Parkinson's Disease

Parkinson's Disease

Parkinsons Disease Dr Rachel Cary, Warwick Hospital Overview Hopefully not anything new (!) Definition of Parkinsons disease Aetiology Presentation Investigations Management: conservative, medical, surgical

Prognosis Parkinsons plus syndromes Definition Parkinsons disease The idiopathic syndrome of Parkinsonism Described by Dr James Parkinson in 1817 the shaking palsy Parkinsonism

Symptom complex: characterised by bradykinesia, tremor and rigidity (classical triad) Causes: Drug induced anti-dopaminergics e.g. clozapine, metoclopramide, domperidone Post-encephalitis Exposure to toxins: e.g. severe CO poisoning How common is it?

65.6-125 per 100,000 Incidence rises steeply with age: 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 Age Male gender Pesticide exposure

Genetic ?born in the springtime Aetiology and pathogenesis 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 Presentation: symptoms + signs 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

Benign essential tremor Drug/toxin induced Huntingons disease Wilsons disease Parkinsons plus syndromes (well come to these later) Lewy body dementia CJD Cerebellar tremor Picks disease Investigations Bedside tests

Blood tests Imaging Clinical diagnosis CT Head Special tests: DAT SPECT -> type of PET looking at striatal dopamine

transporter Associated diseases Dementia in 20-40% Depression 45% Management - conservative Multidisciplinary management Parkinsons nurse Physiotherapy

Avoid Zimmer frames unless they have wheels and a handbrake Occupational therapy Referral to other services as needed Medical

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 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 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 Motor fluctuations on and off Axial problems not responding to treatment Balance Speech Gait disturbance Parkinsons disease dementia Complications

Infections Aspiration pneumonia Pressure sores Poor nutrition Falls Contractures Bowel and bladder disorders Prognosis

Slowly progressive Mean duration 15 years Large variation in progression Parkinsons plus syndromes Features of Parkinsons disease with additional features Multiple system atrophy

Autonomic dysfunction Ataxia Progressive supranuclear palsy 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 Alien hand syndrome Apraxia Aphasia Summary

Parkinsonism Clinical diagnosis Multidisciplinary team management Drugs: levodopa and others Rigidity, bradykinesia, tremor

Problems associated with long-term usage of levodopa etc. DBS Complications and associated comorbidity Prognosis

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