Parkinson s disease in pakistan management issues
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PARKINSON’S DISEASE IN PAKISTAN MANAGEMENT ISSUES. Prof. Shaukat Ali Head of the Department of Neurology Jinnah Postgraduate Medical Centre, Karachi. Parkinson's Disease. James Parkinson’s original 1817 describe “shaking palsy” now called parkinsons disease.

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Parkinson s disease in pakistan management issues

PARKINSON’S DISEASE IN PAKISTANMANAGEMENT ISSUES

Prof. Shaukat Ali

Head of the Department of Neurology

Jinnah Postgraduate Medical Centre, Karachi


Parkinson s disease

Parkinson's Disease

James Parkinson’s original 1817 describe “shaking palsy” now

called parkinsons disease.

Parkinson's disease is a progressive degenerative disorder of the

central nervous system.

Idiopathic Parkinson's disease is caused by the progressive loss of

dopaminergic neurons in the substantia nigra and nigrostriatal

pathway of the midbrain and the presence of lewy bodies.

The hallmark physical signs of Parkinson's disease are tremor,

rigidity and bradykinesia.

Poor postural reflexes are sometimes included as the fourth

hallmark sign. When postural reflexes are inadequate, patients

may fall if they are pushed even slightly forward or backward, or if

they are standing in a moving vehicle such as a bus or train.


Parkinson s disease is a disorder of the basal ganglia

Parkinson’s disease is a disorder of the basal ganglia

Degeneration of

dopamine neurons

in substantia nigra.

These neurons

usually project to

the striatum.

Tremor, slowness of movement (bradykinesia),

trouble initiating movement (akinesia), rigidity.

Affects 1/250 over 40; 1/100 over 65.


Epidemiology

EPIDEMIOLOGY

  • Parkinson’s disease effect over 1% of ll peoples>50years old.

  • 5-10%of patients with PD present at age <40years.

  • There is a similar incidence in males and females.

  • All ethnic group are equally effected.


Clinical menifestation of pd

CLINICAL MENIFESTATION OF PD

Cardinal menifestation:

  • Resting tremor

  • Rigidity

  • Akinesia/bradykinesia

  • Postural instability

    Secondary manifestations:

  • Cognitive dysfunction

  • Ocular dysfunction

  • Facial and oropharyngeal dysfunction

  • Musculoskeletal deformities

  • Pain and sensory symptoms

  • Autonomic dysfunction

  • Dermatological problems


Parkinson s disease1

Parkinson’s Disease

  • PD is a progressive neurological condition causing

    • Physical disability

    • Mental disability

  • Rx does not alter progression of disease

    • helps to alleviate various symptoms

    • helping to live independent & productive lives

  • Ideal management

    • Pharmacological / Surgical

    • Psychiatric / psychological

    • Multidisciplinary

    • Social Rehabilitation

    • Health Education


Lack of specialists

Lack of specialists

  • Population ~160 million

    • Urban35%

    • Rural65%

  • No. of available specialists< 100


  • Lack of awareness amongst healthcare providers

    Lack of awareness - amongst healthcare providers

    • General practitioners managing PD patients

      • Not confident in their diagnosis

      • Inadequate Rx prescribed

      • Not updated in newer available Rx modalities

      • Unable to handle the labile course of disorder / complications / Rx SE

      • Focus only on pharmacological Rx


    Lack of awareness amongst healthcare seekers 1

    Lack of awareness - amongst healthcare seekers (1)

    • ? Nature of illness

      • Consider it to be a part of natural ageing process and

        do not seek medical advice

      • Incorporated in the integrated family system

    • ? Best Rx provider

      • GP

      • Medical Internist

      • Psychiatrist

      • Neurosurgeon

      • Neurologist


    Lack of awareness amongst healthcare seekers 2

    Lack of awareness - amongst healthcare seekers (2)

    • ? Rx options

      • Pharmacological

      • Surgical

      • Rehabilitation

    • Expected Rx outcome

      • A “cure”

      • Unaware that Rx alleviate symptoms which help live an independent &

        productive life, Overall improves the QOL

    • Rx limitations

      • Drug resistance

      • Side effect – involuntary movements, on-off fluctuations, dystonic phenomenon


    Lack of holistic approach

    Lack of “Holistic Approach”

    • “Treatment Bias”

      • Only pharmacological Rx offered

      • Surgical Rx - Limited facilities, costly

      • Lack of recent advanced technologies

    • Lack of Coordinated Multidisciplinary Care

      • Physiotherapy

      • Occupational therapy

      • Speech therapy

      • Psychiartic / psychological therapy

      • Social / occupational rehabilitation

      • Health awareness


    Compliance 1

    Compliance (1)

    • Cost

      • Rx Expensive

        • 33% population below national poverty line

        • 1% of national budget allotted for health

        • Health insurance almost non-existent

      • Low national health priority

        • Infectious diseases of priority

      • No health insurance

    • Lack of awareness

      • Importance of Regularity of Rx

      • Long-term Rx

      • Rx limitations – “not curative”, no reversibility

      • Rx side-effects

      • Rx resistence


    Compliance 2

    Compliance (2)

    • Inconsistent Logistics

      • 65% live in rural areas

      • Inconsistent availability

    • Socio-cultural beliefs

      • No cure No Rx

      • Alternative Rx – faith healer, hakim, homeopath, masseur

      • Normal ageing process & easily incorporated in the integrated family

        system


    Summary

    Summary

    • Not a national health priority

    • Few to non-existing facilities for management of

      chronic diseases

    • Lack of specialists

    • Lack of availability of recent Rx advancements

    • Lack of multidisciplinary input

    • Lack of rehabilitative facilities

    • Lack of sustained logistics

    • Poor socioeconomic conditions

    • Lack of public health education & awareness

    • Easy incorporation in the existing family system


    Parkinson s disease in pakistan management issues

    Thank you


    Nocturnal symptom complex of pd

    NOCTURNAL SYMPTOM COMPLEX OF PD

    Parkinson’s Disease Related

    Insomnia Fragmentation of sleep (sleep

    maintenance insomnia)

    Sleep onset insomnia

    Motor Function- Akinesia (difficulty turning)

    Related Restless Legs

    Periodic limb movements of sleep

    Urinary Difficulties Nocturia

    Nocturia with secondary postural

    hypotension

    Neuropsychiatric/ Depression

    Parasomnias Vivid dreams

    Altered dream content

    Nightmares

    Night terrors

    Sleep talking

    Nocturnal vocalisations

    Somnabulism

    Hallucinations

    Panic attacks

    REM Behavior disorder


    Parkinson s disease in pakistan management issues

    Treatment-Related:

    Motor: Nocturnal off-period-related tremor

    Dystonia

    Dyskinesias

    Off-period-related pain/ paresthesia/

    muscle cramps

    Off-period-related incontinence of urine

    HAllucinations

    Vivid dreaming

    ? Off-Related panic attacks

    ? REM Behavior disorder

    Akathisia

    Insomnia

    Sleep-Altering Medications


    Sleep and parkinson s disease

    Sleep and Parkinson's Disease

    • Sleep disorders secondary to motor

      dysfunction.

      2. Sleep disorders secondary to behavioral

      dysfunction.

    • Sleep disorders associated with

      respiratory dysfunction.


    Autonomic and vegetative functions in parkinson s disease

    Autonomic and Vegetative Functions in Parkinson’s Disease

    • Bladder SymptomsFrequency

      dysfunction

    • Irritative Frequency, urgency57-83%

    • ObstructiveHesitancy, post-viod dribbiling17-23%


    Parkinson s disease in pakistan management issues

    Transient and new Urinary tract infection

    Onset incontinenceMedications

    Faecal impaction.

    Chronic incontinenceParkinsonism

    Lack of mobility

    Anatomic stress incontinence

    (women)

    Bladder-neck obstruction

    (prostate in men)

    Other peripheral or central

    neurological disorders

    Dementia or apathy


    Parkinson s disease in pakistan management issues

    Parkinsonian Idiopathic parkinsonism with central

    syndromesautonomic involvement

    Multiple system atrophy

    DrugsLevodopa

    Dopamine agonists

    Amantadine

    Selegiline (especially combined with lovodopa)

    Antidepressents

    Sedative hypnotics

    Antipsychotics

    Benzodiazepines

    Analgesics

    Antihypertensive

    Vasodilators

    Diuretics


    Parkinson s disease in pakistan management issues

    • Coexistent diseasesAutonomic neuropathies

      (diabetes, alcohol)

      Brainstem and spinal cord lesions

      Dehydration, intercurrent illness

      Decreased oral intake from dysphagia

      Decreased salt intake

      Immobility.


    Parkinson s disease in pakistan management issues

    • Elimination or reduction of hypertensive medications

    • Pharmacortisone management

      Fludrocortisone

      Propranolol

      Clonidine

      Yohimbine

      Ephedrine

      caffeine

      Indomethacin

      Domperidone

    • Non-pharmacological management

      Sodium chloride tablets

      Elevation of the head of the bed 5-20 degrees

      Changing position slowly

      Pressure stockings, pantyhose

      liberalizing salt and fluid intake

      Avoidance of hot weather, hot tubs or baths, alcohol,

      large meals.

      Patient and caregiver education.


    Depression and dementia in parkinson s disease

    Depression and Dementia in Parkinson’s Disease

    Depression in Parkinson’s Disease

    • decreased energy

    • decreased mood

    • decreased enjoyment of activities

    • decreased appetite

    • sleep disturbances

    • psychomotor dysfunction

    • Feelings of worthlessness or guilt

    • problem in concentration

    • indecisiveness

    • emotional lability

    • thoughts of suicide of death

    • pseudo-dementia manifested as forgetfulness.

      TREATMENT OF DEPRESSION IN PD

      DEMENTIA IN PARKINSON’S DISEASE


    Parkinson s disease in pakistan management issues

    Psychosis in Parkinson’s Disease

    • Newer Atypical Antipsychotic Drugs

    • Clozapine

    • Olanzapine

    • Risperidone

    • Quetiapine

    • Cholinesterase Inhibitors

    • Choice of Drug therapy for psychosis in PD


    Basic principles in the pharmacotherapy of parkinson s disease

    Basic Principles in the Pharmacotherapy of Parkinson’s Disease

    • SUBCLINICAL EARLY ASYMPTOMATIC PD

    • CLINICAL MILDLY SYMPTOMATIC PD

    • Vitamin E (2000 iu/d)

    • Selegiline (10 mg/d)

    • Riluzole (100-200 mg/d)

    • Coenzyme Q 10 (300-1200 mg/d)

    • Carbidopa/ levodopa (150-600 mg/d)

    • Bromocriptine


    Parkinson s disease in pakistan management issues

    Fluctuations

    • Early morning akinesia

    • Delayed on

    • End-of-dose wearing-off

    • On-off

    • Freezing

      Dyskinesia

    • Off period dystonia

    • Peak dose dyskinesia

    • Diphasic dyskinesia


    Treatement of advanced pakinson s disease

    TREATEMENT OF ADVANCED PAKINSON’S DISEASE

    • Motor Fluctuations in Advanced PD

    • Early Morning Akinesia

    • Wearing-off

    • On-off

    • Freezing

    • Off Period Dystonia

    • Peak-dose Dyskinesia

    • Diphasic Dyskinesia


    Parkinson s disease in pakistan management issues

    1. Side effects: A. Peripheral (and /or central): a. Nausea, vomiting, anorexia b. Orthostatic hypotension

    B. Central:

    a. Chorea, stereotypy

    b. Dystonia

    c. Myoclonus

    d. Akathesia

    e. Hallucinations

    2. Motor complications:

    A. Motor fluctuations

    a. Delayed onset of response

    b. Wearing off phenomenon

    c. Drug resistant “Off”

    d. Random oscillations “On-Off phenomenon

    e. Freezing

    B. Dyskinesias

    a. Peak dose dyskinesia (I-D-I)

    b. Diphasic dyskinesia (D-I-D)


    Parkinson s disease in pakistan management issues

    THANK YOU


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