PARKINSON’S DISEASE IN PAKISTAN
MANAGEMENT ISSUES
Prof. Shaukat Ali
Head of the Department of Neurology
Jinnah Postgraduate Medical Centre, Karachi
Parkinson's Disease

James Parkinson’s original 1817 describe “shaking palsy” now
called parkinsons disease.
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Parkinson's disease is a progressive degenerative disorder of the
central nervous system.

Idiopathic Parkinson's disease is caused by the progressive loss of
dopaminergic neurons in the substantia nigra and nigrostriatal
pathway of the midbrain and the presence of lewy bodies.
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The hallmark physical signs of Parkinson's disease are tremor,
rigidity and bradykinesia.

Poor postural reflexes are sometimes included as the fourth
hallmark sign. When postural reflexes are inadequate, patients
may fall if they are pushed even slightly forward or backward, or if
they are standing in a moving vehicle such as a bus or train.
Parkinson’s disease is a disorder of the basal ganglia
Degeneration of
dopamine neurons
in substantia nigra.
These neurons
usually project to
the striatum.
Tremor, slowness of movement
(bradykinesia),
trouble initiating movement
(akinesia), rigidity.
Affects 1/250 over 40; 1/100
over 65.
EPIDEMIOLOGY
Parkinson’s disease effect over 1% of ll
peoples>50years old.
 5-10%of patients with PD present at age
<40years.
 There is a similar incidence in males and
females.
 All ethnic group are equally effected.
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CLINICAL MENIFESTATION OF PD
Cardinal menifestation:
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Resting tremor
Rigidity
Akinesia/bradykinesia
Postural instability
Secondary manifestations:
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Cognitive dysfunction
Ocular dysfunction
Facial and oropharyngeal dysfunction
Musculoskeletal deformities
Pain and sensory symptoms
Autonomic dysfunction
Dermatological problems
Parkinson’s Disease

PD is a progressive neurological condition causing
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Rx does not alter progression of disease
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Physical disability
Mental disability
helps to alleviate various symptoms
helping to live independent & productive lives
Ideal management
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Pharmacological / Surgical
Psychiatric / psychological
Multidisciplinary
Social Rehabilitation
Health Education
Lack of specialists
 Population

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 No.
Urban
Rural
of available specialists
~160 million
35%
65%
< 100
Lack of awareness amongst healthcare providers

General practitioners managing PD patients

Not confident in their diagnosis
 Inadequate Rx prescribed
 Not updated in newer available Rx modalities
 Unable to handle the labile course of disorder /
complications / Rx SE
 Focus only on pharmacological Rx
Lack of awareness amongst healthcare seekers (1)

? Nature of illness
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Consider it to be a part of natural ageing process and
do not seek medical advice
Incorporated in the integrated family system
? Best Rx provider
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GP
Medical Internist
Psychiatrist
Neurosurgeon
Neurologist
Lack of awareness amongst healthcare seekers (2)
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? Rx options
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Expected Rx outcome
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Pharmacological
Surgical
Rehabilitation
A “cure”
Unaware that Rx alleviate symptoms which help live an independent &
productive life, Overall improves the QOL
Rx limitations
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Drug resistance
Side effect – involuntary movements, on-off fluctuations, dystonic
phenomenon
Lack of “Holistic Approach”
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“Treatment Bias”
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Only pharmacological Rx offered
Surgical Rx - Limited facilities, costly
Lack of recent advanced technologies
Lack of Coordinated Multidisciplinary Care
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Physiotherapy
Occupational therapy
Speech therapy
Psychiartic / psychological therapy
Social / occupational rehabilitation
Health awareness
Compliance (1)
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Cost
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Rx Expensive
33% population below national poverty line
1% of national budget allotted for health
Health insurance almost non-existent
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Low national health priority
Infectious diseases of priority
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No health insurance
Lack of awareness
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Importance of Regularity of Rx
Long-term Rx
Rx limitations – “not curative”, no reversibility
Rx side-effects
Rx resistence
Compliance (2)
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Inconsistent Logistics
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65% live in rural areas
Inconsistent availability
Socio-cultural beliefs
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No cure No Rx
Alternative Rx – faith healer, hakim, homeopath, masseur
Normal ageing process & easily incorporated in the integrated family
system
Summary
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Not a national health priority
 Few to non-existing facilities for management of
chronic diseases
 Lack of specialists
 Lack of availability of recent Rx advancements
 Lack of multidisciplinary input
 Lack of rehabilitative facilities
 Lack of sustained logistics
 Poor socioeconomic conditions
 Lack of public health education & awareness

Easy incorporation in the existing family system
NOCTURNAL SYMPTOM COMPLEX OF PD
Parkinson’s Disease Related
Insomnia
Fragmentation of sleep (sleep
maintenance insomnia)
Sleep onset insomnia
Motor Function-
Akinesia (difficulty turning)
Related
Restless Legs
Periodic limb movements of sleep
Urinary Difficulties
Nocturia
Nocturia with secondary postural
hypotension
Neuropsychiatric/
Depression
Parasomnias
Vivid dreams
Altered dream content
Nightmares
Night terrors
Sleep talking
Nocturnal vocalisations
Somnabulism
Hallucinations
Panic attacks
REM Behavior disorder
Treatment-Related:
Motor:
Nocturnal off-period-related tremor
Dystonia
Dyskinesias
Off-period-related pain/ paresthesia/
muscle cramps
Off-period-related incontinence of urine
HAllucinations
Vivid dreaming
? Off-Related panic attacks
? REM Behavior disorder
Akathisia
Insomnia
Sleep-Altering Medications
Sleep and Parkinson's Disease
1.
Sleep disorders secondary to motor
dysfunction.
2. Sleep disorders secondary to behavioral
dysfunction.
3.
Sleep disorders associated with
respiratory dysfunction.
Autonomic and Vegetative Functions
in Parkinson’s Disease
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Bladder Symptoms
dysfunction
Frequency
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Irritative
Frequency, urgency 57-83%
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Obstructive
Hesitancy, post-viod dribbiling
17-23%
Transient and new
Onset incontinence
Chronic incontinence
Urinary tract infection
Medications
Faecal impaction.
Parkinsonism
Lack of mobility
Anatomic stress incontinence
(women)
Bladder-neck obstruction
(prostate in men)
Other peripheral or central
neurological disorders
Dementia or apathy
Parkinsonian
syndromes
Drugs
Idiopathic parkinsonism with central
autonomic involvement
Multiple system atrophy
Levodopa
Dopamine agonists
Amantadine
Selegiline (especially combined with
lovodopa)
Antidepressents
Sedative hypnotics
Antipsychotics
Benzodiazepines
Analgesics
Antihypertensive
Vasodilators
Diuretics
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Coexistent diseases
Autonomic neuropathies
(diabetes, alcohol)
Brainstem and spinal cord lesions
Dehydration, intercurrent illness
Decreased oral intake from dysphagia
Decreased salt intake
Immobility.
A.
B.
C.
Elimination or reduction of hypertensive medications
Pharmacortisone management
Fludrocortisone
Propranolol
Clonidine
Yohimbine
Ephedrine
caffeine
Indomethacin
Domperidone
Non-pharmacological management
Sodium chloride tablets
Elevation of the head of the bed 5-20 degrees
Changing position slowly
Pressure stockings, pantyhose
liberalizing salt and fluid intake
Avoidance of hot weather, hot tubs or baths, alcohol,
large meals.
Patient and caregiver education.
Depression and Dementia in
Parkinson’s Disease
Depression in Parkinson’s Disease
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decreased energy
decreased mood
decreased enjoyment of activities
decreased appetite
sleep disturbances
psychomotor dysfunction
Feelings of worthlessness or guilt
problem in concentration
indecisiveness
emotional lability
thoughts of suicide of death
pseudo-dementia manifested as forgetfulness.
TREATMENT OF DEPRESSION IN PD
DEMENTIA IN PARKINSON’S DISEASE
Psychosis in Parkinson’s Disease
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Newer Atypical Antipsychotic Drugs
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Clozapine
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Olanzapine
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Risperidone
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Quetiapine
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Cholinesterase Inhibitors
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Choice of Drug therapy for psychosis in PD
Basic Principles in the Pharmacotherapy
of Parkinson’s Disease
SUBCLINICAL EARLY ASYMPTOMATIC PD
• CLINICAL MILDLY SYMPTOMATIC PD
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Vitamin E (2000 iu/d)
Selegiline (10 mg/d)
Riluzole (100-200 mg/d)
Coenzyme Q 10 (300-1200 mg/d)
Carbidopa/ levodopa (150-600 mg/d)
Bromocriptine
Fluctuations
• Early morning akinesia
• Delayed on
• End-of-dose wearing-off
• On-off
• Freezing
Dyskinesia
• Off period dystonia
• Peak dose dyskinesia
• Diphasic dyskinesia
TREATEMENT OF ADVANCED
PAKINSON’S DISEASE
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Motor Fluctuations in Advanced PD
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Early Morning Akinesia
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Wearing-off
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On-off
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Freezing
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Off Period Dystonia
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Peak-dose Dyskinesia
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Diphasic Dyskinesia
1. Side effects:
A. Peripheral (and /or central):
a. Nausea, vomiting, anorexia
b. Orthostatic hypotension
B. Central:
a. Chorea, stereotypy
b. Dystonia
c. Myoclonus
d. Akathesia
e. Hallucinations
2. Motor complications:
A. Motor fluctuations
a. Delayed onset of response
b. Wearing off phenomenon
c. Drug resistant “Off”
d. Random oscillations “On-Off phenomenon
e. Freezing
B. Dyskinesias
a. Peak dose dyskinesia (I-D-I)
b. Diphasic dyskinesia (D-I-D)
THANK YOU