1. Erica Partridge Parkinson’s Disease

2. Definition Aetiology PD vs Parkinsonism Symptoms and signs Differentials Investigations Management Prognosis

3. 1. What is the definition of Parkinson’s disease?

4. A movement disease characterised by Tremor at rest Rigidity Bradykinesia

5. 2. Aetiology of PD

6. Degeneration of dopaminergic pathways in the substantia nigra

7. 4. What is the difference between PD and Parkinsonism?

8. PD is used to describe idiopathic syndrome of Parkinsonism Parkinsonism is symptoms attributable to an underlying cause

9. 5. Causes of Parkinsonism

10. Drug induced Any drug that blocks dopamine receptors or reduce storage of dopamine Mainly antipsychotics But also antiemetics such as metoclopramide Antihistamines – eg cyclizine 5HT3 receptor blockers – eg ondansetron Dopamine blockers eg metoclopramide, domperidone Following encephalitis Exposure to toxins – manganese dust, sever CO poisioning

11. 6. 3 main features of PD

12. Tremor 4-6 hz Seen at rest – can be induced by concentration Usually apparent in one limb or one side first Rigiditiy Increase in resistance to passive movement Can produce a characteristic flexed posture Cogwheel rigidity Bradykinesia Slowness of voluntary movement Reduced arm swing Progressive reduction in amplitude of repetitive movements

13. 7. How does PD present

14. Insidious onset Peak age of onset is 55-65, slightly more common in men Impairment of dexterity Progressive disorder

15. 8. Other symptoms

16. Fixed facial expression Infrequent blinking Quiet voice Micrographia Gait – short shuffling steps (festination), difficulty in initiating movement and in stopping Non motor Anosmia Depression Dementia Visual hallucinations REM sleep disorders

17. 9. Differential diagnosis

18. Benign essential tremor Far more common – worse on movement, rare at rest Drug or toxin induced

19. 10. In which type of dementia do patient’s have PD symptoms?

20. Lewy body dementia Dementia Fluctuating levels of awareness Signs of mild PD Visual hallucinations Sleep disorgers PD dementia Dementia occuring >1 year after PD diagnosis Visual hallucinations Fluctuating lucidity

21. 11. Diagnosis of PD

22. Bradykinesia plus one of following Muscular rigidity Resting tremor Postural instability Not causes by primary visual, vestibular, cerebellar or proprioceptive dysfunction

23. 12. Investigations

24. Diagnosis is clinical

25. 13. Management

26. Levodopa Taken with a decarboxylase inhibitor Start with low dose and build up Keep dose as low as possible N+V/loss of appetite Dopamine agonists Eg bromocriptine, cabergoline Monotherapy or adjuvant COMT inhibitors Must be taken with levodopa Eg entacapone, tolcapone

27. MAOBi Prevent dopamine being broken down Selegine Has amphetamine metabolites – hallucinations, nightmares, confusion so avoid in elderly Rasagiline No amphetamine metabolites

28. Levodopa Breakdown product Dopamine COMTMAO COMT AADC (decarboxylase) BBB

29. 14. Other management

30. 14. Management OT SALT Exercises to strengthen voice/help control facial expression/swallowing or drooling problems Suggest communication aids Physio PD nurse Support groups

31. 15. Common management problems

32. Motor fluctuations – associated with long term L-dopa On off fluctuations – occur randomly Wearing off phenomenon – before next dose is due Involuntary movements while on – dyskinesias Axial problems Do not respond to treatment Balance, speech and gait Physio, SALT, OT Associated disease Dementia (20-40%) Depression (45%)

33. 16. Complications

34. Infections Aspiration pneumonia Bed sores Poor nutrition Falls Contractures Bowel and bladder disorders

35. 17. Prognosis

36. Slowly progressive with mean duration of 15 years Severity is hugely varied Some show little disability after 20 years Others severely disabled after 10 years

37. Explaining things to patients

38. What do they already know Why they need it What will happen Risks/side effects Do they have any questions? It is fine if you don’t know the answers say you will find out and get back to them Offer to give them information sheets/leaflets

39. References Patient UK Professional Reference NICE guidelines Parkinson’s UK website