What is PD? Dr Catherine Dotchin MD MRCP Consultant Geriatrician

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1 What is PD? Dr Catherine Dotchin MD MRCP Consultant Geriatrician

2 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

3 Case report This 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.

4 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.

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6 After 3 months of treatment with levodopa/carbidopa

7 James Parkinson

8 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

9 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

10 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.

11 Aetiological theory for PD

12 What causes Parkinson s? Ageing Genes Environment Parkinson s disease Possible protective effect: smoking and caffeine

13 When do clinical signs of Parkinson's develop? Striatal dopamine levels Reduced by 80% Cell loss in the substantia nigra Reaches 50%

14 Basal Ganglia simplified functions! controls the preparation, initiation, sequencing and timing of well learnt motor skills auto pilot facility

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16 The Braak hypothesis Stage 5 and 6: Changes spread to the cortex Stage 3 and 4: Pathology spreads to the midbrain and basal ganglia Stage 1 and 2: Pathology confined to certain structures in the brain stem, not yet the substantia nigra Image adapted from The Professionals Guide to Parkinson s Disease,

17 DIAGNOSIS

18 Different Doctors do Different Diagnoses Pathologist - Brainstem Lewy Bodies PM findings Radiologists - Fluorodopa PET scans Clinicians - Varying clinical criteria

19 Diagnostic Accuracy Clinical diagnosis Typically only 90% in specialist hands Several differential diagnoses 70% of parkinsonism will be PD

20 Differential Diagnoses Drug induced parkinsonism Cerebrovascular parkinsonism Lewy body dementia Alzheimers disease Multi system atrophy Progressive supranuclear palsy Benign essential tremor

21 Probable most important diagnostic criteria Asymmetrical onset Progressive condition Responsive to levodopa

22 Speech Hypomimia Reduced arm swing Posture Tremor Arising from a chair Bradykinesia Rigidity Motor symptoms of Parkinson s Motor symptoms of Parkinson's Postural instability Micrographia Turning in bed Turning Freezing Gait festination Shuffling gait Falls

23 Motor symptoms Tremor Absent in up to 30% of people with PD Bradykinesia Rigidity Postural instability Usually later presentation

24 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

25 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

26 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%

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28 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