Pete Smith Pd Management April2007

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Pete Smith Pd Management April2007

  1. 1. Parkinson’s Disease Diagnosis, Management and impact Pete Smith PDNS Northampton Tel 01604 678120 [email_address] Date April 2007
  2. 2. History of PD <ul><ul><li>First described by James Parkinson in 1817 (1) </li></ul></ul><ul><ul><li>-”Involuntary tremulous motion” </li></ul></ul><ul><ul><li>-”A propensity to bend forwards” </li></ul></ul><ul><ul><li>-”The senses and intellect are intact” </li></ul></ul><ul><ul><li>40 years later Charcot named it Parkinson’s Disease </li></ul></ul>
  3. 3. Definition <ul><ul><li>Chronic, progressive, neurological degenerative disease </li></ul></ul><ul><ul><li>-”Multi-system neurological disorder which affects cognitive processes, emotion and autonomic function” (2) </li></ul></ul><ul><ul><li>Greater emphasis on non-motor symptoms </li></ul></ul>
  4. 4. Prevalence <ul><ul><li>2 cases per 1000 (3) </li></ul></ul><ul><ul><li>Approx 120,000 people with PD in UK </li></ul></ul><ul><ul><li>Almost a quarter are in hospital or residential care </li></ul></ul><ul><ul><li>Almost a third in community requiring help </li></ul></ul><ul><ul><li>Nearly half are independent, living in community </li></ul></ul><ul><ul><li>Most cases in 60 – 70yr olds </li></ul></ul><ul><ul><li>Young onset=below 50yrs </li></ul></ul>
  5. 5. Causes <ul><ul><li>In most cases cause is unknown </li></ul></ul><ul><ul><li>More common as we age but not solely responsible </li></ul></ul><ul><ul><li>Genetic causes </li></ul></ul><ul><ul><li>Environmental (More common in rural areas) </li></ul></ul><ul><ul><li>Possibly due to- Pesticides, virus, heavy metals, solvents, head trauma.. </li></ul></ul>
  6. 6. Signs and Symptoms <ul><ul><li>Tremor (25% of Patients don’t shake) </li></ul></ul><ul><ul><li>Rigidity </li></ul></ul><ul><ul><li>Bradykinesia </li></ul></ul><ul><ul><li>Postural instability </li></ul></ul><ul><ul><li>Unilateral presentation </li></ul></ul>
  7. 7. Diagnosis of PD <ul><ul><li>Clinical diagnosis </li></ul></ul><ul><ul><li>UK PDS Brain Bank Diagnostic Criteria (4) </li></ul></ul><ul><ul><li>Bradykinesia plus one of the following- resting tremor,rigidity or postural instability </li></ul></ul><ul><ul><li>SPECT and DACT scans </li></ul></ul><ul><ul><li>Diagnosis by a specialist (prefer pts untreated) </li></ul></ul><ul><ul><li>Insidious onset, initially unilateral symptoms </li></ul></ul><ul><ul><li>25% Wrongly diagnosed (4) </li></ul></ul>
  8. 8. Differential Diagnosis <ul><ul><li>Parkinsonism </li></ul></ul><ul><ul><li>Parkinson’s Plus Syndromes </li></ul></ul><ul><ul><li>Multi-System Atrophy </li></ul></ul><ul><ul><li>Progressive-Supranuclear palsy </li></ul></ul><ul><ul><li>Lewy Body Dementia </li></ul></ul><ul><ul><li>Drug induced Parkinsonism </li></ul></ul><ul><ul><li>Essential tremor </li></ul></ul><ul><ul><li>Vascular Parkinsonism </li></ul></ul><ul><ul><li>Cortico-basal degeneration </li></ul></ul>
  9. 9. Impact on Patient (Newly Diagnosed) <ul><ul><li>Prognosis </li></ul></ul><ul><ul><li>Employment prospects </li></ul></ul><ul><ul><li>Driving </li></ul></ul><ul><ul><li>Financial support/ access to benefits </li></ul></ul><ul><ul><li>Risk of inheritance </li></ul></ul><ul><ul><li>Relationship issues </li></ul></ul><ul><ul><li>Neuro-psychiatric (anxiety and depression) </li></ul></ul><ul><ul><li>Fear of treatment/side effects </li></ul></ul>
  10. 10. Impact on Patient & Carers, Advanced PD <ul><ul><li>Unable to maintain independence </li></ul></ul><ul><ul><li>Cognitive decline </li></ul></ul><ul><ul><li>Hallucinations, psychosis paranoia </li></ul></ul><ul><ul><li>Agitation </li></ul></ul><ul><ul><li>Side effects of treatment </li></ul></ul><ul><ul><li>Motor complications </li></ul></ul><ul><ul><li>Dyskinesia </li></ul></ul><ul><ul><li>Falls </li></ul></ul><ul><ul><li>Immobility </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Communication difficulties </li></ul></ul><ul><ul><li>Swallowing problems/weight loss </li></ul></ul><ul><ul><li>Unable to maintain a safe environment </li></ul></ul><ul><ul><li>Fear of hospitalisation and nursing homes </li></ul></ul><ul><ul><li>Carer strain </li></ul></ul>
  11. 11. Impact on Society <ul><ul><li>Cost to NHS £2,298 (£-1998) per pt per year (5) </li></ul></ul><ul><ul><li>Total cost per year per pt inc social services £5,993 (£-1998) (5) </li></ul></ul><ul><ul><li>Total cost per year for UK £599,300,000 for 100,000 pts (5) </li></ul></ul><ul><ul><li>Cost increases with age and severity </li></ul></ul><ul><ul><li>PD Frequent cause of falls and fractures leading to hospital admission and sometimes death </li></ul></ul>
  12. 12. Management <ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>All suspected cases should be referred to a neurologist untreated </li></ul></ul><ul><ul><li>Diagnosis is usually confirmed based on clinical examination </li></ul></ul><ul><ul><li>In younger onset screen for tumours etc </li></ul></ul><ul><ul><li>If diagnosis uncertain consider DACT scan </li></ul></ul><ul><ul><li>Discuss treatment options with patient </li></ul></ul><ul><ul><li>Commence treatment based on quality of life </li></ul></ul>
  13. 13. Management (cont) <ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Home assessment by PDNS </li></ul></ul><ul><ul><li>Medicine information (not treated during this phase) </li></ul></ul><ul><ul><li>Provide information and advice re PD ie driving & benefits etc </li></ul></ul><ul><ul><li>Help address employment issues </li></ul></ul><ul><ul><li>Counsel pt and family </li></ul></ul><ul><ul><li>Refer to neuro-physiotherapy for exercise programme </li></ul></ul><ul><ul><li>Referral to other members of MDT if appropriate </li></ul></ul><ul><ul><li>Provide contact number of PDNS helpline </li></ul></ul><ul><ul><li>Put in touch with PD Society or fellow pts with PD if appropriate </li></ul></ul><ul><ul><li>Follow up via consultant and PD Nurse clinic </li></ul></ul>
  14. 14. Management <ul><ul><li>Maintainence </li></ul></ul><ul><ul><li>Simple problem free drug regime (honeymoon period) </li></ul></ul><ul><ul><li>Monitoring of condition </li></ul></ul><ul><ul><li>Education of patient on drug use, inc timing and side effects etc </li></ul></ul><ul><ul><li>Involve pt in decision making </li></ul></ul><ul><ul><li>Liasion between GP, Pt and Hosp Consultant etc </li></ul></ul><ul><ul><li>Medicine Management (Nurse Prescriber) </li></ul></ul><ul><ul><li>Referrals to MDT as required </li></ul></ul><ul><ul><li>Out patient appt or ‘telephone clinic’ if required </li></ul></ul><ul><ul><li>Many patients can get on with life during this period with few problems or concerns </li></ul></ul>
  15. 15. Management <ul><ul><li>Complex </li></ul></ul><ul><ul><li>Patients often need several types of drugs and experience troublesome side effects.- Review Medication </li></ul></ul><ul><ul><li>Problematic Co-morbidities </li></ul></ul><ul><ul><li>Management of motor complications </li></ul></ul><ul><ul><li>Management of dyskinesia (amantadine, surgery) </li></ul></ul><ul><ul><li>Management of neuro-psychiatric complications </li></ul></ul><ul><ul><li>Apomorphine therapy </li></ul></ul><ul><ul><li>Greater emphasis on MDT- Adaptations, cares etc </li></ul></ul><ul><ul><li>Consider day care (TULIP Centre Northampton) </li></ul></ul>
  16. 16. Management <ul><ul><li>Complex (cont) </li></ul></ul><ul><ul><li>Fall prevention workshops </li></ul></ul><ul><ul><li>Respite care? </li></ul></ul><ul><ul><li>Regular out-patient reviews (home visits if unable to attend) </li></ul></ul><ul><ul><li>Counseling and support of Pt and carers </li></ul></ul><ul><ul><li>Advanced care planning inc timing of intervention and side effects management etc </li></ul></ul><ul><ul><li>Involve pt in decision making </li></ul></ul>
  17. 17. Management <ul><ul><li>Palliative </li></ul></ul><ul><ul><li>Inability to tolerate adequate dopaminergic therapy </li></ul></ul><ul><ul><li>Unsuitable for surgery </li></ul></ul><ul><ul><li>Advanced co-morbidity (6) </li></ul></ul><ul><ul><li>Shift of emphasis from “high tech” pharmacological approach to a now shortened life span </li></ul></ul><ul><ul><li>Cognitive decline is a marker of poor prognosis </li></ul></ul><ul><ul><li>Does not equate with the end of life </li></ul></ul><ul><ul><li>Mean duration of PD 14.6 yrs – palliative phase 2.2yrs (7) </li></ul></ul>
  18. 18. Management <ul><ul><li>Palliative </li></ul></ul><ul><ul><li>Aim for quality of a now shortened life </li></ul></ul><ul><ul><li>Withdrawal of drugs </li></ul></ul><ul><ul><li>Neuro-psychiatric complications often lead to residential/nursing care </li></ul></ul><ul><ul><li>Dementia care </li></ul></ul><ul><ul><li>Support and advice to carers </li></ul></ul><ul><ul><li>Increased mortality once in care homes (8) </li></ul></ul><ul><ul><li>Skills of palliative care team become crucial </li></ul></ul><ul><ul><li>Increased MDT involvement </li></ul></ul><ul><ul><li>Prevention and management complications </li></ul></ul>
  19. 19. Cause of Death General Population Source Information (9)
  20. 20. Cause of Death General Population Trajectories Source Information (9)
  21. 21. References <ul><ul><li>Parkinson J, 1818: An Essay on Shaking Palsy, Macmillan&PDS. London </li></ul></ul><ul><ul><li>Playfer J, et al. (2001) Parkinson’s Disease in the older Patient. Arnold. London </li></ul></ul><ul><ul><li>Clough C, et al. (2003) Parkinson’s Disease, Health Press Ltd. Oxford </li></ul></ul><ul><ul><li>Quinn N, (1997) Parkinson’s Disease Clinical Features. Balliere’s Clinical Neurology: 6 (1). 1-16 </li></ul></ul><ul><ul><li>National Collaborating Centre for Chronic Conditions. Parkinson’s disease: national clinical guideline for diagnosis and management in primary and secondary care . London: Royal College of Physicians, 2006. </li></ul></ul><ul><ul><li>MacMahon D.G& Thomas, S (1998) J Neurology.245 (suppl 1):S19-22 </li></ul></ul><ul><ul><li>MacMahon D.G, et al (1999) Validation of Pathways Paradigm for the Management of PD. Parkinsonism and Related Disorders.1999:5(S53) </li></ul></ul><ul><ul><li>Goetz CG, & Stebbins GT. (1993) Risk Factors for Nursing Home Placement in Advanced PD. Neurology. 1993:43:2227-2229 </li></ul></ul><ul><ul><li>Lynn et al (2004) Palliative Care the Solid Facts. WHO Europe www.euro.who.int </li></ul></ul><ul><ul><li>Recommended Reading </li></ul></ul><ul><ul><li>http://www.parkinsons.org.uk/PDF/PDAwarePrimaryCareSept03.pdf </li></ul></ul><ul><ul><li>Nice Guidelines ( quick guide) June 2006 </li></ul></ul>

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