Parkinson s Disease in the Elderly A Physicians perspective. Dr John Coyle

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1 Parkinson s Disease in the Elderly A Physicians perspective Dr John Coyle

2 Overview Introduction Epidemiology and aetiology Pathogenesis Diagnosis and clinical features Treatment Psychological issues/ non motor features Dementia

3 Disclosures Education grant from Boehringer. Slides from Orion Pharma.

4 Introduction Parkinson s disease A progressive and fluctuating neurological condition Associated with depletion of dopamine levels in the basal ganglia Dopamine is a neurotransmitter involved in initiation of movement, speech and selfexpression

5 Parkinson s Disease 0.2% population 2:1000 2% elderly population 10% nursing home

6

7 Aetiology Several different factors Genetic.Parkin,LRRK-2. Tau, synuclein Environmental Smoking Toxins - MPTP Trauma

8 Pathogenesis 70-80% loss of Dopamine producing cells in the basal ganglia Pathological marker Lewy bodies. Neuronal cell death mitochondrial dysfunction oxidative damage excitotoxicity inflammatory changes

9

10 Lewy Bodies

11 Diagnosis Difficult - especially in the early stages No specific marker for disease, therefore a clinical diagnosis. Clinico-pathological studies 76% accurate UK clinical diagnostic criteria: 80% sensitive: 30% specific Levodopa or Apomorphine test not recommended

12 Are you sure its Parkinson s

13 Prodromal phase depression fatigue autonomic features frozen shoulder / back pain REM sleep disorder Hyposmia

14 Unusual motor features Clawing 1 foot long distance running swimming in circles Rolex sign Abnormal stillness when seated Poor timing leading to faulty dance steps rest tremor after yawning unexplained episodes gait festination and propulsion

15 Signs and symptoms motor Hypokinesia shuffling, hesitant gait mask-like face drooling soft, mumbled speech micrographia Rigidity cramp-like pain expressionless face cog-wheel rigidity Resting tremor tremor at rest but not when moving or sleeping

16 Signs and symptoms non-motor Autonomic problems orthostatic hypotension constipation increased sweating impotence Depression Dementia

17 UK Clinical Diagnostic Criteria

18 STEP 1: Parkinsonian Syndrome bradykinesia and at least 1 of the following: muscular rigidity 4-6Hz rest tremor postural instability

19 STEP 2 Exclusion Criteria Repeated strokes History encephalitis Oculogyric crisis Neuroleptic treatment at onset >1 affected relative Sustained remission Strictly unilateral after 3 years Supranuclear gaze palsy cerebellar signs early severe autonomic involvement early severe dementia Babinski sign cerebral tumour on CT 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine

20 STEP3 Supportive positive criteria At least 3 or more Unilateral onset Rest tremor present progressive persistent asymmetry affecting side of onset most excellent response to L dopa severe L-dopa induced chorea L-dopa response for >5 years clinical course of >10 years

21 Clinical features that make diagnosis less likely Early instability and falls Pyramidal or cerebellar signs Downgaze palsy Early autonomic failure Early severe dementia

22 If its not Parkinson s what is it then?

23 Common Misdiagnosis Essential tremor postural tremor. Vocal or head Arteriosclerotic pseudoparkinson s Gait apraxia / Lower limb PD Elderly, hypertensive, cognitive impairment, predominantly lower limb Normal Pressure Hydrocephalus

24 Parkinsonian Syndromes MSA PSP Corticobasal degeneration Post encephalitic Drug induced

25 How bad it is and what have I got to look forward to?

26 Prognosis and rating of severity Rating scales include: Hoehn and Yahr Staging of Parkinson s disease Unified Parkinson s Disease Rating Scale (UPDRS) Schwab and England Activities of Daily Living Webster Rating Scales

27 Do I need a Scan or x-ray?

28 Imaging in PD CT / MRI scan - Structural vascular lesions PET 18 F dopa differentiates normal subjects( Research tool mainly) SPECT (DAT scan) differentiates essential tremor from PD

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