Parkinson’s: More Than a Movement Disorder

1. Parkinson’s: More Than a Movement Disorder Kelly Condefer, MD Neurologist, Movement Disorders Specialist Wenatchee Valley Medical Center

2. Fatigue • Sleep Problems • Autonomic Nervous System Problems • Blood pressure regulation • Constipation • Bladder control • Cognitive impairment

3. Fatigue • Can mean different things and be very hard to describe to your doctor. . • Can be just as severe in early stage Parkinson’s as in later stages.

4. Sleepy. . .

5. “Walking through molasses”. . . Decreased activity tolerance. . .

6. Work with your doctor to determine what might be contributing: Bradykinesia? Medication side effect? Depression? A non-Parkinson’s related issue? Fatigue

7. Lab tests sometimes done to evaluate fatigue: • Blood count • Thyroid function studies • Vitamin D and B12 levels

8. Medications for fatigue? • No “miracle drug” available. • Caffeine • Modafinil • Stimulants • Amantadine

10. Sleep problems in Parkinsons

11. Possible reasons for sleep disruption: • Stiffness causing motor discomfort at night; inability to move in bed. • Waking frequently to urinate. • Nighttime leg cramps or dystonia. • Tremor. • Restless legs syndrome. • REM behavior disorder.

12. Stages of sleep

13. What is a sleep study and when is it necessary? • Any signs of sleep apnea: snoring, pauses in breathing, waking up feeling tired, headaches. • Severe leg movements in sleep, acting out dreams violently.

14. REM sleep behavior disorder • A sleep disorder strongly connected to Parkinson’s (affects up to 47%) • Results in sometimes violent movements in sleep • Can develop years before Parkinson’s

15. Managing the sleep issues. . .

16. Sleep medications: • Melatonin-often helps when circadian rhythm is off. • Short acting sedative/hypnotic: temazepam, alprazolam. • Trazodone: often helps anxiety, depression, and sleep; few side effects. • Amitriptyline, nortriptyline, imipramine: also antidepressants; some help with pain; may cause side effects.

17. Do not nap too often. • Avoid caffeine, nicotine, and alcohol too close to bedtime. • Exercise can promote good sleep. • Avoid large meals close to bedtime. (especially spicy food and chocolate). • Ensure adequate exposure to natural light. • Establish a regular relaxing bedtime routine. Try to avoid emotionally upsetting conversations and activities before trying to go to sleep. Don't dwell on, or bring your problems to bed. • Associate your bed with sleep only. • Make sure that the bedroom is pleasant and relaxing. The bed should be comfortable, the room should not be too hot or cold, or too bright. Adapted from Sleep hygeine recommendations, National Sleep foundation, Michael Thorpy, MD

18. Autonomic nervous system problems in Parkinson’s

19. The autonomic nervous system

20. Examples of autonomic problems in Parkinson’s: • Orthostatic hypotension • Bladder dysfunction • Constipation • Losing sense of smell seems to be related to increased risk of developing these types of issues.*

21. Orthostatic hypotension • The body does not properly maintain blood pressure when standing. • Highest risk of occurring in morning, after large meals, or in heat. • Can occur unexpectedly

22. Symptoms of orthostatic hypotension: • Lightheadedness • Passing out • Severe fatigue or mental slowing • Leg buckling • “Coat hanger” pain over the shoulders and back of neck • Falling asleep suddenly

23. Drugs that can worsen orthostatic hypotension: • Blood pressure medications: • beta blockers (propranolol, metoprolol, atenolol. . .), • calcium channel blockers (diltiazem, verapamil), • Diuretics (hydrochlorothiazide, furosemide) • Drugs used for prostate enlargement (terazosin), • Parkinson’s medications, • Tricyclic antidepressants (amitriptyline, nortriptyline.)

24. Orthostatic hypotension- what to do? • Elevate head of bed on blocks • Eat frequent small meals throughout day • Fludrocortisone and high salt diet; may need potassium supplement • Ibuprofen may help post prandial hypotension • Avoid straining (treat constipation) • Squatting, leg crossing; • Custom fitted elastic stockings; must come up to waist

25. Bladder function in Parkinson’s

26. Basal ganglia normally send signals to the bladder that keep it from contracting too soon. . . Nerve impulses to the bladder

27. Normal bladder function Input from higher centers in brain precisely coordinates the proper contractions and relaxations of muscles to result in normal urinating:

28. What happens in PD? • Malfunctioning brain circuits in basal ganglia cause bladder muscle to contract sooner than it should– causes urge. • Results in going to bathroom frequently, and only emptying small amount of urine. • With bradykinesia, may not make it on time– called urge incontinence.

29. Non-medical treatments: • Do not drink liquids after 4PM. • No caffeine after 2 or 3. • Scheduled voiding throughout the day.

30. Tolterodine (brand name Detrol) – relaxes bladder wall only; might cause difficulty emptying. • Oxybutinin (brand name Ditropan)– blocks impulses to bladder and sphincter; should not be used with glaucoma. • Terazocin (brand name Hytrin) and doxazocin (brand name Cardura)– help unblock outflow from bladder; may cause dizziness/fainting.

31. Constipation

32. Constipation The colon has a large network of interconnected nerves that control its function (the enteric nervous system). Lewy Bodies have been identified in these cells in the colons of people with Parkinson’s. • Neurology. 1992 Apr;42(4):726-32. • Gastrointestinal dysfunction in Parkinson's disease: frequency and pathophysiology. • Edwards LL, Quigley EM, Pfeiffer RF.

33. Managing Constipation: • Tip: Senna tea with prunes: brew the tea and soak stewed prunes in the tea; eat prunes and drink down the tea once a day. • Medications like polyethylene glycol. • Regular exercise. • Avoid red meat, breads made with white flour; eat dark green leafy veggies; foods high in fiber.

34. Dementia in Parkinson’s

35. Cognitive impairment and dementia • Dementia isn't a specific disease. Defined as a group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning. • Memory loss generally occurs in dementia of all types. In Parkinson’s related dementia, memory loss may not be the biggest issue. • When a person develops memory impairment that is beyond what is expected from normal aging, but there is no impairment in their day to day function, this is termed mild cognitive impairment.

36. Dementia in Parkinson’s • With idiopathic PD, usually develops late in course. • The earlier the onset of PD, the later dementia usually develops. • It is possible to have both PD and Alzheimer’s. • Memory often more severely affected in this case. • Other persons develop PD related dementia which is related to the condition “dementia with Lewy Bodies”, one of the “atypical parkinsonisms”

37. Atypical Parkinsonisms • Dementia with Lewy Bodies. • Progressive Supranuclear Palsy. • Multiple Systems Atrophy (Types C, P, and A). • Corticobasalganglionic Degeneration.

38. Location of Lewy Bodies in the brain determines symptoms. . .

39. Missing pieces in the Parkinson's disease puzzle. Obeso, JA et al. Nature Medicine Volume:16,Pages:653–661; Year published:(2010)

40. Common to have some word finding difficulties and trouble multi-tasking even very early on in Parkinson’s. • Later on for some people more severe symptoms develop like short term memory loss, confusion, and hallucinations.

41. Keep a stable, quiet home environment. • Keep as regular a routine as possible. • Do not try to argue about hallucinations, redirect attention. • When hallucinations are severe or person is putting self in dangerous situations, medications are option: • Quetiapine, Clozapine. • Medications like donepezil, and rivastigmine often can help with hallucinations and alertness.