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Algorithm For The Management Of Parkinson's Disease 5 |
Management (breakout 9) Pain related to parkinsonism often responds to adjustment of antiparkinsonian medications. Most often, it is linked to levodopa "off" states or insufficient levodopa dosage; thus, optimizing medications (as described later) can be gratifying. Other causes for radicular pain and neuropathy need to be evaluated when appropriate. Pain related to arthritis is not uncommon in elderly patients with PD.[87]
DYSPHAGIA. Significant dysphagia in patients with PD is usually; But not always, related to the severity of disease and occurs in up to 40% of patients. direct involvement of oropharangeal muscles is suggested by the observance that many patients suffer severe dysphagia only when "off," a situation that improves dramatically as soon as a dose of levodopa becomes effective. Swallowing abnormalities include abnormal lingual control and inability to pass a bolus of food backward into the pharynx. Silent aspiration with repetitive reflux of food from the vallecula and pyriform sinuses into the oral cavity are a significant problem. Retention of food and pills in the vallecula are another contributory cause of erratic levodopa absorption, and therefore, a secondary cause of dysphagia. Esophageal dysmotility occurs in as many as 70% of patients but also is present in a significant number of controls.[88,89] Management (breakout 10). Soft diets help most types of dysphagia by making it easier to move food in the mouth and esophagus. Soft food also decreases aspiration by reducing the need for separate liquid intake, since liquids often cause more aspiration than solids. Since dysphagia is usually decreased dramatically during "on" times, the best strategy is to increase "on" time with additional dopaminergic medications, if possible. Increased "off" time, however; is not a realistic goal for many patients. All patients should eat only during an "on" period. Feeding gastrostomies or jejunostomies are a last resort and are rarely necessary in patients with idiopathic PD; but when needed, these procedures provide the benefit of allowing more normal intake of food and medication.
SEBORRHEA. Excessive secretion of oil by sebaceous glands is common in PD. Management (breakout 11) Coal tar shampoos can be used not only for dandruff but also for seborrhea over the eyebrows and forehead. They should not be used more than once or twice weekly Selenium-based shampoos also work in some patients when used in a similar manner. Topical hydrocortisone is most effective on the face but needs to be applied daily.
FALLS
Falls are a leading cause of morbidity and mortality in the elderly population and frequently contribute to nursing home placement.[90,91] The causes of falls in the elderly are usually multifactorial and can be divided into intrinsic and extrinsic factors. Intrinsic factors are age- and disease-related elements in an individual that predispose him to falls. These factors include gait, balance, and weakness (10 to 25%), dizziness and vertigo (5 to 20%), orthostatic hypotension (2 to 15%), syncope (2 to 10%), drop attacks (1 to 10%), and other causes, such as acute illness, confusion, poor eyesight, and drugs (1 to 10%).[92] Extrinsic factors are environmental elements that may cause an individual to fall. Environmental factors account for 30 to 50% of falls in elderly individuals.[92] Falling is a significant problem in PD (breakout 12).[93-95] Older age, longer duration of disease, advanced stage of disease increased disability, rigidity, bradykinesia, inability to rise from chair, posture and gait impairment, and postural instability are factors that predispose patients with PD to falls.[95] Mental status changes, OH, dyskinesias, and age-related physical changes are other possible factors.[96-100]
POSTURAL INSTABILITY. Postural instability often responds poorly to drug therapy especially with advanced disease. Although postural instability improves with the administration of levodopa[94]--or other medications in some patients especially those with more recent onset disease-most patients with more advanced disease fail to improve with a change in levodopa dosage or the addition of dopamine agonists, Gait training and physical therapy may be beneficial, In patients with severe postural instability, wheelchairs can be used to prevent morbidity from falls.
SYMPTOMATIC OH. Symptomatic OH (Orthostatic Hypotension) can cause falls in patients with PD, It is critical for the physician to distinguish this cause from other conditions that also can cause falling. Treatment of OH is discussed in the "Dysautonomias" section.
MOTOR FLUCTUATIONS. Motor fluctuations, including dyskinesias and episodic freezing, may be additive to postural instability and contribute to the tendency to fall. (These problems will also discussed in the "Motor problems" section to follow.)
FREEZING AND FESTINATIONS. Freezing refers to a patient's feet getting stuck to the ground while walking, with an inability to initiate lower limb movement for a few seconds to minutes. In PD, the center of gravity is shifted forward and during ambulation the flexed trunk precedes the lower limbs, leading the patient to take increasingly frequent, short steps, often ending with a fall, This phenomenon is known as "festination." Pharmacologic treatment of freezing and festination is sometimes effective but can be very disappointing in more advanced patients.[101] Occasionally, decreasing or. increasing daily levodopa dosage or adding a dopamine agonist may help. When drugs are of no benefit in freezing and festinations, physical therapy may he helpful. Behavioral therapy is often beneficial in freezing. Gait modification by the use of motor and sensory tricks, such as alteration of the distribution of body weight, walking sideways, rocking movements of the body, stamping feet, walking briskly, taking longer steps, consciously lifting one limb higher and sliding one foot backwards then throwing it forwards,[102] may work for some patients. Having someone rhythmically pull or push or passively elevate the patient's knee also can help,[102] Verbal or auditory stimuli that are used include marching like a soldier to commands, walking or dancing to music, sudden clapping of hands and swearing. Visual stimuli include stepping over objects such as the handle of a walking stick, another person's foot, or carpet patterns; watching other people walk; and imagining white lines to step over.
DEMENTIA. The proportion of patients with PD who are also demented is approximately 15 to 20%.[103] At times, PD may be accompanied by Alzheimer's disease, Cognitive impairment is an independent risk factor for falls in the elderly.[90] Hence, parkinsonian patients with dementia have an even higher risk of falls, Patients and their families should be educated about the increased risk of falls, and occasionally these patients may benefit with gait training and physical therapy.
OTHER NEUROLOGIC DEFICITS. Patients with PD can have associated neurologic conditions that may increase their risk of falls. These conditions include myopathy, cervical degenerative disease, normal pressure hydrocephalus, lower back problems, multiple sensory deficits (eg, visual, vestibular, proprioceptive), cerebellar deficits, and other deficits caused by strokes.[90] If clinical signs and symptoms suggest any other neurologic condition, a detailed workup should be performed. Aging,[104] arthritis, physical inactivity and cardiac disease[105] in the elderly also should be considered as causes of muscle weakness. It often is overlooked in elderly patients because examiners are often too "generous" to grade their muscle strength.[106] Decreased muscle strength in the lower limbs is associated with falling[107,108] and mortality[109,110] among the elderly. Physical therapy plays an important role in strengthening weakened muscles and improving stability and gait.
OTHER MEDICAL CAUSES. Acute illness, such as pneumonia, and the worsening of chronic conditions, such as congestive heart failure, can precipitate falls.[111] Stable parkinsonian patients who suddenly begin to have falls or an acute increase in the frequency of falls should undergo complete medical evaluation. Medications can contribute to falls by causing volume depletion, OH, fatigue, impaired mental alertness, or other unknown mechanisms.[90] The total number of medications used appears to be directly related to the risk of falls.[111]
RECOMMENDATIONS. Every patient with PD who is experiencing falls should have a home safety evaluation performed by a trained therapist. The ability to avoid falls decreases with age, because of changes in posture, body-orienting reflexes, muscle strength, and decreased height of steppage.[112] Extrinsic factors that contribute to the tendency to fall could include poor lighting, torn carpet, loose rugs, slippery surfaces, small objects on the floor, inappropriate furniture, and unsafe stairs.[90] Adaptive equipment, such as walkers, if inappropriately used, also will increase the risk of falling. As the chances of falling are proportional to the number of risk factors,[90,111] everything possible should be done to correct environmental factors. Not all risk factors are correctable and even after optimal treatment some patients continue to experience falls. Prevention is the best strategy, but an occasional patient may be safest using a wheelchair on a permanent basis.
MOTOR PROBLEMS
During the early stages of PD, the clinical responses to levodopa therapy are stable and characterized by a "long-duration" pattern.[113] Patients with early disease require several days to plateau following a change in their levodopa dosage. Once plateaued, they experience no clinical variability, even if doses are late or skipped. If levodopa is stopped, it may take up to a week to return to the pre-levodopa baseline. In contrast, with advancement of PD, the levodopa response shifts to a "short-duration" pattern.[113] Patients with advanced disease experience clinical motor fluctuations that reflect ever-changing brain levodopa levels. Knowledge of the individual patient's short-duration levodopa response pattern is often crucial to arriving at the correct treatment advice The short-duration response typically develops, plateaus, and abates over several hours after a single dose of levodopa. The plateau phase of clinical improvement ("on") typically peaks about 45 to 90 minutes after administration of the standard formulation of carbidopa-levodopa and 60 to 150 minutes after the controlled-release CR) formulation. Rare patients with delayed gastric emptying may have a somewhat more delayed response. The clinician should focus on the adequacy of the peak response, the duration of that response, and the time that the dyskinesias are manifest in the response cycle. This often can be determined from the history but may require observation in the office.
