. Mental Health disorders in Parkinson’s disease Cognitive impairment Anxiety and depression Apathy Impulsive behaviour Psychosis

4. Cognitive function in Parkinson’s disease Impairment of cognitive function is common Memory impairment may not be the main feature Executive function often effected initially Awareness and practical advice is important Symptomatic improvement in PDD/LBD with Acetyl Cholinesterase inhibitors

5. Mental Health disorders in Parkinson’s disease Cognitive impairment Anxiety and depression Apathy Impulsive behaviour Psychosis

6. QUESTION - 2

7. Fluctuating symptoms in Parkinson’s disease Fluctuating motor symptoms can be related to changing in the timing of medication Any cause of delirium will also cause fluctuating motor symptoms Can be a result of variable drug absorption Fluctuating cognitive function is a feature of PDD/LBD

8. Common causes for sudden deterioration in Parkinson’s disease Concurrent illness/surgery/infection Constipation Can be a result of variable drug absorption Stress Dehydration Withdrawal/change in medication/non-compliance

9. Constipation in Parkinson’s disease Present in 50% of patients Probably due to autonomic dysfunction Is closely linked to fluctuating drug absorption Is a common cause for medication “failure” Treatment of constipation improves PD motor control

10. Common causes for sudden deterioration in Parkinson’s disease Concurrent illness/surgery/infection Constipation Can be a result of variable drug absorption Stress Dehydration Withdrawal/change in medication/non-compliance

11. Common causes for sudden deterioration in Parkinson’s disease Use of neuroleptics Depression Acute or chronic pain Anxiety, panic attacks Poor sleep or lack of sleep

12. Deterioration in Parkinson’s disease can result in an increase/appearance of the following Tremor Muscle stiffness Difficulty walking/freezing of gait Poor balance/falls Dyskinesia Delirium Hallucinations Daytime sleepiness

13. QUESTION 3

14. Swallowing difficulty in Parkinson’s disease 90% of patients develop dysphagia during the course of their disease Dysphagia results from motility disorders in all phases of swallow Aspiration can occur in the absence of symptoms Compensatory strategies have been the traditional form of management Can be improved using the Lee Silverman Voice Treatment Programme

15. When a Parkinson’s disease patient cannot swallow safely If possible insert a nasogastric tube Give an equivalent dose of levodopa in dispersible form If nasogastric tube insertion is not possible use the dopamine agonist Rotigotine available as transdermal patch Do not stop medication suddenly Restart normal medication and timings as soon as possible

16. QUESTION - 4

17. Depression in Parkinson’s disease Depression is important to recognize in all stages of the illness May be related to worsening functional ability Can screen for depression with bed side testing (Geriatric depression rating scale/HADS). Does respond well to treatment

18. QUESTION 5

19. Parkinson’s Disease Medication Levodopa/decarboxylase inhibitors are the mainstay of drug treatment Dopamine agonists still play an important role Dispersible/sublingual and transdermal preparations are available. Reduction of some medication may be necessary in advanced disease

20. Thank you