1. Management in Primary Care
Parkinson’s 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 Patient concerns carer support
manage co-morbidity
nursing needs assessment
Patient concerns
driving (DVLA, insurers)
inheritance (rare)

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

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

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

8. 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

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 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

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

16. 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

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

23. Parkinson’s Disease Society
215 Vauxhall Bridge Road,
LONDON SW1V 1EJ
Tel
Helpline