Parkinson’s Disease: a geriatrics syndrome Primary Care Gerald Jogerst, M.D. May 16, 2014 Objectives • Describe a new approach to Parkinson’s disease. • Discuss the diagnostic criteria for Parkinson’s disease. • Compare conditions misdiagnosed as Parkinson’s disease. • List drug and non-drug therapies. • Provide recommendations for practice. Parkinson’s Disease • Described by James Parkinson in 1817 • Kampavata (tremor and akinesia) described in literature in India 4500-1000 B.C. • Prevalence of 1 to 2 million people in North America • Mortality is 2 to 5 times higher versus agematched controls • Age is the single most consistent risk factor Epidemiology • Occurs throughout the world, in all ethnic groups • Slight male predominance • Incidence – Lowest among Asians and African blacks – Highest among whites – African blacks much lower than Afro-Americans – Exponential increase between ages 65 and 90 – Only 5-10% of patients have symptoms before age 40 (risk reduction with smoking) Genetics • Early studies of twins excluded genetic contribution • 1997 study found high concordance among monozygotic twins (one twin had youngonset disease) • Linkage to chromosome 2p13 in six families Pathological Findings • Progressive death of selected but heterogeneous populations of neurons • Sites – Pars compacta of substantia nigra (dopaminergic) – Selected aminergic brain stem nuclei (Catecholaminergic and serotoninergic) – Nucleus basalis of Meynert (cholinergic) – Hypothalamus – Small cortical neurons – Olfactory bulb, sympathetic ganglia, and parasympathetic neurons in the gut Parkinson’s Disease: A New Multidisciplinary Approach for this Old Actor Premotor Phase Clinically Evident (PD) Aspecific non-motor symptoms: • Hyposmia • Constipation • Depression • Articular pain • Fatigue • Orthostatic Hypotension Frail “in situ”: mean 10 years With Complications (PD-D) Specific motor symptoms: Diagnosis 2 yr Aspecific non-motor symptoms, specific in the geriatric setting • Bradykinesia (plus at least) • Rigidity • Tremor • Postural Instability Frail: mean 10 years F. Lauretani et al. / Archives of Gerontology and Geriatrics 54 (2012) 242-246 > 1 yr • Memory Impairment • Sleep Disorder • Acute Delirium • Nocturia • Dysphagia with pneumonia ADL-Disability: mean 7 years Parkinson’s Disease: A New Multidisciplinary Approach for this Old Actor Braak’s Stage 1-2 locus coeruleus dorsal IX/X nucleus Clinical Symptoms Premotor Phase: • Hyposmia • Constipation • Depression • Articular pain • Fatigue • Orthostatic hypotension Braak’s Stage 3-4 Braak’s Stage 5-6 mesocortex substantia nigra locus coeruleus dorsal IX/X nucleus Clinical Symptoms Clinically Evident (PD): • Bradykinesia (plus at least) • Rigidity • Tremor • Postural Instability F. Lauretani et al. / Archives of Gerontology and Geriatrics 54 (2012) 242-246 neocortex (sec. & prim.) neocortex association mesocortex substantia nigra locus coeruleus dorsal IX/X nucleus Clinical Symptoms With Complications (PD-D): • Memory Impairment • Sleep Disorder • Acute Delirium • Nocturia • Dysphagia with pneumonia Diagnosis • No biologic marker to confirm the diagnosis • Underdiagnosis and incorrect diagnosis are common • Classic signs and symptoms - tremor, rigidity, bradykinesia and postural instability • Best differentiate from other parkinsonisms by: – Asymmetry – Resting tremor – Good response to levodopa UK Parkinson’s Disease Society clinical criteria • Step 1 Bradykinesia At least one of the following: Rigidity 4-6 Hz rest tremor Postural instability not caused by primary visual, vestibular, cerebellar or proprioceptive dysfunction UK criteria • Step 2 Exclude other causes of parkinsonism • Step 3: at least 3 of the following criteria: Unilateral onset, rest tremor, progressive disorder, asymmetry primarily affecting side of onset, 70-100% response to levodopa, severe levodopa induced dyskinesia, levodopa response for 5 years or more, clinical course of 10 years or more. Features suggestive of alternative diagnoses • Dementia preceding motor symptoms • In first 3 years: postural instability, freezing, hallucinations ( not related to medication) • Supranuclear gaze palsy (downward gaze) • Severe symptomatic dysautonomia • Documentation of plausible cause of parkinsonism ( focal brain lesion, neuroleptic) Conditions Misdiagnosed as Parkinson’s Disease • • • • • Essential tremor Vascular parkinsonism Drug-induced parkinsonism Dementia with Lewy bodies Atypical parkinsonism ( progressive supranuclear palsy, multisystem atrophy) Tremor • • • • Resting tremor 4-6 Hz Prominent in hands Absent in 25% Tremor Parkinson’s disease • Age at onset 55-75 yrs • Family Hx +/• Frequency (Hz) 4-6 • Characteristics: Suppronation- asymmetric • Rest -> increase • Writing dec. (micrographia) • Face, jaw, lips, chin Essential tremor • 10-80 years • Family Hx ++ • Hz 5-10 • Flexion-extensionsymmetric • Rest -> decrease • Increases (tremulous) • Head, voice Rigidity • Increased tone throughout range of motion • Increases when limbs are moving • By itself, not disabling • Spasticity versus rigidity Bradykinesia • • • • One of the more disabling symptoms Delay in starting all movements Slowness and poverty of movement Arrest of ongoing movements Postural Instability • Inability to maintain equilibrium • Inability to react to abrupt changes in position Modified Hoehn & Yahr Staging • • • • • • • • Stage 0 = No signs of disease Stage 1= Unilateral disease Stage 1.5= Unilateral plus axial involvement Stage 2= Bilateral disease ,no imbalance Stage 2.5= Mild bilateral, recovery on pull test Stage 3= postural instability but independent Stage 4= Severe disability; still able to walk Stage 5= Wheelchair or bed bound. Decision to Start Medical Therapy (consider) • • • • Effect of disease on dominant hand Significant bradykinesia or gait disturbance Personal philosophy regarding drug use DEGREE TO WHICH DISEASE EFFECTS FUNCTION Protective Therapy • No proven treatment to slow progression • Selegiline-ameliorated symptoms/question of increased mortality • High dose Vitamin E ineffective Symptomatic Therapy • Levodopa remains the most effective treatment (Sinemet 25/100 TID) – Most patients benefit over the entire course of the illness – No evidence that it accelerates the neuro-degenerative process – Increases life expectancy – Survival reduced if drug is delayed until greater disability Symptomatic Therapy • Anticholinergics (Artane 0.5-1 mg BID) • Amantadine (100 mg BID) • Selegiline (5 mg BID - last dose mid-day) – All have mild to moderate benefit, but levodopa or dopamine agonists are required as disability progresses • Tolcapone (COMT inhibitor) 100 mg TID monitor LFT’s Symptomatic Therapy Dopamine agonists May provide inadequate benefit (1/3 of patients have good responses) Always require supplementary levodopa but may be adequate alone for two to five years Infrequent fluctuations and dyskinesias Pramipexole versus levodopa complications Figure Legend: Cumulative probability of reaching the first dopaminergic complication (A) and the individual complications wearing off (B), dyskinesias (C), and freezing (D) by treatment assignment. First dopaminergic complication is defined as the first occurrence of wearing off, dyskinesias, or on-off fluctuations. Holloway RG, Shoulson I, Fahn S, et al. Pramipexole vs Levodopa as Initial Treatment for Parkinson Disease: A 4-Year Randomized Controlled Trial Arch Neurol. 2004;61(7):1044-1053. doi:10.1001/archneur.61.7.1044 Copyright © 2014 American Medical Association. All rights reserved. Date of download: 1/10/2014 Dopamine Agonists Ergot-derived (lung and cardiac valve fibrosis) Bromocriptine 20-40 mg/day Non-Ergot-derived (as first-line and adjunctive therapy) Ropinirole Pramipexole Rotigotine up to 24 mg/day, divided TID or SR up to 4.5 mg/day, divided TID or SR up to 6 mg/24 hr patch Late Stage Problems (Disease) • Motor-dysarthria, freezing of gait, postural instability with falls • Nonmotor-dysautonomia, weight loss, pain, changes in mood or behavior, sleep disturbance, cognitive dysfunction, dementia Late Stage Problems (Treatment and Disease) Motor fluctuations: (in 70% treated for 15 years) • Wearing off of drug effect • On-off phenomenon Dyskinesia: (may respond to amantadine) • Peak-dose dyskinesia • Diphasic dyskinesia • Off-period dystonia Psychiatric disturbances - vivid dreams, visual hallucinations, mania, hypersexuality, paranoid psychosis Surgical Therapy • Reserved for disabling, medically refractory symptoms • Ventrointermediate thalamic nucleus lesions reduce contralateral arm tremor by 80% • Pallidotomy - 80% improvement in contralateral drug-induced dyskinesia (akinesia, rigidity and tremor reduced) • Stimulation of subthalamic nuclei-benefits all aspects of parkinsonism Deep Brain Stimulation • For intolerable dyskinesias or motor fluctuation while on levodopa • Appropriate candidates have cognition relatively intact and are less than 70 yrs old. • Benefit: reduction in levodopa dose, improvement in off-medication function and reduced dyskinesias when taking medication. • Risks: depression, decreased verbal fluency, increased falls and impulsivity. Fetal Cell transplantation • 2 patients • Intrastriatal grafts of human fetal ventral mesencephalic tissue (dopaminergic neuroblasts) • Assessed 15 & 18 years post graft. *motor gains over first yr. sustained 18yrs. *patient remained off dopaminergic drugs. Kefalopoulou Z et al, JAMA Neurol. 2013.4749 Support Services • Usual Elder Services • Specific Disease Oriented Organization http://www.ninds.nih.gov/disorders/parkinso ns_disease/org_parkinsons_disease.htm • Physical therapy – disability improves • Occupational therapy- in home interventions • Speech therapy- intensive therapy for 2 week can improve voice problems and gain may last up to 3 months. Assisted Devices Recommendations for Practice • Carbidopa/levodopa, nonergot dopamine agonists, or MAOB-I for initial treatment. • Nonergot dopamine agonists, COMT-I or MAOB-I added to levodopa to treat motor complications. • Consistent, good-quality patient-oriented evidence. Recommendations for Practice • Amantadine for dyskinesias in advanced disease. • Deep brain stimulation for functional impairment despite optimal medical tx. • PT to improve gait and speech therapy to improve speech volume. • Inconsistent patient-oriented evidence. Recommendations for Practice • Physicians with limited experience should refer patients to confirm diagnosis. • OT may help patients maintain family, social and work roles, continue ADLs and improve safety. • Consensus, usual practice, expert opinion, case series. Dementia and Depression Caregiver burden Isolation and Loneliness Parkinson’s Disease: A New Multidisciplinary Approach for this Old Actor Premotor Phase Clinically Evident (PD) Aspecific non-motor symptoms: • Hyposmia • Constipation • Depression • Articular pain • Fatigue • Orthostatic Hypotension Frail “in situ”: mean 10 years With Complications (PD-D) Specific motor symptoms: Diagnosis 2 yr Aspecific non-motor symptoms, specific in the geriatric setting • Bradykinesia (plus at least) • Rigidity • Tremor • Postural Instability Frail: mean 10 years F. Lauretani et al. / Archives of Gerontology and Geriatrics 54 (2012) 242-246 > 1 yr • Memory Impairment • Sleep Disorder • Acute Delirium • Nocturia • Dysphagia with pneumonia ADL-Disability: mean 7 years References Bega D, Krainc D. Long-term clinical outcomes after fetal cell transplantation in parkinson disease: implications for the future of cell therapy. JAMA. 2014 Feb 12;311(6):617-8. doi: 10.1001/jama.2013.285516. 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