Practical management of Parkinson’s disease

Dr Uma NathConsultant NeurologistHead of DepartmentSunderland Royal HospitalMar 2014

Case study 1

• 59 year old male• Wife brings him to clinic• Disturbed sleep (hers)• Thrashing in bed• Vivid dreams• Fell out of bed, broke lamp• Doesn’t snore• Diagnosis?• Relevance ?

Case study 1

• REM sleep behaviour disorder• Male predominance• Commoner in Parkinson’s disease• Easy to treat• Differentiate this parasomnia from sleep apnoea • Can be dangerous• Prognosis • DATSCANs

Premotor features of Parkinson’s disease

RBD Constipation Depression Dizziness/OH Anosmia

Patient 1

• 46 chef• Problems since 2011 right upper limb• Handwriting changed, tremor and hands

ached• Slowed down• Laterality• FH – granddad neurological illness• PMH lower back pain

GR 2

• Examination findings• Stooped• Reduced arm swing• Micrographic• Cogwheel rigidity more right sided• Applause sign. Primitive reflexes.• Progress: Tried ropinirole, rasagiline, madopar, rotigotine –

intolerant• Severely depressed, socially isolated• Outbursts aggressive behaviour• Addenbrookes score 88/100• Admitted Oct 2012

GR3

• MRI atrophic• Copper studies normal• Side effects each drug discussed• Ropinirole – DDS, somnolence• Ropinirole reduced and stopped• More levodopa• Felt much worse• Well back on ropinirole (worries – mood, DDS)• Active, mobile, enjoys various hobbies…• Discussion around advanced therapies in the future

Dopamine agonist side effects

Ergot derivative pergolide Ropinirole Drowsy Dopa dysregulation syndrome Orthostatic hypotension Nausea Cognitive decline eg memory, behaviour,

psychosis, hallucinations

Case 2

• Parkinson’s disease 8 years• Family concerned about confusion• Rather aggressive• Worse at night• Plucking the air• “insects on the carpet”• “strangers passing by”• Diagnosis?• What else do you want to know?• Investigations?treatment?prognosis?

Case study 2

• Differential diagnosis• Lewy Body Dementia• UTI• Pneumonia (? Aspiration)• Medication medication medication..!• Premorbid state• Investigations• Treatment• Prognosis

Lewy body Dementia

PDD or DLB Dementia with visual and concentration deficits Variable Parkinsonism OH, RBD, visual hallucinations treat the treatable triggers Consider cholinesterase inhibitors Eg rivastigmine Consider antipsychotics ? Quetiapine Clozapine Avoid some drugs Positive DATSCAN to distinguish from Alzheimers.

Case study 3

• 65 year old woman with Parkinson’s disease• Depressed, anaemic• Small writing• Piano playing difficult• Responded well to levodopa• Sinemet 62.5mg qds• Feels hands are crampy and stiff late morning and

early afternoon• Foot cramps• Investigations/management/diagnosis/comments

Case study 4

• 35 year old man with Parkinson’s disease• Father also affected with tremor in later life

• Comments• Treatment options• Diagnosis• Prognosis• Heredity and Parkinson’s disease• Parkinsonism

Case 6

• 80 year old man• Pacemaker• Hypertension• Warfarin• Multiple falls, very slow• Parkinson’s disease diagnosed 5 years ago,no tremor• Feet feel glued to floor• Bicycles on bedside fine• Weepy• Comments?• Investigations, treatment, prognosis

Case study 7

• 53 year old man Parkinson’s disease for 4 years• Sinemet 110, 2 tablets six times a day• Rasagiline, inderal, stugeron, aspirin, statin• Difficulty sleeping• Gets a drink at night to ease symptoms• “Crawling up legs”• Diagnosis? Investigations? Management?• Does he really have Parkinsons disease?• Which is better sinemet 110 or 125• “beware little dizzy old ladies…”

Restless legs syndrome

• Common• Worse at night, eased by walking• Voluntary motion of legs• Can be associated with involuntary mvts in sleep (PLMs)• Multiple causes• Remove drugs before adding• Caffeine unhelpful, anemia strong risk factor• Bloods• Ldopa or adartrel• Stop TCI, SSRI etc

Case 9

Man with Parkinson’s disease for 12 years High dose levodopa, ropinirole (requip) XL 20mg daily Three blackouts in six months Two whilst gardening Once wife propped him against a wall He started to fit ? 3 minutes Started on sodium valproate for epilepsy comments

Patient 2 MH

48 year old lady Age 46 left upper limb tremor Now bilateral Disabling Buttons, laces, counting cash difficult Speech quieter Food stuck in throat Urge incontinence

Patient 2

Unsteady Memory good RBD , ? OH Hypophonic Brisk reflexes Rapid tremor Myoclonus Akinetic rigid Leaning,prs

Patient 2

Treat Parkinsonism – higher doses ldopa needed SALT, PT Sleep OH Lee Silverman

Sara Matheson Trust

Palliative care services

Comments

Multiple system atrophy

Red flags Young, poorly responsive Disease rapidly progressive Sighing, blue hands, stridor, Bilateral at onset Autonomic features eg sphincters, OH

Take home messages

This disease is neither untreatable or relentlessly progressive

lots of aspects easy to treat Physician satisfaction Premotor features aid diagnosis Need to get diagnosis right MDT approach, involve palliative care early