PARKINSON

FARMASI UNIVERSITAS MULAWARMAN

Pendahuluan
Penyakit pada sistem penggerak ekstrapiramidal yang lambat, progresif dan neurodegeneratif Neuron dopamin pada substansia nigra >> yang utama dipengaruhi >> gangguan pada kemampuan untuk gerakan tubuh Tidak ada penyembuhan Tujuan terapi :
Mengkontrol gejala Memperlambat progresifitas penyakit

Sistem penggerak ekstrapiramidal

Mengkontrol gerakan saraf melalui jalur sistem dan saluran saraf yang terhubung dengan korteks serebral, basal ganglia, thalamus, cerebellum, reticular formation, dan neuron spinal Pasien kehilangan neuron dopamin di substansia nigra pada batang otak >> penurunan dopamin pada corpus stiatum

Gejala Klinis
Motor Symptoms (TRAP)
T = Tremor at rest (pill rolling) R = Rigidity (stiffness and cogwheel rigidity) A = Akinesia or bradykinesia P = Postural instability and gate abnormalities

Cont
Non-motor Symptoms (SOAP)
S = Sleep disturbances (insomnia, rapid eye movement sleep behavioral disorder, restless legs syndrome) O = Other miscellaneous symptoms (problems with nausea, fatigue, speech, pain, dysesthesias, vision, seborrhea) A = Autonomic symptoms (drooling, constipation, sexual dysfunction, urinary problems, sweating, orthostatic hypotension, dysphagia) P = Psychological symptoms (anxiety, psychosis, cognitive impairment, depression)

Cont
Response Fluctuations (MAD)
M = motor fluctuations (delayed peak, wearing off, random off, freezing) A = akathisia D = dyskinesias (chorea, dystonia, diphasic dyskinesia)

Terapi
Tujuan terapi
Mempertahankan kemandirian pasien, aktivitas sehari-hari, dan kualitas hidup dengan mengurangi gejala pasien, meminimalkan perkembangan fluktuasi respon dan mengurangi efek samping obat

Cont
Terapi dibagi menjadi 3 fase :
perubahan gaya hidup, nutrisi dan olahraga Intervensi farmakologi, terutama dengan obat yang meningkatkan konsentrasi dopamin Operasi untuk yang mengalami kegagalan intervensi farmakologi

Terapi Non-Farmakologi
Modifikasi gaya hidup
Dimulai sejak awal dan selama terapi Meningkatkan aktivitas sehari-hari Meningkatkan kesehatan jiwa Mempertahankan nutrisi yang baik, kondisi fisik dan interaksi sosial Hindari obat yang memblok dopamin utama, karena memperburuk kondisi penyakit Modifikasi makanan >> mengurangi mual & muntah Olahraga & aktivitas >> mengurangi kekurangan tidur di siang hari

Terapi Farmakologi
Terapi dimulai saat ketidakmampuan fisik pasien mengganggu kualitas hidup Dosis disesuaikan dengan kondisi pasien dan frekwensi diatur sepanjang hari untuk memaksimalkan on dan meminimalkan off

Cont
Obat antikolinergik Amantadine Penghambat MAO Agonis dopamin Levodopa / carbidopa catechol-o-methyltransferase (COMT) inhibitors
Mengurangi gejala Memperbaiki kualitas hidup Memperpanjang harapan hidup Tidak menyembuhkan Bekerja dengan meningkatkan konsentrasi dopamin di otak

Terapi

Cont

Case
Chief Complaint MW complains of stiffness, slow movements, and mild tremor that worsens his handwriting PMH Depression for 2 years SH After owning a dry cleaning store for 40 years, he is thinking about retiring because he does not enjoy visiting with the customers anymore; he does not smoke or drink alcohol Meds Fluoxetine 10 mg every morning for 2 years Gen: Pessimistic attitude, apathetic, looks older than stated age, slow movements, thin PE VS: Blood pressure: sitting 130/80 mm Hg, standing 110/80 mm Hg (with orthostatic symptoms); pulse 78 beats per minute, respiratory rate 16/minute, Wt 65 kg (143 lbs) CV: RRR, normal S1, S2; no murmurs, rubs, gallops Abd: Soft, non-tender, non-distended; (+) bowel sounds, no hepatosplenomegaly Skin: Scalp itchy, oily, and flaky silverish scales Exts: Tremor in right hand and foot while sitting, cogwheelrigidity in right elbow Neuro: Steady gait, sensory function intact, alert, normal mental status, UPDRS = 10 while on Labs Within normal limits

Schizoprenia

Farmasi Universitas Mulawarman

Pendahuluan
Istilah yang digunakan untuk menggambarkan kelainan psikiatri utama yang mengganggu persespsi, pemikiran, sikap dan tingkah laku
cognitive impairment (abnormalities in thinking, reasoning,attention, memory, and perception) impaired insight and judgment loss of motivation (avolition) loss of emotional range (restricted affect) a decrease in spontaneous speech (poverty of speech)

Cont
Kelanian kronis terhadap pikiran dan perasaan, menyebabkan gangguan signifikan terhadap kemampuan individu untuk berfungi Mula terjadi biasanya karena suatu kejadian, diawali dengan kemampuan sosial yang menurun, kehilangan minat, perubahan penampilan dan kebersihan, perubahan pada tingkah laku, dan tingkah laku yang aneh
Gejala psikotik Gejala negatif Gangguan kognitif

Selama sekurangnya 6 bulan

Cont
Gejala psikotik = gejala positif (gejalagejala ditambahkan ke kehidupan normal pasien)
Halusinasi (gangguan persepsi) Delusi (keyakinan yang salah) >> paranoid (curiga terhadap orang) Gangguan pikiran (pemikiran dan perkataan yang tidak logis)

Gejala negatif (kualitas pasien berkurang)

apatis secara emosional, kurang dapat mengkontrol diri, gangguan bicara, interaksi sosial yang kurang

Gejala kognitif
Menunjukkan abnormalitas pada area perhatian, kemampuan bicara, ingatan verbal dan visual, kemampuan menyelesaikan masalah, penurunan IQ (80 84)

Tahapan penyakit
1. Prodormal periode
Gangguan komunikasi & sikap Cerita & pengalaman yang tidak biasanya Higenitas pribadi yang memburuk Minat & motivasi berkurang Pasien akan merasa terjadi perubahan dunia yang terjadi dalam dirinya sendiri mempengaruhi kemampuan untuk menangani pekerjaan, mengikuti kegiatan akademik, atau berelasi dnegan teman & keluarga

2. Acute phase
Ditandai dengan munculnya gejala positif (halusinasi, delusi dan gangguan kebiasaan)

3. Third phase
Gejala positif berkurang atau menghilang dan digantikan oleh sejumlah gejala negatif Bertahun dalam beberapa tahun Dapat timbul kondisi yang tiba-tiba memburuk sehingga membutuhkan tambahan obat atau intervensi

Terapi
Pemilihan obat didasarkan pada karakteristik klinik pasien dan efikasi & ES obat 1st line : antipsikotik generasi ke 2
Aripiprazole Olanzapine Quetiapine Risperidone Ziprasidone

For the details please see algorithms & pathway in NICE Guideline schizoprenia p. 50 - 56

case
AG is a 28-year-old single African-American male with an approximately 3-year history of paranoia, increasing use of marijuana and cocaine, and poor work performance. His symptoms seemed to intensify around his being caught taking money from his girlfriends bank account to buy cocaine. Since then he has become suspicious that the police were watching his movements and that people on the street knew personal information about him. He has left several jobs one after another due to his belief that other employees were sabotaging him and that people were talking behind his back. He occasionally hears his father speaking to him but has not seen him in 10 years. He is sad and hopeless about the state of his life and very guilty about his substance abuse and stealing from his girlfriend. Though supportive of him, the patients girlfriend is feeling somewhat frustrated by the patients withdrawal from her and reluctance to socialize to the extent that they had in the past.

Cont
Past Psychiatric History Though AG describes himself as being depressed all my life and remembers that he felt able to read peoples minds in high school, he denied prior psychiatric treatment until his first hospitalization 2 years ago at the height of his paranoia. At that time, he believed there was a conspiracy against him. He lived in constant fear that his phone was tapped and his home was bugged. He felt he was being watched in public places, and therefore he began avoiding going out. He experienced voices commenting on his behavior and believed the television was talking to him and that shows were about him. At times he felt his brain was being squeezed for information, so that his mind was being read. He believed his girlfriend was having affairs, and he could not be reassured. He reported decreased appetite, difficulty sleeping, and suicidal ideation. His toxicology screen and blood alcohol test in the emergency department were negative. In the hospital he was given a diagnosis of major depressive disorder with psychotic features. He was started on olanzapine 10 mg/day for psychosis and fluoxetine 20 mg/day for depression, with some improvement.

Cont
Past Medical History He has no history of medical illness, head trauma, or seizure disorder. Social History He grew up in an upper middle class family, completed high school, and entered the Navy where he was discharged dishonorably due to not following rules. He began using alcohol in high school and continued to use other substances intermittently since then. He has held several jobs, the longest for 6 months. He thinks he might apply for disability. Family Psychiatric History His father had an alcohol problem.

Cont
Mental Status Exam Appearance: Nicely dressed and groomed. No abnormal movements. Poor eye contact. Speech: Quiet and somewhat monotonous. Mood: Nervous. Affect: Guarded and mildly anxious with restricted range. Thought content: Adequate historian but with a tendency to leave out detail. Experiences hearing others call his name, and interpreting the car lights coming down his street as meaning people are out to get him. He denies suicidal or homicidal thoughts. Thought processes: Logical but vague. Cognition: Grossly intact. Insight and judgment: Mixed, as he can at times question his thinking, but at other times has full conviction of his beliefs. He is currently taking his medication and cooperating with the evaluation appointments.

Alzheimer

Farmasi Universitas Mulawarman

Pendahuluan
Dementia yang bersifat non-reversibel, progresif dengan manifestasi gangguan kesadaran & tingkah laku yang bertahap Di diagnosa dengan mengeksklusi dementia Tidak ada gejala khusus untuk alzheimer Mekanisme patofisiologis tidak diketeahui dengan pasti Diduga faktor genetik dan lingkungan Terapi obat dapat memperlambat gejala

Tanda awal alzheimer

1. Memory loss: more than typical forgetfulness without remembering later 2. Difficulty performing familiar everyday tasks (e.g., preparing a meal and grooming) 3. Problems with language: forgetting simple words or substituting unusual words 4. Disorientation to time and place: may forget where they are and/or how they got there 5. Poor or decreased judgment: dress without regard to weather or falling prey to scam artists 6. Problems with abstract thinking: not just difficulty balancing a checkbook, but forgetting what the numbers represent 7. Misplacing things in unusual places: such as placing an iron in a freezer 8. Changes in mood or behavior: rapid mood swings with no apparent reason why 9. Changes in personality: extreme confusion, suspicion, or fearfulness 10. Loss of initiative: passivity and loss of interest in usual activities

Cont
Penyakit ini menghancurkan neuron-neuron yang ada di struktur korteks & limbic di otak yang bertanggung jawab terhadap kemampuan belajar, ingatan, pencarian alasan, kebiasaan & kontrol emosi

Gejala
Pasien mudah lupa Pada tingkat yang lebih parah maka akan menyebabkan kehilangan kemampuan untuk menjalankan fungsi harian Gejala kognitif : kehilangan ingatan (sulit mengingat & lupa sama sekali), disorientasi (gangguan terhadap persepsi waktu dan tidak dapat mengenali orang-orang yang dikenal) Gejala non-kognitif : depresi, gejala psikotik (halusinasi & delusi), gangguan tingkah laku Gejala fungsional : tidak mampu merawat diri sendiri ( berpakaian, mandi, buang air, dan makan)

Terapi
Tujuan :
Mengobati gejala kognitif Mempertahankan fungsi pasien Mengobati gejala psikiatrik & tingkah laku

Terapi Farmakologi
Terapi untuk gejala kognitif
Cholinesterase (ChE) inhibitor

dan / atau
an NMDA (N-methyl D aspartate) antagonist

Terapi

Terapi

case
A woman arrives at the clinic with her 80year-old mother, LB, complaining that her mother is becoming increasingly forgetful and confused with old age. The woman complains that her mother sometimes takes her diabetes and hypertension medications at a frequency greater than that prescribed. This has become more frequent in the last 6 months and the mother has been getting very agitated when her daughter confronts her. The woman asks you for a pill organizer and if any of the over-thecounter drugs claiming to help with memory would help her mother.

Cont

Cont