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Microsoft powerpoint - te060_neurologist track_v7_patient education

Claire Henchcliffe, MD, DPhil
Director of the Parkinson’s Institute at the New York- Presbyterian Hospital/Weill Cornell Medical Center Joseph Friedman, MD
Alpert Medical School of Brown University Director, Educational Strategy and Content Lyons KE, et al. Int J Neurosci. 2011;121:27-36.
Earlier vs. Later Initiation of Treatment: Rationale for Early
Rationale to Delay
Treatment
Treatment
treatment later did not
improve as much
as
Lang AE. Neurology. 2009;72(suppl 2):S39-S43; Parkinson Study Group. Arch Neurol. 2004;61:561-6; Olanow CW, et al. N Engl J Med. 2009;361:1268-78.
Side Effects
Drug-induced motor complications: dyskinesia, medication “wearing-off” effect, oscillations in motor performance with prolonged use Nausea, somnolence, hallucinations, vivid dreams, illusions, hypotension Somnolence with excessive daytime sleepiness, sudden-onset sleep, Dopaminergic side effects: nausea, vomiting, postural hypotension Impulse-control disorders (eg, pathologic gambling, hypersexuality, binge eating) Generally well toleratedSelegiline: dry mouth, insomnia, nausea, dizziness, headache, benign Rasagiline: flu syndrome, arthralgia, depression, dyspepsia, potential risk of adverse food/drug interactions Hallucinations, confusion, dizziness, nausea, vomiting, anxiety, insomnia, nervousness, edema, livedo reticularis in the legs Watts R, et al. Movement Disorders. 3rd ed. New York, NY; Schapira AH, et al. Ann Neurol. 2008;64(Suppl 2):S47-S55; www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm.
Bradykinesia
“Wearing off”
Rigidity
Dyskinesias
Freezing
PRE-DIAGNOSIS
MODERATE PD ADVANCED PD
Constipation
Hyposmia
Nonmotor “offs”
Dementia
– Motor features: bradykinesia, dystonia, muscle cramps, tremor, weakness and difficulty standing from sitting, slowed gait and imbalance – Non-motor features: mood changes and anxiety, dulled thinking, pain and paresthesias, abdominal discomfort, diaphoresis Fahn S, et al. N Engl J Med. 2004;351:2498-508; Espay AJ. Neurol Clin. 2010;28:913-25.
Prevalence and Onset
Risk Factors
Parkinson Study Group. Ann Neurol. 1996;39:37-45; Fahn S, et al. N Engl J Med. 2004;351:2498-508; Espay AJ. Neurol Clin. 2010;28:913-25.
Give levodopa more frequently or at higher doses Comments
Increase “on” time, decrease “off” time significantly improves “off” time, but risk of May be used as a bedtime dose; absorption can be erratic; more effective in patients with less severe “wearing off,” though overall Reduce “wearing off,” but side effects (eg, ankle edema, hallucinations, somnolence, Reduce “off” time, dyskinesia, and dystonia, Espay AJ. Neurol Clin. 2010;28:913-25; Kahn TS. Cleve Clin J Med. 2012;79(Suppl 2):S8-13. • Appropriate for patients with reasonable cognitive function who are experiencing persistent dyskinesias despit • DBS of the STN and GPi may improve “on” time and • PPN targeting may be helpful for the treatment of imbalance and freezing, but there is no effect on akinesia or dopaminergic medication requirements – Infection, intracranial hemorrhage, post-procedural – Rare neurologic, emotional, and/or cognitive side Bronstein JM, et al. Arch Neurol. 2011;68:165; Thevathasan W, et al. Neurosurgery. 2011;69:1248-53; Okun MS. N Engl J Med. 2012;367:1529-38.
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