common problems in neurological common problems in

Dr Annette EdwardsDr Annette Edwards

Consultant in Palliative Consultant in Palliative MedicineMedicine

LeedsLeeds

Common problems in neurological Common problems in neurological disease: Pain and nauseadisease: Pain and nausea

Symptom Burden in Advanced DiseaseSymptom Burden in Advanced Disease

SymptomSymptom

PainPainFatigueFatigueNauseaNauseaConstipationConstipation

DyspnoeaDyspnoea

MSMS22

68%68%80%80%26%26%47%47%

26%26%

Heart Heart diseasedisease11

Resp. Resp. DiseaseDisease11

4141--77%77% 3434--77%77%6969--82%82% 6868--80%80%1717--48%48% ??3838--42%42% 2727--44%44%

6060--88%88% 9090--95%95%

1. Solano, Gomes, Higginson 2006; 2. Kings College London MS Pall. Care Project

CancerCancer11

3535--96%96%3232--90%90%66--68%68%2323--65%65%

1010--70%70%

PainPain

Common symptomMND 73%MS 34% - 82%Parkinson’s 29% - 80%Stroke 2%Dementia ? 25 – 83%

Symptoms in MNDSymptoms in MND

DysphagiaDysphagia 87%87%DyspnoeaDyspnoea 85%85%Weight lossWeight loss 84%84%Speech problemsSpeech problems 74%74%PainPain 73%73%ConstipationConstipation 53%53%DroolingDrooling 23%23%Emotional Emotional labilitylability 23%23%

Causes of pain in neurological Causes of pain in neurological diseasedisease

Directly related to the disease:

MusculoskeletalCrampsNeuropathic:Central eg Post strokeMS - paroxysmal pain

Indirectly related:Skin PressureConstipation / UTISecondary to falls

Treatment related pain:eg Peak dose dystonias

Unrelated to disease:eg Osteoarthritis

Pain in neurological disease Pain in neurological disease

MusculoskeletalMusculoskeletalJoint painJoint painStiffnessStiffnessContractionsContractions

PhysiotherapyPhysiotherapyHeat TENSHeat TENSSimple analgesics, Simple analgesics, NSAIDsNSAIDs? Opioids? Opioids

Muscle crampsMuscle cramps

Spastic musclesSpastic muscles

PhysiotherapyPhysiotherapyPositioningPositioningMuscle relaxantsMuscle relaxants? Quinine? QuininePainful tonic spasms may also respond to antiepileptics eg gabapentin, carbamazepine

?? ?? VitVit E, MgE, Mg

Spasticity managementSpasticity management

Reduction of noxious stimuli Reduction of noxious stimuli –– constipation, pain etcconstipation, pain etc

Multidisciplinary programmeMultidisciplinary programmeAvoidance of precipitating factorsAvoidance of precipitating factorsCareful positioning / stretching /splinting / Careful positioning / stretching /splinting / orthosisorthosisAppropriate seating review etcAppropriate seating review etc

Pharmacotherapy:Pharmacotherapy:Generalised Generalised -- Oral baclofen, Oral baclofen, dantrolenedantrolene, , tizanidinetizanidineRegional Regional -- Intrathecal baclofen or phenolIntrathecal baclofen or phenolFocal Focal -- Intramuscular Intramuscular botulinumbotulinum, phenol , phenol neurolysisneurolysis

SurgerySurgery

AntiAnti--spasmodic medicationsspasmodic medicationsBaclofen 5-20mg tds, Tizanidine 2- 24 mg daily in 3-4 divided dosesBenzodiazepines eg diazepam 5mg nocte to max 10mg qds, clonazepam 1 – 4 mg nocte.Dantrolene 25-100mg qds

Use restricted by unwanted side effects:muscle weakness drowsiness and dry mouth NB Dantrolene acts peripherally - muscle weakness, reports of hepatotoxicity.

Neuropathic painNeuropathic paineg MS eg MS –– paroxysmal symptoms, burning paroxysmal symptoms, burning

dysaesthesias, central pain dysaesthesias, central pain

ManagementManagementCoCo--analgesicsanalgesicsAntidepressants eg amitriptylineAntidepressants eg amitriptylineAnticonvulsants eg gabapentinAnticonvulsants eg gabapentinSteroidsSteroidsNMDA antagonistsNMDA antagonists(?cannabinoids)(?cannabinoids)

Skin pressure painSkin pressure pain

DiscomfortDiscomfortReduced mobility Reduced mobility -- Position Position unchangedunchanged

PositioningPositioningDressingsDressingsOpioidOpioid medication medication -- ?topical?topical

Disease SpecificDisease Specific

MSMS? Pain associated with relapse ? Pain associated with relapse –– liaise with liaise with neurologistneurologist

ParkinsonParkinson’’s Diseases Disease? relationship of pain to PD medicationreview of dopaminergic treatment

Patient concerns that may Patient concerns that may worsen painworsen pain

DiagnosisDiagnosisSymptomsSymptomsDisabilityDisabilityDependenceDependenceDeath and dyingDeath and dyingPsychosocial concernsPsychosocial concernsSpiritual issuesSpiritual issues

Pain ManagementPain ManagementComprehensive holistic assessmentComprehensive holistic assessmentAnalyse likely aetiology / proposed mechanismAnalyse likely aetiology / proposed mechanismAnalgesics:Analgesics:

RegularRegularConsider routeConsider routeTitrate to patientTitrate to patient

Consider other methods eg adjuvant treatmentsConsider other methods eg adjuvant treatmentsRememberRemember

Psychological pain Psychological pain Social painSocial painSpiritual painSpiritual pain

Opioids in MNDOpioids in MNDOral morphine

Mean dose 96mg/24 hours

Median dose 60mg/24 hours

Mean duration 95 daysof use

NauseaNausea

Common symptomCommon symptomUnderUnder--reportedreportedMNDMND ? 20 ? 20 –– 48%48%MSMS 18 18 –– 26% 26% ParkinsonParkinson’’s Disease s Disease 14%14%StrokeStroke ????DementiaDementia ????

Nausea Nausea –– common causes common causes

MedicationMedicationConstipationConstipationUTIUTIIntracranial lesionsIntracranial lesionsNeuropathyNeuropathyGI causesGI causes

NauseaNausea

GastroGastro--intestinal intestinal RefluxRefluxDysphagia Dysphagia Gastric dysfunctionGastric dysfunctionIleusIleusPseudoPseudo--obstructionobstructionOther eg gastritis, ulcerOther eg gastritis, ulcer

Management of nauseaManagement of nauseaSpecific treatmentSpecific treatment

UTI UTI –– antibioticsantibioticsConstipation Constipation -- aperientsaperients

MedicationMedication? Stop ? Stop Add antiAdd anti--emeticemetic

RefluxRefluxAntacid, Antacid, PPIsPPIsMetoclopramideMetoclopramide / / domperidonedomperidoneAttention to feeding regimensAttention to feeding regimens

AntiAnti-- emeticsemetics

Careful useCareful useDomperidoneDomperidone / / metoclopramidemetoclopramide

Acts on stomachActs on stomachCyclizineCyclizine

AntihistamineAntihistamineLevomepromazineLevomepromazine

Broad actingBroad acting

Nausea in ParkinsonNausea in Parkinson’’s Diseases Disease

Causes Causes gastric gastric dysmotilitydysmotility (autonomic effect) (autonomic effect) medication, medication, espesp dopamine agonists eg dopamine agonists eg bromocriptinebromocriptine, , pergolidepergolide, , apomorphoneapomorphone. . otherother

ManagementManagementperipherally acting peripherally acting antidopaminergicantidopaminergic drug eg drug eg domperidonedomperidone, not , not metoclopramidemetoclopramide. . Haloperidol and Haloperidol and levomepromazinelevomepromazine –– D2 antagonists D2 antagonists ––can exacerbate PD. Also risk of eg acute can exacerbate PD. Also risk of eg acute dystoniasdystonias. .