parkinson

1. PARKINSON’S DISEASERESEARCH, EDUCATION, AND CLINICAL CENTERHOUSTON VA MEDICAL CENTER

5. PARKINSON’S DISEASE Parkinson’s disease is a progressive neurodegenerative disease. Although treatment is available to achieve symptomatic improvement, its management is both a challenge and an art. Care of patients with advanced disease need clinical experience, patient cooperation and utilization of all available treatment options.

8. STAGES OFPARKINSON’S DISEASE EARLY - no functional impairment MILD - honeymoon period MODERATE - multiple drugs, occupational and social activities affected SEVERE - side effects from drugs, resistant to therapy, reduced quality of life LATE - dependent in ADL, wheelchair or bed bound

12. PARKINSON’S DISEASEDrug Therapy Monoamine oxidase-B inhibitor Levodopa Anticholinergics Dopamine agonists COMT inhibitor

14. COMPLICATIONS IN ADVANCEDPARKINSON’S DISEASE Motor fluctuations Dyskinesias Posture, gait, falling Neuropsychiatric problems Sleep disorders Sensory phenomena Dysautonomias Speech disturbances

15. MOTOR FLUCTUATIONS Unpredictable response No “on” response “Wearing off” Complex “on-off” oscillations Freezing

16. DYSKINESIA Peak dose dyskinesia Dyskinesia-improvement-dyskinesia Dystonia Complex movements

17. GENERAL TREATMENT STRATEGIES FOR MOTOR COMPLICATIONS Individualize treatment Adjust medication combination Substitute controlled-release with regular levodopa Dose levodopa regularly Smaller doses of levodopa; increase frequency Increase GI transit time Modify distribution of dietary protein

18. SPECIFIC TREATMENT STRATEGIES FORMOTOR COMPLICATIONS Adjust levodopa dosage Maximize dopamine agonist Add COMT inhibitor Simplify medication regimen Amantadine or clozapine for dyskinesia Anxiolytics

19. POSTURAL INSTABILITY, GAIT IMBALANCE, AND FALLING Start hesitation Retropulsion Festination Rigidity Freezing Orthostatic hypotension Associated neurologic deficits Orthopedic symptoms Environmental causes

20. TREATMENTS TO IMPROVE MOBILITY AND AVOID FALLS Keep active Exercise regularly Physical therapy Adjust medication regimen Sensory cues Assistive devices Safety-proof living environment

21. NEUROPSYCHIATRIC PROBLEMS INPARKINSON’S DISEASE Depression Hallucination/delirium Behavioral fluctuation -Anxiety/panic -Agitation Cognitive impairment

22. TREATMENT OF NEUROPSYCHIATRIC PROBLEMS IN PARKINSON’S DISEASE Antidepressants Reduce/discontinue medications Atypical neuroleptics Counseling Anxiolytics Keep active/exercise Educate caregivers

23. SLEEP DISORDERS IN PARKINSON’S DISEASE Insomnia REM behavior disorder Nightmares Obstructive sleep apnea Excessive daytime sleepiness

24. TREATMENT OF SLEEP DISORDERS IN PD Treat depression/anxiety Add controlled-release levodopa at bedtime Sleep hygiene program Short-acting sedative hypnotics Minimize nocturia Clonazepam for RBD Discontinue tricyclic drugs and MAO inhibitors Avoid stimulants in evening Evaluate sleep disorder Judicious use of stimulants for EDS

25. SENSORY PHENOMENA IN PARKINSON’S DISEASE Rigidity/cramps Dystonic pain Musculoskeletal pain associated with immobility Heaviness in limbs

26. TREATMENT OF SENSORY PHENOMENA IN PD Stretching exercises Medication adjustment Physical therapy Baclofen NSAIDs Botulinum toxin injection

27. DYSAUTONOMIAS IN PARKINSON’S DISEASE Constipation Urinary problems Sexual problems Orthostatic hypotension Impaired thermoregulation Dysphagia Siarrhea/drooling

28. SPEECH DISORDER IN PARKINSON’S DISEASE Hypokinetic dysarthria Lack of control of speaking rate Monotone Hoarse/breathy voice Stuttering Hypophonia Imprecise pronunciation/mumbling

29. TREATMENT OF SPEECH DISORDER IN PD Behavioral (drill, exercise) Instrumental (prosthetics, amplifier) Surgical Pharmaco-therapeutic