Challenges w/ Medical Management - Parkinson's Flashcards
sinemet can cause
DYSKINESIA
orthosatic hypotension
behavioral signs
behavioral signs –> sinemet
confusion
hallucinations
paranoia
psychosis
do all pts respond to sinemet
no!
1/3 respond for a lifetime
1/3 for 3-5 years
1/3 for 5-7 years
on/off phenomenon
short duration therapeutic response followed by rapid decline in symptomatic relief
what is the on/off phenomenon d/t
PD meds are toxic to the receptor sight
what does the on/off phenomenon do overtime
grows more dramatic
“on” time becomes shorter
what does the “off” time have
dyskinesia or severe bradykinesia
what other phenomenon is there
“wearing off”
when is PT attempted
“on” times
how can we manage hypertonia
botox injections
botox injection effects
are temporary
surgical approaches
ventrolateral thalamotomy
pallidotomy
intracranial electrical stimulation
ventrolateral thalamotomy
used for pts that have severe motor sxs
refractory to medical tx
B thalatomy
tried for pts w/ B tremor
resulted in severe speech deficits
intracranial electrical stimulation
experimental use of low level stimulators w/ promising results
deep brain stimulation
surgical placement of electrodes into brain regions that control movement
what does DBS allow
electrical stimulation to the area of altered brain activity
what does DBS normalize
pattern of electrical activity w/in specific brain motor circuits
how are the brain regions chosen –> DBS
specific brain sites chosen for specific problems
DBS on one side of the brain
mainly affects sxs on the opposite side of the body
can have B/L DBS if sxs on both sides
DBS inclusion criteria (1)
Dx of IPD
response to L-dopa
medical therapy optimized or limited
disabling tremor, dyskinesia or motor fluctuations
DBS inclusion criteria (2)
no dementia or unstable co-morbid medical problems
appropriate pt expectations
adequate support & compliance
tremor is the primary symptom
DBS exclusion criteria
absolute and relative
absolute DBS exclusion criteria
atypical parkinsonism
lack of response to L-dopa
dementia
unstable co-morbid conditions including behavioral problems
relative DBS exclusion criteria
presence of other CNS dz or brain atrophy
cognitive dysfxn
coagulopathies
unrealistic expectations for outcome
when is first programming for DBS begin
1 month post implantation
when does programming occur
every month until optimized
what is required –> DBS management
annual maintenance checks
what could switch off the DBS generator
any magnetic field
what are contraindicated post implantation
MRI and diathermy
PD is
progressive
death usually occurring secondary to complications
how could outcomes be divided
postural instability/gait disturbed
tremor pre-dominant
tremor pre-dominant
better prognosis
reflecting a slower progression of the destruction of the substantia nigra cells
recent theories in management
fetal nigral or adult adrenal medulla transplants
stem cells from umbilical cord blood or fetal cells
