3Parkinson’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?
5Parkinson’s DiseaseA gradually progressive degenerative disorder of the nervous system that affects movement.
6Parkinson’s Disease Average age of onset: Late 50’s/Early 60’s 1.5x more common in men than womenIncidence: 60,000 new cases per yearPrevalence: 1.6 million in the USAAffects 1% of people over age 605% of people over age 80.
7Neuropathology of Parkinson’s Disease Loss of pigmented dopaminergic neurons in the substantia nigra of the midbrain
8NeurotransmissionFrom: Immunology and Cell Biology, 2012
9Symptoms Associated with Parkinson’s Disease Three cardinal signs:TremorRigidityBradykinesiaPostural instability
10Evaluating Parkinson’s Disease TremorInsidious onsetGradual progressionBegins in the handsUsually unilateral, can become bilateralUsually occurs at rest (Pill rolling)
11Evaluating Parkinson’s Disease Rigidity - Increased resistance to passive movement at a jointSmooth (lead pipe)Oscillating (cog wheeling)
12Evaluating Parkinson’s Disease BradykinesiaSlowness of movementReduced spontaneous movementsDecreased amplitude of movement
13Underwriting Parkinson’s Disease Examples of BradykinesiaMicrographia – Small handwritingHypomimia – Loss of facial expressionDecreased blink rateLoss of hand dexteritySlowness rising from a chair, turning in bedSlow gait, smaller steps, lower cadence, dragging of one leg
14Treatment Sinemet (levodopa/carbidopa) Levodopa is broken down to dopamine in the brain and peripheral circulationPeripheral dopamine causes nauseaCarbidopa prevents peripheral conversion of levodopa to dopamineAllows for use of lower doses of levodopa
15Prognosis Time to severe disability or death: (Before the introduction of Sinemet)Time to severe disability or death:Within 5 years of onset - 25% of patientsWithin 10 years of onset - 65% of patientsWithin 15 years of onset - 89% of patients
16Prognosis (After the introduction of Sinemet) 50% drop in mortality rate
17Estimated life expectancy of Parkinson’s patients compared with the UK population Age Life Expectancy Average age at death(49) (82)(31) (83)(9) (91)Ishihara, LS, et.al., J Neurol Neurosurg Psychiatry 78(12): ,2007.
18Complications With long-term use of Sinemet: Shortened duration of drug effectivenessWider fluctuations in drug effectiveness (on-off phenomena)Dyskinesias (choreiform movements) occur at peak doses of levodopa
19ComplicationsGoal is to use the lowest dose of levodopa as possible
20Treatment Dopamine agonists Mirapex (pramipexole) Requip (ropinerole) Parlodel (bromocriptine)Bind to dopamine receptors in the brain and mimic the action of dopamine
23Progression 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.
24The Goals of Underwriting Add good business to the booksKeep bad business off the books.
30Essential Tremor Benign Risk factors Age Genetic mutation (autosomal dominant)Up to 20x more common than Parkinson’s
31Essential Tremor Insidious onset Can begin in one or both hands Usually bilateral and symmetricalWorse with movement (intention tremor)Can include a “yes” or “no” movement of the headCan be aggravated by stress, fatigue, caffeine, or extreme temperatures
32Essential Tremor Complications include the inability to: Hold a cup of water without spillingEat normallyWriteShave or put on makeupTalk (if the tongue or vocal chords are affected)
34Parkinson’s vs. Essential Tremor Similarities:Insidious onsetUsually begins in the hands/upper extremityCan be aggravated by stress
35Parkinson’s vs. Essential Tremor Differences:Unilateral vs. bilateralMost prominent at rest versus with activityNo involvement of the head and neckMultiple progressive symptoms versus a narrower range of symptomsImprovement with dopamine and dopaminergic agonists!
36Underwriting Parkinson’s Disease If the diagnosis is unclear(i.e. If the characteristic symptomsof PD have yet to be revealed):IssueDeclinePostponeRequest additional informationAllow time for development underlying pathology
37Restless Legs Syndrome Discomfort in the legs, typically in the evening while sitting or lying downRelief when getting up and movingSymptoms worse at nightCan begin at any ageUsually worsens with age
38Restless Legs Syndrome TreatmentRequipMirapexSinemet
39Parkinson’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?