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Parkinsonism Dr Jamie Farmer.

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Presentation on theme: "Parkinsonism Dr Jamie Farmer."— Presentation transcript:

1 Parkinsonism Dr Jamie Farmer

2 Outline Parkinsonism vs PD Causes of parkinsonism
Akinetic rigid syndromes IPD Signs/symptoms Examination Differential diagnosis Investigations Management Complications Case study Explaining to patients

3 Definitions Parkinsonism:
Rigidity Resting tremor Bradykinesia Parkinson’s disease (PD) is a progressive neurodegenerative condition resulting from the death of the dopamine-containing cells of the substantia nigra

4 Parkinsonism IPD: idiopathic parkinson’s disease Drug induced:
Asymmetrical, slow progression, good L-Dopa response Drug induced: Antiemetics: metoclopramide, prochlorperazine Antipsychotics: haloperidol lithium. Symmetrical onset, tremor less prominent Vascular: Bradykinesia, rigidity, lower limbs, upper limb sparing, vascular RF, stuttering evolution Akinetic-rigid syndromes

5 Akinetic-rigid syndromes/parkinson’s +
MSA: MSA-P vs MSA-C. insidious onset parkinsonism, sphincter disturbance, balance, postural hypotension, cerebellar signs, stridor. Poor L-Dopa response. PSNP: prominent axial rigidity, loss of downward vertical gaze, eyelid/facial dystonia→frowning/surprised expression. DLB: nocturnal wandering, hallucinations, early cognitive impairment, myoclonus. Poor response to L-Dopa CBD: parietal lobe affected, alien limb, dysphasia, ext.plantars, myoclonus, dystonia, dementia

6 Idiopathic Parkinson’s Disease
Clinical diagnosis 100–180 people per 100,000 annual incidence of 4–20 per 100,000 Unilateral→bilateral Worse in upper limbs Good response to L-Dopa

7 Signs/symptoms Symptoms Tremor/shaking Stiffness Slowness
Balance problems Gait problems Weak voice Handwriting Buttons/shoes laces Turning over in bed Getting in/out car Signs Festinating gait Freezing Bradykinesia Rigidity Resting tremor Hypomimia Postural instability Dyskinesia Hypophonia/monotone Micrographia

8 Signs/symptoms cont. Non-motor features Constipation
Sleep disturbance: nightmares/sleep walking Daytime hyper-somnolence Depression Cognitive dysfunction/dementia: lewy body collect in SN

9 Examination Extrapyramidal posture: gunslinger/hands on hernias
Hypomimia: poverty of facial expression Tremor 5Hz Bradykinesia: finger thumb test Rigidity: cogwheel at wrist, enhanced with synkinesis Micrographia Buttons/shoes laces= functional assessment Gait: festinating, loss arm swing, freezing/hesitancy, difficulty turning Extras: glabellar tap= loss of attenuation Vertical gaze: PSNP

10 Differential diagnosis
Parkinson’s plus Vascular parkinsonism Drug induced parkinsonism Wilson’s disease Fronto-temporal dementia Infectious: post encephalitis Tumours: frontal lobe meningioma CJD

11 Investigations Bloods: ceruloplasmin, copper, TFT Urinary copper
Imaging CT/MRI head: exclude other pathology DAT scan/SPECT Other L-Dopa trial

12 Management Conservative Physiotherapy Occupational therapy SALT
PD nurse specialist Palliative care

13 Medications Apomorphine: rescue pen/continuous pump
L-DOPA + decarboxylase inh. carbidopa, benserazide S.E= dyskinesia, tolerance, anorexia, postural hypoTN DA: ropinirole, pramipexole, rotigotine S.E= impulse control disorders, hallucinations, postural HypoTN MAOB-I: Rasagiline S.E= flu-like symptoms, serotonergic syndrome COMT-I: Entacapone=peripeheral, tolcapone=central Must be taken with L-Dopa S.E= hepatotoxic, orange urine, dyskinesia Anticholinergics: amantadine for dsykinesia benzatropine for tremor Apomorphine: rescue pen/continuous pump


15 Non-motor symptoms Antidepressants: citalopram Antipsychotics: quetiapine, clozapine Dementia: rivastigmine Sleep disorder: clonazepam Autonomic disturbance: oxybutynin Constipation: movicol etc. Antiemetics: domperidone

16 Surgical Thalamotomy: tremor/hemiballismus
Pallidotomy: dyskinesia/bradykinesia DBS: tremor, dyskinesia Not good for non-motor symptoms/ axial symptoms Duodopa: intrajejunal infusion L-Dopa £30,000 PA Nb surgery does not halt progression of disease but increases the QOL

17 complications Depression Dementia
Autonomic dysfunction: incontinence, retention, erectile dysfunction Side effects of medications

18 Case study 62 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.

19 Explaination 5 mins CT scanning Assess prior knowledge/experience
Outline benefits Outline risks Check patient’s understanding

20 Summary Clinical diagnosis (INV to exclude other Dx)
Triad of bradykinesia, rigidity, tremor MDT approach to management Dopmaine agonists 1st line in younger patients Consider the non-motor complications

21 Further reading NICE clinical guideline 35: Parkinson’s disease: diagnosis and management in primary and secondary care.

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