Transcript Management of Behavioral Problems in Parkinson`s

African and Telemedicine Initiatives
Cameroon
Sous le Haut Patronage du Délégué Régional du MINAS pour le Littoral
Management of
Behavioral Problems
in Parkinson’s Disease
Dr Erero F. Njiengwé
Convergence Psy-Santé
Douala-Cameroun
[email protected]
Gratitude
• To the Movement Disorder Society (MDS)
for launching a Telemedicine Task Force
and sponsoring pilot projects in care,
education, and research for the majority.
• To Dr Esther Cubo for being so Generous
in knowledge, Risk Taking and Optimistic
• Dr Doumbè & The Director of HLD for
hosting and giving it viability to this pilot
project of telemedicine
Parkinson’s Disease
As a chronic and progressive
deteriorative Brain Disease
• Can affect all the functioning of the individual.
• mobility,
• communication at all levels,
• Occupation,
• Cognition,
• Emotional Stability
• Family harmony.
• A Comprehensive approach to its management, helps
the patient (and the caregiver ) to keep in good mental,
physical and emotional situation, in order to maintain
as long as possible a better quality of life.
Learning Objectives
• From the Bio-Psycho-Social perspective:
– Recognize Behavioral Problems in PD
– Differentiate them from other common
changes in PD
– Understand their role in PD
• Describe the main strategies for their
management
Outline
• What means “Behavioral Problems” in PD?
• What makes them different from other
common changes in PD?
• What do they stand for in PD?
• Case Study
• Is there any culturally informed strategies
for their management?
Outline
• What means “Behavioral Problems” in PD?
• What makes them different from other
common changes in PD?
• What do they stand for in PD?
• Case Study
• Is there any culturally informed strategies
for their management?
Do Behavioral problems mean
Motor problems ?
• PD was first described as a purely motor disorder
• But Depression and Anxiety are considered to be
quite common in PD
• Some other "Brain" dysfunctions such as Dementia
are found to be very severe in a number of
individuals with PD (40%).
• Question:
– Is depression behavior? Is anxiety behavior? Is dementia
behavior? Is tremor behavior?
– What is behavior and where is it from?
– What does “management” mean talking about behavior?
Behavior is 4 interdependant
Components
Cognitive
(What I think: internal
conversation)
Physiologic
(bodily processes,
sensations)
The Brain
Motor
(External reactions: What I do)
Emotional
(feelings)
What is Motor...
and What is non Motor in PD?
Yes
•
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•
•
•
•
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•
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•
1. Speech
2. Handling saliva
3. Swallowing & chewing
4. Feeding
5. Dressing
6. Hygiene
7. Handwriting
8. Other fine motor tasks
9. Tremor impact on activities
10. Turning in bed and adjusting bed clothes
11. Getting in and out of bed, car or deep
chair
12. Balance and walking
13. Gait Freezing
Goetz CG et al. MDS UPDRS
No
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Autonomic dysfunction
(constipation, orthostatic
hypotension, urinary
incontinence, sexual dysfunction)
Depression, anxiety, psychosis
(hallucinations & delusions)
Dementia
Sleep Disorders
– Excessive daytime sleepiness
– REM sleep behavior disorder
Fatigue, apathy
Pain
Which Behavioral Problems can we find
in PD?
Depression,
(7.50% of PD suffer melancholic or major depression
and 50 % minor depression)
Apathy
(decrease of conduct aimed at a
goal, of motivation and affective expression: 50% of patients)
Anxiety (very common)
Psychotic disorders :
hallucinations and delusions (In 25% of
nondemented and up to 65% of demented patients)
Disorders of impulse control :
compulsive gambling,
Pathological hypersexuality, punding , compulsive shopping, binge
eating,
We shall consider in PD within the nonmotor features, any
manifestation that can be managed through learning, since
behavior is learned and can influence
Impulse Control Disorder
• A person’s inability to resist a temptation or
impulse
• More likely to happen in those with a previous
history of novelty
seeking or risk – taking behaviours
• Compulsive behaviours have been reported as a
side effect with levodopa and dopamine agonists
• Behaviours can include:
–Pathological gambling
–Hypersexuality
–Compulsive eating
–Compulsive shopping
–Punding
Are Cognitive and Psychiatric Symptoms
Behavioral problems ?
Depression, anxiety, psychosis (hallucinations &
delusions)
And to some extent Dementia
Can be labelled “behavioral problems”
Outline
• What means “Behavioral Problems” in PD?
• What makes them different from other
common changes in PD?
• What do they stand for in PD?
• Case Study
• Is there any culturally informed strategies
for their management?
Depression, Anxiety and Apathy
Associated with Parkinson's
Dysphoria
Sadness
Depression
•
In Parkinson's patients with depression
there is a higher frequency of
The prevalence is estimated
at between 30 and 40%
Pessimism about
the future
Apathy
Anxiety
•
Irritability
Genralised anxiety, agitation, panic
attacks and phobic disorders can occur
in up to 40% of people with PD
• more likely to be a direct consequence of
disease related physiological changes than
a psychological reaction or
adaptation to disability
Professor Richard Walker
Consultant Physician and Honorary Professor of Ageing and International Health
Northumbria Healthcare NHS Foundation Trust
Institute of Health and Society, Newcastle University
Why do they appear ?
Depression
Anxiety / Panic Attack
are extremely common in PD, both
– because of having the Disease
and
– as a brain disorder
Usually due to PD itself or to
phamacological treatment
Levodopa side effects
• Short term
– Nausea and vomiting, postural
hypotension, somnolence, altered sleep
pattern
• Long term
–
–
–
–
psychiatric disturbances
Wearing off
Dyskinesias
Dystonia
• Factors associated with motor complications
– Duration of disease, therapy, severity of disease
Dopamine Agonist Side effects
• Confusion, hallucinations, impulse
control disorder
•
•
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•
Postural hypotension
Fibrotic changes due Ergot derived agonists
Nausea and vomiting
Somnolence
Leg oedema
COMT side effects
• Same as levodopa
• Discolouration of urine
• GI
– Bloated painful abdomen
– Explosive diarrhoea
• Sweating
When do they appear?
In many chronic diseases,
At discovery (onset)
Also in the long run with more
complications and more
decline
Worsen in the elderly
What do they cause as consequences ?
• Isolation
– Loss of personal and broader social connections
– Sense of shame
• Exclusion
• Helplessness with the pace of conversation or
activities of those around them
• Sense of grief in family members and comunity
Consequence: Increase in depression and anxiety
Increased isolation and reduced mental
stimulation can lead to further deterioration
Who’s responsible for handling the
issue ?
• What can the patient do?
• What can the informal care giver do?
• What can the formal care giver do do?
• What can the physician do?
• What can the psychologist do?
What is the aim of the Management?
• Improve function
• Improve quality of life
Outline
• What means “Behavioral Problems” in PD?
• What makes them different from other
common changes in PD?
• What do they stand for in PD?
• Case Study
• Is there any culturally informed strategies
for their management?
Cameroon
• Most of PD persons
have no access to
healthcare facilities;
• The situation is often
handled by families at
home.
• There is a lack of almost
everything:
Research,
Training,
long
term
health care facilities,
adult day-care centers…
A comparison of the clinical profile of a
Cameroonian cohort of PD to the Spanish
PD cohort
74 patients
Cubo et al, 2013
• No significant differences between the Spanish and
Cameroonian cohort in terms of gender, age, PD
duration and presence of comorbidities.
• Cameroonian PD patients were more affected in terms
of motor severity,cognitive impairment,psychosis,
patient and caregiver quality of live.
• In terms of treatments: cameroonian patients reported
an intermittent use of PD therapies mainly due to
economical limitations.
Age related disease?
• Life expectancy in Cameroon:
• 52 years women
• 50 years men
Population age structures
CASE STUDY
(Challenging)
• Mr. H., 75 year old man with more than ten years
history of bizarre tremors
• Known as a task paid farm worker and priest
assistant in the parish
• Seem to be able to read but can’t write
• Remembers almost everything about all the families
of the parish. He’s got a mental map of the
cementery and can tell where to dig and burry a
member of the community when asked for a location.
• Remembers almost all the catechism and prayers
that he presides in the church.
CASE STUDY (cont.)
(Challenging)
• Has been suffering from a bone cancer for almost
15 years and now uses a protesis after his leg has
been cut just a few centimeters below the right
knee.
• Getting worse: his head shakes too much
• Loses balance : the book and the chapelet shakes a
lot when presiding the prayers
• His first child (5 in total) is 25 year old and has
joined a sectarian relgious group.
• Now dead from the aggravation of his cancer, after
an episode of severe delirium during a mass
(accused of having contact with bad spirits: devil)
PD Cardinal Features
Was this man a person with PD?
PD is a chronic, progressive neurological
disease, characterized by Tremor, Rigidity,
Akinesia and Postural instability (TRAP).
• Clinically possible PD (presence of any one of
the 4 features)
• Clinically probable PD (combination of any two
cardinal features)
• Clinically definite (any combination of 3 of the 4
features)
• Patient must be re-examined at several month
intervals (when not all the signs are evident).
CASE STUDY (cont.)
(Challenging)
Was this man a person with PD?
Secondary
parkinsonism (drugs,
toxins, vascular
disease, trauma, tumor,
infectious agents)
What would a culturally
informed management
look like?
How could we manage?
Depression
Anxiety and agitation
Sleep disturbances
Vivid dreams
must include the
patient, their family
and their
environment
Hallucinations
Delirium
Dementia
• Behavior Therapy
• Cognitive Behavior Therapy
• Stress control
Dancing to prevent falls and improve
mobility in PD
Summary
Early intervention in a biopsychosocial
approach may be beneficial in terms of
health-related quality of life
Great need to increase awareness among
population and healthcare providers.
The treatment of behavioral symptoms is
also as important at all stages of
Parkinson's
Thank You
About Erero NJIENGWE
• Senior lecturer in clinical Psychopathology;
Coordinator of the Psychopathology Unit in the
LAPSA (Laboratory of Behavioral Science and
Applied Psychology) at the University of Douala.
• PhD dissertation (Bio-Psych-Social Model) on
Depression in Sickle Cell Disease Toulouse
(France). Member of the comprehensive program
for the management of sickle cell disase at the
Laquintinie Hospital in Douala.
• Co-director of a Masters program on Intervention
and Eduaction in Healthcare, with the University
of Extremadura (Spain).