Parkinsonin tauti

Käypä hoito
10.9.2010
Suomalaisen Lääkäriseuran Duodecimin ja Suomen Neurologisen Yhdistyksen asettama työryhmä

Koosteet

Potilaalle

Keskeinen sisältö

  • Parkinsonin taudin diagnoosi perustuu ensisijaisesti kliiniseen tutkimukseen.
  • Parantavaa tai taudin etenemisen varmasti estävää hoitoa ei tunneta.
  • Oireita lievittävän hoidon ja kuntoutuksen tarve arvioidaan taudin aiheuttaman toiminnallisen haitan perusteella.
  • Nuorempien (yleensä alle 75-vuotiaiden) ja muutoin hyväkuntoisten potilaiden oireita lievittävä hoito suositellaan aloitettavaksi dopamiiniagonistilla tai monoamiinioksidaasi B:n (MAO-B) estäjällä.
  • Diagnoosin varmistumisen jälkeen hoito voidaan aloittaa MAO-B:n estäjällä ennen toiminnallisen haitan kehittymistä.
  • Hoito voidaan aloittaa suoraan levodopalla, kun potilas on iäkkäämpi tai monisairas tai hänellä esiintyy kognitiivisia tai psyykkisiä oireita.
  • Ennen pitkää kaikki potilaat tarvitsevat levodopahoitoa.
  • Taudin edetessä lähes jokaiselle potilaalle ilmaantuu motorisia tilanvaihteluita ja tahattomia liikkeitä sekä usein myös ei-motorisia oireita, kuten autonomisia, psyykkisiä ja kognitiivisia häiriöitä.
  • Edenneen taudin hoidossa levodopan ohella hyödyllisiä ovat dopamiiniagonistit ja katekolioksimetyylitransferaasin (COMT) estäjät ja mahdollisesti myös MAO-B:n estäjät.
  • Kirurgisella hoidolla (aivojen syvien osien stimulaatio) ja duodenaalisella levodopainfuusiolla voidaan auttaa potilaita, joilla esiintyy asianmukaisesta lääkehoidosta huolimatta vaikeita tilanvaihteluita ja lääkityksen aiheuttamia häiritseviä tahattomia liikkeitä.
  • Kuntoutuksen tulee kohdistua toimintakyvyn kannalta keskeisiin ongelmiin, se tulee toteuttaa vaikuttavaksi osoitetulla menetelmällä, ja sitä pitää antaa realistisesti asetetun tavoitteen saavuttamiseksi riittävä määrä.

Tavoitteet

  • Tämän suosituksen tavoitteena on
    • esittää näyttöön perustuva suositus hoidon aiheista, hoitomenetelmien valinnasta, lääkkeiden käytöstä ja kuntoutuksesta
    • yhtenäistää hoitokäytäntöjä.

Kohderyhmät

  • Suositus on tarkoitettu Parkinson-potilaita hoitaville perusterveydenhuollon ja erikoissairaanhoidon lääkäreille sekä muulle hoitohenkilöstölle.

Määritelmä ja oireet

Riskitekijät ja ehkäisy

Diagnostiikka

Hoito

Hoidon tavoitteet

Lääkehoito

Varhaisvaiheen lääkehoidon aloitus

Dopamiiniagonistit

Levodopa

MAO-B:n estäjät

Antikolinergit

Amantadiini

Lääkehoito taudin edetessä

Motoriset komplikaatiot

Motoristen komplikaatioiden hoito

Annosvasteen hiipuminen (wearing off)

Dyskinesiat

Nopea "on-off"-vaihtelu

Jähmettyminen

Kaatuilu

Parkinsonin taudin erityiskysymyksiä

Kivut

Nielemisvaikeudet

Syljen valuminen

Virtsaamisvaivat

Erektiohäiriöt

Seksuaalisuus

Ortostaattinen hypotensio

Depressio

Ahdistuneisuus

Hallusinaatiot ja psykoosi

Dementia

Uupumus (fatigue)

Uneliaisuus

Unihäiriöt

Pahanlaatuinen oireyhtymä

Parkinsonin taudin leikkaushoito

Talamotomia ja talamusstimulaatio

Pallidotomia

  • Pallidotomiaa on käytetty hoitona potilailla, joilla on pitkälle edennyt Parkinsonin tauti ja motorisia komplikaatioita.
  • Se ei estä sairauden etenemistä eikä yksinään käytettynä sovellu Parkinsonin taudin hoitoon.
  • Toispuolinen pallidotomia todennäköisesti lievittää vastakkaisen kehonpuoliskon vapinaa, jäykkyyttä ja akinesiaa «Pallidotomia ja Parkinsonin tauti»5, mutta sen tehosta kävelyvaikeuksiin tai lääkkeiden aiheuttamaan dyskinesiaan ei ole riittävää näyttöä.
  • Molemminpuolisesta pallidotomiasta ei ole riittävää näyttöä minkään käyttöaiheen osalta.

Pallidumin tai subtalaamisen tumakkeen sähköstimulaatio

Kirurgisen hoidon aiheet

Tutkimukset leikkausarviota tehtäessä

  • Pään magneettikuvaus. Jos todetaan merkittävää aivoatrofiaa tai runsaasti vaskulaarisia muutoksia erityisesti tyvitumakkeissa, potilas ei sovellu leikkaushoitoon.
  • Levodopatesti. Yleensä edellytyksenä positiivinen vaste levodopatestissä (paitsi lääkeresistentissä lepovapinassa).
  • Neuropsykologinen testaus keskivaikean tai vaikean dementian pois sulkemiseksi
  • Tarvittaessa psykiatrin konsultaatio

Leikkaushoito ja sen jälkeinen seuranta

Kuntoutus

  • Kuntoutuksen tulisi kohdistua toimintakyvyn kannalta keskeiseen ongelmaan. Se tulisi toteuttaa kyseisen toiminnan harjoittamiseen parhaiten soveltuvalla menetelmällä, ja sitä pitäisi antaa riittävä määrä toivotun tavoitteen saavuttamiseksi.
  • Kuntoutus suunnitellaan alkututkimuksen perusteella siten, että kuntoutuja ja omainen voivat sitoutua sen toteuttamiseen.
  • Etenevässä taudissa kuntoutuksen tulos ei ole pysyvä. Täsmällisempää tietoa kaivataan vielä kuntoutustulosten saavuttamiseksi tarvittavan harjoittelun määrästä ja erityisesti tuloksen säilymisen edellyttämästä kertauksesta tai oman harjoittelun määrästä.
  • Ammatillisen kuntoutuksen tarve on aiheellista huomioida, kun potilas on työiässä.

Fysioterapia, toimintaterapia ja neuropsykologinen kuntoutus

Puheterapia

Perusterveydenhuollon osuus diagnostiikassa ja seurannassa

Laitospotilaiden hoito

Palliatiivinen hoito

  • Pitkälle edennyttä Parkinsonin tautia sairastavat hyötyvät palliatiivisesta hoidosta, johon kuuluu fyysisten ja psyykkisten oireiden hyvän hoidon lisäksi sosiaalinen ja hengellinen tuki.
  • Potilaan kanssa on hyvä keskustella hoitoon liittyvistä toiveista jo siinä vaiheessa, kun hän pystyy vielä ilmaisemaan oman tahtonsa. Hoitotahto on kirjattava esimerkiksi sairauskertomukseen niin, että se on helposti huomioitavissa hoitopäätöksiä tehtäessä.
  • Ks. Käypä hoito -suositus Kuolevan potilaan oireiden hoito «Kuolevan potilaan oireiden hoito»9.

Potilasinformaatio

Suomalaisen Lääkäriseuran Duodecimin ja Suomen Neurologisen yhdistyksen asettama työryhmä

Parkinsonin tauti -suosituksen historiatiedot «Parkinsonin tauti, Käypä hoito -suosituksen historiatiedot»6

Puheenjohtaja:

Reijo Marttila, neurologian emeritus professori; Turun yliopisto

Kokoava kirjoittaja:

Sari Atula, LT, neurologian erikoislääkäri; HYKS:n neurologian klinikka ja Suomalainen Lääkäriseura Duodecim

Jäsenet:

Esa Heikkinen, professori, osastonylilääkäri; OYS:n neurokirurgian klinikka

Marja-Riitta Jaakkola, LL, erikoislääkäri, vastaava ylilääkäri; Mikkelin kaupunki, vanhusten palvelut

Pekka Jousilahti, tutkimusprofessori, Käypä hoito -toimittaja; Terveyden ja hyvinvoinnin laitos ja Suomalainen Lääkäriseura Duodecim

Tapani Keränen, kliinisen farmakologian ja lääkehoidon professori; Itä-Suomen yliopisto

Kirsti Martikainen, LT, neurologian erikoislääkäri; Suomen Parkinson-liitto ja Suomen Parkinson-säätiö

Eero Pekkonen, dosentti, osastonylilääkäri; HYKS:n neurologian klinikka

Kyösti Sotaniemi, dosentti, osastonylilääkäri; OYS:n neurologian klinikka

Sidonnaisuudet

Sari Atula: Toistuvia luentoja lääkealan yrityksen koulutuksissa (Bayer Oy). Ulkomaan kongressimatka lääkealan yrityksen rahoittamana (Merck-Serono Oy).

Esa Heikkinen: Osallistunut ulkomaisiin koulutustilaisuuksiin terveydenhuollon välinevalmistajan kustantamana (Medtronic).

Marja-Riitta Jaakkola: Osallistunut ulkomaisiin kongresseihin lääkealan yritysten rahoittamana (Novartis, Mundipharma, Lundbeck).

Pekka Jousilahti: Ks. www.kaypahoito.fi / Yhteystiedot / Toimitus / Lisätiedot

Tapani Keränen: Osallistunut lääkealan yritysten järjestämiin koulutustilaisuuksiin ja niiden suunnitteluun kutsuttuna luennoitsijana (GlaxoSmithKline, Oy H Lundbeck Ab, UCB Pharma, Pfizer, Ori-on Pharma). Toiminut lääkealan yritysten asiantuntijana (GlaxoSmithKline, Oy H Lundbeck Ab, UCB Pharma). Tehnyt eri yhtiöille lääketutkimusta korvausta vastaan (Eisai, Novartis, Janssen-Cilag, Pfizer, Johnson&Johnson PRD). Osallistunut ulkomaisiin kongresseihin lääkealan yritysten rahoituksella (Eisai, Orion Pharma, Pfizer, UCB Pharma, GlaxoSmithKline).

Kirsi Martikainen: Toistuvia luentoja eri terveydenhuollon yritysten koulutuksissa (Lundbeck, Orionpharma, GlaxoSmithKline). Osallistunut lääkealan yrityksen koulutusten suunnitteluun (Boehringer-Ingelheim). Ulkomaan kongressimatka lääkealan yrityksen rahoittamana (Solvey Pharma).

Reijo Marttila: Toistuvia luentoja lääkealan yritysten koulutuksissa (Allergan Norden, GlaxoSmithKline Oy, Orion OYJ, UCB Pharma Oy, Oy H.Lundbeck Ab). Osallistunut lääkealan yrityksen koulutuksen suunnitteluun (Orion Oyj). Toiminut lääkealan yrityksen asiantuntijana (Orion Oyj).

Eero Pekkonen: Toistuvia luentoja lääkealan yritysten järjestämissä koulutuksissa (Orion, Boehringer-Ingelheim, Lundbeck, Solvay, Medtronic). Ulkomaan kongressimatkoja lääkealan yritysten rahoittamana (GSK, Solvay, Medtronic). Antanut asiantuntija-apua lääkealan yritykselle (Solvay). Päätutkijana lääkealan yrityksen rahoittamassa kliinisessä tutkimuksessa (Solvay). Laatii artikkeleita Neuroexpertti-lehteen, jota toimittaa lääkealan yritys (Boehringer-Ingelheim). Potilasvakuutuskeskuksen asiantuntijalääkäri.

Kyösti Sotaniemi: Osallistunut lääkealan yrityksen koulutustilaisuuden suunnitteluun ja toiminut luennoitsijana (Allergan). Osallistunut ulkomaiseen kongressiin lääkealan yrityksen rahoittamana (Orion Pharma).

Vastuun rajaus

Käypä hoito -suositukset ovat parhaiden asiantuntijoiden laatimia yhteenvetoja yksittäisten sairauksien diagnostiikan ja hoidon vaikuttavuudesta. Ne eivät korvaa lääkärin tai muun terveydenhuollon ammattilaisen omaa arviota yksittäisen potilaan parhaasta mahdollisesta diagnostiikasta, hoidosta ja kuntoutuksesta hoitopäätöksiä tehtäessä.

Tiedonhakukäytäntö

Käypä hoito -suositukset tehdään näyttöön perustuvan lääketieteen (EBM) periaatteilla. Lue lisää artikkelista nix01853

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