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Parkinson

Jimmy
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Parkinson

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    1. Parkinson’s Disease: Management of The Non-Motor Symptoms Dr. Doug MacMahon Royal Cornwall Hospitals NHS Trust Peninsula Medical School

    3. James Parkinson (1817):

    5. Sydney Multicentre study: Non L dopa responsive symptoms predominate at 15 years Hely et al 2005 n=52

    6. How Common? Constipation: Community Study MacMahon, Maguire Care of the Elderly 75% Non Motor Survey 50% When? Honolulu Heart study >10 yrs pre Diagnosis of PD

    7. Combination of ‘idiopathic’ REM sleep behaviour disorder and olfactory dysfunction as possible indicator for a -synucleinopathy demonstrated by dopamine transporter FP-CIT-SPECT

    8. ‘Nocturnal Falls’ 90 yr retired, married, ‘mechanical fall at 0400’

    9. Aetiology e.g. constipation Aging Relative immobility Drugs Lewy bodies in Auerbach's and Meissner's plexuses Olfaction - Braak

    12. Non motor Questionnaire (available on pds web-site) http://www.parkinsons.org.uk/for_professionals/resources/non-motor_symptoms_of_ps_qq.aspx

    13. Non-Motor Scale

    14. Anxiety & Panic Disorder in PD Anxiety may precede motor features by 20 years1 Frequency in established PD 20-40%2,3 generalised anxiety disorder > panic attacks comorbidity with depression may fluctuate with motor state4 Assessment Hospital Anxiety & Depression Scale5 Management treat underlying depression reduce “OFF” periods short term benzodiazepines (e.g. lorazepam)

    15. Depression in PD Common - ? 40% ? Severity Rx: Evidence Free Zone

    16. DLB & PD Dementia: A Spectrum

    17. Dementia in PD Common - ? 40% Evidence of Efficacy – Rivastigmine (Emre et al 2005)

    18. Dopamine Dysregulation Syndrome Self-medication & addiction to DRT Frequency 2-4% Characteristic profile male (80%) early onset-disease severe but well tolerated dyskinesias previous history of mood disorder Hypomanic, manic or cyclothymic affective syndrome in relation to DRT Depression, irritability & anxiety on ? DRT

    19. Punding Complex, prolonged, purposeless & stereotyped behaviour Originally described in amphetamine users LEU = L-dopa equivalent unitsLEU = L-dopa equivalent units

    20. Pathological Gambling “Impulse control disorder” (DSM-IV) Frequently triggered by L-dopa Worse in “on” periods Culturally-determined pattern Associated with: pre-morbid alcohol dependence or abuse major depression

    21. Hypersexuality & Paraphilias Frequency 0.9-3% (male predominant) Libido increased but not necessarily potency No relation between functional improvement & ? sexuality1 Dose dependency between drugs & hypersexual behaviour1 Complication of DBS (pallidum > STN?)2,3 Reversible transvestic fetishism4 dopamine agonists & selegiline

    23. Management of “Dopamine-Driven” Behaviours Explanation to patient & family Withdraw dopaminergic medication in reverse sequence short-term prescriptions? supervised tablet administration? Treat underlying depression (e.g. SSRI) Avoid intermittent s/c apomorphine Low dose quetiapine for DDS/psychosis? Mood stabilizer (e.g. carbamazepine) Psychotherapy?

    24. Multidisciplinary approach

    25. And, finally….. Non-motor problems are common May help as diagnostic markers Many are treatable or at least manageable Best managed by Specialist Multidisciplinary team/s

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