L4 Advanced PD

Question 1

Late Stage PD is stages (Hoehn and Yahr Scale)…

Answer 1

4 and 5

Stage 4: Severe disability, still able to walk or stand unassisted

Stage 5: w/c bound or bedridden unless assisted

Question 2

Carbidopa-levodopa Side effects

Answer 2

GI disturbances
orthostatic hypotension
psychiatric problems

Question 3

Levodopa

Answer 3

most effective drug for treating PD

broken down into dopamine the brain can use after cross the BBB

Question 4

Carbidopa

Answer 4

decarboxylase inhibitor that prevents that breakdown of levodopa to dopamine in PNS

Question 5

Difficulties with levodopa therapies over time

Answer 5

• 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

Question 6

Wearing-off phenomenon for levodopa

Answer 6

• describes the recurrence of motor and non-motor s/s during levodopa-free interval
• affects nearly all pts within 10 years of starting meds

Question 7

RF for developing wearing off phenomenon

Answer 7

• younger age at presentation of initial s/s
• female
• long-duration of tx w/levodopa
• higher doses of levodopa
• use of dopamine agonists

Question 8

Exam timing in PTs with PD

Answer 8

• 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

Question 9

Common off times

Answer 9

• 1st thing in the morning
• between doses of levodopa
• can be gradual or like a switch

Question 10

Levodopa Induced Dyskinesia

Answer 10

• 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

Question 11

RF for levodopa-induced dysfinesia

Answer 11

• 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

Question 12

DBS for PD

Answer 12

• 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

Question 13

Who is a candidate for DBS?

Answer 13

1. pts with uncontrollable tremor for whom meds have not been effective
2. pts with s/s that respond well to meds but who, when drugs wear off, experience severe motor fluctuations and dyskinesias, despite medication adjustments
3. pts whose movement symptoms might respond to higher or more frequent med doses, but are limited to do so because of side effects

Question 14

Other S/S associated with advanced PD

Answer 14

1. Dysphagia and aspiration pneumonia
2. Depression
3. Cognitive Decline
4. Sleep dysfunction
5. GI dysfunction
6. Urinary Tract Dysfunction

Question 15

Dysphagia and aspiration pneumonia

Answer 15

• 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

Question 16

Dysphagia S/S

Answer 16

• report of coughing when eating or drinking
• observed coughing with eating or drinking
• silent aspiration

Question 17

Aspiration pneumonia CP

Answer 17

• dyspnea
• fever
• hypoxemia
• fatigue

Question 18

Depression

Answer 18

• 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

Question 19

Cognitive Decline

Answer 19

• 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

Question 20

Sleep Dysfunction

Answer 20

• 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

Question 21

GI Dysfunction

Answer 21

• very common in PD, earliest manifestations
• 50% have constipation with increasing frequency with advancing disease

Question 22

Urinary Tract Function

Answer 22

• 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

Question 23

Secondary Impairments of PD

Answer 23

• Decreased ROM in jts throughout body
• weakness
• flexed posture
• pain
• falls
• bowel and bladder dysfunction
• hypophonia and dysphagia

Question 24

Decreased ROM due to

Answer 24

rigidity
bradykinesia

Question 25

Weakness due to

Answer 25

bradykinesia leads to disuse atrophy

Question 26

Flexed posture due to

Answer 26

• bradykinesia, leads to disuse of postural mm
• weakness, gravity pulls into flexed position
• impaired sensory integration, less awareness of posture

Question 27

Falls due to

Answer 27

• rigidity
• bradykinesia
• freezing
• inflexible program selection
• impaired sensory integration
• reduced executive function and attention

Question 28

Bowel and Bladder dysfunction

Answer 28

• constipation from immobility
• bladder incontinence due to pelvic floor weakness from immobility

Question 29

Hypophonia and Dysphagia due to

Answer 29

• voice muscle weakness
• chew and swallow muscle weakness

Question 30

Activity and Participation Limitations for PD

Answer 30

• 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

Question 31

PT Exam for PD

Answer 31

• movement analysis to identify constraints of mobility
• measurement to quantify secondary impairments
• cognitive screening of MOCA/MMSE
• outcome measures

Question 32

outcome measures for stage 4

Answer 32

gait outcomes like 6 MWT, 10MWT, TUG, TUG dual, Freezing of Gait, Four square

Question 33

outcome measures for stage 5

Answer 33

fewer options
care tool, description of assistance, DME

Question 34

PT Treatment for Maintenance

Answer 34

• 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

Question 35

Supportive Care for PD

Answer 35

• s/s mangement
• caregiver training
• DME to decrease caregiver burden with mobility tasks
• palliative care team and other supportive services

Question 36

Low Cost external cues

Answer 36

• 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

Question 37

External Cues

Answer 37

• 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