Download - Parkinsonism
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PARKINSONISMDr Jamie Farmer
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OUTLINE Parkinsonism vs PD Causes of parkinsonism Akinetic rigid syndromes IPD Signs/symptoms Examination Differential diagnosis Investigations Management Complications Case study Explaining to patients
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DEFINITIONS Parkinsonism:
Rigidity Resting tremor Bradykinesia
Parkinson’s disease (PD) is a progressive neurodegenerative condition resulting from the death of the dopamine-containing cells of the substantia nigra
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PARKINSONISM IPD: idiopathic parkinson’s disease
Asymmetrical, slow progression, good L-Dopa response
Drug induced: Antiemetics: metoclopramide, prochlorperazine Antipsychotics: haloperidol lithium. Symmetrical onset, tremor less prominent
Vascular: Bradykinesia, rigidity, lower limbs, upper limb sparing, vascular RF, stuttering evolution
Akinetic-rigid syndromes
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AKINETIC-RIGID SYNDROMES/PARKINSON’S +
MSA: MSA-P vs MSA-C. insidious onset parkinsonism, sphincter disturbance, balance, postural hypotension, cerebellar signs, stridor. Poor L-Dopa response.
PSNP: prominent axial rigidity, loss of downward vertical gaze, eyelid/facial dystonia→frowning/surprised expression.
DLB: nocturnal wandering, hallucinations, early cognitive impairment, myoclonus. Poor response to L-Dopa
CBD: parietal lobe affected, alien limb, dysphasia, ext.plantars, myoclonus, dystonia, dementia
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IDIOPATHIC PARKINSON’S DISEASE Clinical diagnosis 100–180 people per 100,000 annual incidence of 4–20 per 100,000 Unilateral→bilateral Worse in upper limbs Good response to L-Dopa
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SIGNS/SYMPTOMSSymptomsTremor/shakingStiffnessSlownessBalance problemsGait problemsWeak voiceHandwritingButtons/shoes lacesTurning over in bedGetting in/out car
SignsFestinating gaitFreezingBradykinesiaRigidityResting tremorHypomimiaPostural instabilityDyskinesiaHypophonia/monotoneMicrographia
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SIGNS/SYMPTOMS CONT.Non-motor features
Constipation Sleep disturbance: nightmares/sleep walking Daytime hyper-somnolence Depression Cognitive dysfunction/dementia: lewy body collect in
SN
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EXAMINATION Extrapyramidal posture: gunslinger/hands on hernias Hypomimia: poverty of facial expression Tremor 5Hz Bradykinesia: finger thumb test Rigidity: cogwheel at wrist, enhanced with synkinesis Micrographia Buttons/shoes laces= functional assessment Gait: festinating, loss arm swing, freezing/hesitancy,
difficulty turning
Extras: glabellar tap= loss of attenuation Vertical gaze: PSNP
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DIFFERENTIAL DIAGNOSIS Parkinson’s plus Vascular parkinsonism Drug induced parkinsonism Wilson’s disease Fronto-temporal dementia Infectious: post encephalitis Tumours: frontal lobe meningioma CJD
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INVESTIGATIONS Bloods: ceruloplasmin, copper, TFT Urinary copper Imaging
CT/MRI head: exclude other pathology DAT scan/SPECT
Other L-Dopa trial
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MANAGEMENTConservative
Physiotherapy Occupational therapy SALT PD nurse specialist Palliative care
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Medications L-DOPA + decarboxylase inh. carbidopa, benserazide
S.E= dyskinesia, tolerance, anorexia, postural hypoTN
DA: ropinirole, pramipexole, rotigotine S.E= impulse control disorders, hallucinations, postural
HypoTN
MAOB-I: Rasagiline S.E= flu-like symptoms, serotonergic syndrome
COMT-I: Entacapone=peripeheral, tolcapone=centralMust be taken with L-DopaS.E= hepatotoxic, orange urine, dyskinesia
Anticholinergics: amantadine for dsykinesia benzatropine for tremor
Apomorphine: rescue pen/continuous pump
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Non-motor symptoms Antidepressants: citalopram Antipsychotics: quetiapine, clozapine Dementia: rivastigmine Sleep disorder: clonazepam Autonomic disturbance: oxybutynin Constipation: movicol etc. Antiemetics: domperidone
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Surgical Thalamotomy: tremor/hemiballismus Pallidotomy: dyskinesia/bradykinesia DBS: tremor, dyskinesia
Not good for non-motor symptoms/ axial symptoms Duodopa: intrajejunal infusion L-Dopa £30,000
PA
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COMPLICATIONS Depression Dementia Autonomic dysfunction: incontinence,
retention, erectile dysfunction Side effects of medications
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CASE STUDY 62 year old man, presents with difficulty
walking and shaking of right hand, keen golfer in spare time PMH: HTN, Asthma, GORD.
83 year old gentleman lives in residential home, staff report unsteady on feet and increased difficulty mobilising for last few months.
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EXPLAINATION 5 MINS CT scanning
Assess prior knowledge/experience Outline benefits Outline risks Check patient’s understanding
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SUMMARY Clinical diagnosis (INV to exclude other Dx) Triad of bradykinesia, rigidity, tremor MDT approach to management Dopmaine agonists 1st line in younger
patients Consider the non-motor complications
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FURTHER READING NICE clinical guideline 35: Parkinson’s
disease: diagnosis and management in primary and secondary care. www.nice.org.uk/CG035