Movement Movement DisordersDisorders

Parkinson’sParkinson’s

EpilepsyEpilepsy

Parkinson’sParkinson’s

• DefinitionsDefinitions– TremorTremor– ChoreaChorea– AthetosisAthetosis– DystoniaDystonia– TicsTics

• Signs & SymptomsSigns & Symptoms– Mask facies/droolMask facies/drool– Scuffle gaitScuffle gait– Tremor/rigidityTremor/rigidity– Pill rollingPill rolling– BradykinesiaBradykinesia– Postural instability Postural instability

with increasing with increasing disabilitydisability

– www.parkinson.orgwww.parkinson.org

The Parkinson Balancing The Parkinson Balancing ActAct

Normal Balance

Parkinson’s Disease

Drug Therapy in Parkinson’s

Metabolism of LevodopaMetabolism of Levodopa

Levodopa

3,O-MethyldopaDopamine

Degradation products

Treatment of Parkinson’sTreatment of Parkinson’s

Drug ActionDrug Action AgentsAgents

Increase DAIncrease DA

Stimulate DA Stimulate DA receptorsreceptors

Levodopa-carbidopa Levodopa-carbidopa (Sinemet)(Sinemet)

Bromocriptine, Bromocriptine, Pergolide(Permax) Pergolide(Permax) Pramipexole(Mirapex), Pramipexole(Mirapex), Ropinirole(Requip)Ropinirole(Requip)

Inhibit DA Inhibit DA MetabolismMetabolism

Selegiline(Eldepryl), Selegiline(Eldepryl), Tolcapone (Tasmar), Tolcapone (Tasmar), Entacapone (Comtan)Entacapone (Comtan)

Increase DA & inhibit Increase DA & inhibit metabolismmetabolism

Carbidopa-levodopa/Carbidopa-levodopa/entacapone (Stalevo)entacapone (Stalevo)

MiscellaneousMiscellaneous Amantadine, benztropin, Amantadine, benztropin, diphenhydramine, diphenhydramine, trihexyphenidyltrihexyphenidyl

Drug TherapyDrug Therapy

• Levodopa Levodopa • Carbidopa/Carbidopa/

Levodopa (Sinemet)Levodopa (Sinemet)– MOAMOA– ToxicityToxicity– Response Response

fluctuationsfluctuations– Drug HolidayDrug Holiday– On/Off PhenomenonOn/Off Phenomenon– Drug InteractionsDrug Interactions

• Dopamine AgonistsDopamine Agonists• Bromocriptine Bromocriptine

(Parlodel)(Parlodel)• Pergolide (Permax)Pergolide (Permax)

– MOAMOA– ToxicityToxicity

• Non-ergot DA AgonistNon-ergot DA Agonist– Pramipexole (MIrapex)Pramipexole (MIrapex)

• AmantadineAmantadine– AntiviralAntiviral

Clinical ManagementClinical Management

• Progressive disease- Benefits of drug Progressive disease- Benefits of drug therapy decrease over timetherapy decrease over time

• Alleviate symptomsAlleviate symptoms• Stepped care treatmentStepped care treatment

– Drug treatmentDrug treatment– Physical TherapyPhysical Therapy– Reduce protein in dietReduce protein in diet– SurgerySurgery

Case Study Parkinson’sCase Study Parkinson’s

M.G. is a 56-year-old female who presented to clinic M.G. is a 56-year-old female who presented to clinic with complaints of anxiety, nervousness, weakness of with complaints of anxiety, nervousness, weakness of the right hand and tremors. She has a history of the right hand and tremors. She has a history of hypertension that has been untreated. At the time of hypertension that has been untreated. At the time of her initial visit, she was given Diazepam 2 mg TID. It her initial visit, she was given Diazepam 2 mg TID. It helped her nervousness, but it did not help her helped her nervousness, but it did not help her tremors. Two months later she returns to clinic. Her tremors. Two months later she returns to clinic. Her complaints are the same. She feels they are complaints are the same. She feels they are worsened by stressful situations. Many of the worsened by stressful situations. Many of the symptoms were initially noted at the time of her symptoms were initially noted at the time of her husband’s death six months ago. Her friends have husband’s death six months ago. Her friends have told her that her voice is changing. On physical told her that her voice is changing. On physical examination the patient appears well nourished in no examination the patient appears well nourished in no acute distress. She has noticeable tremors in both acute distress. She has noticeable tremors in both hands and cogwheel rigidity of both arms. There is hands and cogwheel rigidity of both arms. There is slight mask-like facies. Labs within normal limits slight mask-like facies. Labs within normal limits except borderline glucose.except borderline glucose.

• BP recline 200/112 Fam HX non-contributoryBP recline 200/112 Fam HX non-contributory• Sitting 202/105 PE non-contributorySitting 202/105 PE non-contributory

Points to PonderPoints to Ponder

• Symptoms present for Parkinson’s.Symptoms present for Parkinson’s.• Possible medications that may Possible medications that may

worsen symptoms.worsen symptoms.• What medications should be used to What medications should be used to

treat her symptoms?treat her symptoms?• Comment on her blood pressure.Comment on her blood pressure.• Comment on her psychological Comment on her psychological

problems..problems..

Epilepsy

• Anatomy of a seizure• Pharmacology

• Prevent spread of seizure• Depress motor cortex• Raise seizure threshold• Alter levels of NE• Depress neural discharge

Overview of Triggers

• Genetic Factors• Brain lesion at

birth

• Toxins• Alcohol• Drugs/ Poisons

• Cerebral Vascular• Stroke, TIA• Malformations

• Trauma• Infections

• High fever

• Metabolic Disorders• Low Ca++/Na++• Hypoxia (02)• Glucose (hyper/

hypo)

• Neoplasm

Clinical Management of Epilepsy

• Partial seizure & Tonic/Clonic• Generalized• Infantile • Status Epilepticus

• Life threatening

• Withdrawal• Overdose

Seizure Type by Incidence

10%23%

65%

MOA of Anticonvulsants

• Pharmacology • Prevent spread of

seizure• Depress motor

cortex• Raise seizure

threshold• Alter levels of NE• Depress neural

discharge

• Methods• Blocks Na+

channels• Blocks Ca+

channels• GABA agonist• Glutamate blocker

Pharmacologic Agents

• Phenytoin* (Dilantin)• Fetal Hydantoin

• Carbamazepine * (Tegretol)

• Phenobarbitol *• Primidone* (Mysoline)• Lamotrigine (Lamictal)

• Gabapentin (Neurontin)• Topiramate (Topamox)• Ethosuximide

(Zarontin)• Valproic Acid• Sodium Valproate

(Depakene)

Management of Epilepsy

• Problems• Medication Control

• Side effects• Dosing regimens

• Compliance• Education• Medical Factors• Psychosocial

Factors

• Strategies• Patients can

• Keep informed & diary

• Support group• Reminder systems

• Family can• Minimize barriers• Encouragement

Case StudyEpilepsy

• J.F. is a 44-year-old male who was seen in the clinic complaining of weakness in his right hand, tremors, and nervousness. Not much was thought of this until his return three months later. J.F. now appears depressed with an expressionless face and voice. He has a persistent tremor, blurred vision and difficulty moving. Occasional angina attacks bother him, which are relieved by NTG sublingual tablets. During the visit he becomes increasingly agitated and the physician prescribes Valium 5 mg one dose. As you are talking to him he suddenly falls to the ground and has a grand mal seizure.

• PMH : HTN x10 yr. Glaucoma x3yr Angina x5yr AODM x7yr• PE: BP 185/110 supine tremors in both hands• 182/100 sitting cogwheel rigidity in both arms• Meds Micronase 5 mg bid HCTZ 50mg QD Lotensin 20mg

BID• Nitroquick 0.4mg Betagan 0.5% 1 gtt bid

• Labs Hct 45.3 Na 140 K 3.9 Cl 102 WBC 8.3 BUN 18• Hgb 15.2 Cr 1.0 Gluc 220 Uric Acid 9.5

Points to Ponder

• List symptoms that are of concern.

• List PE and labs that are of concern.

• What are the possible etiologies?• Comment on patient medication

list.• List a possible treatment plan.