Drug Topics - October 22, 2007 - (Page 28)

28 DRUG TOPICS OCTOBER 22, 2007 www.drugtopics.com CONTINUING EDUCATION throughout the intended action, but The American Academy of Neuroloinitiation of learned movement may gy (AAN) 2006 evidence-based guideTable 1 display a hesitation. This is evident lines provide recommendations on how Medications causing when those with bradykinesia walk Parkinsonian-like symptoms to clinically and diagnostically distinwith a short, shuffling gait. Freezing or guish PD from other diseases. Clinically, Antipsychotics intermittent immobility may also octhe AAN suggests that falls at presentaPhenothiazines (i.e., fluphenazine) cur. Freezing is especially likely to occur tion and early in the disease course, poor Butrophenones (i.e., haloperidol) in crowded situations or through narresponse to levodopa, symmetry at onRisperidone row doorways, and may resolve spontaset, rapid progression (Hoehn and Yahr neously within a minute. Other characStage Three within three years), lack of Antiemetics teristics of bradykinesia include reduced tremor, and dysautonomia (i.e., urinary Metoclopramide blinking, hypophonia, and decreased urgency/incontinence and fecal incontiProchlorperazine swallowing, which leads to an increased nence, urinary retention requiring Promethazine drooling. Occupational activities such catheterization, persistent erectile failure Reserpine as shaving, brushing the teeth, getting or symptomatic orthostatic hypotenAlpha-methyldopa dressed, getting out of a chair or bed, sion) are suggestive of PD. AAN’s diagand writing by hand become progresnostic recommendations include a levsively time-consuming. Eventually, PD patients cannot accom- odopa and apomorphine challenge and olfaction testing, since plish these activities without assistance, and thus assume total olfaction is frequently impaired in PD patients. dependence. Akinesia is usually a feature of advanced disease Once a diagnosis is made, a variety of screening tools are and may result in confinement to a bed. available that aid in monitoring the progression of the disease. Postural instability is another disabling symptom of PD. The Hoehn and Yahr staging scale, one of the most common Due to the loss of postural reflexes, persons with PD have a ten- screening tools (see Table 2) is a disease rating system based on dency to lean forward or backward while ambulating. When the presence and severity of postural instability. Another scale, this is combined with a shuffling gait, it is transformed into an the Unified Parkinson’s Disease Rating Scale (UPDRS), is a accelerating gait with a tendency to fall forward. Ambulating more sensitive scale for assessing functional status (with special aids and protective gear are useful in preventing injury for these attention to activities of daily living), disease progression, and patients. Eventually a patient may become wheelchair-bound. effectiveness of the antiparkinson's therapy. The Mini Mental Besides motor function abnormalities, a person may experience Status Exam (MMSE) should be used, in concert with the secondary or nonmotor symptoms of PD, which may be just as aforementioned screenings, to aid the practitioner in charting a troublesome. Nonmotor symptoms may be further classified as patient’s cognitive function. physical or behavioral. Some physical abnormalities include: bladder incontinence, constipation, diaphoresis, orthostatic hypoten- Treatment options sion, and erectile dysfunction. Nonmotor behavioral abnormali- Currently there is no cure for PD—or even a treatment that ties may consist of depression, dementia, sleep disturbances, and will directly reverse or prevent the disorder. There are, however, psychosis. It is important to note that some of theses symptoms a number of drug therapies designed to provide either neuromay be pharmacologically induced; therefore, it is essential to rou- protection and/or symptomatic relief. Pharmacologic options tinely screen a patient’s medication profile. Other symptoms include anticholinergic agents, amantadine, carbidopa/ could include fatigability, oily skin, pedal edema, seborrhea, and levodopa, dopamine agonists, monoamine oxidase type B inweight loss. hibitors, and cactechol-O-methyl-transferase (COMT) inhibitors. Nonpharmacologic treatment modalities are also an Diagnosis integral part of the management of PD. The diagnosis of PD is not an exact science. Unfortunately, there are no biochemical or genetic tests that can accurately diagnose Nonpharmacotherapy PD. Imaging studies using magnetic resonance imaging (MRI), Exercise therapy has been shown to improve the motor sympsingle-photon emission computerized tomography (SPECT), or toms of PD patients. Continual physical therapy has demonflurodopa positron emission tomography (PET) may be per- strated improved stand-sit-walk scores, reductions in UPDRS, formed but are still not definitive. increased ambulation speed, and decreased falls. In conjunction Even with imaging results, the diagnosis of PD is made pri- with physical therapy, occupational therapy should also be permarily upon clinical presentation. Patients may first realize formed. Occupational therapists can assist patients in how to something is wrong when they develop a tremor in a limb, their carry out their activities of daily living—brushing one’s teeth, movements are slowed and activities take longer to perform, or walking with an ambulation device, tying one’s shoes, and feedthey experience stiffness and balance problems. ing oneself. Occupational therapists can also suggest ways to Generally, when two out of the four cardinal symptoms of PD make the home safer in order to prevent falls. Since PD patients are present, a diagnosis of PD can be made, unless there are atypi- may be affected with dysphagia and hypophonia, speech theracal features that suggest an alternative diagnosis. Since initial symp- pists have an important role. Speech therapy can help patients toms may vary from patient to patient, it is not unusual for the di- improve their speech volume. In progressive PD, speech theraagnosis of PD to be missed on initial presentation. Drug-induced pists help evaluate swallowing difficulties. parkinsonism should also be ruled out prior to diagnosis. Invasive nonpharmacologic approaches such as deep brain http://www.drugtopics.com

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Drug Topics - October 22, 2007 Contents Latebreakers Legislative Victory Builds Momentum for Pharmacy Month Letters Health-System Edition R.Ph.s Brace for Payment Denial for Hospital-Acquired Conditions Topical Human Thrombin Helps Arrest Bleeding FDA Panels Fail to Set Target Levels for Renal Patients’ Hemoglobin Warning Letters Raise Patient Safety Concerns for Fentora Ending/Reversing Weight Gain Man Given Fatal Drug Overdose at Staten Island Hospital Pharmacists Playing More Important Role in Dialysis Treatment AHA President R.Ph.'s Here's How You Can Increase Your Value Premier Launches Comprehensive Quality Improvement Project FDA Approves Dexrazoxane for Treatment of Extravasation New Federal, State Reforms to Ease Disaster Relief Kinks 150 Years of American Pharmacy Ten Tips for MTM Success Independent Superstars: The Ones to Watch The New Dynamic Duo A Parkinson's Disease Primer Classified New Products Advertisers Index Viewpoint

Drug Topics - October 22, 2007

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