The first ever Virtual Branch meeting
The Virtual session on Parkinson's running from 21st to 28th February
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
- What are the potential adverse effects when using dopamine agonist ?
- What would you discuss with a patient when starting them on a dopamine agonist ?
- Which drug formulation options are available when patients with Parkinson's are unable to swallow oral tablets or capsules ?
- 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
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: email@example.com
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
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.
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:
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)
- Chronic constipation/slow gut motility
- 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)
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
CPPE suggested answer to Question 1
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.
CPPE suggested answer to Question 2
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.
CPPE suggested answer to Question 3
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
CPPE suggested answer to Question 4
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.