Parkinson Disease An Overview including Community Resources Presented by Christy Prezyna, PT Ellen Tomer, LMSW Members of HCR’s Parkinson’s Program

HCR’s Parkinson’s Team Delivering specialized Parkinson’s care since 2004 Interdisciplinary Team – Physical Therapy – Occupational Therapy – Medical Social Work – Nursing – Speech Therapy – Home Health Aide

The Shaking Palsy An Essay by James Parkinson Published in 1812 “Involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported; with a propensity to bend the trunk forwards, and to pass from a walking to a running pace: the senses and intellects being uninjured.”

What is Parkinson Disease? Parkinson’s is a devastating and complex neuro-degenerative illness that progressively affects the control of movements and causes a wide range of other problems including tremor, rigidity, slow movement, postural changes and gait disturbances. (Paparella 2004)

What is Parkinson’s? cont. PD (Parkinson Disease) is chronic There is no cure for PD, only treatment of the symptoms It progresses slowly - people can live with PD for years

Parkinson’s: The Disease Incidence: 300 per every 100,000 people Average age of onset: 62.4 years Early onset is considered diagnosis prior to age % of cases are undiagnosed

Notable People with Parkinson’s (PWP) Janet Reno Pope John Paul II Muhammad Ali Michael J Fox

Source of Symptoms Loss of dopamine in the Substantia Nigra Diminished excitation of the motor cortex of the brain – Diminished ability to initiate and terminate movement – Symptoms appear when 80% of cells become damaged Proper levels of dopamine allow for smooth, coordinated function of the body's muscles and resultant movement.

Cause Most people with Parkinson’s (PWP) are described as having “idiopathic” PD – Idiopathic= Unknown cause Variety of considerations – Family history- 5-10% of cases – Environmental exposure – Genetic mutation – Head Trauma Currently, researchers suspect that the cause reflects a combination of genetic factors and environmental exposures.

Forms of PD Typical (Idiopathic) Parkinson Disease - 85% of cases Parkinsonism - Parkinson’s-like – Initially other diseases can mask themselves as Parkinson’s, however these diseases are not responsive to medication and symptoms progress at a faster rate – Lewybody Disease, PSP, MSA

Diagnosis Blood or radiology tests are not effective in confirming diagnosis – May be utilized to rule out other conditions Based upon medical history and neurological exam Presence of 2 of 4 cardinal features –Resting Tremor- 75% of PWP –Rigidity- stiffness, increased muscle tone –Bradykinesia- slowness of movement –Postural Instability- loss of postural reflexes Results in balance disturbance and falls Most disabling Medication has little impact Physical Therapy is most effective –“Treading water is a therapeutic victory”– F. Marshall

Motor Symptoms Shuffling Gait- short steps, audible shuffling noise Turning ‘en bloc’- multiple steps for turn completion vs. rotation of neck and trunk Festination- quick, small, shuffling steps Akinesia- Freezing, occurs frequently in tight, cluttered spaces or when initiating gait Hypophonia- Soft, hoarse speech Dysphagia- Impaired swallowing, may lead to aspiration pneumonia in late stage Masked faces Forward flexed posture

Non-motor Symptoms Depression – 30-40% of PWP – Significantly under-diagnosed due to PD presentation – Is treatable - responds well to medication Anxiety – Heightened in anticipation of “off” times and/or when movement is slow and frustrating – Can be brought on by lack of patience by PCG or by PWP

Non-motor Symptoms cont. Mild Cognitive Decline – Bradyphrenia – slowed mentation – Impaired visual-spatial perception – Decreased executive function/problem solving – Lack of attention – Dementia Compulsive Behaviors – excessive fixation on gambling, sex, shopping Psychosis – disorientation, hallucinations, paranoia

Non-motor Symptoms cont. Orthostatic hypotension (a sudden drop in blood pressure; esp sitting to standing) Bladder dysfunction - frequent nighttime voiding Excessive sweating Sexual dysfunction Sleep disorders

Treatment Options

Treatment by Medication Levopoda/Carbidopa – Sinemet – Parcopa “Gold Standard” of PD treatment Positive response to Levopoda is a confirmative diagnosis of PD Levopoda is combined with Carbidopa to prevent breakdown in the stomach

Side Effects Early treatment: Nausea and vomiting Later complications: – Dyskinesia – involuntary movement – Motor fluctuations – Neuropsychological changes Response fluctuations begin as early as the first year and 50% of patients develop motor fluctuations after 5 years of therapy

Medication Effects Wearing off effect Predictable loss of dose effectiveness Dose does not last as long as it once did On-off cycle Response to medication becomes less predictable ‘On’= fluid movement ‘Off’= bradykinesia and akinesia Drug Failure- no response to dose of medication Physicians hold on prescribing medicine as long as possible

Other Medications Dopaminergic – Dopamine Agonists (Requip, Comtan, Mirapex) MAO-B inhibitors – Selegiline Anticholingerics Amantadine COMT inhibitors

Surgical Interventions Deep Brain Stimulation Most responsive symptoms: – Rigidity – Tremor – Slowness – Posture – Dystonia – Dyskinesia – Gait – Balance – Off freezing

Candidates for DBS Diagnosis of typical or idiopathic PD Significant motor disability that is not controlled by medication Positive response to Sinemet Inability to tolerate medications Patient expectations agree with possible outcomes

Alternative Treatment Options Therapies (PT, OT, ST, Music) – Research suggests there is a neuroprotective benefit to exercise specifically Tai Chi Yoga Psychosocial support from MSW

Community Resources National – NPF (National Parkinson Foundation) – PDF (Parkinson’s Disease Foundation) – MJFF (Michael J Fox Foundation) – The goal of these agencies is to raise money for and awareness of PD

Community Resources Local – Parkinson’s Support Group of Upstate NY, Inc. (PSGUNY): Support groups (PWP and Caregivers) Annual PD Symposium Annual Walk/Run Parkinson Cafes Quarterly newsletter – Exercise Groups “Stretching the Limits” HCR’s PD Exercise Program Lifetime Care Drop-In Program

Community Resources – NPF Center of Excellence: U of R Medical Center – Movement Disorders Clinic Multiple neurologists who are specially trained in PD and related movement disorders Drug trials – Home Care Specialty Programs in PD

Questions? Comments?