What is Parkinson’s?
Parkinson’s is a progressive neurological condition for which there is currently no cure. It’s often seen as a condition that only affects older people, but one in 20 will be under the age of 40 at the time of their diagnosis.

Parkinson’s can affect everyday activities such as talking, walking, swallowing and writing, and symptoms can include tremor, slowness of movement and muscle stiffness. Other less visible symptoms may include sleep difficulties, depression, anxiety and memory loss. These are often the symptoms that sufferers find the most debilitating and you may find your patients, or their families, need advice from you or their specialist Parkinson’s nurse on how to manage this at home.

Symptoms usually begin slowly, develop gradually and in no particular order. Early symptoms often include feeling tired and weak. Other early symptoms can include poor hand coordination, problems with handwriting and a tremor in the arm. On top of the physical symptoms, the loss of skills and ability to do every-day things that most of us take for granted can make Parkinson’s a frustrating and isolating condition.

Parkinson’s is a fluctuating condition – meaning that symptoms can vary and change at any time. A person with Parkinson’s can look and seem well one day and not the next, and symptoms can vary from day to day, or even from hour to hour.

What causes Parkinson’s?
Parkinson’s is caused by a lack of dopaminergic cells in the brain. Sufferers have symptoms of the condition when around 70 per cent of these cells are lost. We don’t know why the cells die but Parkinson’s UK is committed to funding cutting edge research into finding better treatment and ultimately a cure.
With the loss of dopaminergic cells, these parts of the brain are unable to work normally, causing the symptoms to appear. The level of dopamine then continues to fall slowly over many years, causing symptoms to further develop and new symptoms to appear.

Drug treatment
People with Parkinson’s will have a carefully balanced combination of medication to control and manage their symptoms and, if they are recently diagnosed, they may need support from you, in conjunction with their Parkinson’s nurse or neurology consultant, in getting their medication into the right routine.

NICE guidelines state that a person with suspected Parkinson’s should be diagnosed by a specialist and so if you come across a patient with undiagnosed Parkinson’s, you should tell them to see their GP so they can be referred to a specialist in the condition.

Drug therapy is the most common form of treatment for Parkinson’s and treatment is usually life-long, however changes to the types and combinations of drugs prescribed and the scheduling of this may change over time. NICE Guidelines (2006) make certain key recommendations regarding the pharmacology of common Parkinson’s drugs. It is not possible to identify a first choice drug therapy for people with Parkinson’s and, instead, drug choice should take into account clinical and lifestyle characteristics and individual preference, once they have been informed of the short and longterm benefits and drawbacks of different drugs. For more information, visit www.nice.org.uk.

Some common side effects
Levodopa, one of the main treatments for Parkinson’s, can have some short term side effects include nausea and vomiting while the body becomes used to the drug, but this can be managed using domperidone. It is important to realise that other antisickness drugs (such as metoclopramide, prochlorperazine and cyclizine) make Parkinson’s symptoms worse.

When taken for a prolonged period of time, levodopa can also cause dyskinesias. Patients can experience what’s referred to as the on/off state of Parkinson’s. This is where symptoms reappear quickly and unexpectedly, and many people describe this as being like a light switch being turned off and on. It is sometimes due to the drugs wearing off quickly.

Other common side effects of certain medications can include: hallucinations, confusion, constipation and problems with sleeping – either excessive daytime sleepiness or insomnia. It’s important to speak to a patient’s specialist Parkinson’s nurse or consultant before making any changes to their medication, but suggestions for them, or their families or carers, to take to appointments could be very useful for many patients. Regular MURs will also be of benefit.

Impulsive and compulsive behaviours
Some people with Parkinson’s who take dopamine agonists can experience problems controlling impulsive or compulsive behaviour, as an unwanted side-effect of this type of medication. Impulsive behaviour is when a person cannot resist carrying out certain activities, some of which could lead them to harm themselves or others. In many cases, this behaviour is out of character. Compulsive behaviour is when a person has an overwhelming urge to act in a certain way to reduce the worry or tension they get from this urge. This behaviour can be expressed in a number of ways, including addictive gambling, impulsive shopping, binge eating and hypersexuality. If you suspect a patient might be experiencing compulsive or impulsive behaviours, then it’s important to speak to them and their Parkinson’s nurse or consultant as soon as possible.

Compliance issues
The timing of medication is crucial for people with the condition. Each person will have a carefully planned programme of drug treatments, with many needing to take different medication at intervals throughout the day.
If people with Parkinson’s don’t get their medication on time, the balance of chemicals in their brains can become severely disrupted – leading to the symptoms of the condition becoming uncontrolled – and they can become very ill. This can happen very quickly. Uncontrolled symptoms can include being unable to move, speak, eat or swallow, uncontrolled movements and distressing psychotic symptoms.

MURs can prove particularly useful for patients with Parkinson’s. A recent pilot (Cotton et al. 2010) has shown that a community pharmacist and specialist nurse working together in partnership can enhance the care delivered to patients with Parkinson’s, with MURs forming an important part of this. An additional study carried out in three primary care trusts (St Helen’s, Brighton and Hove City, and Coventry) demonstrated the value of pharmacists providing regular consultation sessions for Parkinson’s patients (and/or their carers) (Tugwell, C. 2007).

During these sessions, patients were able to discuss their experiences with their medication and any concerns they had about the condition. The pharmacists provided support and counselling on their treatments, including side effects and potential interactions. Advice was also given for optimising dosage timing and, if appropriate, practical aids were provided to reduce problems with drug administration.

 The most frequent problems which pharmacists identified were:

  • Uncontrolled and unmanaged symptoms;
  • The occurrence of side effects;
  • The need for review of dosage or treatment regimen.

A total of 336 consultations were carried out in the study, resulting in nearly 600 identified ‘interventions’. Three quarters of the identified problems could be addressed by the pharmacist, without referral. More than 80 per cent of patients felt the consultations were helpful and 70 per cent felt they were gaining greater benefits from their drug therapy as a result.

Useful information for patients
Liaising with your Parkinson’s patients’ multi-disciplinary team can also be really beneficial. Advice and information from their specialist Parkinson’s nurse or consultant can be invaluable, as well as your experiences being useful to them.

Parkinson’s UK has a wealth of resources available for pharmacists to help them support people with Parkinson’s and find out more about the condition. The charity also offers training for professionals coming into contact with people with Parkinson’s, via its network of education and training officers.

The charity also has a network of information and support workers, who offer local information and support. They also run information and drop-in days, where people can find out more information about the condition and how the charity can support them. If you have patients with Parkinson’s who you think might benefit from this service, visit www.parkinsons.org. uk/isw to find out who your local ISW is and arrange a visit.

Parkinson’s UK has a network for professionals working with people with Parkinson’s. This allows them to have access to the latest information and to share good practice.

Daiga Heisters is the
national education adviser for
Parkinson's UK

References
1. Cotton P, Miller C, Heisters D, McDonald L and Benson P. Parkinson’s disease by community pharmacists and the specialist nurse service, 2010.
2. Tugwell C. (2007). Parkinson’s Disease in Focus, The Pharmaceutical Press, London and Chicago.

Further information
For more information about training opportunities, information and resources from Parkinson’s UK or to join the professionals’ network, visit www.parkinsons.org.uk/professionals. Professionals can also contact the Parkinson’s UK helpline on 0808 800 0303.