Faculty. Joseph Friedman, MD - PDF Free Download

Faculty Claire Henchcliffe, MD, DPhil Associate Professor of Neurology Weill Cornell Medical College Associate Attending Neurologist New York-Presbyterian Hospital Director of the Parkinson s Institute at the New York- Presbyterian Hospital/Weill Cornell Medical Center New York, NY Joseph Friedman, MD Director Movement Disorders Program Director, Movement Disorders Program Butler Hospital Professor (Clinical) and Chief Division of Movement Disorders Department of Neurology Alpert Medical School of Brown University Providence, RI 1

Activity Planner Allison Gardner, PhD Director, Educational Strategy and Content Med-IQ Baltimore, MD Motor and Nonmotor Features of PD Tremor Bradykinesia Rigidity Wearing off Dyskinesias Falls Freezing MOTOR PRE-DIAGNOSIS EARLY PD MODERATE PD ADVANCED PD Constipation Hyposmia RBD Mood Nonmotor offs Mood Dementia NONMOT TOR Diagram courtesy of C. Henchcliffe. 2

Conditions Commonly Misdiagnosed as PD Condition Essential Tremor Vascular Parkinsonism Drug-Induced Parkinsonism Dementia With Lewy Bodies Atypical Parkinsonism* Clinical Features Relatively symmetric postural and action tremor, affects arms more than legs, may also affect head and voice; family history common May have gradual or stepwise progression with poor response to carbidopa/levodopa; typically causes "parkinsonism from the waist down" (ie, mostly gait dysfunction); little or no tremor Clinical features similar to PD; drug history and drug withdrawal evaluation can confirm diagnosis; dopamine receptor blocking antiemetics and psychotropic drugs most common causative agents Onset of motor symptoms preceded or accompanied by dementia and visual hallucinations; fluctuations in attention and cognition; poor response to carbidopa/levodopa Clinical features similar to PD, but with other signs including prominent gait and speech impairment, prominent postural instability; absence of resting tremor; prominent autonomic dysfunction; abnormal eye movements; poor response to carbidopa/levodopa * Includes progressive supranuclear palsy, corticobasal degeneration, and multisystem atrophy Gazewood JD, et al. Am Fam Physician. 2013;87:267-73. Reasons to Diagnose PD Early Helpful for planning Reduces unnecessary testst Reassures patients and family that the issues and symptoms are real Enables patients to be available for research studies Enables patients to get involved in PD support activities Helps patients t and families understand d the many challenges encountered when living with PD However, no available PD treatment has been definitively shown to have a neuroprotective effect Ng DC. West J Med. 1996;165:234-40; Olanow CW, et al. Neurology. 2009;72(suppl 4):S1-S136. 3

Agents for the Initial Treatment of PD Class Agents Side Effects Dopaminergic Agents Carbidopa/ levodopa Drug-induced motor complications: dyskinesia, medication wearing-off effect, oscillations in motor performance with prolonged use Nausea, somnolence, hallucinations, vivid dreams, illusions, hypotension Dopamine Agonists MAO-B Inhibitors NMDA Antagonist Rotigotine Pramipexole Ropinirole Selegiline* Rasagiline Amantadine Somnolence with excessive daytime sleepiness, sudden-onset sleep, hallucinations, peripheral edema Dopaminergic side effects: nausea, vomiting, postural hypotension Impulse-control disorders (eg, pathologic gambling, hypersexuality, binge eating) Generally well tolerated Selegiline: dry mouth, insomnia, nausea, dizziness, headache, benign cardiac arrhythmias Rasagiline: flu syndrome, arthralgia, depression, dyspepsia, potential risk of adverse food/drug interactions Hallucinations, confusion, dizziness, nausea, vomiting, anxiety, insomnia, nervousness, edema, livedo reticularis in the legs * Not FDA approved as monotherapy Watts R, et al. Movement Disorders. 3 rd ed. New York, NY; Schapira AH, et al. Ann Neurol. 2008;64(Suppl 2):S47-S55; www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm. Levodopa-Associated Motor Complications Prevalence and Onset Wearing off: 25% of patients after 6 months 50% of patients after 18 months Dyskinesias: 10% of patients after 6 months 25% of patients after 18 months Risk Factors Young age at onset of PD Greater severity or longer duration of disease Longer duration of exposure to levodopa Exposure to high doses of levodopa Parkinson Study Group. Ann Neurol. 1996;39:37-45; Fahn S, et al. N Engl J Med. 2004;351:2498-508; Espay AJ. Neurol Clin. 2010;28:913-25. 4

Nonpharmacologic Options: Exercise-Based Therapies Resistance training, treadmill exercise, Tai Chi, dance, bicycling, and others Clinical evidence supports multiple beneficial effects of exercise among patients with PD Physical functioning Leg strength Balance Gait speed Health-related quality of life Potential for favorable effects on cognition Identified barriers to exercise among ambulatory patients with PD: low outcome expectations, lack of time, and fear of falling Shulman LE, et al. JAMA Neurol. 2013;70:183-90; Kannus P, et al. Lancet. 2005;366:1885-93; Li E, et al. N Engl J Med. 2012;366:511-9; Snijders AH, et al. Mov Disord. 2011;26:367-71; Suchowersky O, et al. Neurology. 2006;66:976-82; Ahlskog JE. Neurology. 2011;77:288-94; Ellis T, et al. Phys Ther. 2013;Feb 21 [Epub ahead of print]. Role of the PCP in PD Management PCPs have a vital role in: Initially identifying symptoms consistent with PD Making a referral for neurologic evaluation and/or appropriate tests when necessary Identifying and treating nonmotor symptoms of PD as well as raising the alarm on nonmotor complications of PD therapy (psychotic symptoms, sleep disorders, impulse-control problems) Coordinating the care for a complex disorder that affects patients and care partners function, safety, and quality of life Many patients with PD have limited access to specialists; therefore, good foundational knowledge in PD care is critical for PCPs Ng DC. West J Med. 1996;165:234-40; Dall TM, et al. Neurology. 2013;April 17 [Epub ahead of print]. 5