Management of symptoms in the complex stage of Parkinson's

Management of symptoms in the complex stage of Parkinson's

Motor complications are more common as Parkinson’s disease progresses, and typify transition to the complex phase. Many so-called ‘axial’ symptoms of later stage Parkinsons, such as dysphagia, gait disturbance and falls, do not respond to levodopa, but may be helped by multidisciplinary team input as will the non-motor symptoms for example sleep disorders, pain and sialorrhea.

Dementia occurs in up to 80% of people with PD after 20 years’ disease duration. The rate of PD progression is heterogeneous and is generally more rapid in those with older age and more severe motor impairment at onset.

Objectives:

• Recognition of the complex please of Pd and appreciate both motor and non motor fluctuations
• Recognition that Pd is more than a movement disorder and non motor symptoms accrue as Pd progresses
• Treatment strategies for common issues arising in complex Parkinson’s

CPD accreditation

'Management of symptoms in the complex stage of Parkinson's' has been approved by the Federation of the Royal Colleges of Physicians of the United Kingdom for 1 category 1 (external) CPD credit(s). Please note CPD Federation approval does not include satellite symposia sessions. To claim the credit please email events@neurologyacademy.org.

Summary

As Parkinson’s disease (PD) progresses, it’s balance of motor and non-motor symptoms become harder to treat.

Far from being solely a movement disorder, the condition, is an “assault on multiple neurotransmitters”, said Dr Robin Fackrell, adding that this must be considered during management.

Non-pharmacological options in complex disease

The symptoms of advanced PD can be motor, neuro-psychiatric, and autonomic in nature. It’s important to remember that managing non-motor problems can help to improve wellbeing and quality of life.

“It’s also important to say that a lot of the symptoms aren't very dopamine responsive, so aren't really improved by the dopaminergic medications that we use,” said Lisa Brown.

On-related gait freezing, drug-resistant tremor, and some dystonia, for example, may not respond to levodopa medication. And some of the autonomic and psychiatric features of PD can actually be made worse by Parkinson’s medication.

In addition, as the disease progresses, the levodopa effective window becomes smaller, Lisa explained.

“That’s why it is really important to think about how we can help our patients without using other strategies.”

Symptoms and strategies

Dyskinesia, which can be levodopa induces, can sometimes be very disabling, but is often more troublesome or the family and caregivers than the person with PD. For some people, using a blue filter, such as blue eye glasses, can be helpful, though more evidence is needed.

Freezing, which can last anything from a few seconds up to several minutes, can severely limit mobility, increase the risk of falls, and contribute to reductions in socialisation and quality of life. It can respond very well to cueing strategies. These might include creating a path of “stepping stones” from sheets of paper for the patient to walk on, for example.

Dystonia can be related to wearing off, or is often levodopa induced. It can also be very disabling. Some dystonia’s can be helped with dose manipulation, and physiotherapy can also be helpful.

“Things we can always do to help is discuss their symptoms, how they happened and when. We should reassure people that these things are part of their Parkinson’s and put them into context,” said Lisa.

“That means looking at their day and what might be impacting their symptoms – did they have a good night’s sleep? Are they a bit constipated? How are they taking their medication? Exploring how mood, anxiety, fatigue, and sleep can impact on the symptoms can really, really help.”

Referring on

Where the person has moderate to severe problems, a referral to therapy colleagues or to psychological therapies, such as IAPT or CBT, may be appropriate.

Occupational health colleagues can offer a range of services including fatigue and anxiety management, sleep hygiene, goal setting, and cognitive strategies, as well as carer support.

Physiotherapists can encourage exercise and activity, and provide interventions for gait, balance, posture, and transfers. They can also offer pain management and muscle stretches to help with dystonia.

Basal ganglia dysfunction

Motor skills, multitasking, mental processing and executive function are all impacted by basal ganglia dysfunction in PD.

“A lot of the strategies our therapy colleagues use are around engaging conscious attention and ensuring concentration,” see Lisa.

This includes simple advice like reducing simultaneous tasks and distractions, and mentally rehearsing and visualising tasks before carrying them out.

Best practice guidelines for dietitians on the nutritional management of Parkinson’s: 2021 update/review

The initial best practice guidance was published in 2015, and the 2021 update was designed to bring it into line with current knowledge and practice, said Karen Robinson.

“This is guidance for dietitians, but it is really useful for the rest of the MDT to be aware of what is covered within it, so they can be aware of the breadth of issues dietitians can help with,” said Karen.

The updated document looks at nutritional management at different stages of PD.

Diagnosis and early disease

This section places an emphasis on unintended weight loss, malnutrition, and dysphagia, as well as establishing baselines, nutritional intakes, and normal weight. It also features bladder and bowel care advice and information on the use of pre and probiotics.

It advises against the routine use of antioxidants, vitamin E, and co-enzyme Q10, recommends vitamin D supplementation, and suggests VB vitamin supplements be considered.

Advanced disease

The guidance contains additional information on silent aspiration, short-term tube feeding, and deep brain stimulation. It also talks about osteoporosis, and when calcium supplements may be indicated.

In addition, it reinforces current recommendations to avoid daily protein intake, but consider protein redistribution if indicated.

Palliative care

The updated document contains more information on palliative care, and emphasises that patient choice should always be supported

Summary

Summing up, Karen said: “We have reinforced the idea that monitoring should commence at diagnosis and continue as the condition progresses. We have also emphasised that needs will change and evolve throughout the progression of the disease.”

Podcast

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