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Home | Articles | Care of the Elderly | Parkinson’s Disease

Parkinson’s Disease

Last updated 4th March 2024

Overview

  1. Chronic neurodegenerative disorder affecting basal ganglia and resulting from loss of dopamine and dopaminergic neurones
  2. Incidence increases with age affecting 2% population over 80
  3. More common in men
  4. Presents with bradykinesia plus at least one of rigidity, tremor, postural instability
  5. Diagnosis is essentially clinical versus Essential Tremor and Cerebrovascular Parkinsons

Bradykinesia

  1. Patients describe a “weakness” or “tiredness
  2. Reduced dexterity esp buttons, shoelaces, writing, coins
  3. Test finger tapping and heel tapping
  4. Gait freezing or festination
  5. Lack of facial expression

Tremor

  1. Pill rolling, rest tremor, 4-5Hz, unilateral initially
  2. Rarely affects head, can affect legs, lips, jaw and tongue
  3. Worse with anxiety, emotion, stress and cold
  4. Tremor dominant PD often has a better prognosis

Differential Diagnosis Tremor

  1. The main differential is with essential tremor – the distinction is not always easy
    ETPD
    TremorUsually bilateralUsually unilateral initially
    Body PartHands, head, voiceHands, legs, lips, jaw, tongue but not head
    Family HistoryPositive 50%Often negative
    AlcoholMay improve tremorMinimal effect

Rigidity

  1. Increased resistance to passive movement
  2. Unilateral, becomes asymmetric
  3. Cogwheel = tremor and tone
  4. Causes stiffness and pain

Postural Instability

  1. A later feature of the disease
  2. Can elicit using the Pull Test – Subject stands with eyes open and feet shoulder width apart. Examiner stands behind, instructs subject to do whatever it takes to not fall and says that examiner will catch them if they do fall. The examiner gives a sudden, brief backward pull to the shoulders with sufficient force to cause the subject to have to regain their balance. Test is positive if subject takes several steps backwards and needs to be supported to prevent fall.

SPECT Scan

  1. Uses an iodine containing compound to identify presynaptic dopaminergic deficit.
  2. Helps to distinguish between PD/Parkinsonian Plus and Essential Tremor or Cerebrovascular Parkinsonism but doesn’t distinguish between PD and Parkinsons Plus.
  3. Only available in larger centres and expertise is required to interpret scans

Levodopa

  1. Levodopa, the precursor of dopamine, is combined with decarboxyylase inhibitor to prevent breakdown of L-dopa to dopamine outside the brain
  2. First choice in patients with bradykinesia
  3. Quicker action than dopamine agonists
  4. Co-careldopa (Sinemet) = levodopa + carbidopa and is available in tablets or suspension to allow NG administration. 7 day shelf life.
  5. Co-beneldopa (Madopar) = levodopa + benserazide is available as capsules and dispersible tablets but is too gritty for NG tube
  6. Different strengths available:12.5/50, 10/100, 25/100, 25/250
  7. Start low and titrate slowly eg 12.5/50 tid with meals then after approx 2 weeks increase gradually to 25/100 tid
  8. Titrate to lowest dose with the therapeutic response
  9. Initially given with food to reduce nausea, then on an empty stomach in later stages due to delayed gastric emptying
  10. Side effects include nausea, dyskinesias, dystonia, end of dose deterioration, unpredictable on/off effects, postural hypotension, confusion, visual hallucinations, agitation, delusions. Use Domperidone if nauseated
  11. Controlled release preparations no longer advised as poor absorption and poor bioavailability

Dopamine Receptor Agonists

  • First line in younger patients as can delay the need for levodopa
  • Often used as adjunct to levopopa in older patients
  • Commonly used are Ropinirole, Pramipexole (both oral), Rotigotine (patch)
  • Apomorphine available as subcut infusion.
  • Pergolide and Cabergoline withdrawn due to side effects
  • Beware confusion between salt and base eg Pramipexole 0.125mg salt/ 88microgram base
  • Treatments can be given once a day orally or by patch
  • Start with low dose and titrate up
  • Fewer motor fluctuations than levopopa
  • Side effects can be significant and include impulsive behaviour eg gambling – PD team complete an impulsive and compulsive behaviour tool with each patient and partner, ask them to sign it and send a copy to the GP Other side effects are daytime sleepiness, hallucinations, nausea, ankle oedema
  • Withdrawal can be similar to cocaine withdrawal with anxiety, panic attacks, sweating, nausea

Other Drugs

  • MAOB inhibitors eg Selegiline and Rasagiline. Inhibit breakdown of dopamine within the brain. Can be used to delay the need for Levodopa. May be mood enhancing. Side effects include dizziness, abdominal pain, dry mouth, nausea, stomach upset, trouble sleeping, and headache. Risk of serotonergic syndrome with SSRIs and SNRIs.
  • Anticholinergics – went out of fashion because of high risk of side effects but starting to be used again for younger patients with tremor eg Trihexyphenidyl Can be addictive and take months to stop
  • Amantidine – antiviral, known to increase dopamine release and have other effects which have initially seen it used for monotherapy but later to help settle dyskinesias
  • COMT (catechol-O-methyltransferase) inhibitors – Entacapone and Tolcapone (rarely used because of liver toxicity). Prolong the Levodopa effect therefore useful for patients with end of dose wearing off. Stanek is a useful polypil containing levodopa/carbidopa/entacapone in ratio 50/12.5/200. Side effects include confusion and Orange urine.

Drug Rules in Hospital

  1. Never stop drugs suddenly or even miss a dose as risk of Parkinsonian Neuroleptic Malignant Syndrome (NMS)
  2. Patients must be prescribed and given their PD drugs at the times they take it at home – not to fit in with ward rounds
  3. Encourage patients to bring their own meds in for formulation consistency and med rec.
  4. HEPMA – use free form boxes for dosing
  5. Try to give regular release levodopa rather than controlled release as poor absorption and low bioavailablity
  6. Avoid Haloperidol for agitation – Lorazepam is drug of choice if drug required but try to talk down with family first.
  7. If swallowing issues or NBM give co-careldopa suspension via NG or switch to Rotigotine Patch 4mg/24hrs. Patches stocked in surgical HDU

Parkinsonian Neuroleptic Malignant Syndrome

  1. If a patient is NBM for approx 24 hours or longer they are at high risk of Parkinsonian-hyperpyrexia syndrome, very similar to NMS
  2. Features include rigidity, fever, reduced conscious level, autonomic instability and raised CK
  3. Complications are AKI, aspiration pneumonia, DVT/PE, DIC.

Nausea and Vomiting

  1. Rx lowest effective dose Domperidone orally or rectally – NB risk of QT prologation if >60yrs or >30mg daily
  2. Safe alternatives are cyclizine orally/IM/IV or ondansetron
  3. Avoid metoclopramide and prochlorperazine in PD
  4. Refer PD team asap

Confusion/Hallucination/Agitation

  1. Try to avoid prescribing if possible but if necessary Rx Lorazepam – can cause paradoxical increase in agitation so monitor closely
  2. Avoid haloperidol or chlorpromazine in PD, and particularly in Lewy Body Disease
  3. Refer PD team asap

Dizziness and Falls

  1. Check lying/standing BP
  2. Review need for drugs that cause postural hypotension
  3. Note that PD itself and PD drugs can cause postural hypotension
  4. Refer PD team asap

Subcutaneous Apomorphine for Infusion

  1. All patients admitted to hospital on Apomorphine, a dopamine agonist given by SC infusion, should continue on Apomorphine and be referred to PD team asap.
  2. Apomorphine is not suitable for emergency administration in a drug naive patient and should only be started by a member of the PD team

Drug Induced Parkinsonism

  1. Commonly neuroleptics, metoclopramide, prochlorperazine, fluphenazine, cinnarizine.
  2. Lithium, valproate and amiodarone can cause tremor only without other Parkinsonian features.
  3. Recovery from drug induced Parkinsonism can take up to a year.

Parkinson’s Plus

  1. Parkinson’s plus postural hypotension, cerebellar and/or autonomic system involvement = Multiple System Atrophy
  2. Parkinson’s plus early dementia and hallucinations = Lewy Body Disease
  3. Parkinson’s plus failure of vertical, esp downward, gaze or early postural instability with falls = Progressive Supranuclear Palsy
  4. Parkinson’s plus syndromes associated with poor response to levodopa and shortened life expectancy

Parkinson’s and Dementia

  1. Dementia is more common in patients with PD. There are two forms:
  2. Parkinson’s dementia is diagnosed when someone already has the motor symptoms of Parkinson’s and has had them for some time.
  3. Dementia with Lewy bodies is diagnosed when someone has the symptoms of dementia either before or at the same time as they develop Parkinson’s.

Prognosis

  1. Outlook is variable and related to age at onset
  2. If PD starts before 70 then usually progressive and likely to shorten lifespan
  3. Onset after 70 less likely to shorten life but may become severe

Referrals

  1. Please refer before starting treatment as signs can change and patients often not keen to stop treatment once started
  2. Dr Shona Donaldson will see new patients, email [email protected]
  3. Dr Mignon Gerrits can also be contacted, email [email protected]
  4. Laura Chapman, PD Nurse Specialist 33909, is automatically notified of any PD patient’s hospital admission and will try to see on ward to ensure meds are correct etc. However if having problems with a patient’s management and Laura hasn’t seen them, contact Dr Donaldson.

Links

Content by Dr Shona Donaldson