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Parkinsonism

Parkinsonism. Dr Jamie Farmer. 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

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Parkinsonism

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  1. Parkinsonism Dr Jamie Farmer

  2. Outline • Parkinsonism vs PD • Causes of parkinsonism • Akinetic rigid syndromes • IPD • Signs/symptoms • Examination • Differential diagnosis • Investigations • Management • Complications • Case study • Explaining to patients

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. Signs/symptoms cont. Non-motor features • Constipation • Sleep disturbance: nightmares/sleep walking • Daytime hyper-somnolence • Depression • Cognitive dysfunction/dementia: lewy body collect in SN

  9. 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

  10. Differential diagnosis • Parkinson’s plus • Vascular parkinsonism • Drug induced parkinsonism • Wilson’s disease • Fronto-temporal dementia • Infectious: post encephalitis • Tumours: frontal lobe meningioma • CJD

  11. Investigations • Bloods: ceruloplasmin, copper, TFT • Urinary copper • Imaging • CT/MRI head: exclude other pathology • DAT scan/SPECT • Other • L-Dopa trial

  12. Management Conservative • Physiotherapy • Occupational therapy • SALT • PD nurse specialist • Palliative care

  13. 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=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

  14. Non-motor symptoms • Antidepressants: citalopram • Antipsychotics: quetiapine, clozapine • Dementia: rivastigmine • Sleep disorder: clonazepam • Autonomic disturbance: oxybutynin • Constipation: movicol etc. • Antiemetics: domperidone

  15. 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

  16. complications • Depression • Dementia • Autonomic dysfunction: incontinence, retention, erectile dysfunction • Side effects of medications

  17. 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.

  18. Explaination 5 mins • CT scanning • Assess prior knowledge/experience • Outline benefits • Outline risks • Check patient’s understanding

  19. 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

  20. Further reading • NICE clinical guideline 35: Parkinson’s disease: diagnosis and management in primary and secondary care. www.nice.org.uk/CG035

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