Jpp318370 262.272

Palliative Management of Parkinson Disease: Focus on Nonmotor, Distressing Symptoms
Jack J. Chen, Dominick P. Trombetta and Hubert H. Fernandez The online version of this article can be found at: can be found at:
Journal of Pharmacy Practice
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Jack J. Chen, PharmD, BCPS, CGP,aDominick P. Trombetta, PharmD, BCPS, CGP,b andHubert H. Fernandez, MDc Parkinson disease is a progressive neurodegenerative gastrointestinal distress, orthostatic hypotension, pain, disease that commonly affects elderly persons. In the and psychosis, which can be a challenge for clinicians to absence of neuroprotective or curative therapies, currently manage. The presence of distressing symptoms along with available therapies only provide symptomatic benefit. Pro- the fact that Parkinson disease remains incurable necessi- gression to advanced Parkinson disease is often accompa- tate discussion on a palliative care approach to this disor- nied by functional dependence with increased risk of der. This article discusses the symptomatic management admission to a long-term care facility. The prevalence of of distressing symptoms encountered in the long-term Parkinson disease in long-term care facilities, within the care resident with Parkinson disease, including motor United States, has been estimated to be between 5.2% and complications and nonmotor features.
10%. Patients with advanced Parkinson disease alsoexperience other distressing motor and nonmotor condi- Dementia; depression; palliative; Parkin- tions, such as motor complications, dementia, depression, The motor features of PD are characterized by a combination of slowness of voluntary movement, Parkinsonism, the syndrome, is a prevalent movement rigidity, and resting tremor that become progres- disorder of which Parkinson disease (PD) is the most sively disabling over time. During the initial phase of PD, treatment is relatively straightforward and therapy for PD improves motor symptoms and qual- focused on symptomatic improvement of motor fea- ity of life,1-3 the disease remains incurable and is tures. As the disease progresses, nonmotor features associated with progressive disability and increased such as cognitive dysfunction, dysphagia, gastroin- testinal (GI) problems, hallucinations and psychosis,orthostatic hypotension, and pain begin to emerge.
These nonmotor features generally do not improve From the aSchools of Medicine and Pharmacy, Movement with antiparkinson therapy. In fact, antiparkinson Disorders Center, Loma Linda University, California; the drugs, such as dopamimetic and antimuscarinic bGeriatrics/Internal Medicine, College of Pharmacy and Nursing, agents, may exacerbate some of these nonmotor cMovement Disorders Center; director, clinical trials for features, necessitating dosage reduction at the cost movement disorders, Department of Neurology, McKnight Brain of suboptimal symptomatic motor benefits. Addi- Institute/University of Florida, Gainesville, Florida.
tionally, for patients on chronic levodopa therapy, Address correspondence to: Jack J. Chen, PharmD, BCPS, CGP, the development of motor complications (ie, fluctua- Schools of Medicine and Pharmacy, Movement Disorders tions and dyskinesias) adds yet another layer of Center, Loma Linda University, 11262 Campus Street – WestHall, Loma Linda, CA 92350; e-mail: [email protected].
complexity and challenge to PD management.
Management of Parkinson Disease in the Long-Term Care Resident / Chen et al Eventually, many patients with PD are faced with functional dependence, impending immobi-lity, bowel and bladder incontinence, neuropsy- Parkinson disease is estimated to affect approximately chiatric problems, and inability to meaningfully 1 million Americans, or about 1% of the US popula- communicate. Indeed their care needs may not be tion aged 60 years and above.11 The prevalence and manageable by caregivers at home and may neces- incidence of PD has consistently been observed to sitate long-term care admission or the employment increase with age and as the American population of skilled nursing services. In an analysis of 11 882 ages, a doubling of PD cases is likely to occur in the Medicaid patients with PD followed over 2 years, next 15 to 20 years.9,10,12 In a large, multiethnic the largest mean annualized expenditure was epidemiologic study, the incidence of PD rose shar- for long-term care admissions.6 In this cohort, ply among the age ranges of 60 to 69 years (38.8 cases 42% of patients used long-term care. Overall, the per 100 000 person-years), 70 to 79 years (107.2 risk of nursing home placement is significantly cases per 100 000 person-years), and 80 to 89 years increased for patients with PD compared with (119 cases per 100 000 person-years).13 Given the age and sex-matched reference participants.7 In association between PD and age, it should come as no great surprise that the prevalence of the disease residents with PD were moderately to severely in LTCFs is estimated between 5.2% and 10% with functionally disabled, and up to 70% were cogni- a mean age at admission of 80 years.8,14,15 Character- tively impaired, of which a third were severely istics that are associated with a shorter time between the diagnosis of PD and nursing home placement In nursing home residents with PD, the overall include lower education level, older age at onset of 3-year mortality rate is approximately 50%.9 In one PD, poor response to dopaminergic medications, and study, independent predictors of death included age presence of dementia. The presence of the latter three more than 85 years, male gender, severe functional features provides an indication that management of and cognitive impairment, visual disturbances, pres- the LTCF resident with PD will differ from that of the sure ulcers, congestive heart failure, diabetes melli- general community-dwelling PD population.
tus, and pneumonia.9 The specific presence ofaspiration pneumonia had the highest mortality riskratio among all comorbidities.
The progressive nature of PD and the increased morbidity and mortality associated with patients Palliative care is a model of health care delivery that who required long-term care facility (LTCF) has diverse definitions.16 Palliative care services placement necessitate discussion on the ‘‘palliative include an interdisciplinary team of professionals, stage’’ of the disease. However, the role of palliative including a physician, advanced practice nurse or care in PD has not been clearly defined. The goal of nurse practitioner, social worker, chaplain, and a palliative care is to provide the patient with the best variety of other clinical personnel such as consultant quality of life, regardless of the stage of the disease or pharmacists. Irrespective of length of life remaining, the need for other therapies.10 Traditionally, core palliative care would provide appropriate and effec- elements of palliative care are to provide optimal tive care management in a number of chronic diseases pain control as well as control of other distressing including PD. The attention to the comfort measures symptoms while simultaneously addressing the are of primary importance rather than the focus on a patient’s psychological, social, and spiritual needs. In disease specific invervention. Although relief from the patient with advanced PD, distressing symptoms pain is a crucial aspect, palliative care also involves include nonmotor features (eg, dementia, depression, the provision of relief from other distressing symp- GI dysfunction, orthostatic hypotension, pain, and toms (eg, motor and nonmotor features encountered psychosis) as well as motor complications (eg, in advanced PD) that would benefit residents of dyskinesias and off periods). This article discusses the LTCFs with PD. Palliative care provides an opportu- symptomatic management of distressing symptoms nity to re-evaluate each medication, dose, dosage encountered in the long-term care resident with form, frequency, and indication for appropriateness.
PD, including motor complications and nonmotor The long-term care pharmacist is in a unique position to initiate and recommend changes in the pharmacy Journal of Pharmacy Practice / Vol. 21, No. 4, August 2008 care plan based upon the clinical and functional conditions, such as orthostatic hypotension and neu- status of the resident. The clinical care of residents ropsychiatric comorbidities, may be exacerbated by with PD and also the psychological well-being of antiparkinson agents and limit the extent to which residents, families, and caregivers can be maximized antiparkinson agents can be used effectively.
through a systematic care plan that involves func-tional assessment with appropriate interventions.
Palliative care should be available as needs developand before problems become unmanageable. The The pathophysiology underlying the GI changes asso- establishment of goals among the clinician, family, ciated with PD is complex and involves a combination resident, and providers of care, aided by structured of autonomic, central, and enteric nervous system coordination and communication of stated services, dysfunction. Consequent problems such as constipa- could enhance resident and family satisfaction. The tion, delayed gastric emptying, and fecal impaction focus of plans of care should revolve around enhan- are commonly encountered and may result in nausea, cing quality of life, relieving distressing symptoms, anorexia, abdominal pain, and delayed onset of drug and empowering the resident and family to maintain effect. The concurrent use of any drug with a degree of control. A number of detailed educational potent antiperistalsis properties (eg, antimuscarinic resources on palliative care are available.17,18 agents such as benztropine, diphenhydramine, Hospice is one model of palliative care that aims trihexyphenidyl, tricyclic antidepressants, and opioid to provide quality, compassionate care for people analgesics) should be re-evaluated as these agents facing end of life. Generally, hospice care is con- can exacerbate constipation, reduce GI peristalsis, sulted when the estimated life expectancy is less and promote fecal impaction. A bowel regimen con- than 6 months. Care may be provided at home and sisting of adequate hydration with a daily stool soft- also in hospice facilities, hospitals, and nursing ener should be considered. Increased fiber intake homes. The hospice model provides measurable bene- and regular exercise are also beneficial. If initial stra- fits when used in nursing homes, including fewer tegies are ineffective, laxatives and enemas may be emergency room transfers, less use of invasive thera- used. Recently, the drug tegaserod maleate, used for pies, improved control of distressing symptoms, and chronic constipation and constipation-dominant irri- enhanced satisfaction of the decedent’s family.19 table bowel syndrome, was found to be helpful in Barriers to improved outcomes of palliative care in patients with PD as indicated by a double-blind rando- the hospice model include limited hospice stays, diffi- mized placebo-controlled pilot study in 15 patients.20 culty assessing limited prognosis for PD, and obstacles The drug metoclopramide, a centrally acting to interprofessional collaboration. Although not a dopamine receptor blocker, should be avoided in universally implemented service, the development of PD as it is likely to exacerbate parkinsonism. Dom- a palliative care consultation team in the LTCFs could peridone, a dopamine receptor blocker that does not be a practical and beneficial alternative to hospice.
cross the blood brain barrier, is safe to use in PD;however, it is not available in the United States.
Trimethobenzamide and serotonin receptor antago- nists (eg, ondansetron) are reasonable antiemeticalternatives for the patient with PD.
Symptom control in PD is traditionally conceptua- If dysphagia is present, nonpharmacologic thera- lized as optimizing antiparkinson drug therapy (eg, pies include providing appropriate food consistency carbidopa/levodopa, dopamine agonists) to achieve and feeding techniques to avoid swallowing pro- maximal improvements in motor function. However, blems and to minimize sequelae such as aspiration.
there are other PD-related conditions that do not Given that the presence of aspiration pneumonia is respond satisfactorily to antiparkinson treatment and associated with a high mortality risk among this resi- pose a challenge for clinicians. These conditions dent population, screening and periodic swallowing require different or additional therapeutic approaches.
evaluation among PD residents in the LTCF could These include GI problems, neuropsychiatric issues conceivably lower mortality rates.9 In some cases, (eg, dementia, depression, psychosis), orthostatic feeding by means of a nasogastric tube or even per- hypotension, and pain. When present, these condi- cutaneous endoscopic gastrostomy may be required.
tions should be addressed promptly. Some of these The use of orally disintegrating tablet (ODT) Management of Parkinson Disease in the Long-Term Care Resident / Chen et al products may also be useful for residents with dys- Complicating the picture of dementia in PD is phagia. Examples of available ODT anti-PD agents the clinical entity of dementia with Lewy bodies include carbidopa/levodopa and selegiline. Once (DLB), a dementing illness characterized by parkin- placed on the tongue, the ODT dissolves quickly. In sonism, visual hallucinations, and fluctuating cogni- the case of carbidopa/levodopa, the solubilized drug tion.24 There are multiple clinical (parkinsonism, must be swallowed (eg, with saliva) and does not visual hallucinations, attention deficits, executive require coadministration of liquids. The absorption dysfunction) and pathological similarities (Lewy of carbidopa/levodopa however is still intestinal, bodies in the limbic and neocortex) between the two therefore its time-to-peak is not significantly shor- disorders, leading many experts to believe that the tened compared to conventional immediate-release two conditions could be considered as opposite ends carbidopa/levodopa. In the case of selegiline ODT, the drug is absorbed transmucosally, bypassing first- Any of the currently available antiparkinson drugs pass hepatic metabolism and reaching peak levels more can induce confusion or delirium; however, the anti- rapidly than conventional selegiline. Transdermal muscarinic agents are particular culprits and should delivery formulations of anti-PD drugs are now com- be avoided in residents with baseline cognitive impair- mercially available in the United States and Europe.
ment or difficulties. For the medical management of Rotigotine (Neupro1, a dopamine agonist) is available dementia in PD, cholinesterase inhibitors have as a continuous delivery transdermal patch system.
demonstrated modest cognitive and behavioral bene- (Note: Rotigotine transdermal was recently withdrawn fits.26-30 Despite the theoretical risk of worsening of from the US market.) However, the transdermal parkinsonism with pro-cholinergic agents, this has formulation of selegiline (Emsam1) is only indicated not been the general experience with cholinesterase for major depressive disorder in the United States.
inhibitor use in PD.26-30 Memantine may be Sialorrhea, as a result of decreased frequency of beneficial although, at the time of writing, published swallowing, also is frequently encountered in PD.
data on this agent for dementia in PD are not avail- The use of antimuscarinic agents (eg, sublingual able. Overall, the available treatments for dementia atropine) could be attempted to reduce salivary in PD provide modest benefits and are similar to the secretions but is often associated with intolerable existing treatments used for Alzheimer’s dementia.
and undesirable side effects such as agitation,confusion, and somnolence in this population. In experienced hands, injections of botulinum toxininto the parotid and submandibular glands are Most authorities consider depression as an intrinsic effective for treating sialorrhea although dysphagia part of PD rather than a reaction to disability.31 Parkinson disease is an independent predictor ofdepression in the LTCF resident.32 Among LTCFresidents with PD, 80% exhibit poor psychosocial well-being but only 15% to 30% are diagnosed with Cognitive impairment in PD is primarily manifested depression.8,32 These data suggest that depression by executive dysfunction, attention deficits, and may be under-recognized in the LTCF resident with behavioral symptoms.22 The effects of dementia and PD. The reasons for this difference are unclear but associated behavioral and functional problems often may be due to the fact that, in residents of LTCFs, overshadow the motor problems of PD. While demen- the features of depression (ie, psychomotor retarda- tia in PD has been traditionally thought of as occurring tion, difficulty with concentration, sleep disruption, in the ‘‘latter half ’’ of the disease, it may actually paral- changes in appetite, weight changes) may be attribu- lel motor progression from its onset and simply be recognized much later than the motor symptoms.23 Factors that have been consistently correlated The state of dementia is not only debilitating to the with depression in PD include presence of advanced resident but provides a major challenge for the family, disease, anxiety, cognitive impairment, and psycho- health care team, and LTCF staff. Medications sis.33 Longitudinal studies demonstrate that, in the (eg, opioid analgesics, antimuscarinics) or organic majority of depressed PD patients, symptoms will causes (eg, infections, electrolyte/metabolic abnormal- persist or worsen over time.34 Depressed patients ities, pain) could also superimpose a confusional state.
with PD also frequently have distressing or even Journal of Pharmacy Practice / Vol. 21, No. 4, August 2008 painful somatic symptoms that may not be recog- result of delusional states. Pure auditory hallucina- nized as part of the affective disorder.35 Several tions, seen in schizophrenia, are rare in PD.
studies demonstrate that depression in PD not only All antiparkinson drugs may produce psychotic amplifies functional and sensory impairments (eg, symptoms.37 Agents with potent antimuscarinic cognition, motor function, sexual dysfunction, sleep, properties also may trigger hallucinations and and pain) but is also associated with accelerated psychosis but are more commonly associated with states of altered consciousness and reduced alert- Randomized clinical trials assessing the efficacy ness (eg, delirium and confusion).38 Besides antipar- of antidepressants specifically on depressed PD kinson drugs (eg, dopamine agonists, levodopa), patients are an unmet need in PD research.33 How- other factors consistently identified as independent ever, based on published clinical experience and the risk factors for psychosis in PD include cognitive available scientific data, the selective serotonin impairment, depression, disease duration and sever- reuptake inhibitors (SSRIs) are the preferred antide- ity, increased age, and sleep disorders.33 pressants due to improved tolerability over other anti- Hallucinations and psychotic behavior occurring depressants, such as the tricyclic antidepressants.33 in the setting of clouded sensorium or delirium are Rarely, SSRIs can induce parkinsonism. A more likely secondary to an underlying endocrinologic, common finding is that SSRIs may exacerbate action infectious, metabolic, or pharmacotoxic process.
or postural tremors. It is also important to ensure Common triggers include antimuscarinic drugs, that patients are on optimal doses of antiparkinson dehydration, electrolyte imbalance, and respiratory drugs to minimize ‘‘on–off ’’ motor fluctuations that or urinary tract infection. In this situation, the may contribute to mood fluctuations.
hallucinations and delirium should resolve withappropriate identification and correction or removalof the underlying medical/organic cause. Addition- ally, because concomitant chronic medical disorders Psychotic symptoms are common in PD and occur in (eg, dementia, depression, pain syndromes, and 20% to 50% of medication-treated patients.33 Visual sleep disorders) can affect the levels of alertness and hallucinations are the most common psychotic sensory awareness, management of these disorders symptom in PD.36 Hallucinations are abnormal per- should be optimized. Care also should be taken to ceptions without a physical stimulus that can involve any sensory modality and may be simple or complex In the presence of psychosis or hallucinations in form. ‘‘Presence’’ and ‘‘passage’’ hallucinations that are distressing or disruptive, assertive interven- and visual illusions are often referred to as ‘‘minor’’ tion is required with the goal of achieving a partial or hallucinations. These hallucinations consist of a complete resolution of symptoms without worsening sense that a person or sometimes animal is in the motor function. The traditional approach involves room or was briefly present. They may have a visual systematic and stepwise dosage reduction or elimina- component making them difficult to distinguish tion of antiparkinson drugs associated with a high risk from visual hallucinations. Benign visual hallucina- of inducing psychosis but with modest symptomatic tions usually appear earlier and often progress to efficacy (ie, antimuscarinics, amantadine, selegi- malignant hallucinations, confusional states, delu- line). Next, dosage reduction of agents that provide sions, paranoid beliefs, agitation, and delirium over significant symptomatic benefit may be attempted time. Delusional states occur in a condition of clear beginning with the dopamine agonists and then the sensorium with loss of insight and commonly involve levodopa products. In the setting of psychotic themes of home intrusion, external threats of harm, symptoms occurring soon after a recent increase spousal infidelity, and theft of valuable personal of central dopaminergic load (eg, addition of dopa- belongings. Staff members and caregivers should mine agonist, dopamimetic dosage increase, addi- be educated on features of psychosis in PD residents tion of a catechol-O-methyl-transferase [COMT] and encouraged to report symptoms to clinicians.
inhibitor), a corrective downward dosage adjustment For example, staff members may report that the should be considered. If improvement in psychosis is patient is displaying aggressive behavior (physical achieved at a cost of modest deterioration in sympto- or verbal), inappropriate sexual behavior, or refusal matic motor benefit, the outcome may be considered to drink, eat, or take medications, which may be a as an overall positive net gain. However, in most Management of Parkinson Disease in the Long-Term Care Resident / Chen et al cases, patients will eventually require treatment with an atypical antipsychotic to improve psychosis The management of pain syndromes in advanced without significantly worsening the underlying PD is both challenging and difficult. Pain syndromes parkinsonism. With the advent of atypical antipsy- negatively affect health-related quality of life and chotic agents, some clinicians now opt to add an affect up to two thirds of patients with PD.43 In atypical antipsychotic and forgo the aforemen- many cases, PD-related pain discomfort oversha- tioned dopaminergic dose-reduction approach.
dows the discomfort due to motor symptoms.43-45 However, in one study of LTCF residents with Pain in PD could be attributed to a plethora of etiol- PD, when antipsychotic drugs were administered, only 7% were atypical agents.8 The reasons for this akathitic discomfort, and comorbid conditions. Suc- are unclear but may be due to cost containment and cessful management and relief of pain rely on careful formulary restrictions. When an atypical antipsy- assessment of the mechanisms and causes for the chotic is used, quetiapine is preferred as the use pain. Many times the decreased verbalization and of olanzapine or risperidone is implicated in wor- cognitive impairment secondary to dementia also sening parkinsonism and the use of clozapine is can result in under-detection and thus under- associated with a small risk of agranulocytosis and treatment of pain.46 Behavioral pain assessment thus frequent lab monitoring.39 However, because tools have been developed in recent years to aid in the US Food and Drug Administration recently the evaluation of residents with pain. For example, mandated that a black box warning be placed on all the American Geriatrics Society Panel on Persistent atypical antipsychotic drug package inserts for Pain in Older Persons has identified behavioral traits increased mortality among demented and elderly (ie, facial expressions, verbalizations, body move- patients, the search for first line treatment of PD ments/postures, changes in interpersonal interac- psychosis continues. Traditional neuroleptic agents tions, changes in activity patterns, and mental (eg, haloperidol, fluphenazine) should be avoided status changes) that indicate the presence of pain, due to risk of worsening parkinsonism. In a border- especially in the cognitively impaired older adult.47 line ambulatory PD resident, the worsening of par- In the LTCF resident, the rigidity, restricted move- kinsonism or loss of the ability to walk for even a few ment, and mobility changes attributed to PD may weeks may make ambulation permanently impossible confound the assessment of body movements/pos- even if the parkinsonism improves once the offending drug is stopped. Cholinesterase inhibitors may show Concerns with worsening cognitive impairment some promise in alleviating psychosis based on or delirium can lead to an opioid-sparing mentality.
clinical trials in demented PD patients.40,41 For example, data in older patients following hipfracture have shown an increased risk of deliriumassociated with under-treatment of pain.48 Agitation or other behavioral problems can also be a manifes- Symptomatic orthostatic hypotension occurs in up tation of subtherapeutic pain management. In the to 20% of PD patients and may result in dizziness, patient with advanced PD the goals of therapy and syncope, impaired ambulation, and increased fall the plan of care should reflect the titration of bal- and fracture risk.42 Orthostatic hypotension can ance between physical comfort and function and occur as part of autonomic dysfunction but can also occur as a side effect of many drugs, including anti- In LTCF residents with diminished ability to parkinson agents, antihypertensives, and opioid swallow, most LTCFs would prefer not to use inject- analgesics. Medications that are no longer of clinical able analgesics so treatment options become limited.
use in the symptomatic or palliative care of PD in the Morphine sulfate can be administered rectally as LTCF resident can be discontinued. When sympto- suppositories or the oral sustained-release formula- matic and troublesome, the addition of fludrocorti- tion can be administered rectally in dosages equal sone or midodrine may be considered. Other to the oral route. Transdermal fentanyl may be used interventions such as increased fluid and salt intake if rectal administration of medications is unsuitable.
and support stockings may be attempted but tend to Delays in analgesia with transdermal fentanyl with initiation of therapy as well as the inability to readily Journal of Pharmacy Practice / Vol. 21, No. 4, August 2008 Motor and Nonmotor ‘‘Off’’ Symptoms in Parkinson Disease titrate this medication could be problematic for the Dyskinesias are periods of involuntary, chorei- care of some residents. Patients on transdermal fen- form movements associated with peak levels of levo- tanyl require careful monitoring for excess sedation, dopa and predominantly affect the extremities and decreased respirations, and changes in activities of trunk. Patients are generally not disabled by mild daily living; especially with any increased body tem- to moderate dyskinesias but severe dyskinetic or dys- perature secondary to infectious or noninfectious tonic appendicular activity can be painful and can causes (hot packs), which could increase the serum limit mobility and the performance of daily activities.
concentrations of fentanyl and lead to unwanted side Patients with dyskinesia score worse on quality of effects. More important than the choice of analgesic life scales especially in the areas of activities of daily agent is the routine scheduling around the clock living, emotional well-being, communication, and Pain can also be a manifestation of a sudden or As PD progresses, it becomes increasingly difficult wearing ‘‘off ’’ state, which may be relieved by adjust- to administer doses of levodopa that prevent end- ing anti-PD medications. Apomorphine has been of-dose motor fluctuations without causing peak-dose reported to alleviate severe dystonic ‘‘off ’’ pain.49 dyskinesias. The exact mechanism of motor complica-tions is unknown but the ‘‘unnatural’’ pulsatile patternof ‘‘peak’’ and ‘‘trough’’ levodopa levels (due to short elimination half-life and intermittent method of drug Motor complications are to be expected in the LTCF administration), changes of the dopamine receptors, resident with PD. In levodopa-treated patients, up to and alterations of the motor output pathways within 10% will develop associated motor complications the basal ganglia are believed to play major roles.51 within 1 year of treatment, 50% after 5 years, and Generally, methods for controlling motor compli- 80% after 10 years.50,51 Motor complications present cations include adjustments of levodopa/dopamine in different forms: wearing off, sudden off, dose fail- agonist dose and dosing frequency, addition of adjunc- ures, delayed-on, peak-dose dyskinesias and diphasic tive amantadine for dyskinesias, addition of a COMT dyskinesias, and onÀoff fluctuations (yo-yoing).
inhibitor or monoamine oxidase type B (MAO-B) inhi- Motor fluctuations involve the so-called ‘‘end-of-dose bitor for fluctuations, and injectable apomorphine as wearing off’’ that contributes to alternating periods rescue therapy for ‘‘off ’’ episodes56,57 (see Table 2).
of mobility (‘‘on’’) and hypomobility (‘‘off’’) during Generally, LTCF residents with PD will not be candi- the day and night. Motor off times can significantly dates for surgical interventions (eg, deep brain stimu- interrupt the performance of daily activities, lation) due to dementia and other comorbidities.
increase caregiver/staff time, and reduce quality of Therefore, what is acceptable practice for treatment sleep. The ‘‘off’’ periods are also commonly associated of PD in younger patients may be quite different in the with recurrence of various nonmotor features (eg, elderly LTCF resident. For the LTCF resident, strate- anxiety, bladder and bowel problems, cognitive gies such as adjusting levodopa ‘‘med-pass’’ times to changes, pain, and respiratory difficulties), which separate dosing from meal protein intake (which can may go unrecognized as a feature of the off episodes interfere with levodopa activity), promoting optimal gastric emptying time (see GI problems section), or Management of Parkinson Disease in the Long-Term Care Resident / Chen et al Treatment of Motor Complications in Advanced Parkinson Disease – Increase frequency and/or dosage of levo- – Avoid coadministration of high dietary protein – Add a COMT inhibitor– Add a selective MAO-B inhibitor– Add an oral dopamine agonist– Add amantadine– Surgery – Minimize ‘‘off’’ times– Baclofen COMT ¼ catechol-O-methyl-transferase; MAO-B ¼ monoamine oxidase type B.
using levodopa liquid solutions may be better symptoms requires input from the team. Input from tolerated albeit benefits may be modest. Additionally, medical specialists such as neurologists and allied the use of immediate-release levodopa preparations health care specialists such as consultant pharma- may be preferred over controlled-release formulations cists, occupational therapists, speech and language as GI absorption can be erratic and unpredictable therapists, and physiotherapists are vital for compre- with the controlled-release product, and patients with hensive care. The care of the resident with advanced advanced disease may be more sensitive to minor PD and the affected family members are opportu- changes in plasma and brain levodopa levels.
nities for improvement with early implementationof the palliative care process.
In those situations where comorbid conditions qualify the resident for hospice services, the physi- Palliative management decisions regarding manage- cian needs to evaluate the resident and discuss ment of distressing symptoms should be based on those options with the family. The delicate balance careful clinical judgment, taking into account the of dopaminergic pharmacotherapy and the accom- expectations of both patient and caregivers (when panying central and peripheral side effects require possible). It is most crucial that patients have maxi- diligence. Continuing antiparkinson medications mum access to speech, occupational therapists can improve mobility and lessen rigidity but at and physiotherapists, social workers, gait trainers, the expense of causing or exacerbating confusion continence advisors, and consultant pharmacists.
or hallucinations. Conversely, the decision to dis- Provision of a wheelchair may be dictated by the lia- continue these medications can lead to decreased bility to falls due to postural instability and gait mobility, skin ulcer formation, dysphasia, and aspira- abnormality but not by akinesia and rigidity per se.
The Clinical Practice Guidelines for Quality Pallia-tive Care were developed through consensus of five US palliative care organizations.10 Multidisciplinaryteam evaluation and treatment in selected cases is a Decisions regarding nutrition and hydration may key area of palliative care. Management of complex be difficult and need to be addressed with the Journal of Pharmacy Practice / Vol. 21, No. 4, August 2008 family and, if possible, the patient. In the presence of delirium or in the event of an acute deteriorationin a resident’s condition, short-term measures such 1. Biglan KM, Schwid S, Eberly S, et al. Rasagiline as a temporary nasogastric tube can be considered improves quality of life in patients with early Parkinson’s until the resident recovers. However, in end stage disease. Mov Disord. 2006;21:616-623.
2. Noyes K, Dick AW, Holloway RG. Pramipexole versus disease this may be considered inappropriate. Med- levodopa in patients with early Parkinson’s disease: ications that decrease appetite or worsen dysphagia effect on generic and disease-specific quality of life.
should be discontinued. Diet should be evaluated for eating preferences rather than any restrictions, 3. Reichmann H, Boas J, Macmahon D, Myllyla V, and the most comfortable eating atmosphere Hakala A, Reinikainen K. Efficacy of combining levo- should be attempted. Good oral hygiene provides dopa with entacapone on quality of life and activities comfort and the liberal use of water; ice chips, lip of daily living in patients experiencing wearing-off typefluctuations. Acta Neurol Scand. 2005;111:21-28.
lubricant, and artificial saliva are encouraged. A 4. Lees AJ, Katzenschlager R, Head J, Ben-Shlomo Y.
variety of instruments that measure end-of-life care Ten-year follow-up of three different initial treatments and evaluate the impact of current interventions are available.58 As death approaches, the role of the multidisciplinary team, which has been involved 5. D’Amelio M, Ragonese P, Morgante L, et al. Long-term throughout the disease process, is invaluable. Its survival of Parkinson disease: a population-based study.
understanding of the resident and family’s journey up until the terminal phase provides a firm founda- 6. Orsini L, Kennedy S, Castelli-Haley J, Huse D. Health- care utilization and expenditures among Medicaid tion for support and guidance in the last days.
patients with Parkinson’s disease. Paper presented at: Appreciation of culture and diversity is helpful in International Society for Pharmacoeconomics and providing family support, focusing on quality of Outcomes Research; May 16-19, 2004; Arlington, VA.
life, and respecting individual dignity.
7. Parashos SA, Maraganore DM, O’Brien PC, Rocca WA.
The literature on symptom control at the end of Medical services utilization and prognosis in Parkinson life in PD (ie, in the last few days of life) is sparse.
disease: a population-based study. Mayo Clin Proc.
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planned, systematic, and individualized based upon 9. Fernandez HH, Lapane KL. Predictors of mortality prior discussions with the resident and the family among nursing home residents with a diagnosis of rather than the only alternative available.
Parkinson disease. Med Sci Monit. 2002;8:CR241-CR246.
10. National Consensus Project for Quality Palliative Care.
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