1. 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.

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 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

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
Age Life Expectancy Average age at death
(49) (82)
(31) (83)
(9) (91)
Ishihara, LS, et.al., J Neurol Neurosurg Psychiatry 78(12): ,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.