Parkinson’s Disease
…in 45 minutes
Dr. Claire Hinnell
Movement Disorder Neurologist
Director Movement Disorder Clinic
JPOCSC
S
Plan of attack
S Common Symptoms/Diagnostic Criteria
S What causes Parkinson’s disease - brief
S Treatment options – the whole gammut
S Research
Symptoms
Cause of PD
Treatment
1. Medications for PD
2. Don’t forget the non-motor symptoms
3. Alternative treatments
4. It’s not all about drugs
5. What’s on the horizon
Treatment
1. Medications for PD
2. Don’t forget the non-motor symptoms
3. Alternative treatments
4. It’s not all about drugs
5. What’s on the horizon
Major Medication Classes
Pramipexole/Mirapex
Levodopacarbidopa/Sinemet
Ropinirole/Requip
Bromocriptine
Rasagiline/Azilec
t
Selegiline
Add on Medications
Amantadine
Entacapone/
Comtan
Trihexiphenidyl
/Artane
The levodopa myths
Myth
S Sinemet accelerates disease progression
S Reality: Levodopa has been shown to increase lifespan and
dramatically improve quality of life.
Myth
S Sinemet stops working after 5 years so we
need to save it for later
S Reality: Levodopa works for decades. Levodopa does not treat
all of the symptoms of PD, but it dramatically helps many
of the most disabling motor symptoms.
Myth
S Sinemet causes dyskinesias so we need to try
to delay the use of Sinemet as long as
possible.
S Reality: Treatment related side effects are less with levodopa.
PD MED trial 2014
S “Finally, and perhaps most importantly, the
results of this study will help to persuade
physicians and reassure patients that the fears
that have served as the groundwork in
establishing levodopa phobia—that often
results in patients experiencing unnecessary
and easily managed disability and reduction in
quality of life in the early years of their
disease—are unfounded". (Professor Anthony Lang)
Myth
S You should wait as long as possible to
take the next dose of levodopa.
S Reality: Levodopa is most effective when taken on time, just before
the previous dose wears off.
S Secret: A medication timer can help.
Approach to starting
Younger
more emphasis on long-term
considerations to guide early
treatment
longer life expectancy and are
more likely to develop motor
fluctuations and dyskinesias
Older, cognitive
impairment
less emphasis is placed on longterm considerations
focus is on providing adequate
symptomatic benefit in the near
term, with as few adverse effects
as possible
In a nutshell
S levodopa more robust effect
S DA generally more side
effects which increase with
age (somnolence,
hallucinations, peripheral
edema, ICD)
S motor complications occur
earlier with levodopa
Take home messages
1. Medications for PD
2. Don’t forget the non-motor symptoms
3. Alternative treatments
4. It’s not all about drugs
5. What’s on the horizon
Non-motor symptoms
S Depression and anxiety
S Sleep disturbance
S Cognitive concerns
S Psychosis
S Autonomic dysfunction (low blood pressure on standing,
sweating, constipation, urinary problems, sexual
dysfunction)
Non-motor symptoms
IMPORTANT
S Unidentified or untreated non-motor symptoms contribute
to poorer quality of life and poorer motor function overall
“Off ” Non-motor symptoms
S NMS can cycle just as motor symptoms do with OFF times
S Eg: off-anxiety, off-sweating
S Approach is to reduce the off time
Take home messages
1. Medications for PD
2. Don’t forget the non-motor symptoms
3. Alternative treatments
4. It’s not all about drugs
5. What’s on the horizon
QUESTION
S How many take a non-prescribed drug to help with PD?
S Coenzyme Q10
S Creatine
S Vitamin E
S Vitamin D
S Mucuna puriens
S Caffeine
Take home messages
1. Medications for PD
2. Don’t forget the non-motor symptoms
3. Alternative treatments
4. It’s not all about drugs
5. What’s on the horizon
QUESTION
S What forms of exercise are good for Parkinson’s disease?
Essentially, all right answers
Drugs aren’t everything
Deep Brain Stimulation
Take home messages
1. Medications for PD
2. Don’t forget the non-motor symptoms
3. Alternative treatments
4. It’s not all about drugs
5. What’s on the horizon
Duodopa
Neuroprotection
Research
Novel therapies
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Exercise interventions
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Musical walking strategies
S
Caffeine
S
Sleep stimulation
S
S
New ways to give medicine
S
Duodopa
S
Sublingual apomorphine
S
Inhalation (levodopa puffer)
Brain stimulation techniques
S
Galvanic vestibular stimulation**
S
Transcranial magnetic stimulation
S
Direct current stimulation
Genetics
S
S
S
Help to understand the
mechanisms leading to PD
S
Patients with PD
S
Family members of patients with
PD
S
Healthy controls
Identify genetic factors that play
an important role in PD
Combine with neuroimaging
techniques
Neuroimaging
S
MRI – structural picture
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fMRI – function of the brain
S
Rs-fMRI – how regions of the
brain talk to each other
S
PET
S Look at the chemical
function and cell behaviour in
the brain
S
Electrophysiology
S EEG
S EMG
Complications of PD
S
Depression
S
Impulse control disorders
S
Dyskinesias
S
Visual and sensory deficits
S
Balance problems
S
Coping
S
Study using MRI and PET
S
Balance control
Research
S If interested or have questions, please contact
S PPRC research coordinator Tammy Kang 604-822-9722
S Movement disorders clinic at JPOC
Resources
S www.parkinson.ca (Parkinson Society Canada)
S www.parkinson.bc.ca (Parkinson Society BC)
S www.parkinsons.org (National Parkinson’s Foundation,
USA)
S www.pdf.org (Parkinson’s disease foundation)
THANK YOU
Mood
1. Not just sad…often irritability
2. Be open and aggressive in treating mood
disorders
3. If mood is left untreated, motor symptoms
are difficult to treat
Sleep
WHY
S Medication
S PD motor symptoms
S Bladder
S Sleep apnea
S Night dreams or behaviours
S Psychosis
TREATMENT
S Treat the underlying
contributing factors
S Meds – melatonin,
clonazepam, zopiclone,
mirtazipine
Cognitive Issues
S Not Alzheimer’s
S Related to PD
S Requires regular assessment
S There are treatments so it’s important to identify & address
Urinary, bowel, sexual dysfunction
Postural hypotension
WHY
TREATMENT
S Parkinson’s disease
S Reduce causative meds
S Sinemet
S High salt diet
S Other comorbid conditions
S Stockings
S Other meds
S Domperidone
S Other meds
Stem cell therapy
Gene therapy