Parkinson's Workshop

The first ever Virtual Branch meeting

The Virtual session on Parkinson's running from 21st to 28th February

The aim of this session is to introduce you to the topic of Parkinson's Disease. It will be based on the Learning @ Lunch session from the Centre for Pharmacy Postgraduate Education but with an emphasis on the technical role.

If you wish to participate read the suggested reading material and activities below.

Instructions for meeting

You may put your answer to the case study questions on the linoit post it notes, click on brown button labelled your answers to question ....

Registration with lnoit is free.

Pre-session reading and tasks

Task 1 Reflective Questions

  1. What are the potential adverse effects when using dopamine agonist ?
  2. What would you discuss with a patient when starting them on a dopamine agonist ?
  3. Which drug formulation options are available when patients with Parkinson's are unable to swallow oral tablets or capsules ?
  4. Some drugs should be avoided in patients with PD, Which ones would you avoid and what safer alternatives are available?

Task 2 reading

Parkinson's disease: clinical features and diagnosis

Clinical Pharmacist 1 JAN 2011By Annett Blochberger

By Annett Blochberger, DipClinPharm, MRPharmS, and Shelley Jones, DipClinPharm, MRPharmS

Tremor, bradykinesia, hypokinesia and rigidity are well known features of Parkinson’s disease, but patients also experience troublesome non-motor symptoms, such as depression, pain and insomnia.


Parkinson’s disease (PD) is a progressive neurological disorder that results from the loss of dopaminergic neurones in the substantia nigra. The cause of this neuronal damage remains largely unknown, but it is believed to be associated with both genetic and environmental factors.

PD is characterised by motor and non-motor symptoms. The main motor features are rigidity, tremor, bradykinesia and hypokinesia. Non-motor symptoms include: neuropsychiatric conditions (eg, dementia, depression and hallucinations); autonomic disturbances (eg, constipation, postural hypotension); sleep disorders; and sensory symptoms (such as pain).

Annett Blochberger is lead pharmacist for neurosciences at St George’s Healthcare NHS Trust and Shelley Jones is clinical pharmacy team leader for neurosciences at King’s College Hospital NHS Foundation Trust. E:

NICE quick reference guide CG35

Please read the NICE guidelines and make a note of key points that relate to:

  • Communicating with people with Parkinson's & their career.
  • Pharmacological interventions
  • Non motor features of Parkinson's

What policies does your trust have that is relevant to patients with Parkinson's

Suggested answers from pre-reading

Check your answers with the suggested ones from CPPE

Tasks 3 activity

Please watch the video below from the Parkinson's UK website.

The video is titled "Get it on time," the patients perspective on the issues of not receiving their medication at the time, when they have been hospitalised for non Parkinson's related conditions.

Get It On Time - Medicine management for patients with Parkinson's

Parkinson's Case Study 3 - Frederick

Frederick Brown, a 63 year old male has been admitted to the medical ward. The medical notes give you the following information:

Presenting complaint:

Vomiting, confusion & worsening Parkinson's symptoms

History of presenting complaint:

Vomiting started one week ago and was treated with metoclopramide, prescribed by the out of hours GP. Confusion, rigidity & tremor gradually worsened over past week.

Past medical history:

  • Parkinson's Disease for 9 years
  • Benign prostatic hyperplasia (enlarged prostate)
  • Depression
  • Anaemia
  • Chronic constipation/slow gut motility

Drug History:

  • Stalevo 100/25/200 tablets qds at 8am, 11am, 4pm,7pm
  • metoclopramide 10mg tds
  • pramipexole 350micrograms tds at 8am, 2pm, & 10pm (increased from 180 micrograms, tds three weeks ago by consultant due to increasing motor symptoms)
  • sertraline 100mg daily
  • Laxido Orange sachets, 1 bd
  • clonazepam 500micrograms on
  • ferrous sulphate 200mg tds
  • tamsulosin XL 400microgram daily
  • Madopar dispersible 62.5microgram om prn

Family history/social history:

Married with three grown up children, no alcohol, ex smoker (10 years stopped)

On examination:

Resting tremor, bilateral rigidity 'lead pipe' rigidity, slow and shuffling gait.


Urinary tract infection ? Parkinson's exacerbation


Urea & electrolyte (U&E's), full blood count (FBC), including C reactive protein (CRP), urine sample

Your answer to question 1

Q1) What could be the cause of Frederick's worsening Parkinson's symptoms

CPPE suggested answer to Question 1

Metoclopamide is a dopamine antagonist which can cross the blood-brain barrier and may cause extrapyramidal reactions, such as tardive dyskinesia (characterised by repetitive involuntary movements), dystonia (muscle tension) and akathisia (motor restlessness). These effects may be increased in patients with Parkinson's as existing Parkinson's symptoms as exacerbated.

Each Stalevo table contains 100mg of levodopa, 25mg carbidopa and 200mg of entacapone. Levodopa and entacapone may form chelates with iron in the gastrointestinal tract. Therefore if Stalevo and ferrous sulphate preparations are taken less than 2 to 3 hours apart, the availability of the levodopa and entacapone will be reduced. This may cause sub-therapeutic levels, with subsequent deterioration of Parkinson's symptoms.

If Frederick does have a UTI this may cause confusion, vomiting may reduce absorption and the infection itself may worsen Parkinson's control.

Your answer to question 2

Q2) What could be causing the vomiting and confusion

CPPE suggested answer to Question 2

Vomiting and confusion are both reported as common (1/100 to 1/10) adverse effects of dopamine agonists, such as pramipexole. Frederick's pramipexole dose has recently been increased, higher doses of dopamine agonists are associated with an increased incidence of adverse effects.

Confusion and vomiting can be caused by UTI, especially in the elderly population.

Severe constipation can also cause vomiting and confusion. Chronic constipation can lead to urinary retention and infection, which can lead to feeling generally unwell and vomiting. Patients with Parkinson's are particularly at risk and constipation may affect more than 50% of Parkinson's patients, due to immobility of the gut.

Your answer to question 3

Q3) What would be your plan of action for Frederick's treatment?

CPPE suggested answer to Question 3

Stop metoclopramide and replace with domperidone. If Frederick continues vomiting. Although domperidone is a dopamine antagonist it does not cross the blood-brain barrier and is usually the antiemetic of choice in Parkinson's.

Severe constipation should be ruled out be medical staff (abdominal assessment , or ultrasound may be appropriate in the absence of bowel sounds). Also ensure that UTI and/or pyrexia is treated. If appropriate, and are ruled out as causes of vomiting (check mid-stream urine culture).

A specialist review of Parkinson's management should be requested (if available) including advice on the appropriate dose of pramipexole. Frederick would benefit from support from Parkinson's disease nurse specialist.

The patient and ward staff should be counselled to separate ferrous sulphate and Stalevo administration by two to three hours, if possible.

Any UTI should be treated with appropriate antibiotics, according to trust guidelines. This may include trimethoprim for community-acquired UIT with subsequent adjustment once sensitivities are available. Treatment is usually continued for 5 to 7 days.

Constipation should be managed with appropriate laxatives, check compliance with laxido and consider acute use of suppositories or enemas if indicated.

Case Study Part II

The ward staff report Mrs. Brown is concerned about her husband and wants to ask some questions about his medicines. Mrs Brown confides that she was concerned about her husband prior to this admission. He had started getting up for long periods during the night and used the computer. Now she has discovered that unexpected payments have debited their bank account and the computer browsing history includes internet gambling sites.
Your answer to question 4

How do you explain Frederick's behavior and what action would you take?

CPPE suggested answer to Question 4

Frederick's change in behavior may be a sign of impulse control disorder (ICD). Examples of ICD include gambling, binge eating and hyper-sexuality. These actions may be out of character, potentially harmful and have a devastating impact for the patient and their family. ICD behavior is associated with dopamine therapy and particularly dopamine agonists.

Frederick may also be experiencing sleep disturbance as he is spending the night gambling instead of sleeping. 60-90% of patients with Parkinson's experience sleep disturbance and Frederick's depression may be an aggravating factor. Sleep disturbances may be exacerbated by other Parkinson's symptoms, e.g. excessive day time sleepiness, rapid-eye movement behaviour disorder (RBD), poor motor symptom control, leading to difficulty turning at night, and also urological problems which can lead to nocturia.

Frederick should be referred to the movement disorder team. He also needs support regarding his depression and advice on sleep hygiene.

To help Mrs. Brown.

Inform her that you will refer Mr Brown for an urgent review of his therapy with the Parkinson's nurse specialist and/or the consultant.

Signpost Mrs Brown to the Parkinson's UK resources, such as the booklets

  • Drug treatment for Parkinson's
  • The carers guide leaflet on Sleep and night-time problems in Parkinson's

Mrs Brown can access the Parkinson's UK helpline or e-mail service.

Are there different types of Parkinson's?


Lynn Gallagher

Medway School of Pharmacy

Chatham Maritime.

Kent. ME4 4TB