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PARKINSON’S DISEASE IN PARKINSON’S DISEASE IN PAKISTANPAKISTAN
MANAGEMENT ISSUESMANAGEMENT ISSUES
Prof. Shaukat AliProf. Shaukat AliHead of the Department of NeurologyHead of the Department of Neurology
Jinnah Postgraduate Medical Centre, KarachiJinnah Postgraduate Medical Centre, Karachi
Parkinson's DiseaseParkinson's Disease James Parkinson’s original 1817 describe “shaking palsy” James Parkinson’s original 1817 describe “shaking palsy” now now called parkinsons disease.called parkinsons disease.
Parkinson's disease is a progressive degenerative disorder Parkinson's disease is a progressive degenerative disorder of the of the central nervous system.central nervous system. Idiopathic Parkinson's disease is caused by the Idiopathic Parkinson's disease is caused by the progressive loss of progressive loss of dopaminergic neurons in the substantia nigra and dopaminergic neurons in the substantia nigra and nigrostriatal nigrostriatal pathway of the midbrain and the presence of lewy bodies.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
Degeneration ofdopamine neuronsin substantia nigra.
These neuronsusually project tothe striatum.
Tremor, slowness of movement (bradykinesia), trouble initiating movement (akinesia), rigidity.Affects 1/250 over 40; 1/100 over 65.
EPIDEMIOLOGYEPIDEMIOLOGY
Parkinson’s disease effect over 1% of Parkinson’s disease effect over 1% of ll peoples>50years old.ll peoples>50years old.
5-10%of patients with PD present at 5-10%of patients with PD present at age <40years.age <40years.
There is a similar incidence in males There is a similar incidence in males and females.and females.
All ethnic group are equally effected.All ethnic group are equally effected.
CLINICAL MENIFESTATION OF CLINICAL MENIFESTATION OF PDPD
Cardinal menifestation:Cardinal menifestation:
Resting tremorResting tremor RigidityRigidity Akinesia/bradykinesiaAkinesia/bradykinesia Postural instabilityPostural instability
Secondary manifestations:Secondary manifestations:
Cognitive dysfunctionCognitive dysfunction Ocular dysfunctionOcular dysfunction Facial and oropharyngeal dysfunctionFacial and oropharyngeal dysfunction Musculoskeletal deformitiesMusculoskeletal deformities Pain and sensory symptomsPain and sensory symptoms Autonomic dysfunctionAutonomic dysfunction Dermatological problemsDermatological problems
Parkinson’s DiseaseParkinson’s Disease PD is a progressive neurological condition causing PD is a progressive neurological condition causing
Physical disabilityPhysical disability Mental disabilityMental disability
Rx does not alter progression of disease Rx does not alter progression of disease helps to alleviate various symptomshelps to alleviate various symptoms helping to live independent & productive liveshelping to live independent & productive lives
Ideal management Ideal management Pharmacological / SurgicalPharmacological / Surgical Psychiatric / psychologicalPsychiatric / psychological MultidisciplinaryMultidisciplinary Social Rehabilitation Social Rehabilitation Health EducationHealth Education
Lack of specialistsLack of specialists
Population Population ~160 ~160 millionmillion
UrbanUrban 35%35% RuralRural 65%65%
No. of available specialistsNo. of available specialists < 100< 100
Lack of awareness - Lack of awareness - amongst healthcare providers amongst healthcare providers General practitioners managing PD General practitioners managing PD
patientspatients Not confident in their diagnosisNot confident in their diagnosis Inadequate Rx prescribedInadequate Rx prescribed Not updated in newer available Rx modalitiesNot updated in newer available Rx modalities Unable to handle the labile course of disorder / Unable to handle the labile course of disorder /
complications / Rx SEcomplications / Rx SE Focus only on pharmacological RxFocus only on pharmacological Rx
Lack of awareness - Lack of awareness - amongst healthcare seekers amongst healthcare seekers
(1)(1) ? Nature of illness? Nature of illness
Consider it to be a part of natural ageing process andConsider it to be a part of natural ageing process and
do not seek medical advicedo not seek medical advice Incorporated in the integrated family systemIncorporated in the integrated family system
? Best Rx provider? Best Rx provider GPGP Medical InternistMedical Internist PsychiatristPsychiatrist NeurosurgeonNeurosurgeon NeurologistNeurologist
Lack of awareness - Lack of awareness - amongst healthcare seekers amongst healthcare seekers
(2)(2) ? Rx options? Rx options
PharmacologicalPharmacological SurgicalSurgical RehabilitationRehabilitation
Expected Rx outcome Expected Rx outcome A “cure” A “cure” Unaware that Rx alleviate symptoms which help live an Unaware that Rx alleviate symptoms which help live an
independent & independent & productive life, Overall improves the QOL productive life, Overall improves the QOL
Rx limitationsRx limitations Drug resistance Drug resistance Side effect – involuntary movements, on-off fluctuations, Side effect – involuntary movements, on-off fluctuations,
dystonic phenomenondystonic phenomenon
Lack of “Holistic Approach”Lack of “Holistic Approach”
“ “Treatment Bias”Treatment Bias” Only pharmacological Rx offeredOnly pharmacological Rx offered Surgical Rx - Limited facilities, costlySurgical Rx - Limited facilities, costly Lack of recent advanced technologiesLack of recent advanced technologies
Lack of Coordinated Multidisciplinary CareLack of Coordinated Multidisciplinary Care PhysiotherapyPhysiotherapy Occupational therapyOccupational therapy Speech therapySpeech therapy Psychiartic / psychological therapyPsychiartic / psychological therapy Social / occupational rehabilitationSocial / occupational rehabilitation Health awarenessHealth awareness
Compliance (1)Compliance (1) CostCost
Rx ExpensiveRx Expensive33% population below national poverty line33% population below national poverty line1% of national budget allotted for health1% of national budget allotted for healthHealth insurance almost non-existentHealth insurance almost non-existent
Low national health priority Low national health priority Infectious diseases of priorityInfectious diseases of priority
No health insuranceNo health insurance
Lack of awarenessLack of awareness Importance of Regularity of RxImportance of Regularity of Rx Long-term RxLong-term Rx Rx limitations – “not curative”, no reversibilityRx limitations – “not curative”, no reversibility Rx side-effectsRx side-effects Rx resistenceRx resistence
Compliance (2)Compliance (2)
Inconsistent LogisticsInconsistent Logistics 65% live in rural areas65% live in rural areas Inconsistent availabilityInconsistent availability
Socio-cultural beliefsSocio-cultural beliefs No cure No RxNo cure No Rx Alternative Rx – faith healer, hakim, homeopath, Alternative Rx – faith healer, hakim, homeopath,
masseur masseur Normal ageing process & easily incorporated in the Normal ageing process & easily incorporated in the
integrated family integrated family systemsystem
SummarySummary Not a national health priority Not a national health priority Few to non-existing facilities for management ofFew to non-existing facilities for management of
chronic diseaseschronic diseases Lack of specialistsLack of specialists Lack of availability of recent Rx advancementsLack of availability of recent Rx advancements Lack of multidisciplinary input Lack of multidisciplinary input Lack of rehabilitative facilities Lack of rehabilitative facilities Lack of sustained logistics Lack of sustained logistics Poor socioeconomic conditions Poor socioeconomic conditions Lack of public health education & awarenessLack of public health education & awareness Easy incorporation in the existing family systemEasy incorporation in the existing family system
NOCTURNAL SYMPTOM COMPLEX OF PDNOCTURNAL SYMPTOM COMPLEX OF PD
Parkinson’s Disease RelatedParkinson’s Disease Related
InsomniaInsomnia Fragmentation of sleep (sleep Fragmentation of sleep (sleep
maintenance insomnia)maintenance insomnia)
Sleep onset insomniaSleep onset insomnia
Motor Function- Motor Function- Akinesia (difficulty turning)Akinesia (difficulty turning)
Related Related Restless Legs Restless Legs
Periodic limb movements of sleep Periodic limb movements of sleep
Urinary Difficulties Urinary Difficulties NocturiaNocturia
Nocturia with secondary posturalNocturia with secondary postural
hypotensionhypotension
Neuropsychiatric/ Neuropsychiatric/ DepressionDepression
ParasomniasParasomnias Vivid dreams Vivid dreams
Altered dream contentAltered dream content
NightmaresNightmares
Night terrorsNight terrors
Sleep talkingSleep talking
Nocturnal vocalisationsNocturnal vocalisations
SomnabulismSomnabulism
HallucinationsHallucinations
Panic attacksPanic attacks
REM Behavior disorderREM Behavior disorder
Treatment-Related:Treatment-Related:Motor: Motor: Nocturnal off-period-related tremorNocturnal off-period-related tremor
DystoniaDystonia
DyskinesiasDyskinesias
Off-period-related pain/ paresthesia/Off-period-related pain/ paresthesia/
muscle crampsmuscle cramps
Off-period-related incontinence of urineOff-period-related incontinence of urine
HAllucinationsHAllucinations
Vivid dreamingVivid dreaming
? Off-Related panic attacks? Off-Related panic attacks
? REM Behavior disorder? REM Behavior disorder
AkathisiaAkathisia
InsomniaInsomnia
Sleep-Altering MedicationsSleep-Altering Medications
Sleep and Parkinson's Sleep and Parkinson's DiseaseDisease
1.1. Sleep disorders secondary to motor Sleep disorders secondary to motor
dysfunction.dysfunction.
2. Sleep disorders secondary to 2. Sleep disorders secondary to behavioral behavioral
dysfunction.dysfunction.
3.3. Sleep disorders associated with Sleep disorders associated with
respiratory dysfunction. respiratory dysfunction.
Autonomic and Vegetative Autonomic and Vegetative Functions in Parkinson’s DiseaseFunctions in Parkinson’s Disease
Bladder SymptomsBladder Symptoms Frequency Frequency
dysfunctiondysfunction
Irritative Irritative Frequency, urgencyFrequency, urgency 57-57-83%83%
ObstructiveObstructive Hesitancy, post-viod dribbilingHesitancy, post-viod dribbiling
17-23%17-23%
Transient and new Transient and new Urinary tract infection Urinary tract infection
Onset incontinenceOnset incontinence MedicationsMedications
Faecal impaction.Faecal impaction.
Chronic incontinenceChronic incontinence ParkinsonismParkinsonism
Lack of mobility Lack of mobility
Anatomic stress incontinenceAnatomic stress incontinence
(women)(women)
Bladder-neck obstruction Bladder-neck obstruction
(prostate in men)(prostate in men)
Other peripheral or centralOther peripheral or central
neurological disordersneurological disorders
Dementia or apathy Dementia or apathy
ParkinsonianParkinsonian Idiopathic parkinsonism with central Idiopathic parkinsonism with central
syndromessyndromes autonomic involvement autonomic involvement
Multiple system atrophyMultiple system atrophy
DrugsDrugs LevodopaLevodopa
Dopamine agonistsDopamine agonists
Amantadine Amantadine
Selegiline (especially combined Selegiline (especially combined with with lovodopa)lovodopa)
AntidepressentsAntidepressents
Sedative hypnoticsSedative hypnotics
AntipsychoticsAntipsychotics
BenzodiazepinesBenzodiazepines
AnalgesicsAnalgesics
Antihypertensive Antihypertensive
VasodilatorsVasodilators
DiureticsDiuretics
Coexistent diseasesCoexistent diseases Autonomic neuropathiesAutonomic neuropathies
(diabetes, alcohol)(diabetes, alcohol)
Brainstem and spinal Brainstem and spinal cord lesionscord lesions
Dehydration, Dehydration, intercurrent illness intercurrent illness
Decreased oral intake Decreased oral intake from dysphagia from dysphagia
Decreased salt intakeDecreased salt intake
Immobility.Immobility.
A.A. Elimination or reduction of hypertensive medications Elimination or reduction of hypertensive medications B.B. Pharmacortisone management Pharmacortisone management FludrocortisoneFludrocortisone PropranololPropranolol ClonidineClonidine
YohimbineYohimbine EphedrineEphedrine
caffeinecaffeine IndomethacinIndomethacin
DomperidoneDomperidoneC.C. Non-pharmacological managementNon-pharmacological management
Sodium chloride tabletsSodium chloride tabletsElevation of the head of the bed 5-20 degreesElevation of the head of the bed 5-20 degreesChanging position slowlyChanging position slowlyPressure stockings, pantyhosePressure stockings, pantyhoseliberalizing salt and fluid intakeliberalizing salt and fluid intakeAvoidance of hot weather, hot tubs or baths, alcohol, Avoidance of hot weather, hot tubs or baths, alcohol, large meals.large meals.Patient and caregiver education.Patient and caregiver education.
Depression and Dementia in Depression and Dementia in Parkinson’s DiseaseParkinson’s Disease
Depression in Parkinson’s DiseaseDepression in Parkinson’s Disease• decreased energydecreased energy• decreased mooddecreased mood• decreased enjoyment of activitiesdecreased enjoyment of activities• decreased appetite decreased appetite • sleep disturbances sleep disturbances • psychomotor dysfunction psychomotor dysfunction • Feelings of worthlessness or guiltFeelings of worthlessness or guilt• problem in concentrationproblem in concentration• indecisivenessindecisiveness• emotional lability emotional lability • thoughts of suicide of death thoughts of suicide of death • pseudo-dementia manifested as forgetfulness.pseudo-dementia manifested as forgetfulness.
TREATMENT OF DEPRESSION IN PDTREATMENT OF DEPRESSION IN PDDEMENTIA IN PARKINSON’S DISEASEDEMENTIA IN PARKINSON’S DISEASE
Psychosis in Parkinson’s DiseasePsychosis in Parkinson’s Disease
• Newer Atypical Antipsychotic DrugsNewer Atypical Antipsychotic Drugs
• ClozapineClozapine
• OlanzapineOlanzapine
• RisperidoneRisperidone
• QuetiapineQuetiapine
• Cholinesterase InhibitorsCholinesterase Inhibitors
• Choice of Drug therapy for psychosis in PD Choice of Drug therapy for psychosis in PD
Basic Principles in the Basic Principles in the Pharmacotherapy of Parkinson’s Pharmacotherapy of Parkinson’s
DiseaseDisease• SUBCLINICAL EARLY ASYMPTOMATIC PDSUBCLINICAL EARLY ASYMPTOMATIC PD• CLINICAL MILDLY SYMPTOMATIC PDCLINICAL MILDLY SYMPTOMATIC PD
• Vitamin E (2000 iu/d)Vitamin E (2000 iu/d)• Selegiline (10 mg/d)Selegiline (10 mg/d)• Riluzole (100-200 mg/d)Riluzole (100-200 mg/d)• Coenzyme Q 10 (300-1200 mg/d)Coenzyme Q 10 (300-1200 mg/d)• Carbidopa/ levodopa (150-600 mg/d)Carbidopa/ levodopa (150-600 mg/d)• BromocriptineBromocriptine
FluctuationsFluctuations• Early morning akinesiaEarly morning akinesia• Delayed onDelayed on• End-of-dose wearing-offEnd-of-dose wearing-off• On-offOn-off• FreezingFreezingDyskinesiaDyskinesia• Off period dystoniaOff period dystonia• Peak dose dyskinesiaPeak dose dyskinesia• Diphasic dyskinesiaDiphasic dyskinesia
TREATEMENT OF ADVANCED TREATEMENT OF ADVANCED PAKINSON’S DISEASEPAKINSON’S DISEASE
• Motor Fluctuations in Advanced PDMotor Fluctuations in Advanced PD • Early Morning AkinesiaEarly Morning Akinesia
• Wearing-offWearing-off • On-offOn-off
• FreezingFreezing
• Off Period DystoniaOff Period Dystonia • Peak-dose DyskinesiaPeak-dose Dyskinesia
• Diphasic DyskinesiaDiphasic Dyskinesia
1. Side effects:1. Side effects: A. Peripheral (and /or central): A. Peripheral (and /or central): a. Nausea, vomiting, anorexia a. Nausea, vomiting, anorexia b. Orthostatic hypotension b. Orthostatic hypotension
B. Central:B. Central:
a. Chorea, stereotypya. Chorea, stereotypy
b. Dystoniab. Dystonia
c. Myoclonusc. Myoclonus
d. Akathesiad. Akathesia
e. Hallucinationse. Hallucinations
2. Motor complications:2. Motor complications:
A. Motor fluctuationsA. Motor fluctuations
a. Delayed onset of responsea. Delayed onset of response
b. Wearing off phenomenonb. Wearing off phenomenon
c. Drug resistant “Off”c. Drug resistant “Off”
d. Random oscillations “On-Off phenomenond. Random oscillations “On-Off phenomenon
e. Freezinge. Freezing
B. DyskinesiasB. Dyskinesias
a. Peak dose dyskinesia (I-D-I)a. Peak dose dyskinesia (I-D-I)
b. Diphasic dyskinesia (D-I-D) b. Diphasic dyskinesia (D-I-D)
THANK YOUTHANK YOU