TBL XV W5

PharmD Program /Fourth Year
Block XV Neurological and psychological Disorder
PARKINSONISM
TBL
PharmD Faculty of Medicine/ Libyan International Medical University

Intended learning outcomes
2
By the end of this session you will be able to:
 Outline epidemiological features of Parkinsonism.
 Explain the impact of parkinsonism on quality of life.
 Discuss quality of life assessment methods for a patient with

parkinsonism.
 Recommend an initial treatment plan for a patient with Parkinson's
disease based on patient-specific factors.

 Develop a treatment plan for a patient experiencing levodopa-
associated motor complications.

 Explain selfcare tips for a patient with parkinsonism.
06/11/2023
Epidemiological features of Parkinsonism
3
 Idiopathic Parkinson’s Disease (85%), Neuroleptic-induced parkinsonism (7 - 9%)
Multiple system atrophies (MSA) (2.5%), Progressive supranuclear palsy (PSP)
(1.5%), Vascular Parkinson syndrome (3%), MPTP, CO, Mn, recurrent head trauma
(rare), Post-encephalitic parkinsonism (none since 1960s).
 Parkinson’s disease (PD) is the second commonest neurodegenerative disease,
exceeded only by Alzheimer’s disease (AD).
 It is estimated that approximately 1 million persons in the United States, 1 million
in Western Europe & 5 million worldwide suffer from this disorder.
 PD affects men & women of all races, all occupations & all countries.
 The mean age of onset is about 60 years.
 The frequency of PD increases with aging, but cases can be seen in patients in their
20s & even younger.
 Based on the aging of the population & projected demographics, it is estimated
that the prevalence of the disease will dramatically increase in the next several
decades
06/11/2023
06/11/2023
The impact of parkinsonism on quality of life

4
 PD has a severely negative impact on the quality of life (QoL) of patients & their
caregivers.
 In PD, motor symptoms such as slowness or tremor are the most visible
manifestations of the disease & the most prominent negative influencer in the
quality of life.
 Slowness of Movement
5
 Eating and swallowing problem (From European Survey): are common in paient
with PD 84% of people with PD had swallowing problems, 44% had lost weight in
previous 12 months, 60% ate less than normal, 49% felt eating was not enjoyable,
68% were embarrassed eating,
70% were unaware this was treatable
 Falls & “Freezing”
 Communication difficulties
Jean(words, tone/gesture/Body
and I are laughing at the samelanguage)
joke
“I am trying to smile but
the rigid muscles that
are a symptom of my
Parkinson’s often make
it difficult. I am not
being rude. I am not
being miserable. I have
Parkinson’s.”
Terry Kavanagh 06/11/2023
6
 PD patients, however, are likely to also have a range of non-motor symptoms.
These symptoms can be more troubling than motor symptoms. These can increase
distress and social isolation, but are often unreported or overlooked.
The non motor symptom are nocturia, urinary frequency, incontinence,
constipation, pain, tiredness/sleep disorders, drooling, forgetfulness, excessive
sweating, drop in blood pressure, anxiety/ depression, dementia, sexual
dysfunction, psychosis/hallucinations & smell/taste dysfunction
06/11/2023
Quality of life assessment methods for a
patient with parkinsonism
7
06/11/2023
8
 The EQ-5D is a generic measure of HRQoL that is frequently used in PD and is a 5-
dimension questionnaire dealing with aspects related to mobility, self-care, usual
activities, pain/discomfort & anxiety/depression.
 The SF-36 questionnaire is the most widely used generic measure & gathers
information of the patient’s physical & mental status, which are presented as 2
different sub-scores.
The physical component summary encompasses physical functioning, physical role,
bodily pain & general health;
the mental health component encompasses vitality, social functioning, emotional
role & mental health.
This measure has been successfully used to assess the status of various diseases in
clinical practice including PD. This scale, however, has limitations in assessing
change in physical health, but is useful in predicting the course of disease.
06/11/2023
9
 PD-specific scales , such as the 8- and 39-item Parkinson’s Disease Questionnaires
(PDQ-8/PDQ-39), Parkinson’s Impact Scale (PIMS), Scales for Outcomes in
Parkinson’s Disease – Psychosocial questionnaire (SCOPA-PS) or the Parkinson’s
Disease Quality of Life scale (PDQUALIF).
Among the PD-specific instruments, the PDQ-39 is the most widely used.
This instrument captures the impact of both motor & non-motor symptoms.
It assesses 39 aspects of life including activities, feelings, support & capabilities.
It includes items such as walking 0.8 km (0.5 mile) or 92 m (100 yards), carrying
bags, getting around in public or in the home, fastening buttons or shoelaces &
holding drinks without spillage.
This scale also captures the impact of motor fluctuations.
It is convenient & can be completed within 15–20 minutes.
 The PDQ-8 is a short-form of PDQ-39 in which each item represents a dimension of
the extended scale. In PD, wearing-off of drug treatments is a common factor, but
is not well defined & can be missed by clinicians.
06/11/2023
10
 The 32-symptom Wearing-off Questionnaire (WOQ-32) & the shorter 9-symptom

version (WOW-9) are useful instruments for determining treatment wearing-off.
but for determining wearing-off severity, patient diaries are recomended.
 Other prominent generic HRQoL scales in PD include: the Quality of Life
Questionnaire 15D, the Schedule for the Evaluation of Individual Quality of Life-
Direct Weighting & the World Health Organization Quality of Life Assessment
Short Version
06/11/2023
Treatment of Parkinson's disease PD
11
Treatment of Parkinson's disease PD, is categorized

into three types:
1. lifestyle changes, nutrition, and exercise;
2. Pharmacologic intervention,primarily with drugs
that enhance dopamine concentrations.
3. Surgical treatments for those who fail
pharmacologic interventions.
06/11/2023
12
 Initial treatment depends on the patient’s age, risk of adverse

effects, degree of physical impairment, and readiness to
initiate therapy.
 Initiating therapy with levodopa may be more beneficial for
mobility than starting with a MAO-B inhibitor or dopamine
agonists.
 Choice of agent varies based on clinical experience and
patient preference.
 Starting with a dopamine agonist may help to delayt he onset
of dyskinesias and the on and off fluctuations seen with long-
term levodopa use. However, this approach may result inless
motor benefit and greater risk of hallucinations or somnolence.
06/11/2023
13
 Levodopa results in greater motor improvement and

should be used as initial therapy in the elderly (greater
than 75 years) and in those with cognitive impairment.
Data are insufficient to recommend initiating treatment
with combined levodopa and a dopamine agonist.
 Initiating treatment with anticholinergic medications,
amantadine, or MAO-B inhibitors, is recommended only
for patients who have mild symptoms because they are
not as effective as dopamine agonists or levodopa.
06/11/2023
Levodopa-associated motor
14
complications
 Some argue for delaying treatment with levodopa
because approximately 70% of patients experience
motor complications within 6 years.
 Converting patients from oral formulations to enteral or
duodenal levodopa administration reduces motor
fluctuations and improves UPDRS (Unified Parkinson
Disease Rating Scale) scores.
 The levodopa/carbidopacombination, can be
administered directly to the duodenum via a small tube.
This formulation marketed under the trade name
Duodopa in Europe and Canada,
06/11/2023
15
complications
 As well as, Dyskinesiascaused by adding other PD drugs
to levodopa may be improvedby decreasing the
levodopa dose.
 levodopa-associated problems may become disabling
and profoundly affect quality of life. Medications
commonly used to manage these symptoms include
monoamine oxidase type B (MAO-B) inhibitors,
catechol-O-methyltransferase (COMT) inhibitors, and
the NMDA receptor antagonist amantadine and
dopamine receptor agonists. Agents that block MAO-B,
such as rasagiline and selegiline, are used as both
initial and adjunctive therapy in patients with
Parkinson's disease.
06/11/2023
16
complications
 These medications increase concentrations of dopamine in the brain by
blocking its reuptake from the synaptic cleft, a mechanism that can
slow motor decline, increase 'on' time and improve symptoms of
Parkinson's disease.
 Also, agents that block COMT, such as tolcapone and entacapone,
increase the elimination half-life of levodopa. Given adjunctively with
levodopa, COMT inhibitors can decrease 'off' time and increase 'on'
time, as well as lower the daily levodopa dose. Although more potent
than entacapone, tolcapone requires monitoring for hepatotoxicity.
 Amantadine is a noncompetitive NMDA receptor antagonist shown to
lower dyskinesia scores and improve motor complications in patients
with Parkinson's disease when given adjunctively with levodopa.
Dopamine agonists, also used as initial and adjunctive therapy in
Parkinson's disease, improve motor response and decrease 'off' time
purportedly through direct stimulation of dopamine receptors.
06/11/2023

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PharmD Program /Fourth Year

Block XV Neurological and psychological Disorder

PharmD Faculty of Medicine/ Libyan International Medical University

 Explain the impact of parkinsonism on quality of life.

 Discuss quality of life assessment methods for a patient with

disease based on patient-specific factors.

associated motor complications.

The impact of parkinsonism on quality of life

 The 32-symptom Wearing-off Questionnaire (WOQ-32) & the shorter 9-symptom

Treatment of Parkinson's disease PD, is categorized

 Initial treatment depends on the patient’s age, risk of adverse

 Levodopa results in greater motor improvement and

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