Pete Smith Pd Management April2007
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Pete Smith Pd Management April2007

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Pete Smith Pd Management April2007 Presentation Transcript

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