Parkinsons Disease
Clinical features & diagnostic criteria
Lecture notes from Dr R Barber, Consultant Geriatrician.
Lecture contents:
Important Differential Diagnoses
Science
Therapy
U.K. P.D.S. Brain Bank Criteria:
Parkinsonian Syndrome =
- Bradykinesia and at least 1 of:
Rigidity
Rest Tremor
Postural instability
Exclusions for Idiopathic PD
Supportive prospective positive criteria for IPD
Differential Diagnosis - Traps
- Benign Essential Tremor
- Dystonic Tremor
- Progressive Supranuclear Palsy (PSP)
- Multi System Atrophy (MSA)
Benign Essential Tremor (B.E.T.)
Common
Action (rest if severe)
Symmetrical -ish
Doesnt start in legs
May involve Neck & Voice
No Rigidity, no Bradykinesia
Cogwheeling may be present
Dominant inheritance often
Relieved by alcohol,
b blockers, not L dopa
Progressive supranuclear palsy (P.S.P.)
Paresis of downward gaze
Dysarthria
Parkinsonian
Dementia
Relentlessly Progressive
M>F
Poor response to L-dopa
? Family history
Multi system atrophy
Spectrum of 3 clinical syndromes:
Primary autonomic failure (Shy-Drager)
orthostatic hypotension, impotence, diarrhoea, retention.
Striatonigral degeneration (Parkinsonism)
Olivo-ponto-cerebellar degeneneration (Cerebellar)
Poor response to L dopa
Dementia with Lewy Bodies
Cognitive impairment prominent, often before Parkinsonism
Fluctuating Cognitive Function
Falls
Hallucinations
Some response to L-dopa
Sensitivity to neuroleptics
Part 2.
Non Motor aspects of P.D.
Bladder
incontinence, frequency / urgency
Bowels
Constipation, bloating, nausea
Bulbar
Hypersalivation, drooling, dysphagia
Speech
Dysarthria, hypophonia, initiation
Visual
diplopia, blepharospasm, blepharoclonus
Skin
Seborrhoea, hyperhidrosis
Weight loss
Autonomic dysfunction > falls etc.
Psychological
depression, apathy, anxiety
Cognitive
Dementia, confusion, hallucination
Sleep disturbance
REM disorder, Akathisia, somnolence
Pain
dystonia, rigidity
Sexual
impotence, erectile & psychogenic
3. Take Home messages
Diagnosis difficult
PD brain bank criteria
DAT/PET scan if available?
Treat when symptoms start interfering
Low and Slow
Dopamine agonists 1st. in younger
L dopa 1st. in older elderly
Selegiline?
Add L dopa or Dopamine agonist later
Watch for end dose fading
Add COMT inhib.
Apomorphine?
Amantadine?
Surgery ( in younger )?
Watch this space
SE s of medication
GI - nausea, diarrh., abdo pain
Dyskinesia
Neuro psych. -confusion, hallucinations
Postural Hypotension
DONT FORGET OTHER BITS
Constipation
Depression
Dementia
Incontinence/ Frequency-Urgency
Sleep disturbance
Help at home
Groups / PDS for moral support