dr jim george - parkinson's disease service in cumbria
DESCRIPTION
'Parkinson's Disease Service in Cumbria' - Dr Jim George (Consultant Physician for North Cumbria University Trust) from the Cumbria Neuroscience ConferenceTRANSCRIPT
![Page 1: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/1.jpg)
PARKINSON’S DISEASE
Dr J George
![Page 2: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/2.jpg)
Parkinson’s Disease and NICE Guidance
Context Main messages NICE Guidelines Local implications Summary
![Page 3: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/3.jpg)
AN ESSAY ON THE SHAKING PALSY James Parkinson 1817
‘ Involuntary tremulous motion, with
lessened muscular power, in parts not in
action and even when supported; with a
propensity to bend the trunk forward, and
to pass from a walking to a running pace:
the senses and intellects being uninjured ’
![Page 4: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/4.jpg)
![Page 5: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/5.jpg)
Demographics
UK Population projectionsIndexed on 1995 (Royal Commission 1999)
0
50
100
150
200
250
300
1995 2001 2011 2021 2031 2041 2051
under 65
65-74
75-84
85+
10/03/2004
PREVALENCE OF PARKINSON'S DISEASEper 100,000
0
500
1000
1500
2000
2500
0-39 40-49 50-59 60-69 70-79 >80
AGES
Carlisle UK
Iceland
Aberdeen, UK
Northampton, UK
PD IS COMMON-RISING TO ~ 2%OF ELDERLYPOPULATION
1:7 DIAGNOSED < 60 YEARS
Twice the population at risk
Ten-fold increase in prevalence
![Page 6: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/6.jpg)
13/04/23
4 stage clinical management scale
MacMahon DG Thomas S J Neurology (1998) [suppl1]:S19-22
Diagnosis
Maintenance therapy
Complex
Palliative care
![Page 7: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/7.jpg)
13/04/23
How Long do PwPD Live?Duration of Disease
Stage PD yrs Atypical yrs (n=59) (n= 14)
Diagnosis 1.6 ± 1.5 1.8 ± 1.8
Maintenance therapy 5.9 ± 4.8 3.0 ± 2.0
Complex 4.9 ± 4.4 3.5 ± 3.5
Palliative care 2.2 ± 2.2 1.5 ± 1.2
Total 14.6 9.8
Mean Age at onset 64
So, a long term strategy is required even for ‘older’ patients
![Page 8: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/8.jpg)
![Page 9: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/9.jpg)
![Page 10: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/10.jpg)
Lewy Bodies
![Page 11: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/11.jpg)
![Page 12: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/12.jpg)
UK Parkinson’s disease society survey, 2004Main symptoms listed by patients ahead of motor problems
![Page 13: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/13.jpg)
Is the Diagnosis Easy?
50% error rate in primary care 25% error in secondary care Reduced to <10% with use of UKPDS BB
criteria(plus retrospectoscope!)
Meara
Hughes, Lees
![Page 14: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/14.jpg)
NICE GUIDELINES
Full Guidance Quick Reference guide Patient version Levels of Evidence ABCD/GPP Audit Criteria www.nice.org.uk
![Page 15: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/15.jpg)
Diagnosis
Tremor Rigidity Akinesia Postural Instability
![Page 16: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/16.jpg)
Red Flags / Exclusions
Repeated head injury Encephalitis Supranuclear gaze palsy Severe early autonomic involvement Cerebellar signs L dopa unresponsive Early severe dementia Neuroleptic treatment History repeated strokes
![Page 17: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/17.jpg)
Supportive positive criteria (3)
Unilateral onset Rest tremor Progresssive disorder Persistent asymmetry Good response to Ldopa Ldopa reponse 10 years Clinical course 10 years +
![Page 18: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/18.jpg)
Essential tremor Drugs Vascular Atypical Parkinsonism syndromes
Differential Diagnosis
![Page 19: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/19.jpg)
History and examination
Writing,swallowing,drooling,tremor, Falls,slowness,freezing,turning over Getting up from a chair Smell, memory, driving,eyes,voice Tremor,bradykinesia,rigidity, Pull test,spiral, handwriting, gait Carer concerns
![Page 20: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/20.jpg)
National Collaborating Centre for Chronic Conditions
Referral to expert for accurate diagnosis
People with suspected PD should be referred quickly* and untreated to a specialist with expertise in the differential diagnosis of this condition.
* The GDG considered that people with suspected mild PD should be seen within 6 weeks but new referrals in later disease with more complex problems require an appointment within 2 weeks
![Page 21: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/21.jpg)
National Collaborating Centre for Chronic Conditions
Diagnosis and expert review
The diagnosis of PD should be reviewed regularly* and reconsidered if atypical clinical features develop.
Acute levodopa and apomorphine challenge tests should not be used in the differential diagnosis of parkinsonian syndromes.
* The Guideline Development Group considered that people diagnosed with PD should be seen at regular intervals of 6–12 months to review their diagnosis.
![Page 22: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/22.jpg)
Treatment of PD –1969
Brain’s diseases of the nervous system OUP 1969
‘The sufferer should be encouraged to lead an active life as long as possible but should avoid fatigue. A ‘zip’ fastener on the trousers is a convenience.’
‘L-dopa in doses up to 5 grams looks promising’
![Page 23: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/23.jpg)
Drug Treatment
L dopa (A) Dopamine agonists - ergot
- non ergot (A) COMT Inhibitors (A) (not for early disease) MAOB Inhibitors (A)
![Page 24: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/24.jpg)
Drug Treatment (continued)
It is not possible to identify a drug of first choice for early or later disease. The choice should take into account clinical lifestyle characteristics and patient preference.
![Page 25: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/25.jpg)
Non-motor symptoms are important and should be considered in all phases of the disease
NICE PD Guidelines 2006
![Page 26: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/26.jpg)
Dementia
‘The dark secret of Parkinson’s Disease’ 30% cross sectional studies 80% cumulative incidence Subtle cognitive impairment is the norm
Cholinesterase Inhibitors (D)
![Page 27: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/27.jpg)
DLB & PD Dementia: A Disease Spectrum
TimeArbitrary 12 months
DLBDLB PD DementiaPD Dementia
Fluctuating cognition & hallucinations Parkinsonian features
![Page 28: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/28.jpg)
Education from healthcare providers & support groups avoid misinformation & incomplete information Realistic goals
Support professional & peer support emotional & financial counseling
Exercise keep active & avoid deconditioning regular stretching exercises physical therapy
Nutrition balanced diet & suitable consistency nutritional counseling
NON-PHARMACOLOGIC INTERVENTIONS IN PDNON-PHARMACOLOGIC INTERVENTIONS IN PD
![Page 29: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/29.jpg)
Parkinson’s Disease Nurse (C) Physiotherapy (B) Occupational Therapy (D - GPP) Speech Therapy (D - GPP)
Multidisciplinary Care
![Page 30: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/30.jpg)
![Page 31: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/31.jpg)
National Collaborating Centre for Chronic Conditions
Disease progression
Interventions
Communication
Interventions for people with PD
Diagnosis & early disease
Throughout disease
Later disease
Refer untreated to a specialist who makes and reviews diagnosis:
· use UK PDS Brain Bank Criteria
· consider 123 I-FP-CIT SPECT
· specialist should review diagnosis at regular intervals (6-12 months)
It is not possible to identify a universal first choice drug therapy for people with early PD. The choice of drug first prescribed should take into account:
· clinical and lifestyle characteristics
· patient preference
Provide regular access to specialist care particularly for:
· clinical monitoring and medication adjustment
· a continuing point of contact for support, including home visits when appropriate,
which may be provided by a Parkinson’s disease nurse specialist
Consider access to rehabilitation therapies, particularly to:
· maintain independence, including activities of daily living and ensure home safety
· help balance, flexibility, gait, movement initiation
· enhance aerobic activity
· assess and manage communication and swallowing
Consider management of non-motor symptoms in particular:
· depression
· psychosis
· dementia
· sleep disturbance
It is not possible to identify a universal first choice adjuvant drug therapy for people with later PD. The choice of drug prescribed should take into account:
· clinical and lifestyle characteristics
· patient preference
Consider apomorphine in people with severe motor complications unresponsive to oral medication:
· intermittent injections to reduce off time
· continuous subcutaneous infusion to reduce off time and dyskinesia
Consider surgery:
· bilateral STN stimulation for suitable people refractory to best medical therapy
· thalamic stimulation for people with severe tremor for whom STN stimulation is unsuitable
Reach collaborative care decisions by taking into account:
· patient preference and choice after provision of information
· clinical characteristics, patient lifestyle and interventions available
Provide communication and information about:
· PD services and entitlements
· falls, palliative care and end-of-life issues
![Page 32: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/32.jpg)
Local Implications
Parkinson’s disease clinics Parkinson’s disease specialist nurses * Education * Multidisciplinary Team * Drug costs
![Page 33: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/33.jpg)
THE FUTURE ????
![Page 34: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/34.jpg)
Summary
Parkinson’s disease is a dementia with a long motor prodrome
Management is multidisciplinary Referral to a specialist Service should be patient centred
![Page 35: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/35.jpg)
Case 1
School bus driver Tremor only Ethical issue
![Page 36: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/36.jpg)
DATscan images
![Page 37: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/37.jpg)
Case 2
55 year old man Classical bradykinesia and rigidity Good response to L dopa-very active Visual problems 2nd opinion
![Page 38: Dr Jim George - Parkinson's Disease Service in Cumbria](https://reader034.vdocuments.us/reader034/viewer/2022042714/557aaa39d8b42a6f378b4a92/html5/thumbnails/38.jpg)
Case 3
Retired geography teacher lives alone Classical PD-good response L dopa 7 years on/off symptoms Start ropinirole –good response 2013 admission increased confusion,
delusions and hallucinations