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.