Management in Primary Care Parkinson’s Disease Management in Primary Care

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

Recognition Slowness Stiffness Tremor Loss of balance

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

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

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

Complex Parkinson’s PCT priorities Aims maintain good health manage drug regime address disease/complication problems support for patients/carers

Complications Deteriorating function Loss of drug effect 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

Referral Initial Maintenance Complex Palliative

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

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

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

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

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

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

Levodopa used since 1960’s 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

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)

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

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

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

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

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

Parkinson’s Disease Society 215 Vauxhall Bridge Road, LONDON SW1V 1EJ Tel 020 7931 8080 www.parkinsons.org.uk Helpline 0808 800 0303