Download Parkinson`s disease

PARKINSON’S DISEASE
WHAT I NEED TO KNOW AS A PATIENT AND
A CAREGIVER
Mustafa Saad Siddiqui, MD
Assistant Professor
Neurology & Neurosurgery
Director Parkinson’s & Movement Disorders Program
Wake Forest University School of Medicine
North Carolina, USA
Topics
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What is Parkinson’s disease (PD)?
What causes PD?
Is PD hereditary?
What are the motor features of PD?
What are the non-motor features of PD?
What should I expect in advanced PD?
Is there a cure for PD
Why are my medications no longer
working as well?
• Can surgery help me?
Parkinson’s Disease is increasing
• Affects 1 in 100 older than 60 years
• 5-10% diagnosed with PD are less than 40 yrs old
• No social, ethnic or geographical boundaries
Projected Increase in Prevalence of PD by 2030
Dorsey et al.2007
What is PD
• Slowly progressive, degenerative disease
• Leads to gradual loss primarily of dopamine producing
neurons in brain called substantia nigra
• Combination of genetic and environmental factors.
• Age is the only definite risk factor
PD vs Parkinsonism
• Four cardinal features of Parkinsonism are;
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Slowness (bradykinesia)
Stiffness (rigidity)
Shaking (tremor)
Trouble balancing (postural instability)
• PD is the most common form of Parkinsonism
• However not every patient with Parkinsonism has PD.
• A number of other disorders can present with
Parkinsonism and can mimic PD in early years
PD vs Parkinsonism (cont’d)
• The disorders which mimic PD include many
diseases collectively called atypical Parkinsonism or
Parkinson plus syndromes.
• Up to 15% patients originally diagnosed as PD turn
out to have atypical Parkinsonism after the initial
few years
• Atypical Parkinsonism patients do not respond well
to PD medications and usually have faster
progression of disease.
• Diagnosis of PD is made on clinical grounds,
usually by a neurologist.
Clinical Features of PD
• Tremor:
– Present in 70%
– Resting tremor
– Starts on one side and then involves the other side as disease advances
– Tremor dominant PD has a slower progression of disease
– May get a partial or incomplete response from medications
• Bradykinesia (Slowness)
– Difficulty in turning in beds, brushing teeth, cutting food, getting up from
the chair
– If slowness dos not improve with levodopa or Sinemet, diagnosis of PD
becomes doubtful.
• Rigidity: (Stiffness)
• Gait dysfunction;
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Slowness, difficulty initiating and when started difficulty stopping
Stooped posture
Shuffling gait
Freezing gait
Non-Motor Features of PD
MIND, MOOD AND MEMORY
• Depression
• Memory problems and dementia
• Anxiety and panic attacks
• Impulse control disorder (especially after taking Requip / Mirapex)
• Get easily emotional
SLEEP
• wake up at night when medication effect is wearing off
• Restless legs
• Act out their dreams
• Excessive sleepiness in day
AUTONOMIC
• Sweating, feeling hot and cold
• low BP on standing up
• Problem in erection
SENSORY
• Pain
CLINICAL PROGRESSION OF PD
PRE-CLINICAL STAGE
EARLY STAGE
• REM Behavior Disorder
• One sided symptoms
• Loss of smell
• Slowness
• Constipation, ED,
• Masked face
• low BP, urinary freq
• (Stiffness) Rigidity
• Biomarkers: Smell test,
MIBG scan, SPECT, PET
• Shaking (Resting
tremor)
• Dystonia
• Shuffling gait
LATE STAGE
• Symptoms on both side
• Involuntary dancing
movements
• Motor (On-off) fluctuations
• Speech problems
• Some difficulty in swallowing
• Poor memory (dementia)
• Hallucinations, confusion
• Falls
• Freezing of gait
The pace of disease in every patient is different
Motor Fluctuations
Motor (On-off) Fluctuations
Seen in Advanced PD
• Dyskinesias:
– “Dancing movements after pills kick in”
• Wearing off:
– “ PD symptoms come back before the next pill is due”
• On-Off Phenomenon:
– On: When Meds relieve symptoms
– Off: When Meds do not relieve PD symptoms
– “PD symptoms are like a yo-yo all day”
• Dose failures
– “ Pill takes ‘forever’ to kick in and sometimes none at all”
• Freezing gait
– “Foot tends to get stuck to the floor when trying to walk”
KEY POINTS TO UNDERSTAND IN
PD TREATMENT
• Can be effectively treated but no cure yet
• Neuroprotection? Many treatments are
proposed but none is proven.
• Many medication options available
• Every PD patient is unique and so are the
treatments.
• What works out for one person might not
be the best option for the other.
PD Medications cont’d
• Meds improve the main features of PD including rigidity,
slowness, walking
• Tremor may be less responsive or sometimes not
responsive to medications
• Good treatment benefit for approximately 5 years with
regular adjustments of medications
• Afterwards, symptoms can be more difficult to control
and some patients can experience medication related
side effects.
Common Side Effects of Medications
(varies from one drug to another)
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Nausea
Excessive somnolence
Hallucinations
Lowering of BP
Dyskinesias: involuntary dancing movements of
limbs and neck
• Mental Confusion
Most side effects can be well controlled with
medication adjustments
Treatment of PD is a balancing act
How Can You Help Your Doctor Optimize
Your Treatment
• Understand your PD symptoms and commonly used PD terms
• Understand medication side effects (almost all can be managed
with adjustments)
• Make notes prior to your appointment.
– Think what have been your most bothersome problems in the last one
week
– Is there a pattern to your problem; when does it happen after taking of
pills and when does it resolve. Make a diary of your last one week before
apt.
• Take someone with you to the appointment who can take notes
• Take your medications with you and write down the exact
dose and time you take them.
• Before calling a doctor’s office, know the PD medications you
take, their dosages and their time.
Treatment of Parkinson’s Disease
• Neuro-protective therapy; are we there yet?
• Non-pharmacologic therapy
• Medical therapy
– Motor symptoms
– Non motor symptoms
• Surgical therapy
• Over the counter / herbal treatments
• Restorative treatments- experimental only
PD Medications
• Current PD drugs
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Sinemet: Levodopa/Carbidopa
Requip:
Mirapex
Amantadine
Eldepryl: Selegeline
Azilect: Rasagiline (new)
Permax
Parlodel
Artane: Trihexiphenydyl
Cogentin: Benztropine
Stalevo
Comtan
Tasmar
Apomorphine
Surgical Treatment
• Considered when medications fail to provide satisfactory
alleviation of PD symptoms
• Can effectively treat most but not all motor symptoms of PD
DBS vs Lesion Therapy
Advantages
• Reversible
• Adjustable
• Can be done safely on
both sides of the brain so
that both sided PD
symptoms can be treated
Disadvantages
• Very expensive
• Requires regular follow up
visits for adjustments
• Possible hardware related
complications
• Requires skilled support
DBS
Supportive Treatment
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Physical and occupational therapy
Speech therapy
Exercise
Nutrition
National websites for PD
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www.parkinson.org
www.pdf.org
http://wemove.org
http://www.ninds.nih.gov/disorders/parkinsons_diseas
e/parkinsons_disease.htm
– http://www.apdaparkinson.org/user/index.asp
• Support groups
Restorative Therapy
(Experimental)
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Intraputaminal GDNF, BDNF
Gene therapy
Stem cell therapy
Fetal tissue transplantation
Members of a Parkinson’s Disease Program
• Neurologist specialized in Parkinson’s &
Movement Disorders.
• Nurse: specialized in Parkinson’s disease
• Speech therapist
• Physical and Occupational therapist
• Clinical trials for newer PD treatments
• Education
Plenty of Hope for Future
• PD is one of the most researched neurological
diseases
• Very effective medical and surgical treatments
• Stem cells, gene therapy, growth factors hold
promise
• Understanding your PD, only can help you make
the best treatment choices
Be a fighter and never lose hope
Thank You