PD and Movement Disorders Flashcards
What is PD?
Progressive neurodegenerative disorder
Epidemiology of PD
Most common movement disorder
Incidence increases with age (mean age of Dx is 70 years)
More males affected than females
Natural Hx of PD
Disability occurs at all stages of the disease but severity of disability increases with disease duration
Mrs D, 70, living at home with her husband, admitted for 3/52 of worsening motor Sx of PD
Previously walked unaided and independent with ADLs but currently bedbound and needing help from husband to get up from bed/chair, brush teeth and bathe
Husband, 75, previously in good health, has been married to Mrs D for 50 years and they have a good relationship, but he is finding it more difficult physically as his wife needs much more help with personal care and mobility; his back is sore, especially after trying to lift his wife after a fall and he is much more tired, as well as being worried about her (he has been asking his daughter to assist with shopping and stopped going to bingo as he cannot get his wife into the car easily)
PD diagnosed 6 years ago after presenting with rigidity and bradykinesia (no tremor), on Madopar (levodopa and benserazide) 200/50 mg every 3.5 waking hours; sees neurologist in movements disorders clinic and has had multiple hospital admissions related to medication complications
What are the cardinal features of PD?
Tremor
Bradykinesia
Rigidity
Postural instability
Mrs D, 70, living at home with her husband, admitted for 3/52 of worsening motor Sx of PD
O/E: normal orientation/attention/memory, normal oculomotor exam, masked facies, speech monotonous and low volume, no resting tremor, asymmetrical cogwheel rigidity and bradykinesia (R more affected than L), slow hesitant foot tapping, normal power and sensation in limbs but unable to fasten buttons or tie laces, no dyskinesia/dystonia
What gait abnormalities may be seen in PD?
What other special test can be done for PD?
Reduced speed and stride length
Narrow base of support
Forward trunk flexion
Reduced arm swing
Short, shuffling steps
Festination, freezing
Difficulty turning, changing direction, stepping over or moving around objects
Pull test: staggers backwards multiple steps when pulled (retropulsion)
What is dyskinesia? How does it present and how is it treated?
Reversible levodopa-induced motor complication (present in 30-40% of pts on levodopa for 5 years, nearly 60% by 10 years)
Abnormal involuntary movements (choreic, dystonic, ballistic, myotonic)
Treat by adjusting levodopa dosing
What is dystonia? How can it be distinguished from dyskinesia and what is the cause?
Involuntary muscle contraction involving abnormal movements and postures
More sustained abnormal posture than dyskinesia
Can be an undertreated PD motor symptom or a complication of levodopa treatment
Mrs D, 70, living at home with her husband, admitted for 3/52 of worsening motor Sx of PD
Constant rigidity and bradykinesia, not relieved by 3 hourly oral Madopar, but no unpredictable “on-off”, no episodes of freezing and no dyskinesia
Rx: commenced on low dose Madopar (levodopa/benserazide) at Dx (1/4 tablet QID), but 2 years later became immobile before next dose (i.e. “wearing-off” but no unpredictable “off” periods) so neurologist increased dose and frequency to 3-hourly - this was tolerated well with improvement in Sx and no dyskinesia
What is levodopa? What is its mechanism of action and its adverse effects?
Mainstay of PD treatment: most effective for hypokinetic motor Sx, tremor and rigidity, but less effective for postural instability
Replaces DA via prodrug (levodopa)
Always combined with peripheral decarboxylase inhibitor (benserazide) to minimise peripheral conversion to DA and adverse effects resulting from this
AEs: nausea, abdominal cramping, diarrhoea, somnolence, dizziness and headache, confusion, hallucination, delusions, agitation, psychosis, orthostatic hypotension
Complications of levodopa
50% of patients on levodopa for 5 years experience motor fluctuations and dyskinesia
Wearing-off: end-of-dose effect
On-Off syndrome: episodes of unpredictable “off”, alternating with “on” (+/- dyskinesia)
Failure to turn “on” (“no-on”): due to excessively prolonged or severe “off” period
Acute akinesia: sudden exacerbation of PD, akinetic state lasting for days and not responding to anti-Parkinson medications
Sinemet/Kinson
Levodopa + carbidopa (inhibitor)
PD medications
Levodopa (DA prodrug) + peripheral DA decarboxylase inhibitor
COMT inhibitors
Selective MAO type B inhibitors (MAOI)
DA agonists (DA)
Anticholinergics
Amantadine
What are the non-motor features of PD?
Orthostatic hypotension and falls
Urinary frequency
Constipation
Mrs D, 70, living at home with her husband, admitted for 3/52 of worsening motor Sx of PD
Constant rigidity and bradykinesia, not relieved by 3 hourly oral Madopar, but no unpredictable “on-off”, no episodes of freezing and no dyskinesia
DDx for Mrs D’s deterioration?
Reduced levodopa response and motor fluctuations: “wearing off” and/or “failure to turn on”, ?acute akinesia
Underlying systemic infection or intercurrent medical problems (?UTI)
Malnourishment
Dehydration
Deconditioning
Mrs D, 70, living at home with her husband, admitted for 3/52 of worsening motor Sx of PD
Constant rigidity and bradykinesia, not relieved by 3 hourly oral Madopar, but no unpredictable “on-off”, no episodes of freezing and no dyskinesia
Also bothered by orthostatic hypotension, urinary frequency and constipation
Treatment goals?
Motor Sx Mx: several options (in this case apomorphine, a DA agonist, infusion is commenced, together with the anti-emetic domperidone), keep movement chart to monitor motor response as an inpatient
Hydration and nutrition
Dx and treat infection
Treat constipation (bowel program and aperients)
Reconditioning, improve mobility and function (PT and OT involvement, recommend inpatient rehabilitation)
Psychosocial support
Dietitian involvement: meal supplements, regular small meals, avoid large high-fat meals (which slow gastric emptying), schedule protein intake away from levodopa dose
What is the difference between GEM and rehabilitation?
GEM (geriatric evaluation and Mx): “slow stream”, multidisciplinary rehab under geriatrician
Rehabilitation: “fast stream” rehab with daily intensive multidisciplinary therapy under rehab physician
What are the criteria for admission to “fast stream” rehab?
Wants to participate: gives consent, motivated
Can participate, can learn: tolerates 3 hours of therapy per day, medically and psychiatrically stable, cognitive ability to learn and carry over
Has goals: working towards something, functional gains in set time-frame
What are the main goals of rehabilitation?
Prevent complications
Maintain/optimise function, mobility and self-care skills
Educate patient and carers, provide counselling and support
Facilitate community reintegration
What is the evidence for rehabilitation in PD?
General consensus is that PD patients benefit from multidisciplinary rehabilitation and an exercise program focussing on improving ROM, endurance, balance and gait
Gains are not sustained after therapy is discontinued (rehabilitation does not alter the underlying pathology of chronic neurological disorders)
Possible role for long term rehab programs or regular “booster” therapy sessions?
Who may be involved in the rehabilitation team for a pt with PD?
Patient and family
Rehab physician
OT
Social worker
RDNS
PD support group
Psychologist/neuropsychologist
Neurologist
Gastroenterologist
Neurosurgeon
Speech pathologist
PT
Dietician
PD and rehab nurse
How can mobility in PD be improved?
Individual and group PT focussing on:
Flexed, stooped posture
Gait/walking and transfers
Balance
General fitness (address deconditioning)
Setting up a home exercise program to maintain gains
How can flex, stooped posture in PD be improved?
Teach proper posture and trunk extension, breathing exercises
Stretching and ROM exercises (may also help with pain/dystonia)
How can gait/walking and transfers of PD patients be improved?
Widen the stance, increase base of support (walking frame may be needed)
Conscious strategies to initiate gait and maintain cadence (mental rehearsal, counting and singing, marching to rhythm)
Strategies such as rocking to and fro in the chair before rising
How can ADLs of PD patients be improved?
Functional UL training to improve fine motor skills, motor control and dexterity (most effective when task specific)
Provide adaptive aids (e.g. large-handled cutlery, plate guards, built-up pens, velcro instead of buttons and laces)
Teach compensatory strategies
Teach fatigue Mx strategies, relaxation and breathing exercises
Discuss OT driving assessment and retraining of driving skills
Home assessment: removal of floor rugs, proper lighting at night, non-skid surfaces in the bathroom, grab rails, raised chair and toilet seat, commode by bedside
List 5 ways in which falls risk of PD patients can be addressed
Improving posture, gait and balance
Teaching how to break a fall and technique to rise from floor
OT home modifications and assistive equipment
Optimising medications
Addressing orthostatic hypotension
How can orthostatic hypotension in PD be managed non-pharmacologically?
Teaching profiling strategies (rise slowly from a supine/sitting position)
Avoid sudden postural chanes, prolonged recumbence
Elevate head of bed
Use of compressive garments, elastic stockings or abdominal binders
Avoid excessive EtOH and large meals, warm temperature and excessive straining
How can orthostatic hypotension in PD be managed pharmacologically?
Salt supplements
Fludrocortisone
In what % of PD patients does orthostatic hypotension occur?
58%
Occurs late
How can bowel and bladder dysfunction in PD be managed?
Constipation: small regular meals with adequate fibre and water, regular bowel program with aperients/suppository
Urinary frequency: treat any underlying UTI, check post-void residual volume, timed voiding, fluid regulation, commode by bed
How can sexual dysfunction in PD be managed? What is it caused by?
Sexual function affected by PD autonomic dysfunction and/or psychological factors
Intimacy training, sexual counselling and strategies (posture, timing of meds)
Speech therapy assessment of Mrs D found mild oropharyngeal dysphagia, no overt aspiration concern and can tolerate pre-morbid soft/thin diet, mild hypokinetic dysarthria with mild dysphonia but communication is functional
Mx?
Modified food texture (soft), optimise head and neck position when swallowing
Speech exercises: emphasise breath and rate control, improving (exaggerating) articulation, and improving control
Ongoing dietitic input: nutrition
When does cognitive dysfunction and dementia occur in PD?
41% prevalence; occurs late, and might not be apparent on a social level in early disease
What kind of dementia is seen in PD?
Subcortical dementia: psychomotor retardation, memory difficulty, executive dysfunction, visuospatial defects
When is neuropsychology assessment recommended for PD patients?
Return to work
Safety to continue independent living or driving (will also need OT driving assessment)
To teach compensatory cognitive techniques (e.g. memory aids) and educates patient and carers
What psychological problems are commonly encountered in PD patients?
Depression (50% of pts; can trial SSRI)
Anxiety
Apathy and abulia (absence of willpower or inability to act decisely): loss of motivation, diminished speech/motor activity and emotional expression, ascribed to frontal lobe dysfunction and basal ganglia lesion
Sleep disturbance
What social problems are often encountered in PD patients?
Social isolation
Inability to drive decreases social access (e.g. to doctors’ appointments, gym, church group)
Loss of role (decreased ability to participate in home chores)
Personal relationship breakdown
Fear of increasing physical incapacitation and dependence on others
Negative stigma about the illness in society
How can psychological and social aspects of PD be managed?
Counselling
Carer support
Services: home help, shopping assistance, half price taxi card
Information RE PD support group to allow interactions with other patients or families with similar experiences, provide access to useful information
What kind of FU might a PD patient require?
Movement disorder clinic
Rehab clinic
LMO
RDNS (to monitor/maintain apomorphine pump if relevant)
Contact number for PD nurse
Dietician
Outpatient community-based PT and exercise group to maintain gains
