Movement Disorders Parkinson’s Epilepsy
Parkinson’s <ul><li>Definitions </li></ul><ul><ul><li>Tremor </li></ul></ul><ul><ul><li>Chorea </li></ul></ul><ul><ul><li>...
The Parkinson Balancing Act Normal Balance Parkinson’s Disease Drug Therapy in Parkinson’s Acetylcholine  Dopamine
Metabolism of Levodopa Levodopa 3,O-Methyldopa Dopamine Degradation  products COMT COMT inhibitors
Treatment of Parkinson’s Amantadine, benztropin, diphenhydramine, trihexyphenidyl Miscellaneous Carbidopa-levodopa/entacap...
Drug Therapy <ul><li>Levodopa  </li></ul><ul><li>Carbidopa/Levodopa (Sinemet) </li></ul><ul><ul><li>MOA </li></ul></ul><ul...
Clinical Management <ul><li>Progressive disease- Benefits of drug therapy decrease over time </li></ul><ul><li>Alleviate s...
Case Study Parkinson’s
<ul><li>M.G. is a 56-year-old female who presented to clinic with complaints of anxiety, nervousness, weakness of the righ...
Points to Ponder <ul><li>Symptoms present for Parkinson’s. </li></ul><ul><li>Possible medications that may worsen symptoms...
Epilepsy <ul><li>Anatomy of a seizure </li></ul><ul><li>Pharmacology  </li></ul><ul><ul><li>Prevent spread of seizure </li...
Overview of Triggers <ul><li>Genetic Factors </li></ul><ul><ul><li>Brain lesion at birth </li></ul></ul><ul><li>Toxins </l...
Clinical Management of Epilepsy <ul><li>Partial seizure & Tonic/Clonic </li></ul><ul><li>Generalized </li></ul><ul><li>Inf...
Seizure Type by Incidence Generalized Tonic-Clonic Partial Other
MOA of Anticonvulsants <ul><li>Pharmacology  </li></ul><ul><ul><li>Prevent spread of seizure </li></ul></ul><ul><ul><li>De...
 
Pharmacologic Agents <ul><li>Phenytoin* (Dilantin) </li></ul><ul><ul><li>Fetal Hydantoin </li></ul></ul><ul><li>Carbamazep...
Management of Epilepsy <ul><li>Problems </li></ul><ul><li>Medication Control </li></ul><ul><ul><li>Side effects </li></ul>...
Case Study Epilepsy
<ul><li>J.F. is a 44-year-old male who was seen in the clinic complaining of weakness in his right hand, tremors, and nerv...
Points to Ponder <ul><li>List symptoms that are of concern. </li></ul><ul><li>List PE and labs that are of concern. </li><...
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Movement disorders

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Movement disorders

  1. 1. Movement Disorders Parkinson’s Epilepsy
  2. 2. Parkinson’s <ul><li>Definitions </li></ul><ul><ul><li>Tremor </li></ul></ul><ul><ul><li>Chorea </li></ul></ul><ul><ul><li>Athetosis </li></ul></ul><ul><ul><li>Dystonia </li></ul></ul><ul><ul><li>Tics </li></ul></ul><ul><li>Signs & Symptoms </li></ul><ul><ul><li>Mask facies/drool </li></ul></ul><ul><ul><li>Scuffle gait </li></ul></ul><ul><ul><li>Tremor/rigidity </li></ul></ul><ul><ul><li>Pill rolling </li></ul></ul><ul><ul><li>Bradykinesia </li></ul></ul><ul><ul><li>Postural instability with increasing disability </li></ul></ul><ul><ul><li>www.parkinson.org </li></ul></ul>
  3. 3. The Parkinson Balancing Act Normal Balance Parkinson’s Disease Drug Therapy in Parkinson’s Acetylcholine Dopamine
  4. 4. Metabolism of Levodopa Levodopa 3,O-Methyldopa Dopamine Degradation products COMT COMT inhibitors
  5. 5. Treatment of Parkinson’s Amantadine, benztropin, diphenhydramine, trihexyphenidyl Miscellaneous Carbidopa-levodopa/entacapone (Stalevo) Increase DA & inhibit metabolism Selegiline(Eldepryl), Tolcapone (Tasmar), Entacapone (Comtan) Inhibit DA Metabolism Levodopa-carbidopa (Sinemet) Bromocriptine, Pergolide(Permax) Pramipexole(Mirapex), Ropinirole(Requip) Increase DA Stimulate DA receptors Agents Drug Action
  6. 6. Drug Therapy <ul><li>Levodopa </li></ul><ul><li>Carbidopa/Levodopa (Sinemet) </li></ul><ul><ul><li>MOA </li></ul></ul><ul><ul><li>Toxicity </li></ul></ul><ul><ul><li>Response fluctuations </li></ul></ul><ul><ul><li>Drug Holiday </li></ul></ul><ul><ul><li>On/Off Phenomenon </li></ul></ul><ul><ul><li>Drug Interactions </li></ul></ul><ul><li>Dopamine Agonists </li></ul><ul><li>Bromocriptine (Parlodel) </li></ul><ul><li>Pergolide (Permax) </li></ul><ul><ul><li>MOA </li></ul></ul><ul><ul><li>Toxicity </li></ul></ul><ul><li>Non-ergot DA Agonist </li></ul><ul><ul><li>Pramipexole (MIrapex) </li></ul></ul><ul><li>Amantadine </li></ul><ul><ul><li>Antiviral </li></ul></ul>
  7. 7. Clinical Management <ul><li>Progressive disease- Benefits of drug therapy decrease over time </li></ul><ul><li>Alleviate symptoms </li></ul><ul><li>Stepped care treatment </li></ul><ul><ul><li>Drug treatment </li></ul></ul><ul><ul><li>Physical Therapy </li></ul></ul><ul><ul><li>Reduce protein in diet </li></ul></ul><ul><ul><li>Surgery </li></ul></ul>
  8. 8. Case Study Parkinson’s
  9. 9. <ul><li>M.G. is a 56-year-old female who presented to clinic with complaints of anxiety, nervousness, weakness of the right hand and tremors. She has a history of hypertension that has been untreated. At the time of her initial visit, she was given Diazepam 2 mg TID. It helped her nervousness, but it did not help her tremors. Two months later she returns to clinic. Her complaints are the same. She feels they are worsened by stressful situations. Many of the symptoms were initially noted at the time of her husband’s death six months ago. Her friends have told her that her voice is changing. On physical examination the patient appears well nourished in no acute distress. She has noticeable tremors in both hands and cogwheel rigidity of both arms. There is slight mask-like facies. Labs within normal limits except borderline glucose. </li></ul><ul><li>BP recline 200/112 Fam HX non-contributory </li></ul><ul><li>Sitting 202/105 PE non-contributory </li></ul>
  10. 10. Points to Ponder <ul><li>Symptoms present for Parkinson’s. </li></ul><ul><li>Possible medications that may worsen symptoms. </li></ul><ul><li>What medications should be used to treat her symptoms? </li></ul><ul><li>Comment on her blood pressure. </li></ul><ul><li>Comment on her psychological problems.. </li></ul>
  11. 11. Epilepsy <ul><li>Anatomy of a seizure </li></ul><ul><li>Pharmacology </li></ul><ul><ul><li>Prevent spread of seizure </li></ul></ul><ul><ul><li>Depress motor cortex </li></ul></ul><ul><ul><li>Raise seizure threshold </li></ul></ul><ul><ul><li>Alter levels of NE </li></ul></ul><ul><ul><li>Depress neural discharge </li></ul></ul>
  12. 12. Overview of Triggers <ul><li>Genetic Factors </li></ul><ul><ul><li>Brain lesion at birth </li></ul></ul><ul><li>Toxins </li></ul><ul><ul><li>Alcohol </li></ul></ul><ul><ul><li>Drugs/ Poisons </li></ul></ul><ul><li>Cerebral Vascular </li></ul><ul><ul><li>Stroke, TIA </li></ul></ul><ul><ul><li>Malformations </li></ul></ul><ul><li>Trauma </li></ul><ul><li>Infections </li></ul><ul><ul><li>High fever </li></ul></ul><ul><li>Metabolic Disorders </li></ul><ul><ul><li>Low Ca++/Na++ </li></ul></ul><ul><ul><li>Hypoxia (02) </li></ul></ul><ul><ul><li>Glucose (hyper/ hypo) </li></ul></ul><ul><li>Neoplasm </li></ul>
  13. 13. Clinical Management of Epilepsy <ul><li>Partial seizure & Tonic/Clonic </li></ul><ul><li>Generalized </li></ul><ul><li>Infantile </li></ul><ul><li>Status Epilepticus </li></ul><ul><ul><li>Life threatening </li></ul></ul><ul><li>Withdrawal </li></ul><ul><li>Overdose </li></ul>
  14. 14. Seizure Type by Incidence Generalized Tonic-Clonic Partial Other
  15. 15. MOA of Anticonvulsants <ul><li>Pharmacology </li></ul><ul><ul><li>Prevent spread of seizure </li></ul></ul><ul><ul><li>Depress motor cortex </li></ul></ul><ul><ul><li>Raise seizure threshold </li></ul></ul><ul><ul><li>Alter levels of NE </li></ul></ul><ul><ul><li>Depress neural discharge </li></ul></ul><ul><li>Methods </li></ul><ul><ul><li>Blocks Na+ channels </li></ul></ul><ul><ul><li>Blocks Ca+ channels </li></ul></ul><ul><ul><li>GABA agonist </li></ul></ul><ul><ul><li>Glutamate blocker </li></ul></ul>
  16. 17. Pharmacologic Agents <ul><li>Phenytoin* (Dilantin) </li></ul><ul><ul><li>Fetal Hydantoin </li></ul></ul><ul><li>Carbamazepine * (Tegretol) </li></ul><ul><li>Phenobarbitol * </li></ul><ul><li>Primidone* </li></ul><ul><li>(Mysoline) </li></ul><ul><li>Lamotrigine </li></ul><ul><li>(Lamictal) </li></ul><ul><li>Gabapentin </li></ul><ul><li>(Neurontin) </li></ul><ul><li>Topiramate </li></ul><ul><li>(Topamox) </li></ul><ul><li>Ethosuximide (Zarontin) </li></ul><ul><li>Valproic Acid </li></ul><ul><li>Sodium Valproate (Depakene) </li></ul>
  17. 18. Management of Epilepsy <ul><li>Problems </li></ul><ul><li>Medication Control </li></ul><ul><ul><li>Side effects </li></ul></ul><ul><ul><li>Dosing regimens </li></ul></ul><ul><li>Compliance </li></ul><ul><li>Education </li></ul><ul><li>Medical Factors </li></ul><ul><li>Psychosocial Factors </li></ul><ul><li>Strategies </li></ul><ul><li>Patients can </li></ul><ul><ul><li>Keep informed & diary </li></ul></ul><ul><ul><li>Support group </li></ul></ul><ul><ul><li>Reminder systems </li></ul></ul><ul><li>Family can </li></ul><ul><ul><li>Minimize barriers </li></ul></ul><ul><ul><li>Encouragement </li></ul></ul>
  18. 19. Case Study Epilepsy
  19. 20. <ul><li>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. </li></ul><ul><li>PMH : HTN x10 yr. Glaucoma x3yr Angina x5yr AODM x7yr </li></ul><ul><li>PE: BP 185/110 supine tremors in both hands </li></ul><ul><li>182/100 sitting cogwheel rigidity in both arms </li></ul><ul><li>Meds Micronase 5 mg bid HCTZ 50mg QD Lotensin 20mg BID </li></ul><ul><li>Nitroquick 0.4mg Betagan 0.5% 1 gtt bid </li></ul><ul><li>Labs Hct 45.3 Na 140 K 3.9 Cl 102 WBC 8.3 BUN 18 </li></ul><ul><li>Hgb 15.2 Cr 1.0 Gluc 220 Uric Acid 9.5 </li></ul>
  20. 21. Points to Ponder <ul><li>List symptoms that are of concern. </li></ul><ul><li>List PE and labs that are of concern. </li></ul><ul><li>What are the possible etiologies? </li></ul><ul><li>Comment on patient medication list. </li></ul><ul><li>List a possible treatment plan. </li></ul>
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