PARKINSONISMDr Jamie Farmer

OUTLINE Parkinsonism vs PD Causes of parkinsonism Akinetic rigid syndromes IPD Signs/symptoms Examination Differential diagnosis Investigations Management Complications Case study Explaining to patients

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

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

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

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

SIGNS/SYMPTOMSSymptomsTremor/shakingStiffnessSlownessBalance problemsGait problemsWeak voiceHandwritingButtons/shoes lacesTurning over in bedGetting in/out car

SignsFestinating gaitFreezingBradykinesiaRigidityResting tremorHypomimiaPostural instabilityDyskinesiaHypophonia/monotoneMicrographia

SIGNS/SYMPTOMS CONT.Non-motor features

Constipation Sleep disturbance: nightmares/sleep walking Daytime hyper-somnolence Depression Cognitive dysfunction/dementia: lewy body collect in

SN

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

DIFFERENTIAL DIAGNOSIS Parkinson’s plus Vascular parkinsonism Drug induced parkinsonism Wilson’s disease Fronto-temporal dementia Infectious: post encephalitis Tumours: frontal lobe meningioma CJD

INVESTIGATIONS Bloods: ceruloplasmin, copper, TFT Urinary copper Imaging

CT/MRI head: exclude other pathology DAT scan/SPECT

Other L-Dopa trial

MANAGEMENTConservative

Physiotherapy Occupational therapy SALT PD nurse specialist Palliative care

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

Non-motor symptoms Antidepressants: citalopram Antipsychotics: quetiapine, clozapine Dementia: rivastigmine Sleep disorder: clonazepam Autonomic disturbance: oxybutynin Constipation: movicol etc. Antiemetics: domperidone

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

COMPLICATIONS Depression Dementia Autonomic dysfunction: incontinence,

retention, erectile dysfunction Side effects of medications

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.

EXPLAINATION 5 MINS CT scanning

Assess prior knowledge/experience Outline benefits Outline risks Check patient’s understanding

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

FURTHER READING NICE clinical guideline 35: Parkinson’s

disease: diagnosis and management in primary and secondary care. www.nice.org.uk/CG035