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Topic: Parkinsons Disease

Ddx
PD
Parkinsons Plus syndrome
Parkinsonism (stroke in basal ganglia, drug-induced antipsychotic)
Lewy body dementia
Benign essential tremor
Wilsons disease

Common presentation:
TRAP symptoms
Fall
Bladder/bowel incontinence
Depression/anxiety/psychotic sx
Sleeping disturbances
SEs of medications

History:
1. When?
2. Onset sudden/gradual?
3. Progression worse/better/staying the same? Slow progression or
stepwise progression? Any fluctuations?
4. Site asymmetry/symmetrical?
5. Associated symptoms
- Tremor in hands? Worst at rest? Bilateral/asymmetrical?
- Difficulty getting out of bed or changing position?
- Difficulty in initiating task or start walking?
- Instability and falls? Stooped posture? Do you need to use walking
aids such as walker?
- Lack of facial expression?
- Monotonous speech? Talk in low volume?
- Slurred speech?
- Difficulty in swallowing? n/v? heartburn? Cough? SOB?
- Loss of sense of smell?
- Constipation?
- Bladder incontinence? Increased in frequency and urgency to pass
urine?
- Do you feel dizzy when standing up? Any faintness?
- Numbness? Pins and needle?
- Any weakness in the legs?
- Abnormal movements in legs?
- Low mood?
- Sleeping disturbances?
- Agitation?
- Hallucination or delusion?
Do you have any believes that other people find it
difficult to understand or find it a bit strange?
Have you ever seen things that other people around
you dont see or heard things that other people
around you dont hear?
- Dementia
Do you seem to be forgetful lately?
Can you give me examples of your forgetfulness?
Do you forget where you leave your keys/phone? Do
you forget to lock door at night or switch off the
stove after cooking?
- Cognitive function
Any loss of short term or long-term memory? Can
you recognize your wife? Do you remember what
you used to work before?
Difficulties to understand what people are saying to
you? (comprehension)
Any words finding difficulties when you are talking
to people? (language, dysphasia)
Do you know how to read? Any difficulties?
Do you know how to write? Any loss of ability in
writing and spelling? (agraphia)
Any loss of ability to plan or make a decision on
something?

Risk factors:
1. Anyone in the family with PD? Who? What age was diagnosed?
2. Do you know if you carry any genetic mutation? (Parkin gene)
3. Any head injury?
4. Exposure to toxic substance such as heavy metals, pesticides?
5. Hx of psychiatric illnesses? Have you ever been on antipsychotic meds?
What are they? How long?

PMH/Hx of PD
Any admission to hospital due to fall/dehydration/chest infection?
How long were you in the hospital?
Did you get to be admitted in the ICU?
What medications are you on for PD? Any combined medication?
(Levodopa, carbidopa/sinemet)
Any change in your medications? Do you use any levodopa pump?
Any side effects from levodopa/other medications? (agitation, visual
hallucination, wear-off effects, involuntary muscle movement?)
Do you get any physiotherapy? OT? SALT? Dietitian? How often, when
was the last time?
Do you see any psychiatrist?

Social history:
Who lives with you at home?
Do your children or relatives live nearby? Do they come to visit you often?
Do you have any neighbours who come to visit you or help you with
things?
How are you coping at home?
Bedroom and toilet upstairs or downstairs?
Any difficulty going up the stairs?
Do you need any help to change clothes/shower?
Do you need any help with cooking and cleaning?
Do you get help from social worker?
Do you get any meals on wheels?
Do you need help with shopping?
Do you drive?
How does this disease affecting your daily activity?

Investigations:
1. Clinical dx
2. Neuro-imaging
a. DAT-scan dopamine uptake in basal ganglia
b. MRI brain vascular ds in basal ganglia

Management:

Indications to treat:
1. Severity of patient symptoms
2. Degree of functional Impairment
Tremor dominant hand
Unable to work
Unable to walk
Recurrent falls
First Line Agents:
Levodopa preparation or dopamine agonist
Combination of both

Management
Pharmacological L-Dopa
Agents augmenting central L-Dopa access carbidopa, entacapone
Dopamine agonists-
- bromocriptine,pergolide (old)
- pramipexole, ropinerole, cabergoline

Anticholinergics - procyclidine
MAO-inhibitors- Selegiline/ Rasagiline (patch)

MDT input Physio/Occupational Therapy Input


SALT (Hypo-phonia/Dysphagia)
Dietician (Nutrition)
Social Work (Home Care Package/home supports)
Surgery Deep brain stimulation (DBS)
Subthalamic nucleus; globus pallidus internus or thalamus
Medically resistant motor symptoms of PD (tremor and dyskinesias).
Thalamotomy/Pallidotomy
Rarely used now
Replaced by DBS
Duodenal Levodopa Infusion pump
Intra-duodenal infusion

Preventive mx Pain
Depression
Sleep Disturbances
Cognitive screening
Bone protection if increased falls risk calcichew, vit D

Questions:
1. What is PD?
Chronic, progressive neurodegenerative disorder characterized by TRAP
due to degeneration of dopaminergic neuron in substantia nigra.

2. Side effects of levodopa?


Initially n/v, treat with domperidone
Increasingly severe parkinsonism
Autonomic neuropathy
Dysphagia
Dementia
Motor fluctuations (on-off/end of dose)
Visual hallucinations

3. Medication that can cause parkinsonism?


Lithum, phenothiazine, metaclopromide, antipsychotic