Transcript Parkinsons and Movement Disorders - Ralph Gregoryx

Association of British Neurologists
Parkinson’s disease and tremor.
What do I need to know?
Ralph Gregory
Consultant Neurologist
Braak 2002
Anosmia
Vivid dreams
Anxiety
Braak 2002
Olfactory dysfunction predicts early transition to a
Lewy body disease in idiopathic RBD
Mahlknecht et al
Neurology 2015:84;654-8
Rest tremor
Rigidity
Bradykinesia
Braak 2002
Tremor: PD v ET
• Asymmetric v bilateral
• Rest v action
• Leg v Head
• Bradykinesia
What treatment did this lady receive for her tremor?
• 65 year old man seeks your opinion regarding
frozen shoulder
• You note a left sided tremor, and he reports
slowness and stiffness down that side, which
is impairing his ADLs.
• You diagnose PD.
DaTSCAN imaging
Normal
Essential Tremor
PS – H&Y = 2
Clinical utility of DaT-SPECT in diagnosis of parkinsonian syndromes
Bajaj et al
J Neurol Neurosurg Psychiatry 2013:84:1288-95
Very few indications for DAT scan
• ET v PD
• Drug induced PD
• Vascular PD
• It does not differentiate PD from other
parkinsonian disorders
The Menu
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Prescribe no treatment
Prescribe MAOI (Selegeline)
Prescribe dopamine agonist (Ropinirole)
Prescribe l-dopa
(Sinemet/Madopar/Stalevo)
Problems with Levo-dopa
• Associated with high incidence of motor
complications
• Primes for development of dyskinesias
Advantages of dopamine agonists
• Associated with reduced incidence of
motor complications
• Do not prime for the development of
dyskinesias
Disadvantages of dopamine agonists
• Less dopaminergic than levo-dopa
• Difficult dosing schedule
• Precipitate serious side-effects including
compulsive behaviour, psychosis,
somnolence, leg oedema
compulsive behaviour
Rotigotine
The Menu
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Prescribe
Prescribe
Prescribe
Prescribe
no treatment
MAOI (Selegeline)
dopamine agonist (Ropinirole)
l-dopa (Sinemet/Madopar/Stalevo)
Long-term effectiveness of dopamine agonists and monoamine oxidase B inhibitors
compared with levodopa as an initial treatment for Parkinson’s disease (PD Med)
Gray et al
Lancet 2014:384;1196-205
• 55 year old lady with 9 years PD.
• Sometimes you see her she is independent and
can do her own shopping
• Other times her husband brings her in a
wheelchair and she has difficulty even taking a
few steps.
• At other times you witness ballistic involuntary
movements.
• No hallucinations, no dementia.
Days
6am
10am
Noon
2pm
4pm
6pm
1
2
3
4
5
Options
• Change medication. ?Prescribe Amantandine
to suppress dyskinesias
• Consider neurosurgical referral
• Consider apomorphine infusion or Duodopa
Early
6-8 hrs
Moderate
Advanced
2-4 hrs
0.5-2 hrs
Apomorphine and Duodopa
Subthalamic nucleus
Deep brain stimulation for movement disorders
Thevathasan W et al
Practical Neurology 2010: 10; 16-26
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Nursing home visit
75 year old lady with 12 years PD.
Walks with zimmer frame. Frequent falls.
Complains of visual misperceptions and
formed visual hallucinations.
• 18/30 MMSE
• Rx Co-benel dopa, Pramipexole, Selegeline,
and Entacapone
Parkinsonism
Visual Hallucinations
Dementia
Braak 2002
Clinicopathological spectrum
Parkinson’s
Disease
Parkinson’s
Disease Dementia
Cortical Lewy
Body Disease
Options
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Screen for other causes dementia
Simplify medication
Optimise l-dopa therapy medication
Trial of cholinesterase inhibitor
Optimise Levo-dopa therapy
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Before food
Dispersible
Small frequent doses
Avoid controlled release formulation
Improve gastric emptying (constipation, stop
other therapy)
• Low protein diet
Take home messages
• No reason to delay therapy if ADLs impaired
• L-dopa most effective with least side effects
• Beware of compulsive behaviours with dopamine agonists
• Dyskinesias inevitable especially for younger patients
• Surgery is option for a minority of patients
• When hallucinations and dementia develop simplify
dopaminergic medication and consider CEIs
Treatment essential tremor
Propranolol (as required)
Primodone
Gabapentin
Topirimate
Clonazepam