PARKINSON
PARKINSONFARMASI UNIVERSITAS MULAWARMAN
PendahuluanPenyakit pada sistem penggerak ekstrapiramidal yang lambat, progresif dan neurodegeneratifNeuron dopamin pada substansia nigra >> yang utama dipengaruhi >> gangguan pada kemampuan untuk gerakan tubuhTidak ada penyembuhan Tujuan terapi :Mengkontrol gejalaMemperlambat progresifitas penyakitSistem penggerak ekstrapiramidal
Mengkontrol gerakan saraf melalui jalur sistem dan saluran saraf yang terhubung dengan korteks serebral, basal ganglia, thalamus, cerebellum, reticular formation, dan neuron spinalPasien kehilangan neuron dopamin di substansia nigra pada batang otak >> penurunan dopamin pada corpus stiatumGejala KlinisMotor Symptoms (TRAP)T = Tremor at rest (pill rolling)R = Rigidity (stiffness and cogwheel rigidity)A = Akinesia or bradykinesiaP = Postural instability and gate abnormalities
ContNon-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)ContResponse Fluctuations (MAD)M = motor fluctuations (delayed peak, wearing off, random off, freezing)A = akathisiaD = dyskinesias (chorea, dystonia, diphasic dyskinesia)TerapiTujuan terapiMempertahankan kemandirian pasien, aktivitas sehari-hari, dan kualitas hidup dengan mengurangi gejala pasien, meminimalkan perkembangan fluktuasi respon dan mengurangi efek samping obatContTerapi dibagi menjadi 3 fase :perubahan gaya hidup, nutrisi dan olahragaIntervensi farmakologi, terutama dengan obat yang meningkatkan konsentrasi dopaminOperasi untuk yang mengalami kegagalan intervensi farmakologiTerapi Non-FarmakologiModifikasi gaya hidupDimulai sejak awal dan selama terapiMeningkatkan aktivitas sehari-hariMeningkatkan kesehatan jiwaMempertahankan nutrisi yang baik, kondisi fisik dan interaksi sosialHindari obat yang memblok dopamin utama, karena memperburuk kondisi penyakitModifikasi makanan >> mengurangi mual & muntahOlahraga & aktivitas >> mengurangi kekurangan tidur di siang hariTerapi FarmakologiTerapi dimulai saat ketidakmampuan fisik pasien mengganggu kualitas hidupDosis disesuaikan dengan kondisi pasien dan frekwensi diatur sepanjang hari untuk memaksimalkan on dan meminimalkan off
ContObat antikolinergikAmantadinePenghambat MAOAgonis dopaminLevodopa / carbidopacatechol-o-methyltransferase (COMT) inhibitorsMengurangi gejalaMemperbaiki kualitas hidupMemperpanjang harapan hidupTidak menyembuhkanBekerja dengan meningkatkan konsentrasi dopamin di otak
Terapi
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Case Chief ComplaintMW complains of stiffness, slow movements, and mildtremor that worsens his handwritingPMHDepression for 2 yearsSHAfter 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 alcoholMedsFluoxetine 10 mg every morning for 2 yearsGen: Pessimistic attitude, apathetic, looks older than stated age, slow movements, thinPEVS: 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, gallopsAbd: Soft, non-tender, non-distended; (+) bowel sounds, no hepatosplenomegalySkin: Scalp itchy, oily, and flaky silverish scalesExts: Tremor in right hand and foot while sitting, cogwheelrigidity in right elbowNeuro: Steady gait, sensory function intact, alert, normal mental status, UPDRS = 10 while onLabsWithin normal limits
SchizopreniaFarmasi Universitas MulawarmanPendahuluanIstilah yang digunakan untuk menggambarkan kelainan psikiatri utama yang mengganggu persespsi, pemikiran, sikap dan tingkah lakucognitive impairment (abnormalities in thinking, reasoning,attention, memory, and perception)impaired insight and judgmentloss of motivation (avolition)loss of emotional range (restricted affect)a decrease in spontaneous speech (poverty of speech)
ContKelanian kronis terhadap pikiran dan perasaan, menyebabkan gangguan signifikan terhadap kemampuan individu untuk berfungiMula 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 anehGejala psikotikGejala negatifGangguan kognitifSelama sekurangnya 6 bulanContGejala psikotik = gejala positif (gejala-gejala 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 kurangGejala kognitifMenunjukkan abnormalitas pada area perhatian, kemampuan bicara, ingatan verbal dan visual, kemampuan menyelesaikan masalah, penurunan IQ (80 84)Tahapan penyakitProdormal periodeGangguan komunikasi & sikapCerita & pengalaman yang tidak biasanyaHigenitas pribadi yang memburukMinat & motivasi berkurangPasien akan merasa terjadi perubahan dunia yang terjadi dalam dirinya sendiri mempengaruhi kemampuan untuk menangani pekerjaan, mengikuti kegiatan akademik, atau berelasi dnegan teman & keluarga
Acute phaseDitandai dengan munculnya gejala positif (halusinasi, delusi dan gangguan kebiasaan) 3. Third phaseGejala positif berkurang atau menghilang dan digantikan oleh sejumlah gejala negatifBertahun dalam beberapa tahunDapat timbul kondisi yang tiba-tiba memburuk sehingga membutuhkan tambahan obat atau intervensiTerapiPemilihan obat didasarkan pada karakteristik klinik pasien dan efikasi & ES obat1st line : antipsikotik generasi ke 2AripiprazoleOlanzapineQuetiapineRisperidoneZiprasidoneFor the details please see algorithms & pathway in NICE Guideline schizoprenia p. 50 - 56caseAG 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.ContPast Psychiatric HistoryThough 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.ContPast Medical HistoryHe has no history of medical illness, head trauma, or seizure disorder.Social HistoryHe 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 HistoryHis father had an alcohol problem.ContMental Status ExamAppearance: 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.AlzheimerFarmasi Universitas MulawarmanPendahuluanDementia yang bersifat non-reversibel, progresif dengan manifestasi gangguan kesadaran & tingkah laku yang bertahapDi diagnosa dengan mengeksklusi dementiaTidak ada gejala khusus untuk alzheimerMekanisme patofisiologis tidak diketeahui dengan pastiDiduga faktor genetik dan lingkunganTerapi obat dapat memperlambat gejalaTanda awal alzheimerMemory loss: more than typical forgetfulness without remembering laterDifficulty performing familiar everyday tasks (e.g., preparing a meal and grooming)Problems with language: forgetting simple words or substituting unusual wordsDisorientation to time and place: may forget where they are and/or how they got therePoor or decreased judgment: dress without regard to weather or falling prey to scam artistsProblems with abstract thinking: not just difficulty balancing a checkbook, but forgetting what the numbers representMisplacing things in unusual places: such as placing an iron in a freezerChanges in mood or behavior: rapid mood swings with no apparent reason whyChanges in personality: extreme confusion, suspicion, or fearfulnessLoss of initiative: passivity and loss of interest in usual activitiesContPenyakit 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 lupaPada tingkat yang lebih parah maka akan menyebabkan kehilangan kemampuan untuk menjalankan fungsi harianGejala 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 lakuGejala fungsional : tidak mampu merawat diri sendiri ( berpakaian, mandi, buang air, dan makan)
TerapiTujuan :Mengobati gejala kognitifMempertahankan fungsi pasienMengobati gejala psikiatrik & tingkah lakuTerapi FarmakologiTerapi untuk gejala kognitifCholinesterase (ChE) inhibitor dan / atauan NMDA (N-methyl D aspartate) antagonistTerapi
Terapi
caseA woman arrives at the clinic with her 80-year-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-the-counter drugs claiming to help with memory would help her mother.Cont
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