SYMPTOM CONTROL IN
ADVANCED PARKINSON’S
DISEASE
Vicky Travers
PDNS
UHMBT
April 2012
Parkinson’s Disease
• A fluctuating, progressive, neurological
condition
• Results from degeneration of dopamineproducing neurones in substantia nigra
• 1:500 (approx 120,000 people in UK)
• Increasingly prevalent with age
Parkinson’s disease con’d
• Clinical diagnosis (NICE guidelines 2006)
• Motor symptoms / non-motor symptoms
• Cause not known
• Incurable but treatable
• Not life threatening, but can be life
limiting
Core Symptoms for diagnosis
• Rigidity – raised tone in muscles
• Postural Instability – poor balance (often
presents as a later feature)
• Tremor – resting, asymmetrical, 70 % PwPD
• Bradykinesia – slowness of movement
Progression of PD
• Individual progression rate
• Individual manifestation of symptoms
• Individual response / side effects to
medications
• = Need for individualised care throughout
disease trajectory
Stages of Parkinson’s Disease
• Diagnosis
• Maintenance
• Complex
• Palliative
Palliative Care
Should “Offer pain relief and meet needs for
personal, social, psychological and
spiritual support, in line with principles for
palliative care”
NSF for Long Term Neurological Conditions
(Quality requirement 9)
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Advanced care planning
Progressive dopaminergic drug withdrawal
Analgesia, sedation and other palliative measures
Primary and/or secondary care depending on circumstances
Non-motor symptoms
• Cognition
• Pain
• Autonomic symptoms
• Sleep disturbance
• Communication
• Swallowing
• Weight loss
Cognition
• Anxiety
• Depression
• Apathy
• Cognitive impairment
• Dementia
• Psychosis
Symptom control
• Review PD meds
• ? Antidepressants – Mirtazapine
• CBT / talking therapy/ support
• Cholinesterase inhibitors
• Atypical antipsychotics – Quetiapine
Avoid Haloperidol!!!
Pain
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Common and under-reported
Several types of pain [Primary or Secondary]
Musculoskeletal – rigidity or dyskinesia
Dystonic
Off phase pain
Coat hanger pain – postural hypotension
Burning mouth, anal burning
Akathisia/restlessness - RLS
Symptom Control
• Careful assessment
• Exclude co-morbidities
• Review Parkinson’s medication – optimise
dopaminergic treatment
• Analgesia
• Complementary therapies
Autonomic symptoms
(dysautonomia)
• Postural Hypotension
• Sexual dysfunction
• Bladder / bowel dysfunction
• Sweating (Hyperhidrosis)
• Drooling (Sialorrhoea)
Symptom Control
• Medication
Review PD meds,
Hyoscine, Atropine drops sublingually (beware neuropsychiatric side
effects) for drooling
Domperidone (anecdotal evidence), Fludrocortisone, Midodrine for
postural hypotension
• MDT
SALT, Continence team, nursing team, dietician
Sleep disturbance
• REM sleep behaviour disorder
• Akinesia / rigidity
• Dyskinesia
• Restlessness
• Urinary problems
• Hypersomnolence
• Bad dreams / hallucinations
Symptom Control
• Good sleep hygiene
• Medication –
Modafinal for hypersomnolence
Clonazapam for REM sleep behaviour
review Dopaminergic treatment
atypical antipsychotic
(beware side effects/ contraindications)
• MDT
Communication
• Verbal and non-verbal
• Mask like facies (Hypomimia)
• reduced volume (Hypophonia)
• “Stuttery” speech
• Repitition of syllables or words (Palilalia)
• Monotone and monopitch
Symptom Control
• MDT especially SLT
• Alternative communication techniques
- Charts, amplifier, lightwriter, IPAD
Education/ support for PwPD/ carers / family
Swallowing disorders
• Reduced tongue motility / co-ordination
• Food remaining in epiglottic vallecula
• Decreased ability to chew
• Delay of pharyngeal swallow
• Reduced laryngeal closure
• Aspiration
Symptom Control
• Speech and Language Therapy input
• Dietician
• Medication review - ? Change preparation
of medication
• Thickened fluids
• Observed / assisted feeding
• Education for Pwpd / Carers / family
Weight Loss
• Dyskinesia
• Rigidity
• Dysphagia
• Poor intake due to reduced ability /
appetite
Symptom Control
• Dietician / SLT
• Medication review
• Maintain hydration
• Skin care
• Mouth care
• Assisted feeding
Please Remember……
……….Not all solutions work for all
people……………….
……… Sometimes just being there is
enough……………….
Thank you
Any Questions?
Vicky.travers@mbht.nhs.uk
01524 583611 / 07765351985
References
• National Service framework for Long Term
Conditions. DoH (2005)
• Parkinson’s UK
http://www.parkinsons.org.uk/
• Parkinson’s Disease. Diagnosis and
Management in primary and secondary
care. NICE (2006)