parkinson disease: guidelines for providers · pdf fileparkinson disease: guidelines for...

PARKINSON DISEASE: Guidelines for providers

Treating the Symptoms we CAN and CANNOT see

Alana Cozier MD, MS

BACKGROUND Parkinson Disease (PD):

--Chronic, progressive, neurodegenerative disorder

--most common after Alzheimer’s disease.

--1-2 million people in United States suffer from PD (3% population older than 85 years)

--Age is strongest risk factor.

BACKGROUND

BACKGROUND cont

• The annual economic impact of Parkinson’s disease is estimated at $10.8 billion

>>direct medical cost, prescription drug use and nursing home care

• Besides the importance of economic costs of PD is also the discussion of the impact on Health related quality of life (HRQOL)

BACKGROUND cont

• Improving the quality of medical care and how to pay for medical care are currently in the national spotlight

• Recently, the American Academy of Neurology (AAN) has released practice parameters to address quality of care issues in Parkinson’s Disease

– They identified ten PD measures and highlighted both the content of the measure as well as how frequently the measure should be ascertained in the clinical setting

10 Parkinson disease measures

Was the diagnosis of PD reviewed in the past year? Was the patient assessed for psychiatric disorders or

disturbances? Was the patient assessed for cognitive impairment or

dysfunction? Was the patient queried for symptoms of autonomic

dysfunction? Was the patient queried for symptoms of sleep disturbances? Was the patient questioned about falls? Was the patient educated about rehabilitation services? Was the patient assessed for safety issues? Was the patient questioned about motor complications of

medications? Was the patient offered a review of medication and surgical

treatment options?

CLINICAL FEATURES OF PD:

--1.) Resting tremor

--2.) Slowness of movement (bradykinesia)

--3.) Rigidity and/or postural instability

Classically starts asymmetrically but contralateral side eventually affected.

CLINICAL FEATURES OF PD:

Resting tremor:

--most common presenting symptom

--rhythmic oscillatory involuntary movement (“pill-rolling”)

--usually distal upper extremities (LE, face, chin)

--noticeable when speaking, walking, distracted or stressed

CLINICAL FEATURES OF PD:

Bradykinesia:

--difficulty initiating and maintaining movement

--loss of manual dexterity with fine motor tasks

--increase in time needed to complete ADLs

--ex micrographia, hypophonia, hypomimia, masked facies, decreased arm swing

CLINICAL FEATURES OF PD:

Rigidity:

--increased resistance to passive movement of muscle across a joint (lead pipe)

--together with tremor >> “cogwheeling”

--can be augmented with distracting maneuvers (ex. have patient perform task with other limb)

CLINICAL FEATURES OF PD:

Postural Instability/gait disturbance:

--less prominent early in disease (dragging leg, stooped posture)

--later on festination, freezing gait, loss of postural reflexes

>>leads to falls

MEDICAL MANAGEMENT of PD

--dopaminergic agents remain the principal therapy

1.)LEVODOPA: (mainstay)

--combined with carbidopa

--AE: nausea, vomiting,

Drowsiness, dizziness,

Hypotension, hallucinations, dyskinesias, wearing off

STARTING DOSE:

Sinemet 25/100mg PO BID-TID

MEDICAL MANAGEMENT of PD 2.) COMT inhibitors: ex entacapone (comtan), tolcapone (tasmar)

--use with levodopa

--extends half life of levodopa (1-2.5 hrs)

>>reduces OFF time

--AE: nausea, vomiting, diarrhea, pysch

STARTING DOSE:

Entacapone: 200mg with BID (with each dose of sinemet)

Tolcapone: 100mg TID

MEDICAL MANAGEMENT of PD

3.) Dopamine Agonists: ex ropinirole (requip), pramipexole (mirapex), neupro

--can be used as monotherapy

--AE: lethargy, compulsive behavior (gambling,

punding, impulse control, peripheral edema)

MEDICAL MANAGEMENT of PD

4.) MOA-B inhibitors: ex rasagiline (Azilect)

--increase half life dopamine

>>less wearing off

--AE: dopamine overdose

NON MOTOR SYMPTOM MANAGEMENT

1.) DEPRESSION:

--SSRIs and SNRIs

2.)DEMENTIA:

--Rivastagmine (Exelon)

--Memantine (Namenda)

3.) HALLUCINATIONS:

--Quetiapine (seroquel)

--avoid typical anti-pyschotics (haldol)

4.) REM sleep disorder (Periodic Limb Movements of sleep)

--clonazepam QHS

>>Insomnia:

--melatonin

--DBS

NON MOTOR SYMPTOM MANAGEMENT cont

5.) RESTLESS LEG:

--sinemet, dopamine agonists

6.) URINARY INCONTINENCE:

--apomorphine?, anti-cholinergics?

7.) ORTHOSTATIC HYPOTENSION:

--fludrocortisone, indomethacin, domperidone?

8.) FATIGUE:

--methylphenidate

9.) CONSTIPATION:

--polyethylene glycol

10.) ERECTILE DYSFUCTION

--sildenafil

PRACTICE PARAMETERS?

• Compliance with these practice parameters may become critical for healthcare delivery reimbursement

• As these parameters are a surrogate for HRQOL and quality of medical care , refined documentation may also become a manifestation of improved care of PD patients

CLINICAL SITUATIONS? The following are examples of clinical diagnoses that

worsen PD symptoms with inpatients 1.) INFECTIONS >>UTIs, PNA, COPD/CHF exacerbations, sepsis from any

cause 2.) STROKE 3.) Abrupt discontinuation of PD meds 4.) Pain from any source 5.) Delirium (sundowning), anxiety, stress 6.) Iatrogenic

REFERENCES

• Hirtz D, Thurman DJ, Gwinn-Hardy K, Mohamed M, Chaudhuri AR, Zalutsky R. How common are the “common” neurologic disorders? Neurology. 2007; 68:326-337

• Dorsey ER, Constantinescu R, Thompson JP, et al. Projected number of people with Parkinson disease in the most populous nations, 2005 through 2030. Neurology. 2007; 68:384-386

• 0’Brien JA, Ward A, Michels SL, Tzivelekis S, Brandt NJ. Economic burden associated with Parkinson disease. Drug benefit Trends. 2009; 21(6):179-190

• Hely MA, Morris JG, Reid WG, Trafficante R. Sydney mutlicenter study of Parkinson’s disease: non-L-dopa-responsive

problems dominate at 15 years. Mov Disord; 2005; 20(2): 190-199 • Centers for Disease Control and Prevention. Measuring Healthy Days: Population Assessment of Health-Related Quality of

Life. Atlanta GA; CDC: November 2000. • Karlsen KH, Tandberg E, Arsland D, Larsen JP. Health related quality of life in Parkinson’s disease: a prospective longitudinal

study. J Neurol Neurosurg Psychiatry. 2000:69(5):584-589 • Cheng, E.M. et al. Quality improvement in neurology: AAN Parkinson disease quality measures: report of the Quality

Measurement and Reporting Subcommittee of the American Academy of Neurology. Neurology. 2010;75:2021-2027

• Zesiewicz, T.A. et al. Pratice Parameter: Treatment of non motor symtpoms of Parkinson Disease: : report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology. Neurology. 2010;74:924-931

THANK YOU FOR YOUR TIME!

QUESTIONS?