1. Dr Erero F. Njiengwé Convergence Psy-Santé Douala-Cameroun Convergencepsy-sante@gmail.com Sous le Haut Patronage du Délégué Régional du MINAS pour le Littoral Management of Behavioral Problems in Parkinson’s Disease African and Telemedicine Initiatives Cameroon

2. Gratitude To the Movement Disorder Society (MDS) for launching a Telemedicine Task Force and sponsoring pilot projects in care, education, and research for the majority. To Dr Esther Cubo for being so Generous in knowledge, Risk Taking and Optimistic Dr Doumbè & The Director of HLD for hosting and giving it viability to this pilot project of telemedicine

3. Can affect all the functioning of the individual. mobility, communication at all levels, Occupation, Cognition, Emotional Stability Family harmony. A Comprehensive approach to its management, helps the patient ( and the caregiver ) to keep in good mental, physical and emotional situation, in order to maintain as long as possible a better quality of life. Parkinson’s Disease As a chronic and progressive deteriorative Brain Disease

4. Learning Objectives From the Bio-Psycho-Social perspective: –Recognize Behavioral Problems in PD –Differentiate them from other common changes in PD –Understand their role in PD Describe the main strategies for their management

5. Outline What means “Behavioral Problems” in PD? What makes them different from other common changes in PD? What do they stand for in PD? Case Study Is there any culturally informed strategies for their management?

6. Outline What means “Behavioral Problems” in PD? What makes them different from other common changes in PD? What do they stand for in PD? Case Study Is there any culturally informed strategies for their management?

7. Do Behavioral problems mean Motor problems ? PD was first described as a purely motor disorder But Depression and Anxiety are considered to be quite common in PD Some other "Brain" dysfunctions such as Dementia are found to be very severe in a number of individuals with PD (40%). Question: –Is depression behavior? Is anxiety behavior? Is dementia behavior? Is tremor behavior? –What is behavior and where is it from? –What does “management” mean talking about behavior?

8. Behavior is 4 interdependant Components Physiologic (bodily processes, sensations) Cognitive (What I think: internal conversation) Emotional (feelings) Motor (External reactions: What I do) The Brain

9. Yes What is Motor... and What is non Motor in PD? No 1. Speech 2. Handling saliva 3. Swallowing & chewing 4. Feeding 5. Dressing 6. Hygiene 7. Handwriting 8. Other fine motor tasks 9. Tremor impact on activities 10. Turning in bed and adjusting bed clothes 11. Getting in and out of bed, car or deep chair 12. Balance and walking 13. Gait Freezing Autonomic dysfunction (constipation, orthostatic hypotension, urinary incontinence, sexual dysfunction) Depression, anxiety, psychosis (hallucinations & delusions) Dementia Sleep Disorders –Excessive daytime sleepiness –REM sleep behavior disorder Fatigue, apathy Pain Goetz CG et al. MDS UPDRS

10. We shall consider in PD within the nonmotor features, any manifestation that can be managed through learning, since behavior is learned and can influence Which Behavioral Problems can we find in PD? Depression, (7.50% of PD suffer melancholic or major depression and 50 % minor depression) Apathy (decrease of conduct aimed at a goal, of motivation and affective expression: 50% of patients) Anxiety (very common) Psychotic disorders : hallucinations and delusions (In 25% of nondemented and up to 65% of demented patients) Disorders of impulse control : compulsive gambling, Pathological hypersexuality, punding, compulsive shopping, binge eating,

11. Impulse Control Disorder A person’s inability to resist a temptation or impulseA person’s inability to resist a temptation or impulse More likely to happen in those with a previous history of noveltyMore likely to happen in those with a previous history of novelty seeking or risk – taking behaviours seeking or risk – taking behaviours Compulsive behaviours have been reported as a side effect with levodopa and dopamine agonistsCompulsive behaviours have been reported as a side effect with levodopa and dopamine agonists Behaviours can include:Behaviours can include: –Pathological gambling –Hypersexuality –Compulsive eating –Compulsive shopping –Punding

12. Depression, anxiety, psychosis (hallucinations & delusions) And to some extent Dementia Can be labelled “behavioral problems” Are Cognitive and Psychiatric Symptoms Behavioral problems ?

13. Outline What means “Behavioral Problems” in PD? What makes them different from other common changes in PD? What do they stand for in PD? Case Study Is there any culturally informed strategies for their management?

14. Depression, Anxiety and Apathy Associated with Parkinson's In Parkinson's patients with depression there is a higher frequency of Dysphoria Irritability Sadness Pessimism about the future Depression The prevalence is estimated at between 30 and 40% Apathy more likely to be a direct consequence of disease related physiological changes than a psychological reaction or adaptation to disability Anxiety Genralised anxiety, agitation, panic attacks and phobic disorders can occur in up to 40% of people with PD Professor Richard Walker Consultant Physician and Honorary Professor of Ageing and International Health Northumbria Healthcare NHS Foundation Trust Institute of Health and Society, Newcastle University

15. Why do they appear ? Usually due to PD itself or to phamacological treatment Depression Anxiety / Panic Attack are extremely common in PD, both – because of having the Disease and – as a brain disorder

16. Levodopa side effects Short term –Nausea and vomiting, postural hypotension, somnolence, altered sleep pattern Long term –psychiatric disturbances –Wearing off –Dyskinesias –Dystonia Factors associated with motor complications –Duration of disease, therapy, severity of disease

17. Dopamine Agonist Side effects Confusion, hallucinations, impulse control disorder Postural hypotension Fibrotic changes due Ergot derived agonists Nausea and vomiting Somnolence Leg oedema

18. COMT side effects Same as levodopa Discolouration of urine GI –Bloated painful abdomen –Explosive diarrhoea Sweating

19. In many chronic diseases, At discovery (onset) Also in the long run with more complications and more decline Worsen in the elderly When do they appear?

20. Isolation –Loss of personal and broader social connections –Sense of shame Exclusion Helplessness with the pace of conversation or activities of those around them Sense of grief in family members and comunity What do they cause as consequences ? Increased isolation and reduced mental stimulation can lead to further deterioration Consequence: Increase in depression and anxiety

21. What can the patient do? Who’s responsible for handling the issue ? What can the informal care giver do? What can the formal care giver do do? What can the physician do? What can the psychologist do?

22. Improve function Improve quality of life What is the aim of the Management?

23. Outline What means “Behavioral Problems” in PD? What makes them different from other common changes in PD? What do they stand for in PD? Case Study Is there any culturally informed strategies for their management?

24. Cameroon Most of PD persons have no access to healthcare facilities; The situation is often handled by families at home. There is a lack of almost everything: Research, Training, long term health care facilities, adult day-care centers…

25. A comparison of the clinical profile of a Cameroonian cohort of PD to the Spanish PD cohort Cubo et al, 2013 74 patients No significant differences between the Spanish and Cameroonian cohort in terms of gender, age, PD duration and presence of comorbidities. Cameroonian PD patients were more affected in terms of motor severity,cognitive impairment,psychosis, patient and caregiver quality of live. In terms of treatments: cameroonian patients reported an intermittent use of PD therapies mainly due to economical limitations.

26. Life expectancy in Cameroon: 52 years women 50 years men Age related disease?

27. Population age structures

28. Mr. H., 75 year old man with more than ten years history of bizarre tremors Known as a task paid farm worker and priest assistant in the parish Seem to be able to read but can’t write Remembers almost everything about all the families of the parish. He’s got a mental map of the cementery and can tell where to dig and burry a member of the community when asked for a location. Remembers almost all the catechism and prayers that he presides in the church. CASE STUDY (Challenging)

29. Has been suffering from a bone cancer for almost 15 years and now uses a protesis after his leg has been cut just a few centimeters below the right knee. Getting worse: his head shakes too much Loses balance : the book and the chapelet shakes a lot when presiding the prayers His first child (5 in total) is 25 year old and has joined a sectarian relgious group. Now dead from the aggravation of his cancer, after an episode of severe delirium during a mass (accused of having contact with bad spirits: devil) CASE STUDY (cont.) (Challenging)

30. PD Cardinal Features PD is a chronic, progressive neurological disease, characterized by Tremor, Rigidity, Akinesia and Postural instability (TRAP). Clinically possible PD (presence of any one of the 4 features) Clinically probable PD (combination of any two cardinal features) Clinically definite (any combination of 3 of the 4 features) Patient must be re-examined at several month intervals (when not all the signs are evident). Was this man a person with PD?

31. Secondary parkinsonism (drugs, toxins, vascular disease, trauma, tumor, infectious agents) CASE STUDY (cont.) (Challenging) Was this man a person with PD?

32. What would a culturally informed management look like?

33. How could we manage? Behavior Therapy Cognitive Behavior Therapy Stress control Depression Anxiety and agitation Sleep disturbances Vivid dreams Hallucinations Delirium Dementia must include the patient, their family and their environment

34. Dancing to prevent falls and improve mobility in PD

35. Summary Early intervention in a biopsychosocial approach may be beneficial in terms of health-related quality of life Great need to increase awareness among population and healthcare providers. The treatment of behavioral symptoms is also as important at all stages of Parkinson's

36. Thank You

37. About Erero NJIENGWE Senior lecturer in clinical Psychopathology; Coordinator of the Psychopathology Unit in the LAPSA (Laboratory of Behavioral Science and Applied Psychology) at the University of Douala. PhD dissertation (Bio-Psych-Social Model) on Depression in Sickle Cell Disease Toulouse (France). Member of the comprehensive program for the management of sickle cell disase at the Laquintinie Hospital in Douala. Co-director of a Masters program on Intervention and Eduaction in Healthcare, with the University of Extremadura (Spain).