Parkinsonism

3. Parkinson’s disease is a progressiveParkinson’s disease is a progressive
neurodegenerative disorder that results inneurodegenerative disorder that results in
deterioration of neurons in basal ganglia.deterioration of neurons in basal ganglia.

4. EPIDEMIOLOGYEPIDEMIOLOGY
Incidence = 0.2 / 1000Incidence = 0.2 / 1000
Prevalence = 1.5 / 1000Prevalence = 1.5 / 1000
The incidence and prevalence both increase The incidence and prevalence both increase
with age.with age.
Sex incidence is almost equal.Sex incidence is almost equal.
It is less common in smokers.It is less common in smokers.

5. Typical Age of OnsetTypical Age of Onset
Average age of onset is 60 yrs.Average age of onset is 60 yrs.
5-10% of cases occur under the age of 40. 5-10% of cases occur under the age of 40.
Referred to as Referred to as Young-Onset Parkinson Young-Onset Parkinson
Disease.Disease.
Rarely seen under age 30.Rarely seen under age 30.

6. Famous Faces of ParkinsonFamous Faces of Parkinson
Michael J. Fox
Muhammad Ali
Katharine Hepburn
Pope John Paul II
Johnny Cash
Mao Tse Tung

7. EtiologyEtiology
Parkinson’s disease is referred to as Parkinson’s disease is referred to as
idiopathic idiopathic (unknown cause).(unknown cause).
Genetic link is seen in a small number of Genetic link is seen in a small number of
Parkinsons cases. Parkinsons cases.
Larger genetic link is found in young-Larger genetic link is found in young-
onset Parkinsons disease.onset Parkinsons disease.
MPTPMPTP cause severe parkinsonism in cause severe parkinsonism in
young drug usersyoung drug users

8. Risk factorsRisk factors
Positive family history Positive family history
Male genderMale gender
Head injuryHead injury
Exposure to pesticideExposure to pesticide
Consumption of well waterConsumption of well water
Rural livingRural living

10. Factors which decrease incidence of Factors which decrease incidence of
PDPD
SmokingSmoking
Coffee drinkingCoffee drinking
Use of NSAIDSUse of NSAIDS
Estrogen replacement in postmenopausal Estrogen replacement in postmenopausal
women women

11. Repeated head traumaRepeated head trauma
Infectious & post infectious diseaseInfectious & post infectious disease
Drugs (neuroleptics, antipsychotics , alpha Drugs (neuroleptics, antipsychotics , alpha
methyldopa, lithium carbonate , fluoxetine )methyldopa, lithium carbonate , fluoxetine )
ToxinsToxins
MPTP MPTP
CyanidesCyanides
Methanol Methanol

12. Unilateral ParkinsonismUnilateral Parkinsonism
Vascular Vascular
TraumaticTraumatic
Neoplasm Neoplasm
Lower body ParkinsonismLower body Parkinsonism
It may represent a form of vascular It may represent a form of vascular
parkinsonismparkinsonism

13. Parkinsonism plus syndromeParkinsonism plus syndrome
Features of parkinsonism associated with Features of parkinsonism associated with
complex clinical presentation complex clinical presentation
Failure to respond to treatmentFailure to respond to treatment
Worse prognosisWorse prognosis
Examples include : Examples include :
1. Shy Dragger syndrome1. Shy Dragger syndrome
2. Steel Richardson syndrome2. Steel Richardson syndrome
3. Parkinsonism-dementia plus3. Parkinsonism-dementia plus

14. PATHOLOGYPATHOLOGY

There is depletion of pigmented There is depletion of pigmented
dopaminergic neurons in the substantia dopaminergic neurons in the substantia
nigra, atrophic changes in substantia nigra nigra, atrophic changes in substantia nigra
and depletion of neurons in locus and depletion of neurons in locus
coeruleus.coeruleus.

16. PATHOLOGYPATHOLOGY
Reduced dopaminergic output from the Reduced dopaminergic output from the
substantia nigra to globus pallidus leads to substantia nigra to globus pallidus leads to
reduced inhibitory effect on subthalamic reduced inhibitory effect on subthalamic
nucleus, neurons of which become more nucleus, neurons of which become more
active in inhibiting activation of cortex active in inhibiting activation of cortex
resulting in bradykinesia.resulting in bradykinesia.

18. CLINICAL FEATURESCLINICAL FEATURES

Tremors TTremors T
Rigidity RRigidity R
Akinesia / Bradykinesia AAkinesia / Bradykinesia A
Postural instability PPostural instability P

19. Head bent forward
Tremors of head
Maslike facial expression
Drooling
Rigidity
Stooped posture
Weight loss
Akinesia
tremors
Loss of postural
reflexes
Propulsive gait
CLINICAL FEATURES

20. General FeaturesGeneral Features
Expressionless face (mask like)Expressionless face (mask like)
Greasy skinGreasy skin
Soft rapid indistinct speech, monotonousSoft rapid indistinct speech, monotonous
Glabellar tap sign / Myersons signGlabellar tap sign / Myersons sign
Flexed postureFlexed posture
Impaired postural reflexesImpaired postural reflexes

21. GaitGait
Slow to start walkingSlow to start walking
Shortened strideShortened stride
Rapid small steps tendency to turn en blocRapid small steps tendency to turn en bloc
Reduced arm swingReduced arm swing
Impaired balance on turningImpaired balance on turning

22. TremorsTremors
Resting (4 - 6 Hz)Resting (4 - 6 Hz)
Postural (8-10 Hz)Postural (8-10 Hz)

23. RigidityRigidity
Cogwheel :Cogwheel :
mostly in upper limbsmostly in upper limbs
Plastic / lead-pipe:Plastic / lead-pipe:
mostly in lower limbsmostly in lower limbs

24. BradykinesiaBradykinesia
Slowness in initiation or repeating Slowness in initiation or repeating
movementsmovements
Impaired fine movementsImpaired fine movements

25. Hoehn & Yahr ScaleHoehn & Yahr Scale
Stage IStage I: Unilateral involvement only, usually with : Unilateral involvement only, usually with
minimal or no function impairment.minimal or no function impairment.
Stage IIStage II: Bilateral or midline involvement w/o : Bilateral or midline involvement w/o
impairment of balance.impairment of balance.
Stage IIIStage III: 1: 1
stst
signs of righting reflex impairment; signs of righting reflex impairment;
functionally restricted in his/her activities but can functionally restricted in his/her activities but can
lead independent life. Disability mild/moderate.lead independent life. Disability mild/moderate.
Stage IVStage IV: Severely disabled. Able to walk & : Severely disabled. Able to walk &
stand unaided but is markedly handicapped.stand unaided but is markedly handicapped.
Stage VStage V: Confined to bed.: Confined to bed.

28. InvestigationsInvestigations
There is no specific medical test used to There is no specific medical test used to
diagnose Parkinson disease. diagnose Parkinson disease.
However, However, MRIsMRIs and and blood testsblood tests are used are used
to rule out other possible conditions that to rule out other possible conditions that
have similar symptoms to Parkinson have similar symptoms to Parkinson
disease.disease.

29. TREATMENTTREATMENT
Drug therapyDrug therapy
Surgerical Treatment Surgerical Treatment
Physiotherapy Physiotherapy
Speech therapySpeech therapy

30. LEVODOPALEVODOPA
 It is the oldest and most effective treatment ofIt is the oldest and most effective treatment of
PD. PD.
 Brain enzymes modify the drug to create dopamine.Brain enzymes modify the drug to create dopamine.
 It reduces slowness and stiffness of muscles.It reduces slowness and stiffness of muscles.
 Given in combination with peripheral decarboxylase Given in combination with peripheral decarboxylase
inhibitors, carbidopa & benserazide.inhibitors, carbidopa & benserazide.
Combinations are called Sinemet & Madopar Combinations are called Sinemet & Madopar
respectively.respectively.

31. Adverse effectsAdverse effects::
Nausea, vomiting, hypotension,orofacial Nausea, vomiting, hypotension,orofacial
dyskinesias, dystonias, hallucinations.dyskinesias, dystonias, hallucinations.
Two important phenomenon associated Two important phenomenon associated
with levodopa use are:with levodopa use are:
1) end- of- dose deterioration1) end- of- dose deterioration
2) on-off phenomenon2) on-off phenomenon

33. Useful effects on tremors & rigidity butUseful effects on tremors & rigidity but
do not help bradykinesia.do not help bradykinesia.
 Adverse effects :Adverse effects :
Dry mouth , blurred vision , difficult Dry mouth , blurred vision , difficult
urination , constipation, confusion, urination , constipation, confusion,
hallucinations hallucinations

Anticholinergic agentsAnticholinergic agents

34. AmantadineAmantadine
Useful in controlling dyskinesia produced Useful in controlling dyskinesia produced
by dopaminergic treatment later in the by dopaminergic treatment later in the
disease.disease.
Adverse effects:Adverse effects:
livedo reticularis , peripheral edema, livedo reticularis , peripheral edema,
confusion , seizures confusion , seizures

35. Dopamine receptor agonistsDopamine receptor agonists
Bromocriptine , lisuride , pergolide Bromocriptine , lisuride , pergolide
,cabergoline , ropinirole & pramipexole,cabergoline , ropinirole & pramipexole

36. OTHER DRUGSOTHER DRUGS
COMT inhibitors:COMT inhibitors:
Catechol-O-methyl transferase inhibitorsCatechol-O-methyl transferase inhibitors
SelegelineSelegeline

37. Surgical procedures are now available for Surgical procedures are now available for
specific patients who no longer respond to specific patients who no longer respond to
drug treatments.drug treatments.

38. PALLIDOTOMYPALLIDOTOMY
It is a neurosurgical procedure that can It is a neurosurgical procedure that can
reduce many of the symptoms of Parkinson reduce many of the symptoms of Parkinson
DiseaseDisease
Performed by a neurosurgeon, who inserts a Performed by a neurosurgeon, who inserts a
hallow probe into the globus pallidus and then hallow probe into the globus pallidus and then
liquid nitrogen is circulated in the probe.liquid nitrogen is circulated in the probe.
 The probe destroys part of the globus The probe destroys part of the globus
pallidus by creating a scar .pallidus by creating a scar .

39. The patient is awake during the procedure The patient is awake during the procedure
which takes about 6 hours.which takes about 6 hours.
It can permanently eliminate It can permanently eliminate
dyskinesiasdyskinesias
Reduces tremor, rigidity, bradykinesia Reduces tremor, rigidity, bradykinesia
and shuffling gait.and shuffling gait.
It is not a cure.It is not a cure.

40. Stereotatic thalamotomyStereotatic thalamotomy
Used to treat tremors Used to treat tremors

41. Deep Brain StimulationDeep Brain Stimulation
An electrode is placed in one of several parts An electrode is placed in one of several parts
of the brain (thalamus, globus palladus, or of the brain (thalamus, globus palladus, or
subthalamic nucleus).subthalamic nucleus).
The electrode is attached to a computerized The electrode is attached to a computerized
pulse-generator which is put under this skin in pulse-generator which is put under this skin in
the chest.the chest.
Symptoms are relieved through the regulation Symptoms are relieved through the regulation
of electrical impulses from those three areas of electrical impulses from those three areas
of the brain.of the brain.

42. Deep Brain StimulationDeep Brain Stimulation

43. Current ResearchCurrent Research
Neural graftingNeural grafting, or transplantation of nerve , or transplantation of nerve
cells, is an experimental technique cells, is an experimental technique
proposed for treating the disease. proposed for treating the disease.
Investigators have shown in animal Investigators have shown in animal
models that implanting fetal brain tissue models that implanting fetal brain tissue
from the substantia nigra into a from the substantia nigra into a
parkinsonian brain causes damaged nerve parkinsonian brain causes damaged nerve
cells to regenerate. cells to regenerate.
Gene TherapyGene Therapy

44. General Treatment StrategiesGeneral Treatment Strategies
Develop routine for self careDevelop routine for self care
Help family/care partner, along with patient, Help family/care partner, along with patient,
create ideas for adapting home environment to create ideas for adapting home environment to
meet the patient’s needs. meet the patient’s needs.
Modified kitchenModified kitchen
Modified bathroom Modified bathroom
Full bathroom and bedroom on first floorFull bathroom and bedroom on first floor
Lift chairLift chair
Remove rugs/carpet/furniture that could be Remove rugs/carpet/furniture that could be
easily tripped overeasily tripped over

46. Social ParticipationSocial Participation
Support groupsSupport groups
Important to encourage continued Important to encourage continued
involvement in activities important to their involvement in activities important to their
life. life.
Participation in activities which are not Participation in activities which are not
physically taxing.physically taxing.
Introduce techniques for enhancing voice Introduce techniques for enhancing voice
volume.volume.

47. jobjob
Educate & inform co-workersEducate & inform co-workers
Explore work-at-home optionsExplore work-at-home options
Adapt job requirements as disease Adapt job requirements as disease
progressesprogresses

48. PrognosisPrognosis
Depends upon the age of onsetDepends upon the age of onset
If symptom starting in middle life ,the If symptom starting in middle life ,the
disease is usually progressive & likely to disease is usually progressive & likely to
shorten lifespan.shorten lifespan.
After 70 is unlikely to shorten life or After 70 is unlikely to shorten life or
become severe.become severe.