A Hybrid Approach to Clinical Guideline and to Basic Medical Knowledge Conformance A. Bottrighi1, F. Chesani2, P. Mello2, G. Molino3, M. Montali2, S. Montani1, S. Storari4, P. Terenziani1, and M. Torchio3 1 DI, Univ. del Piemonte Orientale, via Bellini 25/g, 15100 - Alessandria, Italy 2 DEIS - Univ. di Bologna, viale Risorgimento 2, 40136 - Bologna, Italy 3 Az. Ospedaliera S. Giovanni Battista, via Bramante 88, Torino, Italy
YOUR QUESTIONS ANSWERED What is Parkinson's disease (PD)?
How did I get PD and who usually gets it?
PD is a disease that affects a specific type of cell in No one knows how PD develops for any given individual, the brain. These cells normally make a substance but the risk of getting PD seems to be affected by called dopamine, which is a "neurotransmitter" that genetic factors and by the environment. In the United carries messages from one brain cell to another. These States, about 1 million people are living with PD, and, messages tell your body to do many things, such as each year, more than 50,000 people learn that they move muscles. When dopamine levels are normal, have PD. In most cases, PD symptoms start to appear the brain can help the body move in a normal and around age 60. Fewer than 10% of patients with PD are coordinated way. In patients with PD, the brain cells that diagnosed before age 50.
make dopamine begin to die, so dopamine levels drop. With less dopamine in the brain, patients are no longer Who will be on my care team?
able to control their movements as well.
You will likely have help from a number of different healthcare providers, including your primary care What are the symptoms of PD?
physician (PCP), nurses, and a neurologist (a doctor who There are two kinds of PD symptoms. "Motor symptoms" specializes in diseases of the brain). Some neurologists affect body movement and muscle control. These are specialize in caring for people with PD, and a neurologist the symptoms that most people think of when PD may help diagnose your PD and plan your treatment. comes to mind. "Nonmotor symptoms" affect things Your PCP, or family doctor, will see you for most of other than movement and muscles.
your day-to-day health concerns. This can also include The experience of PD is different for every patient. Some helping you through any problems you may be having people have symptoms from the start, others have few with your PD treatment (for example, constipation signs at first. Your doctor will ask about your symptoms due to PD and medications) and watching for new and keep an eye out for new ones. It is also important for symptoms. Your PCP and neurologist will work together you to tell your doctor about any new problems as you to make any changes to your treatment. Your PCP will start to have them. also continue to see you for other health issues that are MOTOR SYMPTOMS OF PD
Usually starts on one side of the body and may affect only one body part, like the hand or foot. As PD gets worse, the shaking can affect other parts of the body and may be more noticeable with stress. Shaking often disappears during sleep or when the affected arm or leg is moving.
As movement slows, it may take longer to do common tasks like taking a shower and getting dressed. Stiff Arms
When muscles are tense on a regular basis, it can lead to stiff limbs and problems with moving freely. Affected muscles can ache or be sore.
Other examples: changes in walking, posture, speech, and handwriting; loss of balance; increased risk of falls.
NONMOTOR SYMPTOMS OF PD
Depression, anxiety, seeing things that are not there, impulse problems Cognitive
Confusion, dementia, memory problems, difficulty thinking, some visual problems Autonomic
Constipation, nausea, urinary problems, sweating too much, sexual problems Broken-up sleep, insomnia, daytime sleepiness PAGE 1 OF 4
not related to PD. Other healthcare professionals who Deep brain stimulation (DBS) is a type of surgery that may be part of your care team include: places an electrode into one of three areas of the brain. The electrode is controlled by a device that is placed • Physical therapists. A physical therapist can help
under the skin in the chest, similar to a heart pacemaker. you come up with an exercise plan that works with The device sends electrical pulses to the electrode in and helps your PD symptoms.
the brain, blocking the impulses that cause tremors and • Occupational therapists. Occupational therapists
other PD symptoms. can visit your home and offer tips for some simple changes, such as the location of railings, special toilet What treatment is best for me?
seats, and special kitchen utensils, that can make living with PD easier and safer.
Your doctors will discuss your options for PD treatment. Together, you will decide on a treatment plan that works • Speech therapists. Speech therapists can help if
best for you. The best treatment depends on many speech problems start to develop. They can also factors, such as: help patients who have trouble swallowing. There are special exercises they can suggest that can help build up the muscles involved in these tasks.
n Your symptomsn Your general health How is PD treated?
n Your preference In general, there are two approaches to drug therapy n The expected benefit in PD. The first is to use medications that improve the way dopamine works in the brain. Different drugs can be n The risk of side effects used to help the body make more dopamine, to act like n Your response to past treatment(s) dopamine in the body, or to slow the loss of dopamine. When you start or change any medications, your doctor These medications are mainly used to manage the will talk about what you can expect with the treatment, motor symptoms of PD. In some cases, two agents can including how you will know if it's working and how long be used together for more benefit.
it may take to start working. The second approach to drug therapy involves medications that treat the individual symptoms of PD. What are the risks and
Many of the nonmotor symptoms of PD are treated side effects of PD treatment?
this way. For example, depression in patients with PD is Different treatments have different side effects. treated with an antidepressant and excessive sleepiness Your doctor can talk to you about the side effects that can be treated with medication that helps patients go along with each. It is important to have a plan for managing side effects. Family members and other caregivers should also understand the risk of side Can PD be treated with surgery?
effects. Most patients do not have major side effects. Drug therapy can help most patients with their PD The long list of possible side effects can be scary and symptoms. For some patients, however, at some point may make you want to avoid taking medications until drug therapy may cause almost as many side effects as your symptoms have gotten really bad; your doctor can benefits. For these patients, there are safe and effective talk through this with you if you start having surgical treatments for PD that can be considered.
COMMON DRUG THERAPIES FOR PD
TYPE OF DRUG
BRAND NAME (GENERIC)
HOW IT WORKS
Comtan (entacapone); Tasmar (tolcapone); Given with levodopa/carbidopa to keep dopamine from being destroyed Sinemet, Sinemet CR, Parcopa (levodopa/carbidopa) Helps to make more dopamine in the brain Dopamine
Parlodel (bromocriptine); Mirapex (pramipexole); Acts in the brain the same way that dopamine Requip (ropinirole); Neupro (rotigotine) Azilect (rasagiline); Eldepryl, Zelapar (selegiline) Keeps dopamine from being destroyed Symmetrel (amantadine) Increases dopamine release PAGE 2 OF 4
Will treatment cure me?
Interacting with family, friends, and others in the Researchers are hoping to find a cure, but right now community is important for your psychological and there is no known cure for PD. The current goal of emotional health. As the symptoms of PD appear, some treatment is to identify and control symptoms. By patients may find it challenging to keep up with social focusing on that goal, most patients with PD can live interactions. The physical symptoms of PD can change a enjoyable and rewarding lives. person's voice and facial expressions in ways that others might not understand. Reduced mobility, changes in What other things can I do
mood, and other symptoms can also cause problems with normal social interaction. to improve my quality of life with PD?
Steps for improving social interaction include: In addition to taking medications for PD, you should take part in other healthful activities. All patients with • Find a PD support group that is appropriate for you; PD should practice good sleep habits and eat a healthy for example, some groups focus on young onset or diet. Other habits that can improve your quality of life other aspects of PD. In addition to learning more include exercising and staying socially active. about PD, you and your family members can benefit from the social aspect of the group.
Exercise is important because PD affects your ability • Ask your doctor for a referral to a social worker for to control your muscles. Exercise can improve your information about supportive services, such as strength, flexibility, and ability to move. It can also help community senior centers and transportation services. your balance and gait (the manner in which you walk). Exercise can also put you in a better mood and make How can I find support groups in my area?
you feel better. Some research indicates that physical Several groups are available to help you find PD support exercise may improve memory and thinking. Some in your area. These include: things to keep in mind: • The Parkinson's Disease Foundation (PDF) keeps a • Check with your doctor before starting an exercise list of PD support groups; call them at 1-800-457-6676 program. Ask if there are certain exercises that you to find a support group in your area. should/should not try.
• The National Parkinson Foundation (NPF) has • If your doctor says that you can exercise, start slowly. a searchable online map of local NPF chapters • Choose an activity or hobby that you will enjoy and want to keep doing, such as walking, swimming, Locator); you can also call them at 1-800-4PD-INFO gardening, yoga, dancing, Tai Chi, or water aerobics.
(1-800-473-4636) for support groups and other resources in your area.
PD DRUGS AND THEIR COMMON SIDE EFFECTS
TYPE OF DRUG
BRAND NAME (GENERIC)
Comtan (entacapone); • May exaggerate some levodopa-related side effects Tasmar (tolcapone); Stalevo • Confusion, hallucinations, changes in urine color, diarrhea Sinemet, Sinemet CR, Parcopa • Can cause your muscles to move on their own (with long-term use); these movements are called dyskinesias • Nausea, sleepiness, hallucinations, vivid dreams, illusions, low blood pressure Parlodel (bromocriptine); • Nausea, vomiting, dizziness, light-headedness, confusion, Mirapex (pramipexole); Requip hallucinations, sudden sleepiness (ropinirole); Neupro (rotigotine) • May cause or worsen impulse-control problems Azilect (rasagiline); Eldepryl, • Rasagiline: flu syndrome, joint pain, depression, indigestion, Zelapar (selegiline) risk of adverse food/drug interactions • Selegiline: dry mouth, insomnia, nausea, dizziness, headache, changes in heart rate/rhythm Symmetrel (amantadine) • Hallucinations, confusion, dizziness, nausea, vomiting, anxiety, insomnia, nervousness, swelling, discoloration in the legs PAGE 3 OF 4
What about clinical trials?
Where can I find resources about PD?
Many new treatments for PD are being studied in clinical • American Parkinson Disease Association trials. Types of treatments being looked at include: • Medications to slow the progression of PD • National Parkinson Foundation • Medications to help with symptoms of PD • Surgeries to test new devices for treating PD • Parkinson's Action Network • Other therapies, including exercise, physical therapy, and behavioral therapy • Parkinson's Disease Foundation In many cases, you can participate in a clinical trial while continuing your regular PD treatment. If you are • The Michael J. Fox Foundation for Parkinson's Research interested, ask your doctor if there are any clinical trials that might be an option for you. Participating in a clinical trial can improve your own care. It can also help with the development of new treatments that may help others one day. The decision to join a clinical trial is a highly personal one. Good communication with your doctors is a key factor in such a decision. This activity is supported by an educational grant from Teva Pharmaceuticals.
2013 Med-IQ. All rights reserved.
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