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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
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/SYMPTOMS
SymptomsTremor/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
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