Download Module 1 - Parkinson`s Disease - 3.26 MB

SELECTED GERIATRIC
NEUROLOGIC DISEASE
Module 1
Parkinson’s disease
Bill Lyons, M.D.
UNMC Geriatrics
Asst. Professor
[email protected]
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OVERVIEW
• Parkinson’s disease
• Other movement
disorders
• Stroke and TIA
Objectives
Re: Parkinson’s disease, upon completion
the learner will be able to;
1. List the diagnostic characteristics
2. Describe the key pathologic features
3. Describe evaluation and management
4. List the most common complications
PARKINSON’S DISEASE
• Prevalence increases with age (starts 40s60s)
• Seen in all ethnic groups, M:F about 1.5:1
• Second most common neurodegenerative
disease
• Genetics’ role greater when younger onset
• CO poisoning, rural residence, pesticide or
herbicide exposure, MPTP, encephalitis
Nigrostriatal Dopaminergic
Neurons
Striatum
Substantia
nigra
Substantia
nigra,
Normal
Substantia
nigra, PD
CARDINAL FEATURES OF
PARKINSON’S DISEASE
• TRAP (any
combination)
• Tremor
• Rigidity
• Akinesia/Bradykinesia
• Postural instability
• Onset usually
asymmetric
• Diagnosis clinical
TREMOR OF PARKINSON’S
•
•
•
•
Rest, 3-6 Hz, pill-rolling
Emotional stress may exacerbate
Inhibition by movement or sleep
Absent in ~20%
BRADYKINESIA
•
•
•
•
Slowed voluntary movements
Less arm swing when walking
Reduced facial expression, less blinking
Identify by rapid alternating movements
during examination
OTHER FINDINGS
•
•
•
•
•
Facial and scalp seborrhea
Myerson’s sign
Drooling
Hypophonia, micrographia
Gait: shuffling, less arm swing, flexed,
trouble starting and stopping
• Cognitive decline
• Normal: strength, DTR, Babinski
DIFFERENTIAL DIAGNOSIS
• Depression – facial expression, activity
level
• Drug-induced – onset usually symmetric
• Essential tremor – possibly FH+
• Shy-Drager – parkinsonism + autonomic
insufficiency + other signs
• PSP
• Lewy Body Dementia – parkinsonism,
fluctuating cognition, psychosis
TREATMENT
• Successful levodopa trial makes diagnosis
more likely
• Drug aim: restore DA/ACh balance in
striatum
• No drugs convincingly slow progression
• Wait to start drugs until bothersome
symptoms or functional impairments
DRUG TREATMENT
• Important to
individualize
• Each patient’s
tolerance for side
effects?
• When is need for
mobility greatest?
DRUG TREATMENT
• Amantadine – for mild symptoms, risk of
confusion and mood problems in elders
• Anticholinergics
– Benztropine, trihexyphenidyl
– Confusion…
– Agitation and restlessness…
– Urinary retention…
LEVODOPA
• Converted by body to DA
• Most effective drug
• Combined with carbidopa to inhibit
breakdown outside the brain (less nausea,
hypotension, arrhythmias)
• Sinemet (25/100) start one tid, increase
gradually as needed
• Controlled-release can reduce fluctuations
LEVODOPA, cont’d
•
•
•
•
Amino acids compete for absorption
Take on empty stomach, or soda crackers
Last meal of day has most protein
Contraindications: psychosis, narrowangle glaucoma, MAO-A inhibitors
• Doesn’t help: autonomic dysfunction,
postural instability, dementia, speaking
and swallowing
DOPAMINE AGONISTS
• Fewer dyskinesias than levodopa
• Approved as monotherapy, or as adjunct
to levodopa
• Adjunctive therapy  reduce levodopa 
fewer dyskinesias, motor fluctuations
• Many adverse effects; patients with
cognitive impairment may tolerate
levodopa better
LEVODOPA VS. DA AGONIST
• DA agonist
– Perhaps worse motor
performance
– But less risk of motor
complications
– Greater odds of
adverse drug effects
DA AGONISTS, cont’d
• Newer: pramipexole and ropinirole
• Older (ergot): bromocriptine and pergolide
• Slow dose titration to minimize adverse
effects
• Fatigue, sleepiness, nausea, dyskinesias,
confusion, edema, orthostatic changes,
dizziness, flushing and diaphoresis
COMT INHIBITORS
• Inhibit Catechol O-Methyl Transferase
• Reduce breakdown of levodopa
• Smoother blood levels, reduced response
fluctuations
• Tolcapone – rare fulminant liver failure,
avoid in liver disease, monitor LFTs
• Entacapone – LFTs not necessary
• Watch for diarrhea; reduce Sinemet dose
1/3
SURGICAL TREATMENTS
• Ablation (eg,
pallidotomy) or DBS
• IDEAL CANDIDATE:
cognitively intact,
responds to
dopaminergic drugs
but progressive motor
symptoms, can
withstand procedure
• Neurologist
evaluation
OTHER TREATMENTS
• Physical Therapy – gait training, strength
exercises, assistive devices
• Improves mood, strength, flexibility,
mobility
• Front-wheel walkers typically best
• Occupational Therapy – techniques and
devices for eating, bathing, etc.
• Speech Therapy – speaking, swallowing
GEROPSYCHIATRIC
COMPLICATIONS IN PD
• Psychosis usually due to drug adverse
effect
– Try reduce dopaminergic dose
– Quetiapine, olanzapine, risperidone may help
– Clozapine most effective, risk of
agranulocytosis
• Dementia
– Late development, up to ~30%
– If earlier, consider Lewy Body Dementia
• Depression – in up to ~40%
GASTROINTESTINAL
COMPLICATIONS
• Dysphagia
– Primarily
oropharyngeal
– Cause of drooling
– Choking, coughing,
aspiration
– Treat: speech therapy
GI COMPLICATIONS, cont’d
• Constipation
– Slowed colonic transport
– Abundant fluids with high-fiber diet
– Stool softeners, senna or sorbitol
– Avoid anticholinergic medications
– Periodic enemas, disimpaction may be
needed
Post-test question one
Consider the case of a 78-year-old man with advanced
Parkinson's disease who consults you for problems with
worsening dyskinesias and excessive drooling. On
physical examination you find he has rigidity in both
upper extremities, more pronounced on the right, and
he also has a pronounced pill-rolling tremor in his right
hand. He shows very little spontaneous movement, and
his face is expressionless, with rare blinking. On sternal
nudge he steps back three steps and almost falls.
Which of the following is NOT considered a cardinal
feature of his parkinson?s disease?
A. Rigidity
B. Dyskinesias
C. Tremor
D. Bradykinesia
E. Postural instability
Correct Answer: Dyskinesias
Feedback: The answer is (b) Dyskinesias.
The other four are part of the cardinal
tetrad of Parkinson's disease, which can
be remembered using the "TRAP"
mnemonic: T for tremor, R for rigidity, A for
akinesia or bradykinesia, and P for
postural instability. Let's move on to a
second question about this patient
Post-test question 2
The best way to treat excessive drooling in a
patient with Parkinson's disease is with
an anticholinergic agent such as
trihexyphenidyl.
A. True
B. False
• Correct Answer: False
• Feedback:As you probably surmised this is
false. The drooling in Parkinson's patients
results from improper handling of saliva in the
oral cavity, not from excess production. This
patient may benefit from referral to a speech
pathologist. Use of an anticholinergic agent may
precipitate confusion, urinary retention, visual
complaints, or constipation. End