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Dr. Kleyn Department of Geriatric Medicine SVCMC

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1 Dr. Kleyn Department of Geriatric Medicine SVCMC
Parkinson's Disease Dr. Kleyn Department of Geriatric Medicine SVCMC

2 History James Parkinson 1817, England Shaking palsy Paralysis agitans

3 “Involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported; with a propensity to bend the trunk forward, and to pass from a walking to a running pace, the senses and intellects being uninjured.”

4 Introduction Parkinson’s disease is a chronic neurodegenerative movement disorder affecting voluntary and emotional movements and most commonly seen in the elderly, but is also found in the young and inexorably progresses leading to significant disability.

5 Epidemiology Primarily a disease of the elderly
Mean age 55, Range years Juvenile parkinsonism- Less than 20 years M/F = 3:2 Prevalence increases with age

6 Aging and Parkinson’s disease
Exponential fall Linear fall

7 Anatomy-Basal Ganglia
Internal capsule Putamen Caudate Nucleus Globus pallidus



10 Chemical Balance in Corpus Striatum
Excitatory Cholinergic pathway Inhibitory Dopaminergic pathway BALANCE

11 Chemical Balance in Corpus Striatum
Excitatory Cholinergic pathway Inhibitory Dopaminergic pathway Imbalance

12 Parkinson’s disease - Pathophysiology

13 Pathology - Lewy Bodies
Eosinophilic hyaline inclusion bodies Spherical dense hyaline core with a clear halo Mechanism of formation unknown

14 Pathology Lewy body dementia Parkinson’s disease

15 Pathology-Parkinson’s disease

16 Classification and Etiology
Idiopathic Parkinson’s disease Parkinson-like syndromes Drug induced parkinsonism Hypoxia Tumor Trauma Vascular:Multiinfarct Toxin:Mn, CO, MPTP and cyanide Post-encephalitic parkinsonism (von Economo’s encephalitis) Normal pressure hydrocephalus Wilson’s disease, Hutington’s disease

17 Classification and Etiology
Medications that can cause parkinsonian symptoms, but not PD itself, include the following: Metoclopramide Domperidone Reserpine-containing antihypertensives Neuroleptics Some evidence also indicates that certain environmental factors (including smoking and coffee drinking) may actually have protective associations.

18 Clinical features of Idiopatic Parkinson’s disease.
Major features Resting tremor in hands, arms, legs, jaw, and face Bradykinesia Rigidity- cogwheel or lead-pipe Minor features Bradyphrenia Speech abnormalities Depression Dysautonomia Dystonia Constipation Hallucinations Dysphagia

19 Parkinson’s disease Symptomatology

20 Parkinson’s disease -Symptomatology
Tremor: Rest Fixed frequency 3-6 Hz Not a feature of old age Pill-rolling Usually starts in one limb, and then to other limbs Rarely starts in lower limbs Intermittent for many years They usually disappear briefly during movement and do not occur during sleep. Tremors can also eventually occur in the head, lips, tongue, and feet. In younger patients tremor is usually predominant and often suggests a less aggressive form of the disease. Tremor dominant

21 Parkinson’s disease-Symptomatology
Rigidity Striatal hand: Ulnar deviation, MCP flexion, IP extension Striatal toe: Big toe dorsiflexion Sitting en bloc: Collapses into a chair on attempting to sit down

22 Parkinson’s disease-Symptomatology
Posture Kyphosis Flexed elbows, knees and hips Hands held in front of body Trunk bent forward Head bowed

23 Parkinson’s disease-Symptomatology
Bradykinesia Slowness of motion (bradykinesia) is one of the classic symptoms of Parkinson's disease. Hypomimia- “masked facies”,expressionless face, blinking Speech abnormalities- Hypophonia: soft voice Aprosody of speech: monotonous and lack of inflection Tachyphemia: do not separate syllables together, running words together Patients may eventually develop a stooped posture and a slow, shuffling walk. The gait can be erratic and unsteady.

24 Parkinson’s disease-Symptomatology
Motor fluctuations Freezing phenomenon- Sudden, transient inability to perform active movements, lasting no more than a few seconds Start hesitation Turn hesitation Target hesitation Palilalia (speaking) Apraxia of eyelid opening Writing Kinesia paradoxica-Despite severe rigidity and bradykinesia, they may rise suddenly and move normally

25 Parkinson’s disease-Symptomatology
“Today is a sunny day in Toronto" Loop drawing: Amplitude Interloop distance “Micrographia”

26 Parkinson’s disease-Symptomatology
Festinating gait Drooling of saliva Dysphagia Constipation Dementia Depression Orthostatic hypotension Low resting blood pressure HTN Normotensive Sweating abnormalities-excessive perspiration Blepharospasm/ keratitis

27 Movement Disorders Parkinson’s disease Hutington’s disease
Multiple system atrophy Motor neuron disease Cortical basal ganglionic degeneration Patients with PD may develop a stooped posture and a slow, shuffling walk. The gait can be erratic and unsteady.

28 Movement Disorders “Off”phase

29 Movement Disorders “On” phase

30 Diagnosis There are currently no blood or laboratory tests that have been proven to help in diagnosing PD. Therefore the diagnosis is based on medical history and a neurological examination.  The disease can be difficult to diagnose accurately.  Doctors may sometimes request imaging studies (i.e. MRI’s or brain scans) or laboratory tests in order to rule out other diseases.

31 Differential diagnosis of Parkinson’s diseases.

32 Parkinson’s disease - Management

33 Nonpharmacologic Management

34 Nonpharmacologic Management

35 Nonpharmacologic Management

36 Drugs for Parkinson’s disease

37 The Management of Parkinson’s disease
Dose Dose

38 Surgical Therapy- Deep brain stimulation
When symptoms are uncontrollable with medical therapy None ablative method is used Transpalntation of fetal nigral cells Thalamotomy

39 Parkinson’s disease - Imaging

40 Predicted developments
Research into the causes of Parkinson’s diseases are likely to show that multiple genetic and environmental factors are involved Disease of early onset is more likely to be genetic New drugs acting on both dopaminergic and non- dopaminergic transmitter systems will become available over the next 10 years Clinical trials of new drugs with neuroprotective and neurorescue properties are in progress

41 Research At no time in the past have the basic and clinical sciences applied to Parkinson’s disease been so active. Future progress in understanding the causation and pathogenesis of the disorder will permit the development of new treatments that will slow, halt, or even reverse the currently progressive course of Parkinson’s disease.

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