Rehabilitation Management of Parkinsons Disease

1
Rehabilitation Management of Parkinsons Disease

• Susan Stickevers, MD
• Residency Program Director Assistant Clinical
  Professor, SUNY Stony Brook Dept of PMR

2
Parkinsons Disease

• Is a chronic, progressive neurodegenerative
  disorder with a multifactorial etiology.
• It is superseded only by Alzheimers Disease as
  the most common neurodegenerative disorder

3
Demographics of Parkinsons Disease

• Prevalence of 0.3 in the US population
• 1 2 of all persons gt 65 yrs old
• 4 5 of all persons gt 85 yrs old
• In US gt 1 million have diagnosis of Parkinsons
  this is greater than the combined number of MS,
  ALS, and muscular dystrophy patients added
  together
• Usual age at onset early 60s
• 10 of all those affected are lt 45 yrs old
  referred to as young onset Parkinsons
• 40, 000 new cases of PD will diagnosed this year
• Lifetime risk of Parkinsons for men 2.0
• Lifetime risk for women 1.3
• Incidence of the disease is lower in African
  Americans than in Caucasians in the USA

4
An Interesting Fact

• The Chinese have the lowest rates of Parkinsons
  Disease
• It has been suggested by Fahn Jankovic that
  this is may be due to consumption of large
  amounts of green tea by the Chinese which
  contains antioxidants

5
Etiology

• Parkinsonian symptoms can arise from either the
  neuropathological condition PD (idiopathic PD) or
  other forms of Parkinsonism
• For neuropathological PD, 90 of cases are
  sporadic
• 10 are of genetic origin 6 different gene
  mutations have been identified the Parkin genes
  
• Genetic forms of PD are seen more frequently in
  young onset PD
• A combination of environmental factors or toxins,
  genetic susceptibility, and the aging process may
  account for many of the sporadic cases

6
Secondary Parkinsons

• Can be caused by
• Medications antipsychotics antiemetics,
  lithium, reserpine, aldomet
• Sequelae of CNS infection Prion Diseases, Jakob
  Creuzfeldt, SSPE, HIV, post encephalitic
• Toxin Exposure Manganese, Rotenone, Paraquat
• Vascular Metabolic Disorders Binswangers
  Disease
• Drug Induced MPTP byproduct of Ecstasy
  production
• Certain neurodegenerative conditions may exhibit
  also exhibit Parkinsonian features, these are
  called the Parkinsons Plus Syndromes included
  in this category are progressive supranuclear
  palsy, MSA, Lewy Body Dementia and CBD
• Trauma Pugilistic encephalopathy

7
Risk Factors for Parkinsons Disease

• The most important risk factor for Parkinsons is
  advancing age.
• Other environmental or lifestyle risk factors
  associated with Parkinsons include
• Rural living
• Exposure to herbicides pesticides exposure to
  the synthetic pesticide paraquat is associated
  with Parkinsons (organic pesticides are not
  necessarily safe - rotenone or Derris Dust
  exposure can induce Parkinsonism)
• Drinking well water
• Working with solvents in particular hexane
• Manganese toxicity sometimes seen in welders,
  or patients exposed to incorrectly prepared TPN
  solutions

8
Idiopathic Parkinsonism

• Most common form of Parkinsonism
• Idiopathic form first described by James
  Parkinson, A British surgeon paleontologist in
  1817 in his Essay on the Shaking Palsy

9
Pathophysiology of Idiopathic Parkinsons

• Pathological hallmark of PD degeneration of
  dopaminergic neurons in the substantia nigra
  compacta, resulting in depletion of striatal
  dopamine
• This neurotransmitter regulates excitatory
  inhibitory outflow from the basal ganglia
• Some of the dopaminergic neurons survive, and
  these are found to contain Lewy Bodies

10
Pathophysiology of Parkinsons

• Lewy Bodies are eosinophilic intracytoplasmic
  inclusions, composed of numerous proteins
• Protein accumulation plays a prominent role in
  the pathogenesis of both sporadic familial
  forms of PD
• Lewy bodies may actually be cytoprotective

11
Lewy Bodies

• The neurodegenerative process in PD is not
  limited to the substantia nigra compacta
• Neuronal loss also happens in other brain
  regions, which accounts for the motor non motor
  features of the disease

12
Parkinsons Disease The Six Cardinal Features

1. Tremor at rest
2. Rigidity
3. Bradykinesia
4. Loss of postural reflexes
5. Flexed Posture
6. Freezing (Motor Block)

• Diagnostic Criteria Definite Parkinsons at
  least two of these features must be present, one
  of them being 1 or 2
• Probable Feature 1 or feature 2 is present
• Possible at least two of features 3 6 must
  be present

13
Diagnostic Testing

• There are no clinical tests widely available to
  definitively make the diagnosis, however, if
  confirmation of the clinical diagnosis is
  desired, order serial 6 fluoro L dopa PET scans
  which will demonstrate a gradual decline in
  uptake in the putamen caudate in the
  Parkinsons patient
• Alternative Imaging Study - Serial Beta CIT SPECT
  imaging revealing gradual loss of function in the
  striatum
• On the right, see the PET scan of a patient who
  underwent implantation of fetal tissue into the
  right putamen - note the recovery of function in
  the right putamen and the progressive loss of
  function in the left putamen

14
Typical MRI Appearance in Parkinsons Disease

• Standard MRI studies in Parkinsons are normal
• If warranted, consider High Field Strength 1.5
  Tesla T2 weighted Brain MRI
• Typical Appearance in Parkinsons wider area of
  lucency will be noted in the subthalamic nucleus
  that is probably indicative of increased
  accumulation of iron iron deposition occurs
  when there is a loss of connectivity to the
  cortex

15
Early Non - Specific Signs of Parkinsons

• Generalized stiffness
• Pain or Paresthesias of the limbs in
  particular, shoulder pain
• Constipation
• Low Uric Acid Levels
• Sleeplessness
• Reduction in volume of the voice
• Loss of sense of smell
• Seborrheic Dermatitis see photo on the right
• These symptoms precede onset of the motor
  symptoms of Parkinsons
• A Retrospective Study of Early Symptoms of
  Parkinsons Disease, Przuntek, 1992)

16
Early Signs of Parkinsonism

• Problems with fine motor skills
• Decreased sense of smell
• Loss of appetite
• Tremor occurring with anxiety
• Decreased arm swing on one side a principal
  finding in Parkinsons is asymmetry in
  neurological findings
• Decreased emotional expression
• Personality changes, especially introversion
  inflexibility

17
Parkinsonism is Frequently Misdiagnosed

• Clinical presentation may vary from patient to
  patient
• It is not uncommon for PD symptoms to go
  unrecognized or unreported for years

18
Two Major Forms of Parkinsonism

• Tremor Dominant has a better prognosis
• PIGD Postural Instability Gait Dysfunction
  Variant has a poorer prognosis

19
The Cardinal Features Bradykinesia

• Bradykinesia manifests itself as
• Slow reaction times
• Impaired fine motor coordination that interferes
  with ADL
• Drooling due to failure to swallow saliva
• Monotonic hypophonic dysarthria due to
  incoordination of the muscles of vocalization
• Loss of facial expression (hypomimia) leads to
  mask facies decreased blink rate
• Reduced armswing when walking
• Micrographia small cramped handwriting
• Bradyphrenia slowness of thought

• The extreme form of bradykinesia is akinesia
  the inability to initiate movement
• Bradykinesia is the most disabling feature of
  Parkinsonism.
• With a sudden surge in emotional energy, the
  bradykinetic patient may be able to catch a ball
  or make a fast movement
• This phenomenon is called kinesia paradoxica

20
Pathophysiology of Bradykinesia

• Thought to result from failure of basal ganglia
  output to reinforce the cortical mechanisms that
  prepare execute the commands to move
• Reduced dopaminergic function disrupts normal
  motor cortex activity
• Secondary factors which contribute to
  bradykinesia include muscle weakness, tremor, and
  rigidity
• Bradykinesia results from excessive activity in
  the subthalamic nucleus and the internal segment
  of the globus pallidus

21
The Cardinal Symptoms Tremor

• Resting tremor may be considered to be the most
  typical sign of Parkinsons
• A common initial symptom of the disease is an
  asymmetrical resting tremor seen in 70 90 of
  patients at presentation
• Asymmetrical resting tremor usually involves the
  thumb or wrist
• If resting tremor is not present, consider that
  the patients Parkinsonian symptoms are caused by
  a disorder other than PD
• The typical resting tremor has a frequency
  between 4 6 Hz
• Tremor is most prominent in the distal part of an
  extremity in the hand, called a pill rolling
  tremor
• Pill rolling tremor involves the forefinger
  thumb at a frequency of 3 -6 cycles per second is
  the classical presentation of tremor
• When tremor is present in the head, it occurs in
  the region of the lips, chin and jaw only
  occasionally in the neck
• Tremor is more likely to be the presenting
  symptom in young patients, whereas older patients
  have more prominent bradykinesia

22
Treatment of Tremor

• Anticholinergics are effective in treatment of
  resting tremor
• Usually used in younger patients ( lt 60 yrs) with
  intact cognition predominant tremor
• Benztropine
• Trihexyphenidyl
• Side Effects constipation, blurry vision,
  urinary retention, confusion, hallucinations

23
Prognostic Significance of Tremor

• Presentation with tremor as the initial symptom
  often confers a positive prognosis slower
  progression
• There is a subset of patients with Parkinsons who
  have benign tremulous parkinsonism these
  patients have
• A family history of tremor
• Minimal progression of the disease process
• Poor response to levodopa

24
Rigidity Flexed Posture

• Rigidity is manifested by increased resistance
  throughout the range of motion
• Rigidity can manifest itself proximally in the
  neck, shoulders, and hips
• Gait in Parkinsons is characterized as
• Short shuffling steps
• Stooped posture
• Narrow base of support
• Flexed knees

25
The Cardinal Signs Flexed Posture - Camptocormia

• Patient on the left had camptocormia due to
  unrecognized, untreated Parkinsonism
• The picture on the right depicts his response to
  a single test dose of Sinemet.
• Camptocormia is a postural deformity seen in the
  Parkinsons patient
• This manifestation of Parkinsonism is often
  dismissed by physicians as hysteria

26
The Cardinal Signs Freezing

• Freezing is also known as motor block
• Most often affects the legs when walking, but it
  can also affect the arms and eyelids
• Freezing consists of a sudden, transient
  inability to move
• It typically causes hesitation when initiating
  walking sudden inability to move feet when
  turning or walking thru narrow passages such as
  doors or elevators or when patients are about
  to reach a target destination
• Freezing is thought to related to noradrenergic
  deficiency related to degeneration of the locus
  coeruleus

27
The Use of Gestes Antagonistes to Overcome
Freezing

• Patients learn (or may be taught) a variety of
  tricks (French gestes antagonistes) to overcome
  freezing attacks, such as
• Marching to command (left, right,left, right)
• Stepping over objects, such as a crack in the
  pavement, the end of a walking stick
• Walking to music or a metronome
• Shifting body weight
• Rocking movements trunk
• Train your patient to perform gestes antagonistes
  !!!

28
Association of Freezing with the Parkinsons Plus
Syndromes

• When freezing occurs early in the disease
  process, (lt 3 yrs.) or early postural instability
  (lt 3yrs) is present, or is a predominant symptom
  
• Consider that your patient may have a Parkinsons
  Plus Syndrome not Parkinsons - such as
• PSP
• MSA
• Vascular Parkinsons

29
Non Motor Features of Parkinsons

• The clinical course of Parkinsons is not limited
  to motor symptoms
• Non motor symptoms disorders significantly
  affect the health related quality of life (HRQOL)
  
• Surveys of PD patients reveal that approximately
  90 have at least 1 non motor symptom
• 10 of PD patient have 5 non motor symptoms
• The non motor symptoms contribute to shortened
  life expectancy

30
Common Non - Motor Features of Parkinsons

• Neuropsychiatric
• Impulse Control Disorders
• Sleep Disorders
• Autonomic Dysfunction orthostatic hypotension,
  hyperhidrosis, hypohidrosis, sexual impotence can
  be seen in Parkinsons but if these features
  are noted early in disease process, your patient
  may have MSA
• Sensory Symptoms paresthesias, oral genital
  pain are common as is olfactory dysfunction
• Other Fatigue, Seborrhea, Diplopia, Blurred
  Vision, Weight Loss

31
Neuropsychiatric Disorders in Parkinsons Disease

• Depression
• Anxiety, including panic attacks
• Cognitive Dysfunction
• Dementia
• Psychosis
• Confusion or delirium
• Apathy

32
Depression in Parkinsons

• Most common neuropsychiatric disorder in PD
  patients, affecting up to 50
• Depression is often comorbid with anxiety
  disorder
• Can be observed at any stage of the illness
  including prior to onset of motor symptoms
• Depression is associated with increased
  disability, poor HRQOL, and a more rapid
  progression of motor impairment
• It is unclear whether or not the depression is
  reactive or related to neuropathology
• Most patients with Parkinsons who are depressed
  are not treated or treated inadequately for
  depression resulting in increased disability
• Weintraub et al, J. of Geriatric Psychiatry
  Neurology, 2003
• Routine screening for depression anxiety with a
  validated instrument is recommended
• Validated Instruments Beck Depression
  Inventory, Geriatric Depression Screen, Hamilton
  Depression Inventory, Beck Anxiety Inventory,
  Speilberger State Trait Anxiety Inventory

33
Risk Factors for Depression in the Parkinsonian
Patient

• Increasing severity of cognitive impairment
• Female gender
• Early onset disease
• Personal history of depression prior to onset of
  disease

34
Treatment of Depression Evidence Based Medicine

• Meta Analysis Fewer than 30 studies exist in
  the literature which evaluate the effectiveness
  of antidepressants in PD
• The AAN recommends the use of amitriptyline for
  the treatment of depression in PD based on their
  review of available studies
• TCAs may not be well tolerated by all Parkinsons
  patients due to the side effect profile
  particularly the orthostasis worsening
  cognition

35
Most Frequently Used Antidepressants in
Parkinsons

• SSRIs are the most commonly used antidepressants
• Well tolerated by the major of patients
• This class of drugs do not appear to worsen motor
  symptoms in PD
• In open label clinical trials, most PD patients
  did not experience side effects with maximal
  dosages
• Citalopram, escitalopram, and sertraline are
  recommended - less prone to drug drug
  interactions than paroxetine or fluoxetine

36
Antidepressant Doses
Medication Usage Initial Dose Usual Maintenance Dose Adverse Effects
Citalopram (Celexa) 20 mg 20 40 mg SSRI Side Effects Insommnia Jitteriness Dizziness Nausea Diarrhea Headache Sexual Dysfunction Weight Gain
Sertraline ( Zoloft) 25 50 mg 25 200 mg
Escitalopram (Lexapro) 10 mg 10 20 mg
Pamelor (Nortriptline) 10 25 mg 10 75 mg, target level of 80 120 ng / ml Dry mouth Constipation Sedation Sexual Dysfunction Orthostasis Worsening cognition Urinary Retention
37
Anxiety in Parkinson Patients

• Avoid benzodiazepines as these increase the risk
  to fall
• Consider the use of an antidepressant which is
  also effective against anxiety
• Escitalopram is a good choice of an
  antidepressant which can also act as an
  anxiolytic
• Buspirone is well tolerated but has not been
  formally tested for its effectiveness in PD
  patients

38
Cognitive Dysfunction Dementia in PD

• Prevalence of dementia 20 40 of PD patients
  Six times higher than in the general population
• Characterized by
• Psychomotor slowing
• Impaired executive function
• Inattention
• Impaired visuospatial abilities
• Memory impairment due to poor retrieval of
  information in PD as opposed to poor encoding
  of new information seen in Alzheimers Disease
• Verbal cueing may aide recall in Parkinsons
  patients this is not usually helpful in
  Alzheimers

39
Neurobiology of Development of Dementia in PD

• Neurotransmitter deficits are responsible
• Decreased levels of the following are observed in
  PD
• Acetylcholine
• Dopamine
• Serotonin
• Norepinephrine
• Cholinergic dopaminergic deficits have been
  linked to memory dysfunction dysexecutive
  syndrome
• Noradrenergic deficits have been linked to
  inattention
• Consider neuropsychological testing on all your
  PD patients at regular intervals

40
Recommended Screening Tools for Dementia in the
Parkinsons Patient

• Cambridge Cognitive Examination
• Folstein Mini Mental Status Exam
• Montreal Cognitive Assessment highly effective
  in detecting early cognitive changes
• Hopkins Verbal Learning Test assesses verbal
  memory abilities recognition recall
• Clock Drawing Test useful to asses visuospatial
  executive abilities

41
Comparison of the Clinical Features of Lewy Body
Dementia, Parkinsons Dementia, Alzheimers
Disease
Clinical Features Lewy Body Dementia Parkinsons Dementia Alzheimers Disease
Common Presentation Psychotic symptoms and / or Parkinsonian features Parkinsonian features Memory decline
Psychotic Symptoms Early visual hallucinations with or without delusions Associated with exposure to anti Parkinsonian meds. Usually later in the disease process
Memory Decline As the disease progresses, particularly in accessing memories Difficulty accessing memories Earlier, global progressive difficulty in forming memories
Speech Impairment Usually late in course Hypophonia, dysarthria Aphasia, paraphasias
Parkinsonian Features
Tremors at Rest Present in 20 50 Present in 75 Only late in the disease
Rigidity Common Common Only late in the disease
Gait Abnormality Early in disease process Early or late in disease Only late in the disease
Response to Levodopa Variable Common N/A
Antipsychotic Sensitivity Can be extreme Variable, increased Parkinsonism at higher doses Development of Parkinsonism at higher doses
Efficacy of Cholinesterase Inhibitors One positive efficacy study One positive efficacy study Established
42
Risk Factors for Development of Dementia in
Parkinsons Patients

• Old age
• Older age at onset
• Increased severity of PD
• Depression
• Psychosis
• Early executive impairment
• Early memory deficits

43
Is it Lewy Body Dementia or Parkinsons?

• The presence of dementia psychosis early in the
  disease course is highly uncharacteristic of PD
  and favors a diagnosis of Lewy Body dementia

44
Treatment of Dementia in Parkinsons

• Rivastigmine (Exelon) was found to be moderately
  effective in Parkinsons dementia in a large
  placebo controlled study has received FDA
  approval for this indication
• In small studies, the anticholinesterase
  donepezil in PD patients with dementia
• Very rarely do these medications cause a
  worsening of Parkinsonian symptoms

45
Drugs for Cognitive Dysfunction in Parkinsons
Disease
Drug Usual Initial Dose Usual Maintenance Dose Cost of Therapy Per Month Primary Adverse Effects
Donepezil (Aricept) 5 mg 10 mg 160 Headache, insomnia, nausea, anorexia, vomiting, muscle cramps
Rivastigmine (Exelon) 1.5 mg 3 6 mg BID 195 Headaches, dizziness, nausea, vomiting, diarrhea, abdominal pain
46
Impulse Control Disorders (ICD)

• Impulse control disorders are defined as failure
  to resist an impulse, drive, or temptation to
  perform an act that is harmful to the person or
  others
• Manifestations include compulsive gambling,
  hypersexuality, shopping, and binge eating.
• ICD occurs at a frequency of 1.5 of the general
  population
• In Parkinson Disease, one large scale study
  suggests that ICD affects 10 15 of patients
  with PD

47
Etiology of ICD in Parkinsons

• Primary Etiology of ICD in Parkinsons dopamine
  agonist therapy
• No one agent has been identified to be more
  likely than another to induce ICD
• Higher doses predict a greater risk for ICD
• A history of ICD before onset of Parkinsons is a
  risk factor for exacerbation of this syndrome
  after initiation of dopamine agonist therapy
• When prescribing dopaminergic agonist therapy,
  patients must be warned about the potential for
  developing an ICD
• Screen patients on dopaminergic agonists for an
  ICD with the Minnesota Impulse Disorders
  Interview

48
Treatment of ICDs in Parkinsons

• When ICDs develop in the Parkinsons patient,
  consider
• Dose reduction
• Discontinuing dopaminergic agonist
• Switching to another dopaminergic agonist
• Consider a trial of an SSRI
• Consider a trial of an atypical antipsychotic

49
Sleep Disturbance in Parkinsons

• Some patients remain awake 30 40 of the night
• Sleep dysfunction is manifested as
• Parasomnias
• Nocturnal Insomnia
• Difficulty initiating or maintaining sleep
• Daytime Hypersomnolence

50
Etiologies of Sleep Disturbance in Parkinsons

• Nocturia
• Wearing off motor disability
• Sleep Apnea due to rigidity in phargyneal
  respiratory musculature neuropathological
  changes
• Periodic Leg Movements
• Restless Leg Syndrome occurs in 20 of
  Parkinsons patients
• Depression / Anxiety
• Neuropathological Changes degeneration of the
  brainstem nuclei involved in respiration
• Medication related for example, selegiline has
  amphetamine derative metabolites

51
Treatment of Sleep Dysfunction in PD

• Sleep study to rule out sleep apnea
• Avoid nighttime doses of selegiline or consider
  another MAOB inhibitor, rasagiline, which is less
  likely to affect sleep
• Consider use of small doses of immediate release
  levodopa / carbidopa before bedtime which can
  alleviate insomnia caused by motor symptoms
• Consider use of amitriptyline 5 40 mg po QHS or
  quietiapine to reduce sleep maintenance insomnia
• Deep brain stimulation of the subthalamic nucleus
  significantly reduces motor symptoms and can
  improve sleep duration and quality

52
Treatment of Motor Symptoms In PD

• There is no cure for Parkinsons Disease
• No therapy has been shown to slow or reverse
  progression of the disease
• The most effective agent, levodopa / carbidopa
  has been associated with an increased risk of
  motor fluctuations
• Levodopa induced motor fluctuations dyskinesias
  are difficult to treat are socially
  stigmatizing
• The risk of motor fluctuations is greatest in
  younger patients
• The current treatment paradigm for Parkinsons
  involves maximizing therapy with levodopa sparing
  medications for as long as possible before
  starting levodopa

53
Starting Parkinsons Disease Medication Management
for Mildly Affected Patient

• Delay medication therapy for as long as possible
  until disease process interferes with function
• When clinically significant disability or
  functional impairment begins, consider starting
  with dopaminergic agonist therapy
• Amantidine 100 mg po BID OR
• MAOB Inhibitors
• Seligiline 5 mg po BID
• Rasagiline 1 mg po QD more potent than
  selegiline

54
Amantidine

• Side Effects
• Nausea
• Confusion
• Dizziness
• Livedo Reticularis
• Insomnia
• Hallucinations
• Edema

• Abrupt discontinuation can precipitate worsening
  of Parkinsonian symptoms potential for
  neuroleptic malignant syndrome delirium
• Severe psychosis has been reported in the elderly
  with high plasma levels
• Dose reduction is required in renal insufficiency

55
MAOB Inhibitors Seligiline Rasagiline

• Side Effects
• Nausea
• Orthostatic Hypotension
• Possible Interactions with tricyclics, SSRIs,
  meperidine
• No significant adverse reaction with tyramine
  rich foods at usual doses

56
Other Dopaminergic Agonists for Possible
Monotherapy

• Side Effects with these agents are more common
  than with levodopa / carbidopa
• May be used for early monotherapy
• The non ergot dopamine agonists, pramipexole
  (Mirapex) or ropinirole (ReQuip) can delay the
  need for levodopa
• Pramipexole 0.25 mg 1 mg po TID
• Ropinirole 2 mg po TID

57
Levodopa

• The most effective agent for the treatment of
  motor symptoms of PD
• It is the prodrug of dopamine, and it crosses the
  blood brain barrier
• It is then decarboxylated to dopamine in the
  nigrostriatal pathways
• Levodopa is always given with carbidopa,(marketed
  as Sinemet) which prevents peripheral metabolism
  of levodopa allows a higher percentage of of
  levodopa to cross the blood brain barrier
• Administration of carbidopa minimizes the adverse
  effects of peripheral dopamine including nausea
  hypotension

58
Response to Levodopa

• Initially patients have a good sustained
  response to levodopa with small amounts given
  three times per day
• This honeymoon period may last 5 7 yrs.
• As the disease and the treatment progresses,
  motor complications occur in most patients
• Motor complications include a shortened duration
  of drug benefit called wearing off and drug
  induced dyskinesias

59
Wearing Off

• The half life of levodopa is 90 minutes
• With progressive disease, the benefits of each
  dose become shorter, with a wearing off of
  benefit before the next dose
• Patients may also experience loss of benefit from
  a usually effective dose an unpredictable,
  sudden loss of drug effect recurrence of severe
  PD symptoms -
• This is known as an on off motor fluctuation

60
Managing Motor Fluctuations

• Reduce each individual dose of levodopa
  increase frequency of administration
• Add a dopamine agonist, such as ropinirole or
  pramipexole or amantidine
• Consider the use of a COMT inhibitor a drug
  which inhibits a peripheral enzyme which
  metabolizes levodopa examples entacapone
  (Comtan) 200 mg po TID QID or tolcapone
  (Tasmar) 100 mg po TID LFTs must be monitored
  for patients on Tasmar
• Levodopa entacapone are available in a
  combination tablet called Stalevo for convenience
  in this situation
• Switch from standard levodopa / carbidopa to
  sustained release formulations of the drug
• Often Parkinsons patients have delayed gastric
  emptying malabsorption of Sinemet from chronic
  Helicobacter pylori infection if your patient
  has motor fluctuations, consider workup
  treatment for Helicobacter

61
Management of Dyskinesias

• Reduce each dose of levodopa
• Add agents to treat dyskinesias, such as
  amantidine
• Reduce or discontinue anticholinergic therapy

62
Surgery for PD

• Pallidotomy is no longer performed in the
  management of Parkinsons it is not as effective
  as Deep Brain Stimulation (DBS)
• DBS is indicated for patients with drug resistant
  motor fluctuations
• Bilateral Deep brain stimulation (DBS) of the
  subthalamic nucleus (STN) reduces both the
  primary symptoms of PD and its motor
  complications including tremor, bradykinesia,
  wearing off, dyskinesias, and dystonia

63
Effects of DBS

• Reduction in daily levodopa dose by 55
• 69 reduction in dyskinesias
• 68 reduction in off periods
• 34.5 improvement in quality of life

64
Patient Selection for DBS Potential
Complications

• Patient Selection
• Medically refractory motor fluctuations or
  tremor
• Stable medical problems
• Normal cognitive function
• Complications
• Hemorrhage
• Stroke
• Infection
• Failure of stimulator
• Memory Loss

65
Exercise Interventions in Parkinsons Disease

• A meta analysis found that physical
  occupational therapy improved gait speed, stride
  length, and ADL, but no change in the
  neurological cardinal signs De Goede et al,
  Archives of PMR, 2001
• Train your patient to perform gestes
  antagonistes, such as marching with the metronome
  this is not frequently done by therapists

66
Weight Supported Ambulation Training

• Weight supported ambulation training with Lite
  Gait or Biodex has been shown to improve gait in
  Parkinsons patients, as published in the Archives
  of PMR

67
Speech Language Pathology Services

• Dysphagia in Parkinsons is observed due to the
  weakness of pharnygeal esophageal musculature,
  as well as due to lower esophageal sphincter
  dysfunction
• Consider regular screening of the PD patient for
  dysphagia with modified barium videofluoroscopic
  swallowing studies

68
Speech Language Pathology Services

• Helpful in the management of dysarthria
  associated with Parkinsons
• For PD related hypomimia, training the PD patient
  to shout has been found to be effective this is
  known as the Lee Silverman technique

69
Diet

• Levodopa absorption can be impaired by ingestion
  of amino acids, especially in patients with motor
  fluctuations, which can potentially reduce its
  effectiveness
• A high fiber diet (or fiber supplementation) as
  well as adequate fluid intake can minimize the
  constipation commonly seen in the Parkinsons
  patient

70
Vitamin D Deficiency in Parkinsons
E-MOVE reports from the Annual Meeting of the American Academy of Neurology, Chicago, April 14-18, 2008. Poster and platform session numbers are from Neurology 200870(suppl 1)  

High prevalence of vitamin D deficiency in a Parkinson's disease (PD) cohort ML Evatt, M DeLong, N Khazai, A Rosen, S Triche, V Tangpricha S03.005, A107    More than half of PD patients are vitamin D-deficient, according to this study.
71
NEJM April 1, 2010 Case Report Cycling for Tx.
Of Freezing in A Parkinsons Patient

• A 58-year-old man with a 10-year history of
  idiopathic Parkinson's disease presented with an
  incapacitating freezing of gait
• The patient had severe difficulties initiating
  gait and was able to take only a few shuffling
  steps when provided with a visual cue (the
  examiner's foot placed in front of the patient).
• Attempts to walk evolved rapidly into forward
  festination and ultimately a fall to the ground.
  Axial turning was impossible.
• However, the patient's ability to ride a bicycle
  was remarkably preserved Gait freezing recurred
  instantaneously after he dismounted the bicycle.
  This striking kinesia paradoxica may be explained
  by the bicycle's rotating pedals, which may act
  as an external pacing cue.
• Alternatively, the motor-control mechanisms
  involved in gait as compared with other
  activities engaging the legs, such as cycling,
  could be affected differentially in Parkinson's
  disease.
• Cycling may offer a useful approach for exercise
  training in patients with Parkinson's who are
  "grounded" by freezing

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Treatment of Sialorrhea in Parkinsons

• Sialorrhea often results from the PD patients
  inability to swallow their own secretions
• If severe, it can interfere with fluid nutrient
  intake
• Botulinum Toxin A B have been used to curtail
  sialorrhea
• Dose of Botulinum Toxin A 10 units per parotid
  gland, 15 units per submandibular gland
  procedure must be done bilaterally

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Equipment for the Parkinsons Patient

• Rolling Walkers are best canes standard
  walkers are frequently carried by the patient
• Shower chairs
• Grab Bars
• Raised Toilet Seats with armrests ie Versaframe
  
• Chairs with arms to assist patient to lower
  themselves to the chair without falling

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Considerations for the Primary Care Physician

• Parkinsons patients have a lower incidence of
  cancer than the general population with the
  exception of
• Malignant melanoma Parkinsons patients are at
  2 x greater risk of developing melanoma than the
  general population order sunblock !

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On the Horizon

• Implantation of fetal tissue
• Implantation of retinal tissue
• Gene Therapy
• Neuroprotection Strategies for patients with
  early Parkinsonism their family members
• Antioxidant Trials - Vitamins E C
• Coenzyme Q 10 at doses 2400 mg / day

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Thanks for Your Attention

• Questions ?