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Differing Demographics of Vascular Parkinsonism and Idiopathic Parkinsons Disease Karthik Sarma MD Resident PGY4 Shreyansh Shah MD and William Ondo MD.

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Presentation on theme: "Differing Demographics of Vascular Parkinsonism and Idiopathic Parkinsons Disease Karthik Sarma MD Resident PGY4 Shreyansh Shah MD and William Ondo MD."— Presentation transcript:

1 Differing Demographics of Vascular Parkinsonism and Idiopathic Parkinsons Disease Karthik Sarma MD Resident PGY4 Shreyansh Shah MD and William Ondo MD Dept of Neurology 14 th April, rd AAN Annual Meeting, Hawaii, 2011.

2 Disclosures Anand K Sarma, MD Shreyansh D Shah, MD William G Ondo, MD No disclosures W. Ondo: Grant Support: Ipsen, Acadia, Bayer, Takeda, Allergan, PSG, HSG, IMPAX Speaking / Consulting fees: GSK, Allergan, Novartis, Ipsen, TEVA, UCB Pharma, Merz, Lundbeck

3 Vascular Parkinsonism Critchley introduced the term in 1929 Initially used to describe clinical presentations consisting of… rigidity short-stepping gait fixed facies pyramidal, pseudobulbar signs and cerebellar signs dementia and urinary incontinence Variously referred to as Lower Body Parkinsonism, Arteriosclerotic Pseudo- Parkinsonism, etc.

4 Features of VP Clinical Typically older age of onset Shorter duration of symptoms at presentation Symmetric gait difficulties No rest tremor Imaging Typically chronic small vessel ischemic changes Pathology Absence of Lewy body pathology

5 Imaging Source: BCM imaging database

6 Diagnosing VP No consensus diagnostic criteria available Diagnostic problem in the community especially when non-neurologists and non-movement disorders experts involved in making the diagnosis of Parkinsonian symptoms Several criteria proposed including: Vascular Rating Scale by Winikates and Jankovic Loeb and Gandolfos modification of Hachinski score Zijlmans et al criteria for VP

7 Epidemiology of idiopathic PD Age of the patient considered as one of the most important risk factors for development of PD AGE α RISK of PD Studies have revealed that both Incidence and Prevalence increase with age

8 Prevalence studies

9 Incidence of PD Incidence and distribution of parkinsonism in Olmsted County, Minnesota, Bower JH, Maraganore DM, McDonnell SK, Rocca WA. Neurology Apr 12;52(6): Age- and sex-specific average annual incidence rates (per 100,000 person-years) of parkinsonism and its types: Olmsted County, MN, 1976–1990 *

10 Question… Does the misdiagnosis of VP as PD increase the age of onset of PD in epidemiologic studies?

11 Hypothesis VP misdiagnosed as PD would cause the average age at symptom onset of PD to increase, altering the age related distribution of PD and hence the epidemiology of PD. The incidence of PD in the population follows a bell shaped (normal) distribution about a median age of 60 years.

12 Study Methods Queried the PDCMDC database for the last 100 consecutive active patients with a diagnosis of VP and PD each. Collected demographic information including age at symptom onset, risk factors, clinical and radiological features. Examined entire database for diagnoses ratio. Calculated how VP would alter epidemiology of PD if labeled as PD.

13 Results DiagnosisNo. of Patients Mean Age at Sx Onset VP without overt stroke VP with overt stroke All VP98 (31F)73.59 PD102 (37F)57.81 No. of VP charts examined: 108 Diagnosis changed after initial assignment: 10 Total No. of VP considered for analysis: 98 The difference of the mean age at symptom onset between VP with and without overt stroke was not significantly different, p = 0.34

14 Results continued VPPDp value * Mean age in years at presentation (SD) (6.58)63.4 (12.22)< Mean age in years at symptom onset (SD) 73.1 (7.62)57.8 (11.22)< *- using Mann Whitney U test

15 Early Clinical Features: Comparison Prominent Symptom VP (%)PD (%)p value* Bradykinesia Tremor 1370< Gait 8713< RBD UE symptoms * Chi Square test

16 Prominent Clinical Features at Presentation % Patients Clinical features

17 Risk Factors: Comparison Risk FactorVP (%)PD (%)p value* HTN Smoking HLD CAD DM Afib TIA Stroke171< PVD111 Carotid Dz121 No known risk * Chi Square test

18 Risk Factors: Comparison Risk FactorVP (%)PD (%)p value* HTN Smoking HLD CAD DM Afib TIA Stroke171< PVD111 Carotid Dz121 No known risk * Chi Square test

19 Risk Factors % Patients Vascular Risk Factors

20 Imaging Characteristics % Patients

21 Age wise distribution of Onset of Symptoms % Patients Age Groups in years

22 Caveats of extrapolating the results to predict age of onset for PD… Sample of 200 patients may not be a representative sample of the database Patient sample and database may not be representative of the population Obvious recruitment bias at a Parkinsons Disease center Relative occurrence of VP and PD in the population are not similar to database

23 But if we did extrapolate… VPPDTotal Study Patient Nos Mean age at onset of symptoms in Study Database Patient Nos Does VP misdiagnosed as PD increase the average age at onset of PD?

24 Mean Age at Onset for PD would increase from: to [ * 805 / 7742 ] + [ * 6937 / 7742 ] = Proportional weighting based on relative occurrence

25 Value of study Provides a possible explanation for variability in epidemiology trials of age of onset for PD and more commonly, falsely elevated ages Encouraged future studies such as the ongoing sorting of our entire database Demands a population based incidence study differentiating VP and PD Importance of differentiating the two in the community given disparate pathophysiology, progression, response to treatment, prognosis and importantly, person making the diagnosis.

26 Acknowledgements I would like to thank my friend and colleague, Yogeshwar V Kalkonde for his valuable input and help.

27 View of Waikiki sunset from my room. Karthik Sarma; 9th April, Questions? Thank you!


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