What is PD?

Dr Catherine Dotchin MD MRCP

Consultant Geriatrician

Overview of presentation

• Case history

• Video example pre and post treatment

• Historical review

• PD in the UK

• Epidemiology and aetiology

• Making the diagnosis

• Main clinical features

Case reportThis man was seen, and diagnosed, in 1995, when Richard was

investigating stroke in the Hai district.

At that stage, he was 30 years old and displayed clear signs of

Parkinsonism. He had been unable to afford to visit anyone regarding

his condition and as a result had become increasingly slow and his

mobility had deteriorated markedly. He has left-sided tremor

predominant PD. This has led him to give up work in his ‘shamba’, his

only source of income.

He has many other symptoms, including freezing, difficulty rising from a

chair, drooling of saliva, cramps and pain in his legs and arms, quiet

voice, difficulty communicating, nocturia and frequency and constipation.

Case report cont.

• CD visited him again at the end of 2005 (an annually

since then)

• Now, he is 40 years and is limited to mobilising around

his house and in the small area of yard outside it. He has

tried various treatments from the village traditional healer

who had diagnosed ‘evil spirits’. These have included

oral medication, topical treatment, inhalations and

tattoos, but none of them had benefit. He relies upon

help and financial support from his nephews. Many find

his symptoms distressing, as they believe he is a “young

man who has grown old too soon”.

After 3 months of treatment with

levodopa/carbidopa

James Parkinson

The History of Parkinson’s

Disease

• Parkinson’s Disease (PD) was first described by

James Parkinson in 1817

• He noted

– ‘involuntary tremulous motion’

– ‘a propensity to bend forwards’

– ‘to pass from a walking to running pace’

– ‘the senses and intellect being uninjured’

• 40 years later Charcot named Parkinson’s

Disease

Parkinson’s Disease Defined

• Parkinson’s Disease is:

– A chronic, progressive, neurological

degenerative disease

• The contemporary definition is:

– ‘Multi-system neurological disorder which

affects cognitive processes, emotion and

autonomic function.’ (Playfer 2001)

Pathological findings:

• Progressive loss of dopaminergic cells in the

substantia nigra of the basal ganglia

Epidemiology (UK)

• 1% of population > 65 years have PD.

• A typical GP practice will have no more

than 5 PD patients.

• 6% of NH residents have PD.

• 150,000 NH + 350,000 Res care beds.

• Therefore 30,000 PD pts in care (£300m).

• Complex needs.

Aetiological theory for PD

What causes Parkinson’s?

Parkinson’s disease

Ageing Genes

50

60

70

Possible protective effect: smoking and caffeine

Environment

When do clinical signs of

Parkinson's develop?

Striatal dopamine levels

Reduced by 80%

Cell loss in the substantia nigra

Reaches 50%

Basal Ganglia simplified functions!

• controls the preparation, initiation,

sequencing and timing of well learnt motor

skills

• ‘auto pilot’ facility

The ‘Braak hypothesis’

Stage 1 and 2:

Pathology confined to certain

structures in the brain stem,

not yet the substantia nigra

Stage 3 and 4:

Pathology spreads to the

midbrain and basal ganglia

Stage 5 and 6:

Changes spread to the

cortex

Image adapted from The Professionals Guide to Parkinson’s Disease,

Parkinson'sS

DIAGNOSIS

Different Doctors do Different

Diagnoses

• Pathologist - Brainstem Lewy Bodies – PM

findings

• Radiologists - Fluorodopa PET scans

• Clinicians - Varying clinical criteria

Diagnostic Accuracy

• Clinical diagnosis

• Typically only 90% in specialist hands

• Several differential diagnoses

• 70% of parkinsonism will be PD

Differential Diagnoses

• Drug induced parkinsonism

• Cerebrovascular parkinsonism

• Lewy body dementia

• Alzheimers disease

• Multi system atrophy

• Progressive supranuclear palsy

• Benign essential tremor

Probable most important

diagnostic criteria

• Asymmetrical onset

• Progressive condition

• Responsive to levodopa

Motor symptoms of Parkinson’s

Freezing

Postural

instability

Bradykinesia

Rigidity

Tremor

Motor

symptoms

of Parkinson's

Speech

Arising from

a chair

Posture

Reduced arm

swing

Hypomimia

Shuffling gait

Gait festination

Turning

Turning in bed

Micrographia

Falls

Motor symptoms

• Tremor

– Absent in up to 30% of people with PD

• Bradykinesia

• Rigidity

• Postural instability

– Usually later presentation

Non motor symptoms of

Parkinson’s Disease• Cognitive deficiencies

• Depression

• Raised anxiety levels

• Balance and falls

• Sleep disturbance

• Fatigue

• Pain

• Bowel and bladder problems

• Sexual dysfunction

• Weight loss

• Skin

Clinical Diagnosis

• “Neurological signs that improve on

Ldopa”

• Often not apparent on first assessment

• The use of time as a diagnostic tool

• Interdisciplinary assessments

• No straightforward test

Investigations

• Routine blood investigations

• DAT Scan – normal in essential tremor and drug-induced Parkinsonism

• +/- MRI Scan

• ?Dopamine challenge – reasonable dose for reasonable length of time

• “Sniffin sticks” – objective change in sense of smell at diagnosis in over 70%

Conclusion

• Progressive, chronic, multisystem

neurological condition

• Clinical criteria used to make diagnosis by

physicians

• Risk factors – age, family history, genetics,

environment

• Good symptomatic treatment is available

which will improve quality of life