Flasqpd

♦ This is the first assessment tool designed for screening of appropriate DBS (deep brain stimulation) surgical candidates (101).

♦ There is a five-section questionnaire with questions assessing:

O Criteria for the diagnosis of PD. O Potential contraindications to DBS surgery (e.g. abnormal eye movements, abnormal cognitive reflexes, autonomic failure). O General patient characteristics (e.g. age, duration of symptoms). O Favourable/unfavourable characteristics with regard to DBS surgery (e.g. response to levodopa, cognitive function). O Medication trial information subscores.

101 Florida Surgical Questionnaire. A 5-part questionnaire to assess PD surgery candidates, covering diagnosis, contraindications ('red flags'), clinical characteristics and therapy responses. Sections 3-5 are scored between 0 and 3, with a maximum possible total of 34.The scoring system is designed to assign higher scores to better candidates.

Florida Surgical Questionnaire for Parkinson's Disease (FLASQ-PD)

1 DIAGNOSIS OF IDIOPATHIC PD

No

Yes*

2 POTENTIAL CONTRAINDICATIONS

N/A

Yes**

Is bradykinesia present?

• Primitive reflexes: presence of a grasp, snout, root, suck, or Myerson's sign (= glabellar tap)

Are two or more of the following present?

• Postural instability not caused by primary visual, vestibular cerebellar, proprioceptive dysfunction

• Supranuclear gaze palsy present

• Ideomotor apraxia present

• Presence of autonomic dysfunction - new severe orthostatic hypotension not due to medications; erectile dysfunction; or other autonomic disturbance within the first year or two of disease onset

Are three or more of the following present?

• Unilateral onset

• Rest tremor present

• Progressive disorder

• Persistent asymmetry affecting side of onset most

• Excellent response (70-100%) to levodopa

• Severe levodopa-induced dyskinesia

• Levodopa response for 5 years or more

• Clinical course of 5 years or more

• Wide-based gait present

• Presence of more than mild dementia -frequently disorientated or severe cognitive difficulties or severe memory problems, or anomia

• Presence of severe psychosis, refractory to medications

* 'Yes' answers to all three suggest the diagnosis of idiopathic PD ** Any 'red flag' may be a contraindication to surgery

• History of unresponsiveness to levodopa

• Parkinsonism is clearly not responsive to levodopa, or patient is dopamine naive, or patient has not had a trial of levodopa

FLASQ-PD continued

3 GENERAL PATIENT CHARACTERISTICS

0

1

2

3

Age in years

>80 y

71-80y

61-70 y

<61 y

Duration of Parkinson's symptoms

<3 years

4-5 years

>5 years

On/off fluctuations (medications wear off, fluctuate with dyskinesia and akinesia)

No

Yes

Dyskinesias

None

<50% of the time

>50% of the time

4 FAVOURABLE / UNFAVOURABLE CHARACTERISTICS

None

<50% of the time

>50% of the time

(if applicable)

Not responsive to levodopa during the best 'on'

Responsive to levodopa during the best 'on'

(if applicable)

Not responsive to levodopa during the best 'on'

Responsive to levodopa during the best 'on'

Warfarin or other blood thinners

On blood thinner besides antiplatelet therapy

Not on blood thinner besides antiplatelet therapy

Cognitive function

Memory difficulties or frontal deficits

No signs or symptoms of cognitive dysfunction

Swallowing function

Frequent choking or aspiration

Occasional choking

Rare choking

No swallowing difficulties

Continence

Incontinent of bowel and bladder

Incontinent of bladder only

No incontinence

Depression

Severe depression with vegetative symptoms

Treated, moderate depression

Mild depressive symptoms

No depression

Psychosis

5 MEDICATION TRIALS

Frequent hallucinations

Occasional hallucinations -probably medication-related

No hallucinations

Historical response to levodopa

Uncertain response, or no trial

History of modest improvement

History of marked improvement

Trial of Sinemet (carbidopa/levodopa or Madopar or equivalent)

No trial or <3 times a day

Three times a day

Four times a day

>4 times a day

Trial of dopamine agonist

No trial or <3 times a day

Three times a day

Four times a day

>4 times a day

Trial of Sinemet extender

No trial

Trial of either tolcapone or entacapone

Trial of a combination of Sinemet or equivalent with a dopamine agonist

No trial

Trial of Sinemet or equivalent with a dopamine agonist

♦ Higher scores are assigned to better candidates.

♦ The range of scores is from 0 with 8 red flags (worst possible) to 34 with 0 red flags (best possible).

♦ Scores of 25 or greater indicate a good candidate for surgery.

♦ Scores of 15 or below indicate late-stage PD or a parkinsonian syndrome other than PD.

O It is the only tool designed to assess appropriate candidates for DBS surgery. O It is objective and may be useful for non-movement disorders specialists to decide when to refer patients for surgery.

O This scale needs prospective evaluation and validation.

O It does not replace the complete multi-

disciplinary surgical evaluation. O Some items listed as unfavourable characteristics are controversial (e.g. abnormal cognitive reflexes). O There are certain groups of patients with low FLASQ-PD scores who would still be considered excellent DBS candidates (e.g. patients with treatment-resistant tremor, patients with severe dyskinesias).

CHAPTER 7

0 0

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