PARKINS ON CENTER. Parkinson s Disease: Diagnosis and Management. Learning Objectives: Recognition of PD OHSU. Disclosure Information

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1 OHSU PARKINS ON CENTER Parkinson s Disease: Diagnosis and Management for Every MD Disclosure Information Grants/Research Support: National Parkinson Foundation, NIH, Michael J. Fox Foundation Consultant: Elan Pharmaceuticals, Lundbeck Inc., ONO Pharma, SynAgile Corp, Prexa Inc., US World Med, Ceregene, Lilly/Medtronics Honoraria: American Academy of Neurology, Movement Disorder Society John Nutt, MD Dept. Neurology Learning Objectives: Be able to recognize Parkinson s disease (PD) Be aware of many non-motor features of PD Recognition of PD Know basics of management of PD

2 Parkinson s Disease: A Clinical Diagnosis Rest Tremor Rest tremor Rigidity Bradykinesia Hand > leg or jaw and tongue Disappears with action Asymmetrical Absent in 20% of patients Progressive Rest Tremor Essential Tremor

3 Rigidity Bradykinesia May have aching and stiffness Increased tone on exam to passive movement of joints Differentiate from musculoskeletal syndromes Slowness and loss of dexterity Not weakness but slow to develop full strength. Sensation and reflexes are normal. Differentiate from carpal tunnel syndrome, radiculopathy, stroke Bradykinesia Gait Disorder of PD Slowing of gait Unilateral loss of arm swing and scuffing of foot Narrow base Freezing is rare early in the disease

4 Early PD Gait Gait Disorder That May Resemble PD Slowing of gait Symmetrical Arm swing retained Widened base Freezing may occur early in the disease Freezing: Vascular PD Freezing: PD

5 Diagnostic Tests CAUDATE Clinical diagnosis for typical case Neurological consultation MRI? (after consultation) Beta CIT SPECT scan for difficult cases PUTAMEN Beta-CIT SPECT Scan Differential of PD for PCP Drug induced parkinsonism Typical neuroleptics Atypical neuroleptics (risperidone) Metoclopramide (Reglan ) Prochlorperazine (Compazine ) Valproate

6 Take Home Messages: Diagnosis Clinical diagnosis based on tremor, rigidity, bradykinesia Other tremor syndromes and gait disorders are most common entities confused with PD. Always consider drug-induced parkinsonism in differential. Non-Motor Signs of PD PD: Non-motor Aspects PD: Depression & Anxiety Mood (depression and anxiety) Cognition Sleep Autonomic nervous system Depression and anxiety are common in PD. Both are strongly related to quality of life. Treat depression and anxiety conventionally Warning: Lorazepam and delirium

7 PD: Cognition PD: Sleep Normal Mild cognitive impairment Working memory, multitasking, processing speed, shifting Dementia confusion, delirium, visual hallucinations Warning: Anticholinergics and confusion Restless legs syndrome REM sleep behavior syndrome Nocturia Nocturnal discomfort from PD Depression Hallucinations and confusion Excessive daytime sleepiness PD: Autonomic Dysfunction Myocardial 18 F-Dopamine Scans GI: constipation and impaction GU: urinary urgency, frequency and infection Cardiovascular: orthostatic hypotension Normal Parkinson 08/25/99 01/18/01 Warning: Flomax and orthostatic hypotension Li et al., 2002

8 Take home messages: Non-motor PD is more than motor disorder Non-motor aspects of disease are major contributors to quality of life. Management of PD for the non-neurologist Basic Pharmacology Basic Pharmacokinetics Drugs largely affect the dopaminergic systems Carbidopa/Levodopa Dopamine agonists MAO-B Inhibitors COMT Inhibitors Amantadine Levodopa has a short half-life. Absorption from gut and transport to brain is affected by food. Motor fluctuations: clinical state changes minute to minute on off dyskinesia

9 Off On Medication Interactions: Antiemetics Medication Interactions: Antipsychotics Anti-Emetic LIMITED OPTIONS NO typical anti-emetics, such as Reglan or Compazine Only allowable anti-emetics: Ondansetron / Zofran Trimethobenzamide / Tigan Anti-psychotic treatment LIMITED OPTIONS AVOID TYPICAL AND ATYPICAL ANTIPSYCHOTICS SUCH AS HALOPERIDOL AND RISPERIDONE Use quetiapine/seroquel or

10 PD: SUDDEN DETERIORATION PD: Keep PD Patients Moving Clinical manifestations Confusion, hallucinations Falls Deterioration in ADLs Causes Infection (UTI, respiratory, other) Impaction (reduced colic-gastric reflex) Inadvertent or inappropriate drug changes. Treat comorbidities Use PT, OT, ST and psychologists Encourage physical and cognitive activities Recognize hospitalizations are problematic for people with PD Conclusions You are critical to care of people with PD! You: Will be the first to suspect the diagnosis Will encounter many of the non-motor features of PD Will manage various aspects of care for PD patients