evaluation of movement disorders bryan yanaga, m.d. medical director bankers life and casualty
TRANSCRIPT
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 Life Expectancy Average age at death
25-39 38 (49) 71 (82)
40-64 21 (31) 73 (83)
65+ 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 TremorComplications 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 informationAllow 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.