1. www.wemove.org Parkinson’s Disease Slide Library Version 2.0 - All Contents Copyright © WE MOVE 2001 Management of Late-Stage Parkinson’s Disease Part 5 of 7

2. Late Complications Motor –response fluctuations, dyskinesias, dystonia, freezing, falls Behavioral/neuropsychological –depression, sleep disorders, psychosis Autonomic –orthostatic hypotension; hyperhidrosis, constipation, impotence, urinary incontinence or retention www.wemove.org

3. Stages in Decline of Response to LD I: Patient not aware of effect of individual dose II: Mid-afternoon loss of benefit III: Loss of sleep benefit; early-morning akinesia, possible foot dystonia IV: Regular “wearing off” every 4 hours at first, shortens with time V: Frequent wearing off, abrupt on-off, unpredictable dose response www.wemove.org

4. LD Response Fluctuations Peripheral causes: –delayed gastric emptying –dietary protein –short plasma half-life Central causes: –pulsatile delivery to striatal receptors –impaired storage capacity –alteration of DA receptors www.wemove.org

5. Response Fluctuations: Treatment Increase LD dose Increase DCI dose Add dopamine agonist Add COMT inhibitor –reduce LD –liver function monitoring Apomorphine rescue www.wemove.org

6. Peak Dose Dyskinesia or Dystonia Chorea more common than dystonia May be worse on more affected side May not be as disabling as akinesia/rigidity Dose adjustments, add-ons: –reduce LD dose, increase dose frequency –convert to LD-CR –reduce LD, add DA, COMT inhibitor, or MAO- B inhibitor www.wemove.org

7. Off-period Dystonia Appears when LD level is low, especially early AM w/ or w/o parkinsonism Dose adjustments, add-ons: –more frequent LD dosing to avoid low plasma levels –add DA, COMT inhibitor, MAO-B inhibitor www.wemove.org

8. Wearing Off Regular and predictable decline in response 2-4 hours after LD dose Most common motor fluctuation Dose adjustments, add-ons: –change to LD-CR, or increase LD frequency –reduce LD, add DA or COMT inhibitor www.wemove.org

9. On-off Response Sudden and unpredictable off periods unrelated to dosing schedule One of the hardest features to manage Dose adjustments, add-ons: –reduce LD, add DA www.wemove.org

10. Other Motor Complications Diphasic dyskinesia –dyskinesia at beginning and end of dose –Dose adjustments, add-ons: add DA Drug failure –late afternoon, probably related to poor gastric emptying or absorption –liquid preparations; increase gastric motility; decrease dietary protein –apomorphine rescue www.wemove.org

11. Freezing and Falls Freezing –motoric block; at initiation of gait, turning, narrow spaces –use auditory, visual, proprioceptive cues Falls –physical therapy evaluation –cane, scooter, wheelchair may be necessary www.wemove.org

12. Cognitive Assessment Memory difficulties: 11-29% of PD patients –Benign forgetfulness –Delirium –Alzheimer’s disease –Other dementias Evaluation –Brain imaging –Lumbar puncture –EEG –Blood work for thyroid profile, vitamin B12, serology, chemistry panel www.wemove.org

13. Psychosis Features –Vivid dreams/nightmares, disorientation, hallucinations, delusional thought Simplify medical regimen –Stop unnecessary non-PD meds –Stop: anticholinergic drugs, amantadine, selegiline, dopamine agonists, COMT inhibitors Change from CR to standard carbidopa/levodopa Try atypical antipsychotic agents Try low-potency traditional antipsychotic agents www.wemove.org

14. Anti-psychotic Agents Molindone –low-potency neuroleptic; may aggravate PD symptoms, but can sometimes use 5-10 mg at HS Risperidone –D3 antagonist; D1/D2 agonist; aggravates PD at doses > 3 mg/d. Olanzapine –D4 antagonist. D1/D2 inhibition > 10 mg/d Quetiapine –5-HT1-2 antagonist. Dosage 25 - 500 mg/d Clozapine –D4 antagonist; no confirmed aggravation of PD or causation of TD –Fatal agranulocytosis in 9 patients; weekly CBC www.wemove.org

15. Depression Reported in 30-90% of PD patients Difficult to discern from vegetative symptoms Requires inquiry into depression symptoms Usually responds quickly to medications –Tricyclic agents –Selective serotonin re-uptake inhibitors If ECT needed, will transiently improve PD symptoms www.wemove.org

16. Anxiety/Restlessness Primary anxiety disorder: treat with benzodiazepines –Associated with “off-periods” or low-levodopa levels: adjust levodopa dosing Restless Leg Syndrome: benzodiazepines, narcotics, levodopa, dopamine agonists www.wemove.org

17. Sleep Disorders Insomnia –careful history –difficulty with sleep initiation: tricyclic agents, benzodiazepines, diphenhydramine, chloral hydrate – treat depression –REM-behavioral disorder: clonazepam Excessive daytime sleepiness –Correct poor sleep at night –Discontinue anticholinergics, amantadine –Reduce dopamine agonist, levodopa dosages if possible –selegeline; caffeine; methylphenidate 5-20 mgs/d www.wemove.org

18. Orthostatic Hypotension Light-headedness, dizziness, fatigue, shoulder or neck pain, blood pressure drops when standing Taper anti-hypertensive agents Taper non-PD drugs Increase salt intake Compression stockings Fludrocortisone (0.1-0.4 mg/d) Midodrine (2.5 - 20 mg/d) www.wemove.org

19. Urinary Incontinence/Frequency Rule out urinary tract infection Bladder evaluation for –detrusor hyperactivity oxybutinin 5 -30 mg/d; propanthaline 7.5 - 15 mg/d –detrusor hypoactivity phenoxybenzamine; prazosin Urinary frequency –avoid fluid pooling in feet –DDAVP inhaler; tolterodine tartrate 2mg hs to 2mg tid www.wemove.org

20. Sexual Dysfunction Medical screening –depression, anxiety, iatrogenic causes Endocrinologic evaluation –prolactin, testosterone, lutenizing hormone, thyroid screen Urologic evaluation –yohimbine, sildenafil www.wemove.org

21. Nausea Levodopa-related: take with meals, add carbidopa, add domperidone Other anti-PD medications: same. –If no improvement: withdraw newest agent, re- initiate at minimal doses, slowly increase www.wemove.org

22. Excessive Sweating Usually levodopa related, and may be seen at peak or trough dose drug levels –reduce levodopa –add dopamine agonist or COMT inhibitor –add carbidopa –add Beta-blocker www.wemove.org

23. Faculty for the WE MOVE Parkinson’s Disease Teaching Slide Set Mark Stacy, MD Barrow Neurological Institute Phoenix, Arizona, USA Charles H. Adler, MD, PhD Mayo Clinic Scottsdale Scottsdale, Arizona, USA Kathleen Albany, PT, MPH WE MOVE New York, USA Richard B. Dewey, Jr., MD University of Texas Southwestern Medical Center Dallas, Texas, USA William G. Ondo, MD Baylor College of Medicine Houston, Texas, USA Rajesh Pahwa, MD University of Kansas Medical Center Kansas City, Kansas, USA Ali H. Rajput, MD Royal University Hospital Saskatoon, Saskatchewan, Canada Lisa M. Shulman, MD Health Policy Fellow U.S. House of Representatives Washington, DC, USA Celia Stewart, PhD Mount Sinai Medical Center New York, New York, USA Reviewed by the Education Committee of the Movement Disorder Society www.wemove.org