PENYAKIT PARKINSON

UTOYO SUNARYO
RSUD Dr.MOHAMAD SALEH
KOTA PROBOLINGGO

PROBOLINGGO , 23 NOVEMBER 2005

OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
MAKRO ANATOMI SUSUNAN
SARAF PUSAT
OTAK.
OTAK BESAR ( SEREBRUM).
OTAK KECIL ( SEREBELUM).
DIENSEFALON.
THALAMUS.
HIPOTHALAMUS
BATANG OTAK ( TRUNKUS SEREBRI).
- MESENSEFALON.
- PONS.
- MEDULA OBLONGATA.
MEDULA SPINALIS
OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
 GANGLIA BASALIS

1. Striatum (neostriatum & limbic striatum)

Neostriatum : - Putamen &
- Nucleus Caudatus
2. Globus Palidus (GP) : Interna & Externa.
3. Substansia Nigra (SN) :
- SNc : Pars Compacta
- SNr : Pars Reticular
4. Subthalamic Nucleus (STN)
CORTICAL MOTOR AREAS

THALAMUS BASAL
GANGLIA

CEREBELLUM

BRAINSTEM

SPINAL
CORD
 Ganglia Basalis dalam
Menciptakan Gerakan :

Stimulasi Korteks Motorik.

Melalui pintu masuk putamen

(di Striatum)
Keluar melalui Globus Palidus

internus
Menciptakan jalur direk dan indirek.
OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
PATOFISIOLOGI PENYAKIT
PARKINSON
Ketidak seimbangan saraf
dopaminergik dan kolinergik
DA AK AK = ASETIL KOLIN
DA = DOPAMIN

NORMAL
(AK=DA)

PENYAKIT PARKINSON
(AK>DA)
 BRAIN
Ganglia basalis
Dopamin Acetylcholin
Normal
MAO MAO I ( selegiline )
Anticholinergic
Perokside Radical H (Trihexylphenidyl)
Dopamin Tissue
Receptor D2 damage
Decarboxylase
Levodopa Acetylcholin PD
BLOOD BRAIN BARIER
Levodopa 3 OMD
COMT Inhibitor
COMT
Dopamin Agonist (entacapone)
Decarboxylase

Decarboxylase Inhibitor
Ergot Non Ergot
Dopamin
(Benzeraside)
(bromocryptin) (pramipexole ) (carbidopa)
PERIFER
OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
EPIDEMIOLOGI

Prevalensi dari Penyakit Parkinson belum

diketahui secara pasti diperkirakan 1 %
dari jumlah penduduk antara usia 50 th
s/d 70 th dari pria atau wanita dengan ras
Kaukasian lebih banyak dibanding Afro
Amerika .
Poli saraf RS Dr Soetomo Sby : sekitar 190
pasien parkinson per tahun.
OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
 Parkinsons Disease
Definisi by James Parkinson 1817 :

T
R
Penyakit A
Parkinsonisme
Parkinson P
What is Parkinsons Disease?

Clinical syndrome manifesting

characteristically with parkinsonism
(bradikinesia, hipo/akinesia. rigidity,
tremors, and postural instability),
caused by significant dopaminergic
striatal denervation. (Wolters, 2007)

19
PENYAKIT PARKINSON
vs PARKINSONISM

PARKINSONISM

SINDROMA :
Tremor, Rigidity, Akinesia, Postural
instability (TRAP)

MACAM-MACAM PENYEBAB
PENYAKIT PARKINSON
Etiologi : Idiopatik
Degenerasi neuron di substansia nigra &
ada lewy bodies
80% Parkinsonism
Onset :
>50 TAHUN
PUNCAK 70 an TAHUN

PRIA : WANITA = 3 :2
Rata-rata 9 tahun meninggal tanpa
terapi
KLASIFIKASI PARKINSONISM
Parkinsonism Idiopatik / Primer
= Penyakit Parkinson=
Parkinsonism Simptomatik / Sekunder
Drugs Induced, Infectious, Head Trauma,
Tumor/paraneoplastik, Vascular, Toxins,
Metabolic, Hidrocephalus,Anoxic encephalopathy
Parkinsonism Plus
Dementia syndroma (Alzheimers Disease) ,
Multiple System Atrophy, Normal Pressure
Hydrocephalus, Progressive supranuclear palsy,
Corticobasal ganglionic degeneration, Hereditary
disorders.
 Parkinsons Disease
ETIOLOGY:

Etiology dari Penyakit Parkinson belum

diketahui secara pasti , namun ada beberapa
faktor yang dapat meningkatkan Resiko
dari Penyakit Parkinson :
 Parkinsons Disease
Faktor yang dapat menyebabkan
meningkatnya Resiko Penyakit Parkinson :

Aging , Gender ( Men) , and Ras ( White )

Riwayat Keluarga :
Trauma
Stress Emosional
Personality ( Shyness and Depressiveness)
Environmental Exposures
Metals ( Manganese , Iron )
Drinking unwell water
Farming
Herbicide and Pepticide exposure
MPTP ( methyl phenyl tetrahydropiridine)
OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
 PENYAKIT PARKINSON

GEJALA UTAMA (TRAP)

TREMOR

RIGIDITY

AKINESIA

POSTURAL INSTABILITY
Tremor

Resting tremor, postural tremor

Kasar, 3-7 getaran / detik
Tangan, kaki, badan, bibir
Rigidity

Cogwheel phenomenon

Leher, Lengan, Tungkai, Badan

Akinesia

Lama tidak bergerak atau lambat

(Bradikinesia)

Muka topeng, kurang berkedip

Postural Instability

Mudah terjatuh, propulsi

Pada stadium lanjut

 Diagnosis
KRITERIA KLINIS
Dua dari 3 gejala kardinal (TRA)

Tiga dari 4 gejala utama (TRAP)

Responsif terhadap L-dopa

KRITERIA HUGHES
POSSIBLE
Tdpt salah satu gejala utama:
Tremor istirahat.
Rigiditas
Bradikinesia.
Kegagalan reflesk postural
KRITERIA HUGHES
PROBABLE
Bila terdapat kombinasi dua gejala utama
( termasuk kegagalan refleks postural)
DEFINITE

Bila terdapat kombinasi tiga dari empat

gejala.
 TIGA FASE PARKINSON
DISEASE
1. Preclinical stage at this PD-spesific
pathology is present with no clinical
signs at all and potential imaging and
biomarker abnormalities may be able
to detect these changes
2. Pre-motor extranigral pathology
causing symptoms
3. Motor PD classical nigral pathology
AAN 2012
GNM/Pre-motor
Penyakit Parkinson (PP)
Yang disepakati sebagai gejala dini PP
berdasar HistoPA dari Braak dkk:

Tolosa, E, et al. Neurology 2009 ( Suppl 2 ): S12-S20. 35

GNM lainnya

Gejala Non-Motor sebelum dan sesudah

dx. PP ditegakkan, sbb.:
Neuropsikiatri:
* gg. kognisi dan demensia
* apatis, ansietas, panik
* ilusi, delusi, halusinasi, dilirium
* ICDs (impulse control disorders)
* depresi.
36
 GNM lainnya
Gangguan tidur:
* RBD (REM behavior disorders)
* EDS (excessive daytime sleepiness)
* RLS (restless legs syndrome)
* PLMS (periodic limb movement in sleep)

Gangguan sistem saraf otonom:

* hipotensi ortostatik * OAB (overactive bladder)
* disfungsi ereksi * hiperseks
* konstipasi * drooling saliva 37
Progresifitas Parkinson
Disease

AAN 2012
PERJALANAN PENYAKIT
( Hoehn and Yahr )
Stadium 1: gejala dan tanda pada satu
sisi, terdapat gejala yg ringan, terdpt
gejala mengganggu ttp tdk
menimbulkan kecacatan, biasanya
tremor pd satu anggota gerak, gejala
yg timbul dapat dikenali orang terdekat.
 Stadium 2 : terdapat gejala bilateral,
terdapat kecacatan minimal, sikap/cara
berjalan terganggu.
Stadium 3 : gerak tubuh nyata
melambat, keseimbangan mulai
terganggu saat berjalan/berdiri,
disfungsi umum sedang.
 Stadium 4 : terdapat gejala yang lebih
berat, masih dpt berjalan hanya utk
jarak tertentu, rigiditas dan
bradikinesia, tdk mampu berdiri sendiri,
tremor dpt berkurang dibanding
stadium sebelumnya.
 Stadium 5 : stadium kakhetik ( cachetic
stage ) , kecacatan total, tidak mampu
berdiri dan berjalan, memerlukan
perawatan tetap.
OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
Brook D.J: Neuroimaging in Parkinsons Disease,Neuro RX 1: 243-254,2004
Marek K et al: ( 123 I )B CIT Spect Imaging Assesment of the rate of Parkinson Disease
Progression, Neurology 2001, 57:2089 -2054
OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
NEUROPATOLOGI

DEGENERASI NEURON SUBSTANSIA

NIGRA.
o TERDAPAT LEWI BODY.
OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
PENGOBATAN
FARMAKOLOGIS DIBAGI: (1)
NEUROPROTEKTIF.
1.1 MAOIs (Monoamin oxidase inhibitory )
Selegine.
Rasagiline.
Lazabernide.
1.2 Obat antiexcitatory.
NMDA Antagonis: remacemide,amantadine,riluzole .
Coenzyme Q10 dan nicotinamide.
PENGOBATAN
FARMAKOLOGIS DIBAGI : (2)
1.3 Faktor tropik.
GDNF.
GMI ganglioside.
1.4 Immunomodulator.
NSAID.
Immunophyllins.
1.5 Cyclosporine A, calpain inhibitor, caspase inhibitor.
PENGOBATAN
FARMAKOLOGIS DIBAGI : (3)
DOPAMINERGIK.
2.1 Prekursor dopamin.
Levodopa.
Levodopa CR
Levodopa cair.
Obat obat menaikkan kadar levodopa.
o Levodopa + decarboxylase inhibitor.
o Levodopa + COMT inhibitor.
o Levodopa + selegilene.
PENGOBATAN
FARMAKOLOGIS DIBAGI: (4)
2.2 Agonis dopamin.
Derivat ergot: bromocriptin, pergolide, lisuride,
cabergoline.
Derivat non ergot: PRAMIPEXOLE, ropinirole,
talipexole, apomorfin, selegiline.
PENGOBATAN
FARMAKOLOGIS DIBAGI: (5)
NON DOPAMINERGIK.
ANTIKOLINERGIK: Trihexyfenidyl, benstropin.
GLUTAMAT ANTAGONIS: Amantadine, memantine.
ADENOSINE A2A ANTAGONIS.
GM 1 GANGLIOSIDE.
 ALGORITMA
PENATALAKSANAAN
PENYAKIT PARKINSON

Konsensus POKDI
Gangguan Gerak
PERDOSSI 2003
OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
 UNIFIED PARKINSONS DISABILITY
RATING SCALE ( UPDRS )
Mentation, Behaviour and Mood.
Intelectual impairment.
Thought disorder.
Depresion.
Motivation initiative.
Activities of Daily Living.
Speech.
Salivation.
Swallowing.
Handwriting.
Cutting food-handling utensils.
Dressing.
Hygiene.
Turning in Beds-Adjusting Bed Clothes.
Falling-unrelated to freezing.
Walking.
Tremor.
Sensory Complaints related to Parkinsonism
 UNIFIED PARKINSONS DISABILITY
RATING SCALE ( UPDRS ) cont
Motor Examination.
Speech.
Facial Expression.
Tremor at Rest.
Action or Postural Tremor.
Rigidity.
Finger Tab.
Hand Movement.
Rapid Alternating Movement.
Leg Agility.
Arising from Chair.
Posture.
Gait.
Postural Stability.
Body Bradykinesia.
 UNIFIED PARKINSONS DISABILITY
RATING SCALE ( UPDRS )

TESTING FUNCTIONAL PERFORMANCE

IN PEOPLE WITH PARKINSON
DISEASE
Definitif skor setiap item : 0 - 5
Total skor : 0 - 199
Skor 199 : Parkinson Berat.
OUTLINE
NEUROANATOMI.
NEUROFISIOLOGI.
NEUROPATOFISIOLOGI.
NEUROEPIDEMIOLOGI
BATASAN.
GEJALA KLINIS.
NEURORADIOLOGI.
NEUROPATOLOGI.
NEUROFARMAKOLOGI.
UNIFIED PARKINSONS DISABILITY RATING SCALE
( UPDRS )
LIVING WITH PARKINSON S DISEASE
UTOYO SUNARYO, NEUROLOGIST OF MOHAMAD SALEH MD HOSPITAL , PROBOL INGGO