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SYMPTOM CONTROL IN ADVANCED PARKINSON’S DISEASE

SYMPTOM CONTROL IN ADVANCED PARKINSON’S DISEASE. Vicky Travers PDNS UHMBT April 2012. Parkinson’s Disease. A fluctuating, progressive, neurological condition Results from degeneration of dopamine- producing neurones in substantia nigra 1:500 (approx 120,000 people in UK)

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SYMPTOM CONTROL IN ADVANCED PARKINSON’S DISEASE

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  1. SYMPTOM CONTROL IN ADVANCED PARKINSON’S DISEASE Vicky Travers PDNS UHMBT April 2012

  2. Parkinson’s Disease • A fluctuating, progressive, neurological condition • Results from degeneration of dopamine- producing neurones in substantia nigra • 1:500 (approx 120,000 people in UK) • Increasingly prevalent with age

  3. Parkinson’s disease con’d • Clinical diagnosis (NICE guidelines 2006) • Motor symptoms / non-motor symptoms • Cause not known • Incurable but treatable • Not life threatening, but can be life limiting

  4. Core Symptoms for diagnosis • Rigidity – raised tone in muscles • Postural Instability – poor balance (often presents as a later feature) • Tremor – resting, asymmetrical, 70 % PwPD • Bradykinesia – slowness of movement

  5. Progression of PD • Individual progression rate • Individual manifestation of symptoms • Individual response / side effects to medications • = Need for individualised care throughout disease trajectory

  6. Stages of Parkinson’s Disease • Diagnosis • Maintenance • Complex • Palliative

  7. Palliative Care Should “Offer pain relief and meet needs for personal, social, psychological and spiritual support, in line with principles for palliative care” NSF for Long Term Neurological Conditions (Quality requirement 9) • Advanced care planning • Progressive dopaminergic drug withdrawal • Analgesia, sedation and other palliative measures • Primary and/or secondary care depending on circumstances

  8. Non-motor symptoms • Cognition • Pain • Autonomic symptoms • Sleep disturbance • Communication • Swallowing • Weight loss

  9. Cognition • Anxiety • Depression • Apathy • Cognitive impairment • Dementia • Psychosis

  10. Symptom control • Review PD meds • ? Antidepressants – Mirtazapine • CBT / talking therapy/ support • Cholinesterase inhibitors • Atypical antipsychotics – Quetiapine Avoid Haloperidol!!!

  11. Pain • Common and under-reported • Several types of pain [Primary or Secondary] • Musculoskeletal – rigidity or dyskinesia • Dystonic • Off phase pain • Coat hanger pain – postural hypotension • Burning mouth, anal burning • Akathisia/restlessness - RLS

  12. Symptom Control • Careful assessment • Exclude co-morbidities • Review Parkinson’s medication – optimise dopaminergic treatment • Analgesia • Complementary therapies

  13. Autonomic symptoms (dysautonomia) • Postural Hypotension • Sexual dysfunction • Bladder / bowel dysfunction • Sweating (Hyperhidrosis) • Drooling (Sialorrhoea)

  14. Symptom Control • Medication Review PD meds, Hyoscine, Atropine drops sublingually (beware neuropsychiatric side effects) for drooling Domperidone (anecdotal evidence), Fludrocortisone, Midodrine for postural hypotension • MDT SALT, Continence team, nursing team, dietician

  15. Sleep disturbance • REM sleep behaviour disorder • Akinesia / rigidity • Dyskinesia • Restlessness • Urinary problems • Hypersomnolence • Bad dreams / hallucinations

  16. Symptom Control • Good sleep hygiene • Medication – Modafinal for hypersomnolence Clonazapam for REM sleep behaviour review Dopaminergic treatment atypical antipsychotic (beware side effects/ contraindications) • MDT

  17. Communication • Verbal and non-verbal • Mask like facies (Hypomimia) • reduced volume (Hypophonia) • “Stuttery” speech • Repitition of syllables or words (Palilalia) • Monotone and monopitch

  18. Symptom Control • MDT especially SLT • Alternative communication techniques - Charts, amplifier, lightwriter, IPAD Education/ support for PwPD/ carers / family

  19. Swallowing disorders • Reduced tongue motility / co-ordination • Food remaining in epiglottic vallecula • Decreased ability to chew • Delay of pharyngeal swallow • Reduced laryngeal closure • Aspiration

  20. Symptom Control • Speech and Language Therapy input • Dietician • Medication review - ? Change preparation of medication • Thickened fluids • Observed / assisted feeding • Education for Pwpd / Carers / family

  21. Weight Loss • Dyskinesia • Rigidity • Dysphagia • Poor intake due to reduced ability / appetite

  22. Symptom Control • Dietician / SLT • Medication review • Maintain hydration • Skin care • Mouth care • Assisted feeding

  23. Please Remember…… ……….Not all solutions work for all people………………. ……… Sometimes just being there is enough……………….

  24. Thank you Any Questions? Vicky.travers@mbht.nhs.uk 01524 583611 / 07765351985

  25. References • National Service framework for Long Term Conditions. DoH (2005) • Parkinson’s UK http://www.parkinsons.org.uk/ • Parkinson’s Disease. Diagnosis and Management in primary and secondary care. NICE (2006)

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