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.