Evaluation of Movement Disorders

1. Evaluation of Movement Disorders Bryan Yanaga, M.D. Medical Director Bankers Life and Casualty

2. Parkinson’s Disease

3. 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?

5. Parkinson’s Disease • A gradually progressive degenerative disorder of the nervous system that affects movement.

6. 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.

7. Neuropathology of Parkinson’s Disease • Loss of pigmented dopaminergic neurons in the substantia nigra of the midbrain

8. Neurotransmission From: Immunology and Cell Biology, 2012

9. Symptoms Associated with Parkinson’s Disease Three cardinal signs: • Tremor • Rigidity • Bradykinesia • Postural instability

10. Evaluating Parkinson’s Disease Tremor • Insidious onset • Gradual progression • Begins in the hands • Usually unilateral, can become bilateral • Usually occurs at rest (Pill rolling)

11. Evaluating Parkinson’s Disease Rigidity - Increased resistance to passive movement at a joint • Smooth (lead pipe) • Oscillating (cog wheeling)

12. Evaluating Parkinson’s Disease Bradykinesia • Slowness of movement • Reduced spontaneous movements • Decreased amplitude of movement

13. 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

14. 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

15. 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

16. Prognosis (After the introduction of Sinemet) • 50% drop in mortality rate

17. Estimated life expectancy of Parkinson’s patients compared with the UK population AgeLife ExpectancyAverage 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.

18. 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

19. Complications • Goal is to use the lowest dose of levodopa as possible

20. Treatment Dopamine agonists • Mirapex (pramipexole) • Requip (ropinerole) • Parlodel (bromocriptine) • Bind to dopamine receptors in the brain and mimic the action of dopamine

22. 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

23. 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.

24. The Goals of Underwriting • Add good business to the books • Keep bad business off the books.

25. 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

26. When is a tremor just a tremor?

27. Tremor – Differential Diagnosis Neurological Disorders • Parkinson’s disease • Multiple sclerosis • Stroke • Traumatic brain injury

28. Tremor – Differential Diagnosis Other Medical Conditions • Chronic kidney disease • Alcohol abuse or withdrawal • Hyperthyroidism • Liver failure • Hypoglycemia • Wilson’s disease (in younger patients)

29. Tremor – Differential Diagnosis Deficiencies • Thiamine • Magnesium • Vitamins (B1, B6, B12, E) • Sleep

30. Essential Tremor Benign Risk factors • Age • Genetic mutation (autosomal dominant) • Up to 20x more common than Parkinson’s

31. 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

32. Essential Tremor Complications 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)

33. Essential Tremor Test

34. Parkinson’s vs. Essential Tremor Similarities: • Insidious onset • Usually begins in the hands/upper extremity • Can be aggravated by stress

35. 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!

36. 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 information Allow time for development underlying pathology

37. 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

38. Restless Legs Syndrome Treatment • Requip • Mirapex • Sinemet

39. 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?

40. Thank you.