Evaluation of Movement
Disorders
Bryan Yanaga, M.D.
Medical Director
Bankers Life and Casualty
Parkinson’s Disease
Parkinson’s Disease
•
•
•
•
What is it?
What are the (early) symptoms?
How is it treated?
How do you differentiate (early) PD
from a movement disorder that could be
benign or reversible?
• Why this is important for underwriting and
claims?
Parkinson’s Disease
• A gradually progressive degenerative
disorder of the nervous system that affects
movement.
Parkinson’s Disease
•
•
•
•
•
Average age of onset: Late 50’s/Early 60’s
1.5x more common in men than women
Incidence: 60,000 new cases per year
Prevalence: 1.6 million in the USA
Affects 1% of people over age 60
5% of people over age 80.
Neuropathology of Parkinson’s
Disease
• Loss of pigmented dopaminergic
neurons in the substantia nigra of the
midbrain
Neurotransmission
From: Immunology and Cell Biology, 2012
Symptoms Associated with
Parkinson’s Disease
Three cardinal signs:
• Tremor
• Rigidity
• Bradykinesia
• Postural instability
Evaluating Parkinson’s Disease
Tremor
•
•
•
•
•
Insidious onset
Gradual progression
Begins in the hands
Usually unilateral, can become bilateral
Usually occurs at rest (Pill rolling)
Evaluating Parkinson’s Disease
Rigidity - Increased resistance to passive
movement at a joint
• Smooth (lead pipe)
• Oscillating (cog wheeling)
Evaluating Parkinson’s Disease
Bradykinesia
• Slowness of movement
• Reduced spontaneous movements
• Decreased amplitude of movement
Underwriting Parkinson’s Disease
Examples of Bradykinesia
•
•
•
•
•
•
Micrographia – Small handwriting
Hypomimia – Loss of facial expression
Decreased blink rate
Loss of hand dexterity
Slowness rising from a chair, turning in bed
Slow gait, smaller steps, lower cadence,
dragging of one leg
Treatment
Sinemet (levodopa/carbidopa)
• Levodopa is broken down to dopamine in
the brain and peripheral circulation
• Peripheral dopamine causes nausea
• Carbidopa prevents peripheral conversion
of levodopa to dopamine
• Allows for use of lower doses of levodopa
Prognosis
(Before the introduction of Sinemet)
Time to severe disability or death:
• Within 5 years of onset - 25% of patients
• Within 10 years of onset - 65% of patients
• Within 15 years of onset - 89% of patients
Prognosis
(After the introduction of Sinemet)
• 50% drop in mortality rate
Estimated life expectancy of
Parkinson’s patients compared with
the UK population
Age
25-39
40-64
65+
•
Life Expectancy Average age at death
38 (49)
71 (82)
21 (31)
73 (83)
5 (9)
88 (91)
Ishihara, LS, et.al., J Neurol Neurosurg Psychiatry 78(12): 1304-1309,2007.
Complications
With long-term use of Sinemet:
• Shortened duration of drug effectiveness
• Wider fluctuations in drug effectiveness
(on-off phenomena)
• Dyskinesias (choreiform movements)
occur at peak doses of levodopa
Complications
• Goal is to use the lowest dose of
levodopa as possible
Treatment
Dopamine agonists
• Mirapex (pramipexole)
• Requip (ropinerole)
• Parlodel (bromocriptine)
• Bind to dopamine receptors in the brain
and mimic the action of dopamine
Progression of Parkinson’s Disease
Unified Parkinson’s Disease Rating
Scale (UPDRS)
•
•
•
•
•
•
No medication needed
Good response to medications
Waning medication response
Unpredictable medication response
Dyskinesias
Severely Unpredictable Symptoms
Progression of Parkinson’s Disease
Unified Parkinson’s Disease Rating Scale (UPDRS)
•
•
•
•
•
•
No medication needed. Patient with Newly Diagnosed Parkinson’s disease:
Good response to Medications: Symptoms are markedly reduced without
evidence of breakthrough symptoms between doses. Can last five years or
longer on Sinemet.
Waning medication response: Breakthrough symptoms begin to occur
towards the end of each dose of medication. The dosage and/or frequency
of medication must be increased.
Unpredictable medication response. The breakthrough symptoms occur
randomly. May be associated with On-Off Fluctuations: This stage is
associated with more severe disability.
Patient with Dyskinesias: These potentially disabling involuntary
movements can occur when peak doses of medications are given.
Surgical options for treatment can be considered.
Severely Unpredictable Symptoms: May fluctuate between severe off state
and severe dyskinesias despite careful medication management. Surgical
options for treatment can be considered.
The Goals of Underwriting
• Add good business to the books
• Keep bad business off the books.
Progression of Parkinson’s Disease
Unified Parkinson’s Disease Rating
Scale (UPDRS)
•
•
•
•
•
•
No medication needed
Good response to medications
Waning medication response
Unpredictable medication response
Dyskinesias
Severely Unpredictable Symptoms
When is a tremor just a tremor?
Tremor – Differential Diagnosis
Neurological Disorders
•
•
•
•
Parkinson’s disease
Multiple sclerosis
Stroke
Traumatic brain injury
Tremor – Differential Diagnosis
Other Medical Conditions
•
•
•
•
•
•
Chronic kidney disease
Alcohol abuse or withdrawal
Hyperthyroidism
Liver failure
Hypoglycemia
Wilson’s disease (in younger patients)
Tremor – Differential Diagnosis
Deficiencies
•
•
•
•
Thiamine
Magnesium
Vitamins (B1, B6, B12, E)
Sleep
Essential Tremor
Benign
Risk factors
• Age
• Genetic mutation (autosomal dominant)
• Up to 20x more common than Parkinson’s
Essential Tremor
•
•
•
•
•
Insidious onset
Can begin in one or both hands
Usually bilateral and symmetrical
Worse with movement (intention tremor)
Can include a “yes” or “no” movement of
the head
• Can be aggravated by stress, fatigue,
caffeine, or extreme temperatures
Essential Tremor
Complications include the inability to:
•
•
•
•
•
Hold a cup of water without spilling
Eat normally
Write
Shave or put on makeup
Talk (if the tongue or vocal chords are
affected)
Essential Tremor Test
Parkinson’s vs. Essential Tremor
Similarities:
• Insidious onset
• Usually begins in the hands/upper
extremity
• Can be aggravated by stress
Parkinson’s vs. Essential Tremor
Differences:
•
•
•
•
Unilateral vs. bilateral
Most prominent at rest versus with activity
No involvement of the head and neck
Multiple progressive symptoms versus a
narrower range of symptoms
• Improvement with dopamine and
dopaminergic agonists!
Underwriting Parkinson’s Disease
If the diagnosis is unclear
(i.e. If the characteristic symptoms
of PD have yet to be revealed):
• Issue
• Decline
• Postpone
Request additional information
Allow time for development underlying
pathology
Restless Legs Syndrome
• Discomfort in the legs, typically in the
evening while sitting or lying down
• Relief when getting up and moving
• Symptoms worse at night
• Can begin at any age
• Usually worsens with age
Restless Legs Syndrome
Treatment
• Requip
• Mirapex
• Sinemet
Parkinson’s Disease
•
•
•
•
What is it?
What are the (early) symptoms?
How is it treated?
How do you differentiate (early) PD
from a movement disorder that could be
benign or reversible?
• Why this is important in underwriting and
claims?
Thank you.