PARKINSON’S DISEASE

1. PARKINSON’S DISEASE Mustafa Saad Siddiqui, MD Assistant Professor Neurology & Neurosurgery Director Parkinson’s & Movement Disorders Program Wake Forest University School of Medicine North Carolina, USA WHAT I NEED TO KNOW AS A PATIENT AND A CAREGIVER

2. Topics • What is Parkinson’s disease (PD)? • What causes PD? • Is PD hereditary? • What are the motor features of PD? • What are the non-motor features of PD? • What should I expect in advanced PD? • Is there a cure for PD • Why are my medications no longer working as well? • Can surgery help me?

3. Parkinson’s Disease is increasing • Affects 1 in 100 older than 60 years • 5-10% diagnosed with PD are less than 40 yrs old • No social, ethnic or geographical boundaries Projected Increase in Prevalence of PD by 2030 Dorsey et al.2007

4. What is PD • Slowly progressive, degenerative disease • Leads to gradual loss primarily of dopamine producing neurons in brain called substantia nigra • Combination of genetic and environmental factors. • Age is the only definite risk factor

5. PD vs Parkinsonism • Four cardinal features of Parkinsonism are; • Slowness (bradykinesia) • Stiffness (rigidity) • Shaking (tremor) • Trouble balancing (postural instability) • PD is the most common form of Parkinsonism • However not every patient with Parkinsonism has PD. • A number of other disorders can present with Parkinsonism and can mimic PD in early years

6. PD vs Parkinsonism (cont’d) • The disorders which mimic PD include many diseases collectively called atypical Parkinsonism or Parkinson plus syndromes. • Up to 15% patients originally diagnosed as PD turn out to have atypical Parkinsonism after the initial few years • Atypical Parkinsonism patients do not respond well to PD medications and usually have faster progression of disease. • Diagnosis of PD is made on clinical grounds, usually by a neurologist.

7. Clinical Features of PD • Tremor: • Present in 70% • Resting tremor • Starts on one side and then involves the other side as disease advances • Tremor dominant PD has a slower progression of disease • May get a partial or incomplete response from medications • Bradykinesia (Slowness) • Difficulty in turning in beds, brushing teeth, cutting food, getting up from the chair • If slowness dos not improve with levodopa or Sinemet, diagnosis of PD becomes doubtful. • Rigidity: (Stiffness) • Gait dysfunction; • Slowness, difficulty initiating and when started difficulty stopping • Stooped posture • Shuffling gait • Freezing gait

8. Non-Motor Features of PD • MIND, MOOD AND MEMORY • Depression • Memory problems and dementia • Anxiety and panic attacks • Impulse control disorder (especially after taking Requip / Mirapex) • Get easily emotional • SLEEP • wake up at night when medication effect is wearing off • Restless legs • Act out their dreams • Excessive sleepiness in day • AUTONOMIC • Sweating, feeling hot and cold • low BP on standing up • Problem in erection • SENSORY • Pain

9. CLINICAL PROGRESSION OF PD • PRE-CLINICAL STAGE • REM Behavior Disorder • Loss of smell • Constipation, ED, • low BP, urinary freq • Biomarkers: Smell test, MIBG scan, SPECT, PET • EARLY STAGE • One sided symptoms • Slowness • Masked face • (Stiffness) Rigidity • Shaking (Resting tremor) • Dystonia • Shuffling gait • LATE STAGE • Symptoms on both side • Involuntary dancing movements • Motor (On-off) fluctuations • Speech problems • Some difficulty in swallowing • Poor memory (dementia) • Hallucinations, confusion • Falls • Freezing of gait The pace of disease in every patient is different

10. Motor Fluctuations

11. Motor (On-off) FluctuationsSeen in Advanced PD • Dyskinesias: • “Dancing movements after pills kick in” • Wearing off: • “ PD symptoms come back before the next pill is due” • On-Off Phenomenon: • On: When Meds relieve symptoms • Off: When Meds do not relieve PD symptoms • “PD symptoms are like a yo-yo all day” • Dose failures • “ Pill takes ‘forever’ to kick in and sometimes none at all” • Freezing gait • “Foot tends to get stuck to the floor when trying to walk”

12. KEY POINTS TO UNDERSTAND IN PD TREATMENT • Can be effectively treated but no cure yet • Neuroprotection? Many treatments are proposed but none is proven. • Many medication options available • Every PD patient is unique and so are the treatments. • What works out for one person might not be the best option for the other.

13. PD Medications cont’d • Meds improve the main features of PD including rigidity, slowness, walking • Tremor may be less responsive or sometimes not responsive to medications • Good treatment benefit for approximately 5 years with regular adjustments of medications • Afterwards, symptoms can be more difficult to control and some patients can experience medication related side effects.

14. Common Side Effects of Medications(varies from one drug to another) • Nausea • Excessive somnolence • Hallucinations • Lowering of BP • Dyskinesias: involuntary dancing movements of limbs and neck • Mental Confusion Most side effects can be well controlled with medication adjustments

15. Treatment of PD is a balancing act

16. How Can You Help Your Doctor Optimize Your Treatment • Understand your PD symptoms and commonly used PD terms • Understand medication side effects (almost all can be managed with adjustments) • Make notes prior to your appointment. • Think what have been your most bothersome problems in the last one week • Is there a pattern to your problem; when does it happen after taking of pills and when does it resolve. Make a diary of your last one week before apt. • Take someone with you to the appointment who can take notes • Take your medications with you and write down the exact dose and time you take them. • Before calling a doctor’s office, know the PD medications you take, their dosages and their time.

17. Treatment of Parkinson’s Disease • Neuro-protective therapy; are we there yet? • Non-pharmacologic therapy • Medical therapy • Motor symptoms • Non motor symptoms • Surgical therapy • Over the counter / herbal treatments • Restorative treatments- experimental only

18. PD Medications • Current PD drugs • Sinemet: Levodopa/Carbidopa • Requip: • Mirapex • Amantadine • Eldepryl: Selegeline • Azilect: Rasagiline (new) • Permax • Parlodel • Artane: Trihexiphenydyl • Cogentin: Benztropine • Stalevo • Comtan • Tasmar • Apomorphine

19. Surgical Treatment • Considered when medications fail to provide satisfactory alleviation of PD symptoms • Can effectively treat most but not all motor symptoms of PD DBS vs Lesion Therapy

20. DBS

21. Supportive Treatment • Physical and occupational therapy • Speech therapy • Exercise • Nutrition • National websites for PD • www.parkinson.org • www.pdf.org • http://wemove.org • http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_disease.htm • http://www.apdaparkinson.org/user/index.asp • Support groups

22. Restorative Therapy(Experimental) • Intraputaminal GDNF, BDNF • Gene therapy • Stem cell therapy • Fetal tissue transplantation

23. Members of a Parkinson’s Disease Program • Neurologist specialized in Parkinson’s & Movement Disorders. • Nurse: specialized in Parkinson’s disease • Speech therapist • Physical and Occupational therapist • Clinical trials for newer PD treatments • Education

24. Plenty of Hope for Future • PD is one of the most researched neurological diseases • Very effective medical and surgical treatments • Stem cells, gene therapy, growth factors hold promise • Understanding your PD, only can help you make the best treatment choices

25. Thank You Be a fighter and never lose hope