Transcript Parkinsonism

PARKINSONISM
Dr Jamie Farmer
OUTLINE
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Parkinsonism vs PD
Causes of parkinsonism
Akinetic rigid syndromes
IPD
Signs/symptoms
Examination
Differential diagnosis
Investigations
Management
Complications
Case study
Explaining to patients
DEFINITIONS
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Parkinsonism:
Rigidity
 Resting tremor
 Bradykinesia
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Parkinson’s disease (PD) is a progressive
neurodegenerative condition resulting from the
death of the dopamine-containing cells of the
substantia nigra
PARKINSONISM
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IPD: idiopathic parkinson’s disease
Asymmetrical, slow progression, good L-Dopa response
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Drug induced:
Antiemetics: metoclopramide, prochlorperazine
Antipsychotics: haloperidol
lithium.
Symmetrical onset, tremor less prominent
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Vascular:
Bradykinesia, rigidity, lower limbs, upper limb
sparing, vascular RF, stuttering evolution
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Akinetic-rigid syndromes
AKINETIC-RIGID SYNDROMES/PARKINSON’S +
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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
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SIGNS/SYMPTOMS
Symptoms
Tremor/shaking
Stiffness
Slowness
Balance problems
Gait problems
Weak voice
Handwriting
Buttons/shoes laces
Turning over in bed
Getting in/out car
Signs
Festinating gait
Freezing
Bradykinesia
Rigidity
Resting tremor
Hypomimia
Postural instability
Dyskinesia
Hypophonia/monotone
Micrographia
SIGNS/SYMPTOMS CONT.
Non-motor features
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Constipation
Sleep disturbance: nightmares/sleep walking
Daytime hyper-somnolence
Depression
Cognitive dysfunction/dementia: lewy body collect in SN
EXAMINATION
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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
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INVESTIGATIONS
Bloods: ceruloplasmin, copper, TFT
 Urinary copper
 Imaging
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CT/MRI head: exclude other pathology
 DAT scan/SPECT
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Other
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L-Dopa trial
MANAGEMENT
Conservative
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Physiotherapy
Occupational therapy
SALT
PD nurse specialist
Palliative care
Medications
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L-DOPA + decarboxylase inh. carbidopa, benserazide
S.E= dyskinesia, tolerance, anorexia, postural hypoTN
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DA: ropinirole, pramipexole, rotigotine
 S.E= impulse control disorders, hallucinations, postural
HypoTN
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MAOB-I: Rasagiline
 S.E= flu-like symptoms, serotonergic syndrome
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COMT-I: Entacapone=peripeheral, tolcapone=central
Must be taken with L-Dopa
S.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
Surgical
Thalamotomy: tremor/hemiballismus
 Pallidotomy: dyskinesia/bradykinesia
 DBS: tremor, dyskinesia
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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
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CASE STUDY
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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
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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
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NICE clinical guideline 35: Parkinson’s disease:
diagnosis and management in primary and
secondary care. www.nice.org.uk/CG035