movement disorders in the elderly - parkinson’s disease ... · parkinson’s disease features...
TRANSCRIPT
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MOVEMENT DISORDERS
IN THE ELDERLY
Eugene C. Lai, M.D., Ph.D.Michael E. DeBakey VA Medical Center
Baylor College of Medicine
Houston, Texas
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MOVEMENT DISORDERS
Neurologic dysfunctions in which there is either
a paucity of voluntary and
automatic movements
(HYPOKINESIA)
or an excess of movement
(HYPERKINESIA)
or uncontrolled movements
(DYSKINESIA)
typically unassociated with weakness or spasticity
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HYPOKINESIAS
• Parkinson‟s disease
• Secondary Parkinsonism
• Parkinson‟s plus syndromes
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HYPERKINESIAS
• Akathisia
• Athetosis
• Ballism
• Chorea
• Dystonia
• Hemifacial spasm
• Myoclonus
• Restless leg syndrome
• Tics
• Tremor
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COMMON MOVEMENT
DISORDERS IN THE ELDERLY
• Parkinsonism
• Tremor
• Gait disorder
• Restless leg syndrome
• Drug-induced syndrome
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PARKINSONISM
• Parkinson‟s disease
• Secondary parkinsonism• Drug-induced parkinsonism
• Vascular parkinsonism
• Parkinson‟s plus syndromes• Multiple system atrophy
• Progressive supranuclear palsy
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PARKINSON’S DISEASE
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PARKINSON’S DISEASEClassical Clinical Features
•Resting Tremor
•Cogwheel Rigidity
•Bradykinesia
•Postural Instability
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PARKINSON’S DISEASEAssociated Clinical Features
• Micrographia
• Hypophonia
• Hypomimia
• Shuffling gait / festination
• Drooling
• Dysphagia
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NON-MOTOR COMPLICATIONS
IN PARKINSON’S DISEASE
• Sleep disturbances
• Autonomic dysfunctions
• Sensory phenomena
• Neuropsychiatric manifestations
• Cognitive impairment
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PARKINSON’S DISEASEGeneral Considerations
• The second most common progressive neurodegenerative disorder
• The most common neurodegenerative movement disorder
• It is a complex disease with variable symptoms
• Symptoms and neuropathology are well characterized
• Pathogenesis of PD is not clear
• May be multifactorial and heterogeneous in etiology
• Misdiagnosis rate of PD is about 10-25%
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PARKINSON’S DISEASEIncidence and Epidemiology
Prevalence Rate : 200 per 100,000
Rare for individuals < 40 years of age
1% for individuals > 60 years of age
2% for individuals > 85 years of age
Men > Women
Incidence rate : 20 per 100,000 (annually)
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PARKINSON’S DISEASEFeatures supporting diagnosis
• Unilateral symptom onset
• Characteristic resting tremor
• Narrow-based gait with flexed/
stooped posture
• Reduced arm swing with
tremor when walking
• Sustained and significant
levodopa effect
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PARKINSONISMAAN Practice Parameter Recommendations:Clinical features distinguishing other parkinsonian
syndromes from PD
• Falls at presentation and early in the disease
course
• Poor response to levodopa
• Symmetry at onset
• Rapid progression of postural imbalance and
dysfunction
• Lack of tremor
• Early dysautonomia
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PARKINSON’S DISEASEPoor Prognosis for Morbidity & Mortality
• Age
• Postural Instability Gait
Disorder (PIGD) subtype
• Medical co-morbidities
• Cognitive impairment
• Immobility and lack of exercise
• Lack of specialty attention
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TREATMENT OPTIONS
FOR PARKINSON’S DISEASE
• Pharmacological treatments
• Non-pharmacological
treatments
• Surgical treatments
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PARKINSON’S DISEASEPharmacological Treatments
• Monoamine oxidase-B inhibitor
• Levodopa
• Anticholinergics
• Dopamine agonists
• COMT inhibitor
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NON-PHARMACOLOGIC
INTERVENTIONS IN PD• Education
– from healthcare providers & support groups
– avoid misinformation & incomplete information
• Support
– professional & peer support
– emotional & financial counseling
• Exercise
– keep active & avoid deconditioning
– regular stretching exercises
– physical therapy
• Nutrition
– balanced diet & suitable consistency
– nutritional counseling
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COMPLICATIONS IN ADVANCED
PARKINSON’S DISEASE
• Motor fluctuations
• Dyskinesias
• Posture, gait, falling
• Neuropsychiatric problems
• Sleep disorders
• Sensory phenomena
• Dysautonomias
• Speech disturbances
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Exercise Class
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MEDICALLY REFRACTORY
SYMPTOMS OF ADVANCED PD
• Dopa-induced dyskinesia
• Excessive tremor
• “On-off” motor fluctuation
• Rigidity with pain
• Freezing
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Deep Brain Stimulation
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DEEP BRAIN STIMULATION (DBS)
• High frequency, pulsatile electrical stimulation
• Stereotactically placed into target nucleus
• Can be activated and deactivated by an external magnet
• Exact physiology unknown, but higher frequencies mimic cellular ablation, not stimulation
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DBS vs. BMT CONCLUSIONS• 255 patients randomized to BMT (134) and DBS (121) and
followed for 6 months.
• „Off‟ time reduced by 47% and „On‟ time without
troublesome dyskinesia improved by 81%.
• DBS is superior to BMT in improving PD motor function and
quality of life.
• Adverse events are significant in patients undergoing DBS.
• Mild neurocognitive changes are observed in DBS patients.
• Benefits of DBS need to be weighed against the risk of
complications related to surgery.
• Caution should be exercised against over- or under-stating
the risks of DBS for PD.
JAMA 2009;301:63-73
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TREMORInvoluntary, somewhat rhythmic, muscle
contraction and relaxation involving
to-and-fro movements (oscillations or twitching)
of one or more parts of the body
It is the most common of all movement
disorders and can affect all parts of the body
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COMMON FUNCTIONAL
DISABILITIES IN TREMOR
• Handwriting
• Drinking liquids
• Fine manipulations
• Eating
• Dressing
• Speaking
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Anxiety
Embarrassment
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TREMOR• Most common movement disorder in the elderly
• Affects men and women equally
• Rhythmic shaking of hands, arms, head, legs, voice
• Dysfunction of muscle control and coordination of agonist & antagonist muscles
• Triggered by or become exaggerated during stress or strong emotion, physical exhaustion, or with certain postures or movements
• Many causes: idiopathic, brain injury, drug-induced, alcohol, toxin (mercury), metabolic (thyroid & liver diseases)
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CLASSIFICATION OF
TREMORS• Resting tremor
- Parkinsonian tremor
• Action tremor- Postural tremor
- Kinetic tremor
• Psychogenic tremor
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RESTING TREMOR
• Idiopathic Parkinson‟s disease
• Pronation / supination
• Slower rate (5-6 Hz)
• Present when walking
• Reemergence tremor
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ACTION TREMOR
• Essential tremor
• Physiologic tremor
• Dystonic tremor
• Cerebellar tremor
• Orthostatic tremor
• Task-specific tremor
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ESSENTIAL TREMOR• Present in about 4% of population over 65
• Probably hereditary, but exact etiology and pathology are unknown
• Affects both sides of body, but usually asymmetric: hands, arms, head, voice (tongue, legs, trunk)
• Typically high frequency tremor involving flexion/extension muscles
• Severity increases with age
• Reduction with alcohol and a positive family history are supportive information
• Treatment with beta-blocker, primidone, botulinum toxin injection or deep brain stimulation
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PHYSIOLOGIC TREMOR• Very fine, high frequency, low amplitude tremor
• Occurs in normal individual & typically without clinical significance
• Enhanced physiologic tremor is heightening PT to more visible levels
• Caused by strong emotion, physical exhaustion, hypoglycemia, hyperthyroidism, heavy metal poisoning, stimulants, alcohol withdrawal, or fever
• Usually reversible once the cause is corrected
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DYSTONIC TREMOR• Occurs in individuals with dystonia: sustained
involuntary muscle contractions causing twisting and repetitive motions and/or painful and abnormal postures or positions
• Dystonic head tremor
• Occurs when the individual is in a certain position or moves a certain way
• Occurs irregularly and often relieved by complete rest
• Touching the affected body part or muscle may reduce tremor severity
• Responds well to botulinum toxin treatment
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CEREBELLAR TREMOR
• Slow, high amplitude, irregular tremor that occurs at the end of a purposeful movement
• Caused by lesion in or damage to the cerebellum and its outgoing nerves by stroke, tumor, multiple sclerosis, degenerative diseases, alcoholism, and certain medications
• Often most prominent when the individual is active or is maintaining a particular posture
• May be accompanied by dysarthria, nystagmus, and gait ataxia
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ORTHOSTATIC TREMOR
• Rhythmic contractions that occur in the legs and trunk immediately after standing
• Cramps in thighs and legs
• Shakes uncontrollably when the individual is asked to stand in one spot
• No clinical signs or symptoms when the individual sits or is lifted off the ground
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TASK-SPECIFIC TREMOR• Also known as focal tremor or occupational
tremor
• Occurs mostly in hands when in a certain position or performing a certain task: writing, throwing a ball, bowing the violin, swinging a golf club, gripping a glass
• May benefit from beta-blocker, anticholinergic, or botulinum toxin injection
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PSYCHOGENIC TREMOR
• Occurs at rest or during postural or kinetic movements
• Sudden onset and remission, increased incidence with stress
• Bizarre movements that are distractible, variable and inconsistent
• Associated with conversion disorder and psychiatric disease
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SYMPTOMATIC TREATMENT OF
ACTION TREMOR
• Pharmacological therapy– Beta-blocker, anticholinergics, clonazepam
• Physical rehabilitation– Weighted bracelets, occupational therapy
• Botulinum toxin treatment– Intramuscular injection to weaken dominant
muscles
• Neurosurgical procedure– Deep brain stimulation
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GAIT DISORDERS
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GAIT DISORDER• Normal gait depends upon normal functioning of
the nervous, muscular, skeletal, circulatory, and
respiratory systems in a highly coordinated and
integrated manner.
• Gait disorders are heterogeneous and often
multifactorial
• Gait disorders are common in the elderly
• 15% of community-dwelling patients over 65
have gait impairment.
• Gait disorders cause immobility, fall injuries, and
institution of patients
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GAIT DISORDER
• > 2 unexplained falls in previous year
• Needs walking aid
• Cannot walk more than 300 feet
• Cannot go up 15 steps of stairs without
support
• Housebound and goes out only when
assistance and/or transportation is available
• Walking speed <50% of previous best speed
• Condition existed more than one month
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EFFECTS OF AGE ON GAIT
AND BALANCE• Slowing of walking speed
• Decrease in stride length
• Forward flexion posture
• Increase in body sway
• Increase in double-support stance time
• Decrease in push-off power
• Disorganization of muscle synergy
• Decline in dynamic balance
• Mild decrease in rotations of hip and knees
• Changes attributable to an adaptation related to a safer (less destabilizing) gait stride
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BALANCE AND GAIT
ABNORMALITIES WITH FALLS IN
THE ELDERLY
BALANCE
• Unsteady sitting down
• Unable to stand on one leg unsupported
• Unsteady turning
• Unsteady after gentle push
GAIT
• Increase trunk sway
• Unable to pick up walking pace
• Increase path deviation
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SYNDROMES OF
GAIT DISORDERS
• Akinetic-rigid syndrome
Parkinsonian gait
• Ataxic syndrome
Cerebellar ataxia
Sensory ataxia
• Frontal lobe syndrome
Multi-infarct state
Hydrocephalus
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SYNDROMES OF
GAIT DISORDERS (Cont.)
• Upper motor neuron syndrome
Hemiparetic gait
Spastic gait
• Lower motor neuron syndrome
Steppage gait
Waddling gait
• Mixed gait syndrome
Senile gait
Vertiginous gait
• Hysterical gait syndrome
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SENILE GAIT SYNDROME(A Mixed Condition)
• Age related gait decline
• Slow, wide-based, shuffling
• Multiple mild sensory deficits
• Modest leg weakness
• Cervical and lumbar spondylosis
• Loss of confidence when walking
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NORMAL PRESSURE
HYDROCEPHALUS
• Syndrome of gait disturbance, urinary incontinence, and a dementing process
• Gait disturbance is early and prominent in this condition
• Characterized by wide-based ‘magnetic’gait and unsteadiness
• Diagnosis is by neuroimaging and large volume cerebrospinal fluid drain
• Treatment is by CSF shunting procedure
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RISK FACTORS FOR FALLS
IN THE ELDERLY
• Use of sedatives
• Cognitive impairment
• Lower-extremity disability
• Foot problems
• History of previous falls
• Acute illness
• Age
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TREATMENTS TO IMPROVE
MOBILITY AND AVOID FALLS
• Keep active
• Exercise regularly
• Physical therapy
• Adjust medication regimen
• Sensory cues
• Assistive devices
• Safety-proof living environment
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RESTLESS LEG
SYNDROME
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RESTLESS LEG
SYNDROME• Very common movement disorder
• Occurrence and intensity increase with age
• 10-12% of adults and >19% in those 80 years or older
• Disagreeable and troublesome sensation in legs
• Diagnostic criteria:– Urge to move legs
– Worsening of symptoms with rest
– Relief with activity
– Intensification during the evening
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RESTLESS LEG
SYNDROME
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RESTLESS LEG
SYNDROME• Causes anxiety, sleep deprivation, malaise,
fatigue
• Associated with iron deficiency, peripheral neuropathy, kidney or liver disease, and offending medications
• Recognizing symptoms and seeking medical attention are important
• Accompanied by periodic limb movements of sleep
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RESTLESS LEG
SYNDROME• Treatments include:
– Removing offending medications: SSRI, neuroleptics, Li, antihistamines, MAOI
– Iron supplement
– Medical treatment
– Avoid idleness
– Good sleep hygiene
– Dopamine agonist
– Opiates
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DRUG-INDUCED
MOVEMENT DISORDERS• Caused by dopamine-receptor blocking agents,
antiepileptics, stimulants, alcohol, heavy metal
• 5% annual risk of tardive syndromes in the elderly taking traditional neuroleptics – 20-26% in 5 years
• Exposure within 6 months of symptom onset and lasting at least 1 month after drug cessation
• Risk factors include: older age, women, longer use and higher dose of offending drug, diabetes, organic brain damage
• Treatment include: removing the offending drug, anxiolytics, anticholinergics, botulinum toxin, tetrabenazine
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DRUG-INDUCED
MOVEMENT DISORDERS
• Tardive parkinsonism– Slowness, stiffness, tremor, abnormal gait
– Caused by: metoclopramide, neuroleptics, antiemetics
• Tardive dystonia– Muscle spasm, sustained posturing, facial twitching,
stiffness in limbs
– Caused by: neuroleptics, antiemetics, SSRI
• Tardive dyskinesia– Stereotypic orofacial movements, chorea, dystonia,
akathisia
– Caused by: neuroleptics, antiemetics
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DRUG-INDUCED
MOVEMENT DISORDERS
• Drug-induced tremor– Exacerbation of physiologic tremor or essential tremor
– Caused by epinephrine, theophyline, lithium, divalproax, amphetamines, phenothiazines, alcohol withdrawal
– Treatment: cessation of drug, anxiolytics
• Drug-induced gait disorders– Caused by: antiepileptics, cyclosporine, methotrexate,
lithium, amidarone, barbiturates, antineoplastics, dextromethophan, phencyclidine, alcohol
– Treatment: cessation of drug, physical therapy
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MOVEMENT DISORDERS
IN THE ELDERLYSummary
• Movement disorders are common in the
elderly
• Many of them share features of slowness,
stiffness, tremor, unsteadiness
• Distinguishing them from normal aging
process can be challenging
• Some of them are highly treatable
• Recognizing them and seeking appropriate
treatment are important
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REFERENCES• Baron MS. Movement disorders in the older patient: differential
diagnosis and general management. Clevel Clin J Med 2005;72:S38-
51.
• Lee AJ, Hardy J, Revesz T. Parkinson‟s disease. Lancet
2009;373:2055-66.
• Thanvi B, Lo N, Robinson T. Essential tremor-the most common
movement disorder in older people. Age and aging 2006;35:344-9.
• Baloh RW, Ying S, Jacobson K. A longitudinal study of gait and
balance dysfunction in normal older people. Arch Neurol
2003;60:835-9.
• Ekbom K, Ulfberg J. Restless leg syndrome. J Intern Med
2009;266:419-31.
• We Move www.wemove.org
• National Parkinson Foundation www.parkinson.org
• American Parkinson Disease Association www.apdaparkinson.org
• International Essential Tremor Foundation www.essentialtremor.org
• The Restless Leg Syndrome Foundation www.rls.org