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Parkinson’s Disease

Parkinson’s Disease. By Nik Sanyal. This = movement disorder caused by degeneration of dopamine pathways in substantia nigra Characterised by : TREMOR RIGIDITY BRADYKINESIA +/- postural instability. Epidemiology + Risk Factors. Peak age of onset = 55-65 Men > Women

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Parkinson’s Disease

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  1. Parkinson’s Disease By Nik Sanyal

  2. This = movement disorder caused by degeneration of dopamine pathways in substantia nigra • Characterised by: • TREMOR • RIGIDITY • BRADYKINESIA • +/- postural instability

  3. Epidemiology + Risk Factors • Peak age of onset = 55-65 • Men > Women • 2nd most common neurodegenerative disease after Alzheimer’s • Risk factors: • Age • Gender • Spring birth • Exposure to pesticides e.g. paraquat or Agent Orange

  4. Pathogenesis • Most cases = idiopathic PD. Leading to a progressive degeneration + development of Lewy bodies in substantianigra. • Other pathways – mesocortical, mesolimbic + tubero-hypophyseal • Genetics (lead to early onset): • mutations in c’some 6 = AR PD • Alpha synuclein mutation • Parkin gene Dopamine has a role in disinhibition of motor activity hence why reduced levels leads to dyskinesia.

  5. Pathophysiology • Cell death in substantia nigra (particularly pars compacta) leads to reduced dopamine secreting cells. • Dopamine acts to facilitate release of inhibition and as such in PD there is greater exertion required to initiate a movement as there is less release of inhibition.

  6. Clinical features • Resting tremor = usually unilateral before it becomes generalised. It is 4-6 Hz pill-rolling.Typically absent during activity. • Rigidity = lead pipe. Cog-wheeling occurs when lead pipe rigidity is broken up by tremor. • Bradykinesia = festinant gait (slow to start + small shuffling steps + difficult turns) Has diminished arm swing = leads to recurrent falls. You also get reduction in amplitude of repetitive movements.

  7. Other features • Progressive decline over years • Mask-like face • Impaired swallowing – drooling, choking on food • Cognitive decline = depression + dementia • Quiet voice progressing to dysarthria • Micrographia (small + spidery writing)

  8. DDx • Wilson’s • Lewy Body dementia: get visual hallucinations • CJD: Dementia + myoclonic jerking • Parkinson’s plus • Huntington’s disease • Drug-induced PD • Antipsychotics (APAT side effects: acute dystonia, parkinsonism, akathisia, tardive dyskinesia) • Lithium • Benign essential tremor • Rarely at rest, worse on movement • Family hx

  9. NICE criteria for Dx • Exclude other causes • Bradykinesia + at least 1 of: • Rigidity • 4-6Hz resting tremor • Postural instability • Supportive criteria: • Unilateral • Progressive nature • Asymmetry before bilateral • Response to L-Dopa

  10. Investigations • Typically a clinical diagnosis • Use: • Bedside: BP lying + standing, urine dip • Bloods: Genetic testing for Huntington’s or caeruloplasmin for Wilson’s • Imaging: CT/MRI • Fail to respond to L-Dopa • Can visualise structural defects • Special tests: DAT scan can differentiate between drug-induced + PD.

  11. Conservative management • Advice + explanation, consider non-physical problems (depression, poor sleep, dementia). • Limited time frame for meds so start when really needed + started by neurologist! • MDT: specialist nurses, OT, SALT, psychiatrist, GP, neurologist, dietician • Inform DVLA • REHAB

  12. Medical management • Drugs alter the natural progression – they just improve symptoms. • Levodopa • Is the most effective drug. • It crosses the BBB and enters the nigrostriatal neurones and is converted to dopamine. • Give with dopa-decarboxylase inhibitor e.g. carbidopa to inhibit peripheral metabolism. S/E = N+V, confusion, on-off phenomena, wearing off + dyskinesia, hallucination

  13. Dopamine agonists e.g. Pramipexole =good for motor sx • 1st line in younger patients • MAO-B inhibitors = selegiline = block dopamine breakdown. Good for motor sx. • COMT inhibitors = entacapone = inhibits peripheral break down. S/E = hepatotoxic, N+V, confusion. • Amantadine: can be used as monotherapy in early PD but has poor evidence base. Enhances dopamine release. • Apomorphine can reduce off periods given as s/c injection. S/E confusion + hallucinations

  14. Surgical • Deep brain stimulation • Pallidotomy involves surgical destruction of the globus pallidus to control dyskinesia.

  15. Complications • Infection • Aspiration pneumonia • Bed sores • Poor nutrition • Falls • PD dementia

  16. Prognosis • Slowly progressive • Mean duration 15 years • Variable severity • Earlier age of onset = poorer prognosis • Death usually from complications e.g. pneumonia.

  17. Parkinson’s plus syndromes • Disorders with parkinsonism + additional features + specific pathology. • Vascular dementia • Orthotic hypotension = multi-system atrophy gives insomnia, somnolence, restless legs, hallucinations. Use fludrocortisone for BP • Dementia + vertical gaze palsy= progressive supra-nuclear palsy • Kayser-Fleischer rings = Wilson’s • Apraxic gait – communicating hydrocephalus

  18. Good luck!  • Parkinson’s notes • http://www.patient.co.uk/doctor/parkinsonism-and-parkinsons-disease • Extrapyramidal exam • http://youtu.be/6PDxANv_ME8 • Gait • http://youtu.be/7SyTpEdhBLw

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