SYMPTOM CONTROL IN SYMPTOM CONTROL IN ADVANCED PARKINSON’S ADVANCED PARKINSON’S

DISEASEDISEASE

Vicky TraversVicky TraversPDNSPDNS

UHMBTUHMBTApril 2012April 2012

Parkinson’s DiseaseParkinson’s Disease

• A fluctuating, progressive, A fluctuating, progressive, neurological conditionneurological condition

• Results from degeneration of Results from degeneration of dopamine- producing neurones in dopamine- producing neurones in substantia nigrasubstantia nigra

• 1:500 (approx 120,000 people in UK)1:500 (approx 120,000 people in UK)

• Increasingly prevalent with ageIncreasingly prevalent with age

Parkinson’s disease con’dParkinson’s disease con’d

• Clinical diagnosis (NICE guidelines Clinical diagnosis (NICE guidelines 2006)2006)

• Motor symptoms / non-motor Motor symptoms / non-motor symptomssymptoms

• Cause not knownCause not known

• Incurable but treatableIncurable but treatable

• Not life threatening, but can be life Not life threatening, but can be life limitinglimiting

Core Symptoms for Core Symptoms for diagnosisdiagnosis• Rigidity – raised tone in musclesRigidity – raised tone in muscles

• Postural Instability – poor balance (often Postural Instability – poor balance (often presents as a later feature)presents as a later feature)

• Tremor – resting, asymmetrical, 70 % PwPDTremor – resting, asymmetrical, 70 % PwPD

• Bradykinesia – slowness of movementBradykinesia – slowness of movement

Progression of PDProgression of PD

• Individual progression rateIndividual progression rate

• Individual manifestation of symptomsIndividual manifestation of symptoms

• Individual response / side effects to Individual response / side effects to medicationsmedications

• = Need for individualised care = Need for individualised care throughout disease trajectorythroughout disease trajectory

Stages of Parkinson’s Stages of Parkinson’s DiseaseDisease• DiagnosisDiagnosis

• MaintenanceMaintenance

• ComplexComplex

• PalliativePalliative

Palliative CarePalliative Care

Should “Offer pain relief and meet Should “Offer pain relief and meet needs for personal, social, needs for personal, social, psychological and spiritual support, in psychological and spiritual support, in line with principles for palliative care”line with principles for palliative care”

NSF for Long Term Neurological NSF for Long Term Neurological Conditions (Quality requirement 9)Conditions (Quality requirement 9)

• Advanced care planningAdvanced care planning• Progressive dopaminergic drug withdrawalProgressive dopaminergic drug withdrawal• Analgesia, sedation and other palliative measuresAnalgesia, sedation and other palliative measures• Primary and/or secondary care depending on Primary and/or secondary care depending on

circumstancescircumstances

Non-motor symptomsNon-motor symptoms

• Cognition Cognition

• PainPain

• Autonomic symptomsAutonomic symptoms

• Sleep disturbanceSleep disturbance

• CommunicationCommunication

• SwallowingSwallowing

• Weight lossWeight loss

CognitionCognition

• AnxietyAnxiety

• DepressionDepression

• ApathyApathy

• Cognitive impairmentCognitive impairment

• DementiaDementia

• PsychosisPsychosis

Symptom controlSymptom control

• Review PD medsReview PD meds

• ? Antidepressants – Mirtazapine ? Antidepressants – Mirtazapine

• CBT / talking therapy/ supportCBT / talking therapy/ support

• Cholinesterase inhibitorsCholinesterase inhibitors

• Atypical antipsychotics – QuetiapineAtypical antipsychotics – Quetiapine

Avoid Haloperidol!!!Avoid Haloperidol!!!

PainPain

• Common and under-reportedCommon and under-reported

• Several types of pain [Primary or Secondary]Several types of pain [Primary or Secondary]

• Musculoskeletal – rigidity or dyskinesiaMusculoskeletal – rigidity or dyskinesia

• Dystonic Dystonic

• Off phase painOff phase pain

• Coat hanger pain – postural hypotensionCoat hanger pain – postural hypotension

• Burning mouth, anal burningBurning mouth, anal burning

• Akathisia/restlessness - RLSAkathisia/restlessness - RLS

Symptom ControlSymptom Control

• Careful assessmentCareful assessment

• Exclude co-morbiditiesExclude co-morbidities

• Review Parkinson’s medication – Review Parkinson’s medication – optimise dopaminergic treatmentoptimise dopaminergic treatment

• AnalgesiaAnalgesia

• Complementary therapiesComplementary therapies

Autonomic symptoms Autonomic symptoms (dysautonomia)(dysautonomia)

• Postural HypotensionPostural Hypotension

• Sexual dysfunctionSexual dysfunction

• Bladder / bowel dysfunctionBladder / bowel dysfunction

• Sweating (Hyperhidrosis) Sweating (Hyperhidrosis)

• Drooling (Sialorrhoea)Drooling (Sialorrhoea)

Symptom ControlSymptom Control

• MedicationMedicationReview PD meds, Review PD meds,

Hyoscine, Atropine drops sublingually (beware Hyoscine, Atropine drops sublingually (beware neuropsychiatric side effects) for droolingneuropsychiatric side effects) for drooling

Domperidone (anecdotal evidence), Fludrocortisone, Domperidone (anecdotal evidence), Fludrocortisone, Midodrine for postural hypotensionMidodrine for postural hypotension

• MDT MDT SALT, Continence team, nursing team, dieticianSALT, Continence team, nursing team, dietician

Sleep disturbanceSleep disturbance

• REM sleep behaviour disorderREM sleep behaviour disorder

• Akinesia / rigidityAkinesia / rigidity

• DyskinesiaDyskinesia

• RestlessnessRestlessness

• Urinary problemsUrinary problems

• HypersomnolenceHypersomnolence

• Bad dreams / hallucinationsBad dreams / hallucinations

Symptom ControlSymptom Control

• Good sleep hygieneGood sleep hygiene

• Medication – Medication – Modafinal for hypersomnolenceModafinal for hypersomnolenceClonazapam for REM sleep behaviourClonazapam for REM sleep behaviour review Dopaminergic treatmentreview Dopaminergic treatment atypical antipsychotic atypical antipsychotic

(beware side effects/ contraindications)(beware side effects/ contraindications)

• MDTMDT

CommunicationCommunication

• Verbal and non-verbalVerbal and non-verbal

• Mask like facies (Hypomimia)Mask like facies (Hypomimia)

• reduced volume (Hypophonia)reduced volume (Hypophonia)

• ““Stuttery” speechStuttery” speech

• Repitition of syllables or words Repitition of syllables or words (Palilalia)(Palilalia)

• Monotone and monopitchMonotone and monopitch

Symptom ControlSymptom Control

• MDT especially SLTMDT especially SLT

• Alternative communication techniquesAlternative communication techniques

- Charts, amplifier, lightwriter, IPAD- Charts, amplifier, lightwriter, IPAD

Education/ support for PwPD/ carers / Education/ support for PwPD/ carers / familyfamily

Swallowing disordersSwallowing disorders

• Reduced tongue motility / co-Reduced tongue motility / co-ordinationordination

• Food remaining in epiglottic valleculaFood remaining in epiglottic vallecula

• Decreased ability to chewDecreased ability to chew

• Delay of pharyngeal swallowDelay of pharyngeal swallow

• Reduced laryngeal closure Reduced laryngeal closure

• AspirationAspiration

Symptom ControlSymptom Control

• Speech and Language Therapy inputSpeech and Language Therapy input

• DieticianDietician

• Medication review - ? Change Medication review - ? Change preparation of medicationpreparation of medication

• Thickened fluidsThickened fluids

• Observed / assisted feedingObserved / assisted feeding

• Education for Pwpd / Carers / familyEducation for Pwpd / Carers / family

Weight LossWeight Loss

• DyskinesiaDyskinesia

• RigidityRigidity

• DysphagiaDysphagia

• Poor intake due to reduced ability / Poor intake due to reduced ability / appetiteappetite

Symptom ControlSymptom Control

• Dietician / SLTDietician / SLT

• Medication reviewMedication review

• Maintain hydrationMaintain hydration

• Skin careSkin care

• Mouth careMouth care

• Assisted feedingAssisted feeding

Please Remember……Please Remember……

……………….Not all solutions work for all .Not all solutions work for all people……………….people……………….

……… ……… Sometimes just being there is Sometimes just being there is enough……………….enough……………….

Thank youThank you

Any Questions?Any Questions?

Vicky.travers@mbht.nhs.uk

01524 583611 / 0776535198501524 583611 / 07765351985

ReferencesReferences

•National Service framework for Long Term Conditions. DoH (2005)

• Parkinson’s UK Parkinson’s UK http://www.parkinsons.org.uk/

• Parkinson’s Disease. Diagnosis and Parkinson’s Disease. Diagnosis and Management in primary and Management in primary and secondary care. NICE (2006)secondary care. NICE (2006)