Treatment of Advanced Parkinson Disease and Related Disorders (Movement Disorders 2016)

Educational Objectives

The goal of this lecture is to improve diagnosis and treatment of movement disorders. After hearing and assimilating this lecture, the clinician will be better able to:

1. Manage common symptoms in patients with Parkinson disease.

Summary

Aging in patients with PD: PD now considered spectrum of illness; patients affected early (eg, 40 years of age) may have slow progression of disease and course that spans decades; patient diagnosed at, eg, 75 years of age likely to have more rapid progression, less risk for dyskinesia, poorer response to levodopa, comorbidities that affect management, cognitive changes, and dementia; typical patient diagnosed with PD at 55 years of age may have less response to medication, dyskinesias, dystonia, and excessive off time by late 60s; use of medications may be limited by orthostatic hypotension, confusion, or dementia; neurologist should assess which symptoms most concerning to patient; reducing dose of levodopa may decrease motor control but improve mental clarity; bothersome symptoms include constipation, dysphagia, and orthostatic hypotension.

Constipation: Patients often have constipation for years before onset of motor symptoms; patient may gradually become accustomed to having fewer bowel movements and fail to realize frequency abnormal; managed with increased hydration and diet high in vegetables, fruits, and fiber; fiber-increasing agents slow transit times and worsen constipation; most effective agent polyethylene glycol 3350; 17 g dose may be given several times daily without negatively affecting motility of bowel; unaddressed constipation can cause obstruction and death in patients with PD; constipation slows transit of medications and decreases efficacy of levodopa; constipation and delayed gastric emptying believed to be most common reasons for dose failures.

Orthostatic hypotension: Managed by optimizing hydration; many patients have urinary frequency and restrict their fluid intake; drinking sufficient quantity of water before 6 PM may reduce nocturia; patients who need treatment may use midodrine to increase blood pressure (BP); maximum dose 15 mg given three times daily; to monitor BP, patients should lie down for 5 minutes, take BP, stand up, wait 2 to 3 minutes, then repeat BP measurement; if systolic BP decreases by >20 mm Hg, patient has orthostatic hypotension; systolic BP <90 mm Hg when standing indicates absolute hypotension; patients who feel lightheaded after large meal should eat frequent small meals, avoid sitting for long periods, and avoid alcohol with meals; fludrocortisone less efficacious and may cause hypokalemia; potassium should be monitored when starting medication or adjusting dose; pressure stockings effective for some patients; however, most effective stocking covers torso up to axillae and may be impractical for patient with urinary frequency and poor dexterity; in future, electronically controlled abdominal binders may be used to increase venous return and reduce orthostatic hypotension.

Dysphagia and aspiration: History may not be helpful because patients often unaware of aspiration; gold standard for diagnosis videofluoroscopy; even patients with moderate PD (Hoehn and Yahr stage 2) may aspirate; in addition to performing videofluoroscopy, neurologist should partner with speech-language pathologist familiar with PD and parkinsonian disorders; patients who aspirate or cough with liquids or solids should be treated with staged approach (physical methods should precede enteral feeding); nectar-thickness fluids used at first; patient should avoid crusty breads, nuts, and soups with heterogeneous consistencies (pureed soup safer than stew with chunks of meat); gravies and sauces help with swallowing and may forestall weight loss of PD (related to, eg, early satiety, secretion of cachexins); consumption of high-calorie foods within short period recommended for maintenance of weight, particularly because frailty in PD associated with increased mortality.

Motor complications: With progression of disease, patients become less responsive to levodopa and experience more pain; pain probably musculoskeletal and caused by stiffness; physician should encourage exercise; in patients with limited range of motion, passive range of motion exercises (performed with help of family or caregiver) may be of benefit.

Palliative care specialists: In United States, palliative care often focused on end of life while in other countries, palliative care physicians address any stage of illness; for example, newly diagnosed patient may have questions and concerns about effects of PD on career, family, and relationships; palliative care can help address their distress; patients with advanced PD may perceive themselves as burdensome; palliative care team can help patient find hope and meaning; caregiver distress often significant; advanced stages of many illnesses last months or few years, but patients with PD deteriorate over several years or decades; palliative care team can support strained caregivers and families by treating pain, shortness of breath, and other symptoms; neurologist should maintain contact with palliative care specialist because many medications used for delirium not appropriate in patients with PD (eg, haloperidol); neurologist can provide valuable input and personal connection when patient transitions to facility with skilled nursing care.

Readings

Miyasaki JM. Treatment of advanced prkinson disease and related disorders. Continuum (Minneap Minn) 2016;22(4 Movement Disorders).

Disclosures

For this program, the following was disclosed: Dr. Miyasaki received personal compensation as a consultant from Merz Pharma Group and as a lecturer for Teva Pharmaceuticals Industries Ltd, has received research/grant support as principal investigator of studies for Parkinson Alberta and Patient-Centered Outcomes Research Institute, and receives royalties from UpToDate Inc. Unlabeled Use of Products/Investigational Use Disclosure:Dr. Miyasaki reports nothing to disclose. To view disclosures of planning committee members with relevant financial relationships, visit: audiodigest.org/continuumaudio/committee. All other members of the planning committee report nothing to disclose.

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

CA051402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.