Evaluation of Movement Disorders Bryan Yanaga, M.D. Medical Director Bankers Life and Casualty There are over 600 different movement disorders, so let’s get started.

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 Time to severe disability or death: (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 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)

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 information Allow 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.