2 Outline Parkinsonism vs PD Causes of parkinsonism Akinetic rigid syndromesIPDSigns/symptomsExaminationDifferential diagnosisInvestigationsManagementComplicationsCase studyExplaining to patients
3 Definitions Parkinsonism: RigidityResting tremorBradykinesiaParkinson’s disease (PD) is a progressive neurodegenerative condition resulting from the death of the dopamine-containing cells of the substantia nigra
6 Idiopathic Parkinson’s Disease Clinical diagnosis100–180 people per 100,000annual incidence of 4–20 per 100,000Unilateral→bilateralWorse in upper limbsGood response to L-Dopa
7 Signs/symptoms Symptoms Tremor/shaking Stiffness Slowness Balance problemsGait problemsWeak voiceHandwritingButtons/shoes lacesTurning over in bedGetting in/out carSignsFestinating gaitFreezingBradykinesiaRigidityResting tremorHypomimiaPostural instabilityDyskinesiaHypophonia/monotoneMicrographia
8 Signs/symptoms cont. Non-motor features Constipation Sleep disturbance: nightmares/sleep walkingDaytime hyper-somnolenceDepressionCognitive dysfunction/dementia: lewy body collect in SN
9 Examination Extrapyramidal posture: gunslinger/hands on hernias Hypomimia: poverty of facial expressionTremor 5HzBradykinesia: finger thumb testRigidity: cogwheel at wrist, enhanced with synkinesisMicrographiaButtons/shoes laces= functional assessmentGait: festinating, loss arm swing, freezing/hesitancy, difficulty turningExtras: glabellar tap= loss of attenuationVertical gaze: PSNP
16 Surgical Thalamotomy: tremor/hemiballismus Pallidotomy: dyskinesia/bradykinesiaDBS: tremor, dyskinesiaNot good for non-motor symptoms/ axial symptomsDuodopa: intrajejunal infusion L-Dopa £30,000 PANb surgery does not halt progression of disease but increases the QOL
18 Case study62 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.
20 Summary Clinical diagnosis (INV to exclude other Dx) Triad of bradykinesia, rigidity, tremorMDT approach to managementDopmaine agonists 1st line in younger patientsConsider the non-motor complications
21 Further readingNICE clinical guideline 35: Parkinson’s disease: diagnosis and management in primary and secondary care.