What sort of tremor is seen in Parkinson’s disease?
- Pill-rolling
- Often starts unilateral
- Fine tremor
- Resting tremor
What sort of tremor is an essential tremor?
- Coarse tremor
- Worse on movement
- Jaw tremor
- Familial history
- Non-specific beta-blockers (ex propanolol) have been found to help
What is Parkinsonism?
Classical triad of symptoms:
- Resting tremor
- Bradykinesia
- Rigidity
Often also see postural and gait instability
What are the features and what is the management for Idiopathic Parkinson’s disease?
Key features:
- Extrapyramidal features (ex tremor, bradykinesia, rigidity)
- Asymmetry of clinical signs
- Unilateral at initial presentation
Other features:
- Secondary motor symptoms (ex hypomimia, hypophonia, gait abnormalities)
- Non-motor features (ex REM sleep disturbance, anosmia)
Principle management:
- Levodopa OR
- Dopamine agonist
- Physical activity/therapy
What are the features and what is the management of Dementia with Lewy bodies?
Key features:
- Triad:
- Dementia
- Parkinsonism
- Visual hallucinations
Other features:
- Prominent visual hallucinations
- Fluctuations in alertness
Principle management:
- Shared care with psychiatry/neurology/geriatrics
What are the features and what is the management of Drug-induced parkinsonism?
Key features:
- History of dopamine blocking drugs (ex antipsychotics, metoclopramide)
Other features:
- Symmetrical rigidity and lack of facial expression
Principle management:
- Reduce or stop drug if possible
- Liaise with psychiatry
What are the features and what is the management of Multi-systems atrophy?
Key features:
- Prominent early autonomic features (ex hypotension, bladder instability)
Other features:
- Symmetrical parkinsonism
- Autonomic complications
Principle management:
- Levodopa and supportive treatments
What are the features and what is the management of Progressive supranuclear palsy?
Key features:
- Early falls
- Truncal rigidity
- Vertical gaze palsy
Other features:
- Reduction in mid-brain volume on MRI (hummingbird sign)
Principle management:
- Early speech and language reivew
- Supportive measures
What are the features and what is the management of Normal pressure hydrocephalus?
Key features:
- Triad:
- Dementia
- Gait disorder
- Bladder instability
Other features:
-Signs of normal pressure hydrocephalus on neuro-imaging
Principle management:
- Diagnostic lumbar punctire and CSF removal
- Ventriculo-peritoneal shunt
What are the features and what is the management of cortico-basal degeneration?
Key features:
- Asymmetrical parkinsonism
- Dyspraxia
Other features:
- Cortical sensory deficit
- Alien limb phenomenin
Principle management:
- Symptomatic(???)
- Does not respond to levodopa
What are the secondary features of Parkinson’s diease?
- Micrographia (small handwriting)
- Camptocormia (stooped posture)
- Festinant gait
- Difficult with floor aptterns, doorways, obstructions
What is the diagnostic criteria for Idiopathic Parkinson’s Disease?
UK Brain bank criteria:
Diagnosis of a parkinsonian syndrome:
Bradykineasia with at least one of the following:
- Muscular rigidity
- Resting tremor (4-6Hz)
- Postural instability unrelated to primary visual, cerebellar, vestibular or proprioceptive dysfunction
Exclusion criteria for PD:
History of:
- Repeated stroked with stepwise pregression
- Repeated head injury
- Antipsychotic drugs (dopamine depleting)
- Presence of neurological features making other diagnoses more likely
- Sustained remission
- Presence of cerebral tumour/hydrocephalus seen on imaging
Supportive critera for PD Three or more required for definite diagnosis: - Unilateral onset - Resting tremor present - Progressive disorder - Persistent asymmetry - Excellent response to levodopa - Severe levodopa-induced chora - Levodopa response for over 5 years - Clinical course of over 10 years
How should you manage someone with suspected Parkinson’s Disease?
- Refer all patients with suspected Parkinson’s disease URGENTLY, and untreated to a specialised with expertise in movement disorders (ex neurologist or geriatrician)
- This will help confirm the diagnosis and exclude alternative diagnoses
If Parkinson’s is suspected, but the patient is taking medications known to induce parkinsonism
- Reduce or stop the drug in primary care if possible and appropriate
- Do not delay specialist referral to assess the response
What is the NICE guidance on management of patients with confirmed Parkinson’s diease
- Ensure that the patient is under the care of a specialist in movement disorders
- Ensure they are under an MDT (including a PD nurse specialist) to provide management and support
- Ensure a comprehensive review at least every 6-12 months
- Reconsider the diagnosis is atypical features develop
- If there is any uncertainty in diagnosis, seek advice from specialist
- Provide patient and family with written information for support (Parkinson’s UK, Parkinson’s and you guide)
- At the time of diagnosis, and at times of change in disease, advise patients who drive to inform the DVLA and their insurance company
Consider referral to other members of the MDT:
- SALT
- Physiotherapy
- Occupational therapy
- Dietetics
- Social care
- Community nursing
- Continence and urology
- Mental health
- Assess for need of a carer
- Offer regular medications reviews
- Advise vitamin D supplementation
ENSURE AWARENESS OF MEDICATION TIMINGS!
What is the average age of onset of Parkinson’s disease?
60
Name an example of a:
- Monoamine oxidase-B inhibitor
- Dopamine agonist
- Form of levodopa qith a dopa decarboxylase inhibitor
MAO-B: Rasagaline, Selegiline
DA: Ropinirole
Levodopa: Co-beneldopa (Madopar)
What are some non-motor problems in Parkinson’s disease?
- Constipation
- Bladder problems - urgency
- Drooling
- Swallowing issues
- Choking
- Back pain
- Poor sleep
- Vivid dreams
- Moving during dreams
- Short-term memory loss
- Anxiety
- Depression
What are the side effects of dopamine agonists?
- Confusion
- Hallucinations
- Disinhibition
- Impulse control disorders
What are the four stages of Parkinson’s disease?
- Pre-diagnosis: nigrostriatal degeneration occurs without overt motor symptoms
- Diagnosis/maintenance: drug treatment is commenced with good response and no motor complications
- Complex: may be development of dyskinesias, unpredictable on/off motor issues, neuropsychiatric issues (ex cognitive impairment, psychosis)
- Palliative: poor drug response, developing Parkinson’s disease dementia predominate. Swallow impairment, PEG tube may be needed, end of life care, cognitive impairment and dementia are common at this stage.
Which part of the brain degenerated in Parkinson’s disease?
The pars compacta of the substantia nigra (midbrain)
Dopamine loss is responsible for the motor signs and symptoms
What is the most common side-effect of levodopa treatment?
Postural hypotension
Ensure to counsel patients about this
At clinical visits, lying and standing BP should be taken
