L4 Advanced PD Flashcards
Late Stage PD is stages (Hoehn and Yahr Scale)…
4 and 5
Stage 4: Severe disability, still able to walk or stand unassisted
Stage 5: w/c bound or bedridden unless assisted
Carbidopa-levodopa Side effects
GI disturbances
orthostatic hypotension
psychiatric problems
Levodopa
most effective drug for treating PD
broken down into dopamine the brain can use after cross the BBB
Carbidopa
decarboxylase inhibitor that prevents that breakdown of levodopa to dopamine in PNS
Difficulties with levodopa therapies over time
- wearing off, decreased effectiveness of the therapies at the end of period between doses
- induced dyskinesias or excessive movement due to abnormal response to dopamine in system
- manage with extended or sustained release versions of levodopa
Wearing-off phenomenon for levodopa
- describes the recurrence of motor and non-motor s/s during levodopa-free interval
- affects nearly all pts within 10 years of starting meds
RF for developing wearing off phenomenon
- younger age at presentation of initial s/s
- female
- long-duration of tx w/levodopa
- higher doses of levodopa
- use of dopamine agonists
Exam timing in PTs with PD
- Time of day should be consistent to establish accurate baseline
- Time of day should be the same for exam of patient for baseline and all other follow up progress notes
- wearing off will be individual for each patient
Common off times
- 1st thing in the morning
- between doses of levodopa
- can be gradual or like a switch
Levodopa Induced Dyskinesia
- long-term use can lead to motor fluctuations and dyskinesias
- s/s are more likely to start on side of body first impacted
- starts usually after 6 years of treatment with levodopa for about 50% of patients
- more likely in pts with advanced PD s/s
RF for levodopa-induced dysfinesia
- developing s/s of PD at younger ages (40s)
- higher cumulative dose
- low body weight
- natives of north american geographic region
- female
- more severe UPDRS Part 2 score
DBS for PD
- ideal window is when pts are still responding to levodopa but not able to control motor s/s with medication alone
- treats motor s/s like stiffness, tremor, dyskinesias
- allows for lower dose of meds to treat PD
- good for 1-2 years, long term benefit is less clear, but can be up to 10 yrs
Who is a candidate for DBS?
- pts with uncontrollable tremor for whom meds have not been effective
- pts with s/s that respond well to meds but who, when drugs wear off, experience severe motor fluctuations and dyskinesias, despite medication adjustments
- pts whose movement symptoms might respond to higher or more frequent med doses, but are limited to do so because of side effects
Other S/S associated with advanced PD
- Dysphagia and aspiration pneumonia
- Depression
- Cognitive Decline
- Sleep dysfunction
- GI dysfunction
- Urinary Tract Dysfunction
Dysphagia and aspiration pneumonia
- any pt that develops weakness of chewing and swallow muscles due to any a disease will be at risk for dysphagia and aspiration pneumonia
- observing symptoms of aspiration pneumonia and dysphagia would be a reason to refer to a MD/SLP
Dysphagia S/S
- report of coughing when eating or drinking
- observed coughing with eating or drinking
- silent aspiration
Aspiration pneumonia CP
- dyspnea
- fever
- hypoxemia
- fatigue
Depression
- most common nonmotor systems occuring in PD, impacts about 35% of pts
- more frequent in pts with PD than in general elderly population
- key determinant of poor health related QOL
- associated with reduced functioning, cognitive impairment, increased stress for caregivers
Cognitive Decline
- 75-80% will develop dementia after 20 years
- about 25% of pts suffer from mild cognitive impairment in early stages of PD
- hallucinations occur in 20-40%, etiology is unclear
Sleep Dysfunction
- 60-98% of PD pts have nocturnal sleep disturbances
- onset of sleep dysfunction before motor impairment
- can include sleep fragmentation, apnea, restless leg syndrome, period limb movement during sleep, REM sleep behavior disorder
- can also have REM sleep behavior disorder, where they reenact dreams or vigorous movements
GI Dysfunction
- very common in PD, earliest manifestations
- 50% have constipation with increasing frequency with advancing disease
Urinary Tract Function
- Storage Dysfunction related to an overactive bladder contractiity causing increased frequency, urgency, and nocturia
- result of DA deficiency-induced disinhibition and hyperactivation of micturition reflex
Secondary Impairments of PD
- Decreased ROM in jts throughout body
- weakness
- flexed posture
- pain
- falls
- bowel and bladder dysfunction
- hypophonia and dysphagia
Decreased ROM due to
rigidity
bradykinesia
Weakness due to
bradykinesia leads to disuse atrophy
Flexed posture due to
- bradykinesia, leads to disuse of postural mm
- weakness, gravity pulls into flexed position
- impaired sensory integration, less awareness of posture
Falls due to
- rigidity
- bradykinesia
- freezing
- inflexible program selection
- impaired sensory integration
- reduced executive function and attention
Bowel and Bladder dysfunction
- constipation from immobility
- bladder incontinence due to pelvic floor weakness from immobility
Hypophonia and Dysphagia due to
- voice muscle weakness
- chew and swallow muscle weakness
Activity and Participation Limitations for PD
- decline in independence
- decreased ability to perform ADLs
- decreased social interaction due to declining mobility, worsening cognitive function, depression, flat affect
- decreased participation in hobbies and leisure
PT Exam for PD
- movement analysis to identify constraints of mobility
- measurement to quantify secondary impairments
- cognitive screening of MOCA/MMSE
- outcome measures
outcome measures for stage 4
gait outcomes like 6 MWT, 10MWT, TUG, TUG dual, Freezing of Gait, Four square
outcome measures for stage 5
fewer options
care tool, description of assistance, DME
PT Treatment for Maintenance
- exercise and mobility training considerations due to progressive declines in cognition and executive function in later stages of PD
- limit dual task, decrease cognitive load, high repetition, blocked practice
- HEP will be with caregiver, and need more external cues
Supportive Care for PD
- s/s mangement
- caregiver training
- DME to decrease caregiver burden with mobility tasks
- palliative care team and other supportive services
Low Cost external cues
- try another movement
- change direction
- visualize an object on ground in front of you
- use metronome
- humming a song
- count 1-2-3-go
- march in place then step forward
- shift attention then trying harder to avoid freezing
External Cues
- no one specific external cueing strategy is superior over another
- continuous auditory or visual cues may be more appropriate in pts with cognitive or visual-spatial impairments
- retention of benefits from cueing has not been established
- external focus cues may improve performance more than internal focus
