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1. Debra Vincent ScottClinical nurse specialist in Parkinson's diseaseEmail debra.vincent-scott@fhft.nhs.ukMOBILE 07979005687 This presentation has been produced by GlaxoSmithKline

2. Aims • Prevalence • Diagnosing • Non Motor symptoms • Stages of PD • Treatment • Patients experience

3. Prevalance • 1 in 500 UK resident have PD • 1 in 100 > 60 yrs have PD • 127000 Pt have formal PD diagnosis (GPRD database) • 1 in 20 Pt; Develop symptoms under 40 yrs of age • By 2020: PD no will rise- 162000 • 28% rise in PD cases • Economic burden of PD is ~ £2 billion annually (Imperial College) (1, 2)

4. Diagnosing PD • A set of characteristic symptoms that affect motor control: • resting tremor, • bradykinesia, and • hypertonia. • Resting tremor is an oscillating movement (4—6 Hrzd) that occurs when the patient is trying to be still; disappears on action • Essential Tremor: Persists on movement • Cerebellar Tremor: Intentional tremor

5. Bradykinesia means slowness of movement. • Usually experienced as ‘weakness’ or ‘stiffness’ of limb • Hypertonia means excessive muscle tone. • Manifest itself as rigidity or stiffness. • Other typical features: are • a Stooped posture/ Slow, shuffling festinant gait/ Reduced arm swing/ Facial appearance (Masked like ‘hypomimia’)/ Low volume speech/ Excessive drooling of saliva

6. The ‘Braak hypothesis’ Stage 5 and 6:Changes spread to the cortex Stage 3 and 4:Pathology spreads to the midbrain and basal ganglia Stage 1 and 2:Pathology confined to certain structures in the brain stem, not yet the substantia nigra Image adapted from The Professionals Guide to Parkinson’s Disease, Parkinson'sS

7. Non-motor symptoms of PD 3 Autonomic Neuropsychiatric Sleep disturbance Sensory symptoms Dementia Depression Apathy Anxiety Loss of libido REM sleep disorder RLS Vivid dreams Daytime somnolence Dystonia Constipation Urinary incontinence Erectile dysfunction Excessive sweating Postural hypotension Excessive salivation Pain Paraesthesia

8. Criteria for entry into staging categories Parkinson's Disease Diagnosis / early Knowledge of disease Ideas and perceptions Employment issues Neuro rehab • Levodopa or Dopamine agonists • Rasagiline. selegiline Maintenance Promote normal function Regular reviews-red flags Support MDT input Entacapone Stalevo Complex Motor complications. Neuropsychiatric complications Reduction of drugs. Carer support/respite/hospice Amantadine. Apomorphine Duodopa DBS Symptoms versus side effects Advanced care needs Palliative 4 .MacMahon D.G Thomas.S Practical Approach to Parkinson’s Disease. Journal of Neurology (1998) 245 (SUPP1)S19.S22

9. TREATMENT Begins with Diagnosis Patient education.MDT input Discussion of when and which drug Treatments. Bradykinesia dominated disease may need earlier treatment than tremor dominated disease People with suspected Parkinson’s should be referred quickly and untreated to a specialist (NICE 2006)

10. Drug classes in Parkinson’s DAs Dopamine agonists Levodopa MAO-B inhibitors Monoamine oxidase B inhibitors COMTs Catechol-O-methyltransferase inhibitors Anticholinergics

11. Drugs to avoid

12. Drug management As responses to drugs are variable, treatment regimes differ from person to person The timing of drugs is important in order to achieve continuous dopaminergic stimulation Nurses have a key role in helping the patients manage complex drug regimes Sudden discontinuation of treatment should be avoided as it can result in Neuroleptic Malignant Syndrome. Get it on time campaign. NH homes to send in medication with patient

13. End note Start ‘slow and low’ Watch for side effects; low BP, Orthostatic hypotension, ICD NMS are more common in older pts NMS are often confusing & poorly recognised Insomnia: likely due to Akathisia (inner restlessness), stiffness (rigidity), difficulty turning in bed, as well as tremor Anxiety: likely due to Akathisia Cramps: could be ‘dystonias’: inspect feet for inversion, great toe Pain/ Paresthesia/ depression: may be levodopa responsive Avoid hospitalisation The patient is the expert

14. References findley LJ The economic impact of Parkinson's disease. Parkinsonism RelatDisord. 2007 Sep;13 Suppl:S8-S12. Epub 2007 Aug 16. Oliver H.H. Gerlach, MD,* AniaWinogrodzka, MD, PhD, and Wim E.J. Weber, MD, PhD; Clinical Problems in the Hospitalized Parkinson’s Disease Patient: Systematic ReviewMovement Disorders, Vol. 26, No. 2, 2011 Huse DM, Schulman K, Orsini L, Castelli-Haley J, Kennedy S, Lenhart G. Burden of illness in Parkinson’s disease. MovDisord 2005;20:1449–1454 Parkinson’s-UK. ‘‘Get It on Time.’’ www.parkinsons.org.uk. Shulman LM, Taback RL, Rabinstein AA, Weiner WJ. Non-recognition of depression and other non-motor symptoms in Parkinson’s disease. Parkinsonism RelatDisord. 2002;8(3): 193–197. Miyasaki JM, Shannon K, Voon V, et al. Quality Standards Subcommittee of the American Academy of Neurology. Practice Parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;66(7):996–1002. Poewe WH, Lees AJ, Stern GM. Low-dose L-dopa therapy in Parkinson’s disease: a 6-year follow-up study. Neurology1986;36:1528-1530. Kumar N, Van Gerpen JA, Bower JH, Ahlskog JE. Levodopa-dyskinesia incidence by age of Parkinson’s disease onset. MovDisord 2005; 20:342-344 Holloway RG, Shoulson I, Fahn S, Kieburtz K, Lang A, Marek K, et al. Pramipexole vs levodopa as initial treatment for Parkinson disease: a 4-year randomized controlled trial. Arch Neurol 2004;61:1044-1053 Dodd, Klos KJ, Bower JH, Geda YE, Josephs KA, Ahlskog JE. Pathological gambling caused by drugs used to treat Parkinson disease. Arch Neurol 2005;62:1377-1381. Nirenberg MJ, Waters C. Compulsive eating and weight gain related to dopamine agonist use. MovDisord 2006;21:524-529. 73. Voon V, Hassan K, Zurowski M, de Souza M, Thomsen T, Fox S, et al. Prevalence of repetitive and reward-seeking behaviors in Parkinson disease. Neurology 2006;67:1254-1257

15. Parkinson’s-UK. ‘‘Get It on Time.’’ www.parkinsons.org.uk. Shulman LM, Taback RL, Rabinstein AA, Weiner WJ. Non-recognition of depression and other non-motor symptoms in Parkinson’s disease. Parkinsonism RelatDisord. 2002;8(3): 193–197. Miyasaki JM, Shannon K, Voon V, et al. Quality Standards Subcommittee of the American Academy of Neurology. Practice Parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;66(7):996–1002. Poewe WH, Lees AJ, Stern GM. Low-dose L-dopa therapy in Parkinson’s disease: a 6-year follow-up study. Neurology1986;36:1528-1530. Kumar N, Van Gerpen JA, Bower JH, Ahlskog JE. Levodopa-dyskinesia incidence by age of Parkinson’s disease onset. MovDisord 2005; 20:342-344 Holloway RG, Shoulson I, Fahn S, Kieburtz K, Lang A, Marek K, et al. Pramipexole vs levodopa as initial treatment for Parkinson disease: a 4-year randomized controlled trial. Arch Neurol 2004;61:1044-1053 Dodd ML, Klos KJ, Bower JH, Geda YE, Josephs KA, Ahlskog JE. Pathological gambling caused by drugs used to treat Parkinson disease. Arch Neurol 2005;62:1377-1381. Nirenberg MJ, Waters C. Compulsive eating and weight gain related to dopamine agonist use. MovDisord 2006;21:524-529. 73. MacMahon D.G Thomas.S Practical Approach to Parkinson’s Disease. Journal of Neurology (1998) 245 (SUPP1)S19.S22 Voon V, Hassan K, Zurowski M, de Souza M, Thomsen T, Fox S, et al. Prevalence of repetitive and reward-seeking behaviors in Parkinson disease. Neurology 2006;67:1254-1257