Vague Neurological Disorders

Transcription

1 Vague Neurological Disorders Dr. Philip Smalley MD FRCPC SVP & Global Chief Medical Officer RGA International Rose Conference, September 17, 2015

2 Agenda Vague neurological symptoms associated with: Alzheimer s, Parkinson s, Stroke, Traumatic Brain Injury, Multiple Sclerosis and Migraine Headaches New definition of TIAs and its implication on the diagnosis and incidence of stroke Usual time course for recovery to assess degree of disability How to evidence these findings?

3 Causes of Long Term Disability Claims Impairment New Claims Existing Claims MSK 28.6% 28.7% Nervous System 7.7% 15.2% Circulatory / CVD 8.7% 12.4% Cancer 15.1% 9.1% Mental 8.3% 7.7% Council for Disability Awareness (CDA) 2014 Report

4 Critical Illness Impairments Demanding Neurological Sequelae Stroke Multiple Sclerosis Coma Major Head Trauma Benign Brain Tumor Parkinson s Disease Alzheimer s Disease Bacterial Meningitis Encephalitis Motor Neuron Disease Muscular Dystrophy Blindness Deafness Paralysis Loss of speech Loss of Independence

5 Alzheimer s Disease Incidence Rates Doubles every 6.3 years after age 60 World Alzheimer Report 2015 Brookmeyer R et al. Alzheimers Dement. 2011;7(1):61-73

6 Risk Factors for Alzheimer Disease Diabetes Hypertension Obesity Depression Physical Inactivity Smoking Low education Barnes, D et al, Lancet Neurology July 19,

7 Role of Our Microbiome 10X more bacteria than human cells Health and disease Obesity, Metabolic syndrome, Diabetes, Autoimmune-disease Anxiety, neuropsychiatric diseases, schizophrenia and Alzheimer Disease Hill JM et al, Front Aging Neurosci Jun 16;6:127

8 Caregivers of Demented Relatives have more disability Ho, A., Collins, S., Davis, K. & Doty, M. A Look at Working-Age Caregivers Roles, Health Concerns, and Need for Support (2005)

9 Old Definition Questionnaires Neuropsych testing Alzheimer s Disease New Definition Biomarkers CSF exam PET scan IMPACT Make diagnosis 10 years sooner Sperling RA et al, Alzheimers Dement May;7(3):280-92

10 Pathology of Parkinson s Disease (PD) Destruction of the Substantia Nigra in mid-brain

11 Non-motor Symptoms PD Diminished sense of smell (90% of PD) Sleep disturbance / REM Behaviour Disorder 38% develop Parkinson s Low voice volume Painful foot cramps Fatigue / Daytime sleepiness Falls Autonomic dysfunction: Constipation, Drooling, Increased sweating, Urinary frequency/urgency Male erectile dysfunction

12 Motor Symptoms - PD Tremor (85%) (resting, 4-6 Hz, spares head) Bradykinesia Rigidity and freezing in place Stooped, shuffling gait Decreased arm swing when walking Difficulty arising from a chair Micrographia (small handwriting) Lack of facial expression Slowed activities of daily living Difficulty turning in bed Postural instability

13 Mental Manifestations of PD 40-50% of PD patients get depression 50% get psychotic symptoms 20-40% get dementia If occurs < 1 year of motor PD features, then likely diagnosis is Lewy Body Disease, not PD Less common if PD onset is less than 50

14 Hoehn and Yahr Staging Scale Stage 1 One side, mild, not disabling Stage 2 Bilateral, minimal disability, posture and gait affected Stage 3 Significant slowing of movement, early balance problems walking and standing Stage 4 Severe symptoms, can still walk to limited extent, unable to live alone Stage 5 Invalidism complete, cannot stand or walk Hoehn, MM, Yahr, MD, Neurology 1967; 17:427

15 Time Spent in Each Stage Mean duration of disease 14.6 years Time spent in each stage: Diagnosis 1.5 years Maintenance 6 years Complex 5 years Palliative 2.2 years MacMahon DG et al, J Neurol May;245 Suppl 1:S19-22

16 Deep Brain Stimulation Surgical pacemaker inserted in brain Improves disability in some PD patients $15,000 - $20,000

17 Stroke: Signs and Symptoms Depend on Location Left

18 Clinical Presentation Abrupt onset of focal neurological signs Deficit may remain fixed or rapidly improve or progress 10% of strokes have preceding history of one or more Transient Ischemic Attack (TIA) Seizures at the time of stroke occur in 3-5% of infarctions Headache is not common with simple stroke 18

19 Differential Diagnosis Transient Ischemic Attack Lasts usually 5 20 minutes Others. Seizure Hypoglycemia Migraine Multiple Sclerosis Cranial or peripheral nerve palsy Subdural hematoma

20 Migraine Headache ± Aura 12% of population, Female > Male, highest in age group 19th leading reason of disability worldwide as per WHO Number of neurologic and psychiatric disorders, including epilepsy, stroke, major depression and anxiety disorder, show increased co-morbidity with migraine Headache 4-72 hours Unilateral and throbbing o 75%: Headache and no Aura o 38%: Aura with headache o 4%: Aura and no headache Aura Visual disturbances

21 Transient Ischemic Attack (TIA) Old Definition New Definition IMPACT Time based Definition < 24 hours Imaging based Definition 30% - 50% of TIAs actually have a related deficit TIA 28% STROKE 8.1% Easton JD et al, Stroke Jun;40(6):

22 Prevalence Silent Brain Infarcts Silent strokes are common and >> symptomatic strokes Vermeer SE et al. Stroke Jan;33(1):21-5

23 Stroke Prognosis At 5 years post Stroke: 71% had mild impairment (NIHSS < 5) 22.5% had dementia 33% had depression, falls or incontinence 9.4% developed seizures 15% institutionalized At 6 months post Stroke, 6% - 16% have completely recovered with Rankin Score 0 (Bruins Slot, K et al. BMJ 2008;336; ) Feigin VL et al, Neurology Nov 2;75(18):

24 Modified Rankin Score Score 0 = No symptoms Score 1 = No significant disability despite symptoms, able to carry out all usual duties and activities Score 2 = Slight disability, unable to carry out all previous activities but able to look after own affairs without assistance Score 3 = Moderate disability, requiring some help, but able to walk without assistance Score 4 = Moderately severe disabililty, unable to walk without assistance and unable to attend to own bodily needs without assistance Score 5 = Severe disability, bedridden, incontinent and requiring constant nursing care and attention Score 6 = Dead

25 Stroke Recovery Course 58% of strokes reach maximum recovery by 2 weeks Neurological recover plateau s 12 weeks after a stroke Newman M. Stroke Nov-Dec;3(6):702-10

26 Traumatic Brain Injury Coup / Contrecoup Injury Ropper, Allan H et al. N Engl J Med Volume 356(2): January 11, 20

27 Traumatic Brain Injury (TBI) Sequela Post-concussion Syndrome Memory difficulty has ranged from 4% to 59% Concussion does not cause a loss of autobiographical information, such as one s name and birth date Headache and dizziness have been as high as 90% at 1 month and approximately 25% at 1 year or more 32% of mild TBI patients have severe fatigue 6 months post TBI Focal neurological signs Seizures (20% if intracranial bleed and can be recurrent) Ropper, AH et al. N Engl J Med 2007;356(2): Stulemeijer M et al, J Neurol Aug;253(8):1041-7

28 Anosmia (Loss of Smell) Occurs in 11% - 33% of TBI But 1% - 2% of population have some olfactory dysfunction Test on exam or with Evoked Response Olfactometry MRI and SPECT can be abnormal Recovery 11.3% % return to normal < 6 months and unlikely to return to normal > 6 months Some recovery for up to 2 years

29 Multiple Sclerosis (MS) Slowly progressive autoimmune disease targeting myelin in the CNS First described 1868

30 Symptoms - MS Most common presenting symptoms are: Paresthesias (tend to resolve in 6 8 weeks) Weakness or fatiguibility Visual disturbances Bladder or sexual dysfunction Excess heat may worsen symptoms Uhthoff phenomenon

31 Signs / Examination - MS Scotoma, decreased acuity, colour blindness, diplopia Limb weakness but testing often does not correlate with degree of difficulty walking Ataxia, dysarthria, tremor, slow scanning speech

32 Mental Manifestations - MS Fatigue Seen in 72% of patients Responsible for 65% of the disability Not correlated to degree of physical disability Might respond to brief naps Apathy, lack of judgment, emotional lability, euphoria, sudden crying or forced laughter Dementia can be late symptom Depression and suicide

33 Relapses - MS Symptoms develop over days, peak less than a week, remain constant for 3 to 4 weeks, slowly resolve over ~ 1 month Relapses every ~1-2 years but ~5-10 new lesions per year on MRI Frequency of relapses decreases with age & duration of disease Most recovery occurs in first 3 months but can take up to a year

34 Types of MS Relapsing Remitting 85-90% start with RRMS More inflammatory Benign 10% of MS is benign Secondary Progressive 50% of RRMS develop Secondary Progressive MS More neurodegenerative Primary Progressive Primary Progressive MS Lack of response to immunetx

35 Kurtzke Expanded Disability Status Scale (EDSS) 0 = Normal exam 1 = No significant disability despite symptoms, able to perform all duties/activities 2 = Slight disability, unable to carry out all previous activities, able to look after self 3 = Moderate disability, fully ambulatory 4 = Fully ambulatory, self-sufficient, can walk 500 m without aid or rest 5 = Disability severe enough to impair full daily activities 6 = Uses cane or crutch 7 = Restricted to wheelchair 8 = Restricted to bed or chair 9 = Can still communicate and eat

36 Major Causes of Disability in MS Fatigue Cognitive and memory Spastic paraparesis Poor coordination Sphincter dysfunction

37 Median time to Disability - MS To EDSS 3 was 8-12 years To EDSS 6 was years Time to EDSS 3 for progressive disease: Secondary progressive: 8 years Primary progressive: 3 years Pittock SJ et al, Neurology 2004;62:601-6 Degenhardt A et al. Nat Rev Neurol. 2009;5(12):672-82

38 Summary Ageing work force and adverse lifestyles leading to more neurological disability claims New clinical TIA definition Neurological recovery unlikely after 3 months Vague neurological symptoms are common and can be disabling psmalley@rgare.com

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