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Parkinsons Disease Management in Primary Care. Introduction Progressive condition 1:500 whole population 1:50 of elderly 1:10 Nursing Home Residents.

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Presentation on theme: "Parkinsons Disease Management in Primary Care. Introduction Progressive condition 1:500 whole population 1:50 of elderly 1:10 Nursing Home Residents."— Presentation transcript:

1 Parkinsons Disease Management in Primary Care

2 Introduction Progressive condition 1:500 whole population 1:50 of elderly 1:10 Nursing Home Residents

3 Recognition Slowness Stiffness Tremor Loss of balance

4 First Diagnosis PCT priorities carer support manage co-morbidity nursing needs assessment Patient concerns driving (DVLA, insurers) inheritance (rare)

5 Management Aims Initial acceptance of diagnosis control symptoms reduce distress improve outlook Subsequent relieve morbidity prevent complications

6 Maintenance PCT priorities complications follow-up arrangements ?shared care Patient concerns work/finance/benefits sexuality

7 Complex Parkinsons PCT priorities Aims maintain good health manage drug regime address disease/complication problems support for patients/carers

8 Complications Deteriorating function immobility, slowness, loss of activity Loss of drug effect end-dose, on-off effects Involuntary movements (dyskinesia) Confusion, depression, hallucination Constipation, incontinence, wt loss, hypotension

9 Referral Initial Maintenance Complex Palliative

10 Referral: Initial Confirmation of diagnosis Management multi-disciplinary team see later drug treatment Special Interest follow-up monitoring side effects

11 Referral: Maintenance Multi-disciplinary team Occupational Therapy Physiotherapy Dietician Speech/Language therapy Social Services Podiatrist Continence Advisor

12 Referral: Complex Specialist team in major role access to secondary care neurosurgery watch for complications communication

13 Referral: Palliative Appropriate support palliative care services social needs assessment care in home, nursing home or hospice

14 Drug Treatment Progression PD inevitably progresses Tachyphylaxis Levodopa only works for 4-5 years More levodopa = late side effects 50% of patients by 4-5 years Polypharmacy

15 Drug Treatment Levodopa Dopamine agonists Selegiline (MAOI type B) COMT inhibitors Anticholinergics Amantadine

16 Levodopa used since 1960s mixed with dopa decarboxylase inhibitor good for rigidity/bradykinesia not so good for tremor Side Effects: confusion, hallucinations, mood changes/swings involuntary movements: on-off

17 Dopamine Agonists Bromocriptine, Pergolide, Ropinirole, Cabergoline, Pramipexole single Rx co-Rx with levodopa Apomorphine subcutaneous injection in advanced refractory disease usually initiated in-patient (ADR)

18 Selegiline MAOI prevents Dopamine breakdown co-Rx with levodopa unexpectedly high mortality (?autonomic ADR)

19 COMT inhibitors Inhibit alternative dopamine degradation pathway Allow reduction levodopa dose (30- 50%) LFTs need to be monitored

20 Anticholinergics Benzhexol, orphenadrine useful in younger patients with tremor avoid in elderly (ADR)

21 Amantadine Useful in younger/mildly-affected patient Loses effect quickly (months) Good for mild akinesia/tremor

22 Drugs to avoid Phenothiazines Prochlorperazine, fluphenazine, haloperidol, sulpiride Metoclopramide MAOIs: provoke ADR with levodopa Atypical antipsychotics clozapine, olanzapine

23 Parkinsons Disease Society 215 Vauxhall Bridge Road, LONDON SW1V 1EJ Tel Helpline


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