Evaluation of Parkinson s Patients and Primary Care Providers

Transcription

1 Evaluation of Parkinson s Patients and Primary Care Providers 2018 Movement Disorders Half Day Symposium Elise Anderson MD Medical Co-Director, PBSI Movement Disorders 6/28/2018 1

2 Disclosures GE Speaker, DaTSCAN 6/28/2018 2

3 Outline PD diagnosis Motor and nonmotor symptoms Differential diagnosis Cases Treatment Options and the Impact on Other Chronic Diseases after the break! 6/28/2018 3

4 PD pathophysiology Degeneration of dopaminergic neurons in the brainstem substantia nigra Appearance of Lewy bodies in brainstem and other parts of the brain Lewy bodies contain alpha-synuclein and ubiquitin: markers of abnormal protein folding Mechanism: oxidative stress, mitochondria dysfunction, abnormal protein phosphorylation? Braaket al. NeurobiolAging 2003;24: /28/2018 4

5 PD Cardinal Features Resting tremor Asymmetric rigidity Bradykinesia Postural instability Later in disease course Parkinsonian gait 6/28/2018 5

6 Tremor Resting tremor that improves with action 4-6 Hz Pill-rolling Asymmetric Worsens during anxiety/excitement or walking Hand tremor more common than foot as presenting feature Chin tremor 6/28/2018 6

7 PD tremor 6/28/2018 7

8 Rigidity Raised resistance during passive range of motion Cogwheeling Often more noticeable when tremor present Enhanced during mental task or contralateral limb movement 6/28/2018 8

9 Bradykinesia Slowness of movement Difficulty with fine motor tasks Buttoning Handwriting: micrographia Brushing teeth, washing hair On exam: FFM, RAM, heel tapping, or arm swing Rotator cuff injury 6/28/2018 9

10 Postural Instability Gradual onset of poor balance Increased risk of falls Retropulsion Pull test: can the patient catch herself Shuffling and narrow based gait En bloc turning Freezing With initiation or when encountering obstacles 6/28/

11 Parkinsonism Postural Instability 6/28/

12 PD Gait 6/28/

13 PD Clinical Diagnosis Queen s Square criteria: bradykinesia plus 1 of: Rigidity Rest tremor Postural instability, AND... Typical PD features: Unilateral onset Levodopa response Development of dyskinesia PLUS: absence of exclusion criteria... Gibb et al, J Neuro NeurosurgPsychiatry /28/

14 PD Exclusion criteria Exposure to drugs that can cause parkinsonism Cerebellar signs Corticospinal tract signs Eye movement abnormalities Severe dysautonomia Early moderate/severe gait disturbance or dementia History of encephalitis or recurrent head injury Evidence of severe subcortical white matter disease, hydrocephalus, or structural lesions on MRI 6/28/

15 Non-Motor Features of Preclinical ipd Strong evidence Constipation Olfactory deficit REM Sleep Behavior Disorder (RBD) Depression Weaker evidence Restless Legs Syndrome Apathy Fatigue Anxiety 6/28/

16 Dx of PD: premotor and motor phases Parkinsonsed.com 6/28/

17 Non-Motor Features in ipd Autonomic symptoms Bladder disturbances: nocturia, urgency, frequency Sweating Orthostatic hypotension Sexual dysfunction Dry eyes GI Symptoms Sialorrhea Dysphagia Constipation Chauduri, Lancet Neurol /28/

18 Non-Motor Features in ipd Neuropsychiatric symptoms Depression, anxiety, anhedonia Attention deficit Psychosis Dementia Confusion Sleep disorders RLS, periodic limb movements REM sleep behavior disorder Excessive daytime somnolence Insomnia Sleep disordered breathing Chauduri, Lancet Neurol /28/

19 Imaging: DaTSCAN SPECT scan (single-photon emission CT) DaT uptake (dopamine transporter) Abnormal if decrease in striatal binding FDA approved in 2011 to distinguish ET vs. PD Useful to distinguish PD from medication induced or vascular parkinsonism, identify atypical presentations of PD Not useful to distinguish ipd from PD-plus or to stage disease severity Catafau AM, Tolosa E. Mov Disord 2004;19: /28/

20 Imaging: DaTSCAN (a) healthy age-matched control subject (b) asymptomatic carrier of a mutation in LRRK2 Stoessl AJ, Brooks DJ, et al. Mov Disord 2011; 26:

21 When to refer? Early! We can help confirm diagnosis, establish team care, connect patient with resources If symptoms are bothersome, I recommend initiating treatment (more on that next) at the same time as referral Med response confirms diagnosis 6/28/

22 Case #1, Pt JL 57 year old man presenting with RUE tremor Tremor is noticeable at rest, improves with action No other complaints except stiff R shoulder PD ROS: +anosmia, constipation, RBD almost hit his wife in his sleep a few times Exam: Motor: R>L rest tremor, generalized bradykinesia with slowed spontaneous movements on L. Normal foot taps. Gait: sl lean to R, R>L tremor, mild stoop narrow base 6/28/

23 Pt JL, con t Impression: suspect ipd Plan: start rotigotine patch, PT referral, check MRI brain Next visit: normal MRI. Pt stopped patch due to foggy thinking, fatigue, hallucinations. PCP has started prozac for anxiety Plan: start artane for tremor Next visit: artane partially helps tremor but with brain fog and dry mouth Tremor is worse, pt is working full time Plan: start sinemet 25/100 TID 6/28/

24 Pt JL, con t Next visit: tremor better, but pt has more fatigue esp right after taking sinemet, and more apathy, anxiety, constipation and fatigue 18 months later: more tremor responding to more levodopa, but more fatigue, sedation, cognitive issues Discussion regarding retirement, disability app Start screening process for DBS 6/28/

25 Exam pre-dbs 6/28/

26 Exam post-dbs (same day, after initial programming) 6/28/