CBL PARKINSON'S DISEASE

Q11)Was the initial treatment plan reasonable? Why or why not?

Q10

Q13) What adjustments in drug therapy do you recommend at this time?

Q12) What side effects from therapy does the patient now manifest?

Q1) List and assess each one of the patient’s complaints.

Q3

Q8) What drug, dosage form, dose, schedule, and duration of therapy are best for this patient’s current problems?

Non-motor symptoms of PD include :

Motor problems of PD :

Symptoms of PD are mild and only seen on one side of the body which affects unilateral involvement.

Mild rigidity in the right arm. Decreased fine motor coordination on the right

Mild problems with facial expression, rigidity in right limbs, rapid alternating movements in the right hand, and bradykinesia.

Stiffness on her right side (for over 6 months)

Slowness of thinking

Constipation and decreased libido

Muscle stiffness.

Bradykinesia

Dry yellow scales in her eyebrows

Decreased :

Handwriting is somewhat slow and progressively smaller in size (Micrographia)

Volume of speech

Facial expression

Eye blinking

Q7 : Based on the patient’s signs and symptoms, what pharmacotherapeutic alternatives are viable options for her at this time ?

Q9)Which monitoring parameters should be used to evaluate the patient’s response to medications and to detect adverse effects?

Q5 : What are the goals of therapy for patients with PD?

Q15) List the patient’s problems at this visit.

Q6) What nonpharmacologic alternatives may be beneficial for the treatment of PD in this patient?

Q16)16. What adjustments in drug therapy do you recommend at this time?

Has lost her initiative to do activities and participate in social events.

Takes more than 30 minutes to fall asleep because she feels restless.

Hard for her to make decisions

Unable to move in bed.

Has mild depression, sleep problems, and forgetfulness.

Complains of being off when she awakens again at 7:00 AM.

Slower and clumsier in almost all activities.

Has bad tremors until her noon dose starts to work

Her symptoms are now bilateral and include tremor, rigidity, stiffness, and gait problems

Has a positive glabellar reflex (Myerson’s sign).

Anticholinergics

Benztropine (Cogentin)

Dose : 0.5mg, 1mg, 2mg

Schedule : 0.5mg per day to 1 mg per day(twice daily)

Dosage Form : Tablet

Duration of therapy : until a satisfactory clinical response is obtained gradually.

Carbidopa/levodopa

Immediate and sustained-release carbidopa/levodopa (Sinemet)

Schedule : 300mg/day (2-3 three times daily)

Duration of therapy : until a satisfactory clinical response is obtained gradually.

Dose : can be started at a dose of 50 mg daily, increasing every 3-7 days by 50 mg to an initial maintenance dose of 50-100 mg 3x daily.

Adverse effect :Nausea, somnolence, dyskinesia, hypotension, hallucinations

Dopamine agonists

Bromocriptine (Parlodel)

Schedule : 2.5-5mg/day (Twice a day, increased at 2-4 week interval)

Duration of therapy : until a satisfactory clinical response is obtained gradually.

Dose : 2.5mg, 5mg

Adverse effect : Nausea, headache, dizziness

Dosage Form : Tablet

Dosage Form : Tablet

Adverse effect : Dry mouth, dry eyes, constipation, hypotension, cognitive impairment, urinary retention

Seborrheic dermatitis is common in some PD patients

It is a secondary motor symptom experienced by some PD patients.

NON MOTOR SYMPTOMS

  • Cognitive dysfunction and dementia
  • Psychosis and hallucinations
  • Mood disorders
  • Sleep disturbances
  • Fatigue
  • Autonomic dysfunction
  • Olfactory dysfunction
  • Gastrointestinal dysfunction
  • Dermatologic findings
  • Pain and sensory disturbances

SIGN AND SYMPTOMS IN THIS PATIENT

  • Bradykinesia - takes her longer to do things because it takes more effort to get movement started
  • Rigidity - her muscles feel stiff
  • Cognitive dysfunction and dementia - does not think as quickly and it takes her longer to remember things
  • Gastrointestinal dysfunction - constipation
  • decreased libido
  • Decreased fine motor coordination on the right
  • decreased volume of speech, decreased facial expression, decreased eye blinking
  • rapid alternating movements in right hand

CARDINAL MOTOR SYMPTOMS

  • tremor
  • bradykinesia
  • rigidity
  • Postural instability

PATIENT EDUCATION


Educate about Parkinson disease and its treatment. That way you can be actively involved in your care.


Exercise or do physical therapy

  • body less affected by stiffness and other symptoms
  • feel more confident and gain a sense of control over their disease

Join social support groups

  • can talk to other people who understand the situation
  • share experiences and information
  • overcome anger, fear, depression, anxiety, resentment, or a combination of these emotions

Make your home safer, so that you are less likely to fall . patients and caretakers are encouraged to make the home as safe as possible by:

  • installing shower or tub grab-bars.
  • Having adequate lighting in the house, especially at night. Use of light-sensitive night lights or lamps on a timer may be helpful

Driving ability

  • continue to drive as long as their motor symptoms remain mild
  • monitored and formally reevaluated if and when motor and cognitive symptoms worsen.

Problems with speech, including slurred speech and speaking too quietly, are common

  • A voice or speech therapist can help overcome speech problems.

Nutrition ( minimize side effect )

  • protein in a meal blocks the effect of levodopa taken around meal time
  • speak to doctor if notice the effcect bout adjusting the timing of their medications, rather than simply avoiding protein, which can lead to loss of muscle mass.

Take adequate number of calories & nutrients to maintain strength, bone structure, and muscle mas


Constipation

  • a frequent problem for people with Parkinson disease
  • because of disease-related changes in the bowels or as a side effect of Parkinson disease medications
  • experience straining with bowel movements because of incomplete relaxation of muscles in the pelvis.
  • using step stools to elevate the knees while seated on the toilet can help relax the pelvic muscles.

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Q4) Staging based on Hoehn–Yahr Scale

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STAGE ONE


-symptoms of PD are mild
-affects unilateral involvement

rapid alternating movements in right hand

bradykinesia

rigidity in right limbs

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The initial treatment plan was reasonable because it improves her symptoms

However, she complained of having :

Blurred vision

Itchy eyebrows and scalp

Her husband complains that her personality has changed

Shops excessively that strains their budget

Q2) Assess the potential problems observed in the physical examination and laboratory findings.

Physical Examination

Laboratory findings

VS: BP 118/76 sitting, 114/70 standing

Skin: Small amount of dry yellow scales in her eyebrows

Age 58- In most people who have PD, symptoms become noticeable at the age of 60 years or over.However, in 5–10 percent of cases they appear earlier. When PD develops before the age of 50 years, this is called “early onset” PD.

Sex: Men appear to have a 50-percent higher chance of developing PD than women.However, at least one study has found that, as women get older, their chance of developing it increases.

Gen: The patient is a Caucasian woman-they are under white countries who has higher rates of parkinson disease.

Decreased volume of speech- PD causes damage to the nerves in the brain and in the body.

Decreased facial expression- Parkinson's disease (PD) patients have impairment of facial expressivity (hypomimia) and difficulties in interpreting the emotional facial expressions produced by others, especially for aversive emotions.

Decreased eye blinking- Eye blinking symptoms may also be caused by conditions occurring in the nervous system. A severe decrease in blinking is seen chiefly in Parkinson's disease, a brain disorder that impairs movement and coordination.

platelets are high

Homocysteine count is high

,Benefiber,Docusate sodium and Magnesium hydroxide are consumed to solve constipation problems

carbidopa/levodopa 25/100 mg 3 times daily

a higher dose for the patient.

Dosage may be increased by one tablet every day or every other day, as necessary, until a dosage of eight tablets of SINEMET 25-100 a day is reached

Marijuana has mind-altering compounds that affect both your brain and body and helps in treating disorientation.

Cholinesterase inhibitors are prescribed to treat symptoms related to memory, thinking, language, judgment and other thought processes.Three cholinesterase inhibitors are commonly prescribed are Donepezil,Galantamine and Rivastigmine.

PD don't have specific pharmacotherapy like other diseases.
Therapy given based on patient-specific factors including age, comorbidities, severity of functional impairment, nonmotor symptoms, patient preferences, therapeutic goals and outcomes and etc.


OPTIONAL PHARMACOTHERAPY FOR THIS PATIENT


1) All patients will require the use of carbidopa/levodopa (either as monotherapy or in combination with other agents)


2) Patients should administer carbiopa/levodopa more frequently, with the development of motor fluctuations.


3) Alternatively, addition of a COMT inhibitor, MAO-B inhibitor, or dopamine agonist to the carbidopa/levodopa regimen should be considered.


4) For management of carbodopa/levodopa–induced peak-dose dyskinesias, a reduction in l-dopa dose and/or addition of amantadine should be considered.


EXAMPLE OF GROUP OF DRUGS FOR STAGE 1/ EARLY STAGE PD


  • Levodopa
  • Entacapone (catechol-O-methyltransferase (COMT))
  • Dopamine agonists
  • MAO-B inhibitors = Selegiline (deprenyl)
                              = Rasagiline

Q14 : Educate this patient to ensure successful therapy, enhance compliance, and minimize adverse effects

Monitor for safety and efficacy of medications

Review the patient’s profile for current medications to ensure that they do not exacerbate/worsen PD symptoms with drugs

Monitor for drug-drug interactions such as: carbidopa/levodopa with nonselective MAO inhibitors as these classes together are contraindicated and require a 2-week separation period.

Offer alternatives to patients that can no longer swallow oral medications

Report any adverse effects to the patient's PCP that may be intolerable.

Advise patients not to crush any oral medications before checking with their PCP or pharmacists

Educate patients and their families on the importance of adherence and not to abruptly discontinue any medications.

Rasagiline : blurred vision

Multivitamin (rare) : itchy eyebrow scalp may due to allergic reaction (must seek doctor)

Pramipexole : impulse control disorders (ICD) such as gambling, compulsive buying, and pathological hypersexuality.

Maintain overall quality of life

Improve mobility and function

Reduce rigidity

Reduce tremor

Reverse slowed movements

Improve posture, gait, balance, speech, and writing skills

Maintain mental sharpness

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MONITORING PARAMETERS

Based on the drug given,we also must evaluate the patient's response to detect adverse effects.

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Response to therapy(improvement of patient's sign and symptoms due to Parkinson disease)

Monitor adverse effects such as urinary retention,GI depression,decreased sweating and hypotension.

Evaluate patient understanding on drug therapy

Assess for mentioned contraindications and cautions such as glaucoma and myasthenia gravis.

Perform a thorough physical assessment to obtain baseline data,determine drug therapy effectiveness and monitor side effects.

Monitor laboratory test results to determine need for possible dose adjustment.

Monitor risk for impaired thermoregulation related to anticholinergic effects.

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immediate- and sustained-release carbidopa/levodopa (Sinemet)

Bromocriptine (Parlodel)

Benztropine (Cogentin)

PERGOLIDE

  • Mental status
  • Anticholinergic side effects: dry mouth, constipation, urinary retention
  1. Educate the patient that IR form is best absorbed on an empty stomach but is commonly taken with food to minimize nausea.
  1. Monitor daytime drowsiness (reduce dosage of c/l to address)
  1. Monitor for abnormal involuntary movements (reduce dose of c/l, consider adding on either: dopamine agonist, MAO-I or COMT-I
  • Baseline CXR (pleuropulmonary disease, PPD)
  • Cardiac symptoms (retroperitoneal fibrosis, cardiac valve dysfunction)
  • Mental status (consider reducing dose if pt experiences confusion, drowsiness, or hallucinations/delusions)
  • Nausea (alleviate by titrating down slowly and taking dose with food)
  • Blood pressure and dizziness upon standing (orthostatic hypotension) (reduce dose it pt is experiencing)

Assess CV status including ECG before initiation of treatment and periodically thereafter. Perform baseline evaluation of ESR, other inflammatory markers, lung function/chest X-ray, serum creatine, renal function and monitor thereafter. Monitor for signs and symptoms of valvulopathy (e.g. dyspnoea, oedema, CHF, cardiac murmurs), fibrotic disorders (e.g. cough, dyspnoea, oedema, CHF, cardiac rub, uri

nary tract obstruction), development of impulse control disorders.

physiotherapy

occupational therapy

speech therapy

cognitive training

deep brain stimulation

active exercise therapy

This patient can change Rasagiline and Pramipexole into Levodopa. As we know, Rasagiline might cause a side effect which is blurred vision, meanwhile Pramipexole can cause impulse control disorder. To eliminate these side effects, the patient can take Levodopa, but Levodopa has interaction with Rasagiline and Pramipexole.

rasagiline + levodopa
Mechanism: pharmacodynamic synergism. Modify Therapy/Monitor Closely. Risk of acute hypertensive episode.

levodopa + pramipexole
levodopa and pramipexole both increase dopaminergic effects. Use with caution/Monitor.

L-dopa, the most effective drug available, is the immediate precursor of dopamine. It crosses the blood–brain barrier, whereas dopamine does not. In the CNS and elsewhere, L-dopa is converted by L-amino acid decarboxylase (L-AAD) to dopamine. In the periphery, L-AAD can be blocked by administering carbidopa or benserazide, which does not cross the blood–brain barrier. Carbidopa therefore increases the CNS penetration of exogenously administered L-dopa and decreases adverse effects (e.g., nausea, vomiting, cardiac arrhythmias, postural hypotension, vivid dreams) from peripheral L-dopa metabolism to dopamine.