Transcript Parkinson`s Disease

Parkinson’s Disease
Dr Rachel Cary, Warwick Hospital
Overview
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Hopefully not anything new (!)
Definition of Parkinson’s disease
Aetiology
Presentation
Investigations
Management: conservative, medical, surgical
Prognosis
Parkinson’s plus syndromes
Definition
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Parkinson’s disease
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The idiopathic syndrome of Parkinsonism
Described by Dr James Parkinson in 1817 – ‘the shaking palsy’
Parkinsonism
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Symptom complex: characterised by bradykinesia, tremor and
rigidity (classical triad)
Causes:
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Drug induced – anti-dopaminergics e.g. clozapine, metoclopramide,
domperidone
Post-encephalitis
Exposure to toxins: e.g. severe CO poisoning
How common is it?
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65.6-125 per 100,000
Incidence rises steeply with age:
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17.4 in 100,000 person years between age 50-59
93.1 in 100,000 person years between 70 and 79 years
Risk factors
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Age
Male gender
Pesticide exposure
Genetic
?born in the springtime
Aetiology and pathogenesis
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Death of dopamine
generating cells in the
substantia nigra
Pathology characterised
by accumulation of
alpha-synuclein into
inclusions  Lewy
bodies
Insufficient formation
and activity of dopamine
in the midbrain
Presentation: symptoms + signs
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Tremor 4-6Hz – unilateral onset
Rigidity
Slowness of movement
Postural instability
Gait: festinating, shuffling, reduced arm swing
Gait freezing
Turning en bloc
Hypomimia
Micrographia
Hypophonia
How will you elicit these in an OSCE?
Differential diagnosis
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Benign essential tremor
Drug/toxin induced
Huntingon’s disease
Wilson’s disease
Parkinson’s plus syndromes (we’ll come to these later)
Lewy body dementia
CJD
Cerebellar tremor
Pick’s disease
Investigations
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Bedside tests
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Blood tests
Imaging
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Clinical diagnosis
CT Head
Special tests: DAT
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SPECT -> type of PET looking at striatal dopamine transporter
Associated diseases
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Dementia in 20-40%
Depression – 45%
Management - conservative
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Multidisciplinary management
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Parkinson’s nurse
Physiotherapy
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Avoid Zimmer frames unless they have wheels and a handbrake
Occupational therapy
Referral to other services as needed
Medical
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Dopamine agonists e.g. ropinirole, bromocriptine
MAO inhibitors e.g. selegeline
Levodopa + decarboxylase inhibitor
COMT e.g. entacapaone
Continuous dopamine therapy
Supportive medication e.g. baclofen
Choice of drug
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Depends on impact of improving motor disability vs risk
of motor complications, and neuropsychiatric
complications
Levodopa is the most effective drug: Sinemet, Madopar
Long term levodopa treatment associated with adverse
motor effects that limit its use
Surgery
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Bilateral subthalamic nucleus stimulation in patients
refractory to medical treatment
Globus pallidus interna is also recommended by NICE,
but rarely performed in the UK
Thalamic stimulation is an alternative for patients with
sever tremor who are unsuitable for STN stimulation
Longer term problems
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Motor fluctuations – “on” and “off”
Axial problems not responding to treatment
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Balance
Speech
Gait disturbance
Parkinson’s disease dementia
Complications
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Infections
Aspiration pneumonia
Pressure sores
Poor nutrition
Falls
Contractures
Bowel and bladder disorders
Prognosis
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Slowly progressive
Mean duration 15 years
Large variation in progression
Parkinson’s plus syndromes
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Features of Parkinson’s disease with additional features
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Multiple system atrophy
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Autonomic dysfunction
Ataxia
Progressive supranuclear palsy
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Often symmetrical onset
Lack of/irregular resting tremor
Reduced response to dopaminergic drugs
Often more rapidly progressive
Supranuclear opthalmoplegia
Neck dystonia
Pseudobulbar palsy
Frequent falls, imbalance, and difficulty walking
Behavioural and cognitive impairment
Corticobasal degeneration
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Alien hand syndrome
Apraxia
Aphasia
Summary
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Parkinsonism
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Clinical diagnosis
Multidisciplinary team management
Drugs: levodopa and others
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Rigidity, bradykinesia, tremor
Problems associated with long-term usage of levodopa etc.
DBS
Complications and associated comorbidity
Prognosis