Professional Documents
Culture Documents
disease.
Dr. Sanjiv Chandratre.
Consultant in med. for elderly 2010
What you should expect from
this teaching session.
• How to diagnose PD.
• What is the D/D of PD
• How to treat PD ( Medical treatment.)
• When to refer pts to secondary care.
• Tricks of the trade in managing special problems
related to PD.
• What services are available in our area for PD
patients.
• Nice guidelines on PD and results of our audit.
James parkinson 1817
• Involuntary tremulous motion, with
lessened muscular power, in part not in
action and even when supported;with a
propensity to bend the trunk forward, and to
pass from a walking to a running pace: the
senses and intellect being uninjured.
Terminology in P. D.
• Parkinson’s disease or Idiopathic P. D.
• Parkinsonism / Parkinsonian syndrome.
• Drug induced Parkinsonism.
• Post encephalitic parkinsonism.
• Vascular pseudo Parkinsonism.
• Lower body parkinsonism.
Terminology in P. D.
• Parkinsonism plus syndrome.
– PSP
– MSA
– CBD
Parkinson’s disease
• Progressive, disabling and distressing
• Appropriate management and planning
right from the start can prevent some of the
most distressing features
• Team work can solve most of the problems
and can help deliver better care cost
effectively
• The 4 stages….
4 stage clinical management
scale
• Diagnosis
• Maintenance therapy
• Complex
• Palliative care
Incidence and Prevalence
• Incidence • Prevalence
• Number of new cases • Total number of
in a population, people in a population
usually /100,000 with the condition,
• I.e.cumulative
• Around 11 per
incidence per annum
100,000 minus deaths.
• Around 100- 200 per
100,000
Prevalence
• Per GP. • Per district / pct.
• Say 2500 • Say 200,000
Brain Bank Criteria
• Step 1
• Diagnosis of parkinsonian syndrome
• Step2
• Exclusion criteria for IPD
• Step3
• Supportive criteria for IPD
Step1- Diagnosis of parkinsonian
Syndrome.
• Bradykinesia +at least one of the following
• Muscular rigidity
• 4 –6 Hz resting tremor
• Postural instability
Brady / Hypokinesia
• Hypokinesia –poverty of movement
• Loss of facial expression, arm swing,
gesture etc.
• Bradykinesia -Slowness of movement
• ‘Decay’ – finger/ heel tap
Rigidity
• Resistance to passive movement
– Reinforcement – ‘froment’s manoeuvre’
• Constant [ c. f. ‘clasp-knife’]
– ‘Lead pipe’
– ‘cogwheel’
• Gagenhalten
Tremor
• Involuntary rhythmical alternating
movement
• Begins unilaterally – upper limb
• 4 – 6 hertz, ‘pill rolling’
• First symptom in 75%
• - 20 % never develop it
• Postural tremor can also occur
Postural instability.
• Last cardinal feature to appear
• Limited diagnostic specificity in the elderly.
• Pull test
• Early falls – ‘red flag’
Step 2 – exclusion criteria
• History of repeated strokes.
• History of repeated head injury.
• History of definite encephalitis.
• Cerebellar signs.
• Early severe autonomic involvement
• Supranuclear gaze palsy
• Neuroleptic drugs
• Negative response to large doses of levodopa
Step3- positive supportive
criteria
• [>3 for ‘definite’ PD ]
• Unilateral onset.
• Rest tremor
• Progressive
• Persistent asymmetry
• Excellent levodopa response
• Severe levodopa induced chorea
• Levodopa response>=5years
• Clinical course>=10 years
Diagnosis- Accuracy
• Meara 1999 Age and ageing
• Community study- 402 cases
• 73 % Parkinsonism
• 53% ‘probable’ IPD
• Essential tremor
• Alzheimer’s disease
• vascular
Accuracy of diagnosis
• Brain bank post mortem series
• 24 % error rate.
• 10 % latest studies.
• 2% MD specialists.
• Community series
• >50 % error rate
Is the diagnosis correct?
• Diagnosis of P. D. can be very difficult.
• There is no diagnostic test.
• Diagnosis is made clinically.
• DAT scan of limited value.
• Error rate is high. 25 % in the hands of
neurologist. Upto 50 % in the community.
• F.U. and review of diagnosis is important.
Dopamine Transporter Imaging agent
•Parkinson’s disease •Essential Tremor
•Progressive Supranuclear •Neuroleptic-induced
Palsy Parkinsonism
•Multiple System Atrophy •Vascular disease
Differential diagnosis of
parkinsonian syndrome
• Idiopathic Parkinson’s disease
• Drug induced – phenothiazines
• Multiple cerebral infarct state.
• Trauma – pugilistic encephalopathy
• Toxin induced- MPTP, CO, Mn, Cu,
• Parkinson’s plus syndromes
Essential tremor
• Most common diagnostic error.
• 10 times more common than PD.
• Postural or action tremor.
• Titubation.
• Family history.
• B – Blockers help.
Drug induced parkinsonism.
• Causes
– Predictable Neuroleptic drugs (both typical and
atypical)
Hidden neuroleptics- metoclopromide, prochlorperazine
Combination with antidepressants( fluphenazine )
Calcium antagonist
--Idiosyncratic
Lithium, sodium valproate, amiodarone
mainly tremor but parkinsonism reported.
Multiple infarct state
• Synonymous with leucoariosis,
Binswanger’s encephalopathy
• Related to hypertension and other risk
factors
• Common misdiagnosis.
• Poor prognosis
• Aspirin and dipyridamole retard may be
effective and safe
Vascular parkinsonism
• PM studies 2-3 %incidence of ‘pure’
vascular causes
-no lewy bodies or nigral degeneration
Acute or abrupt onset
basal ganglia infarct
Insidious progression
Diffuse sub cortical white matter ischaemia.
Dementia with Lewy bodies
• Fluctuating alertness • Tremor less common
• Hallucinations • More symmetrical
• Mild parkinsonism • Myoclonus more
• Neuroleptic sensitivity common
• More rigid, less
bradykinetic
Medical treatment of P. D.
• Antiemetics
– Metoclopromide (Maxalon)
– Prochlorperazine (Stemetil)
• The only recommended antiemetics are
– Domperidone
– 5ht3 antagonists eg. Ondensetron.
Drugs to avoid 2
• Antipychotics
– Chlorpromazine
– Sulpride
– Haloperidol
– Thioridazine.
• Newer antipsychotic can be used with
caution
When to start treatment ?
• Controversial
• Is the diagnosis certain.
• Age of patient.
• Effect on ADL.
• Patient Choice.
Drugs in PD
• Levodopa preparations.
• Dopamine receptor agonists.
• Monoamine oxidase-B inhibitors.
• Catechol-o-methyltransferase inhibitors.
• Anticholinergics.
• Amantadine
Levodopa
• Used since the 1960’s
• Remains the ‘gold standard’
• Always used with dopa decarboxylase
inhibitor.( either carbidopa or benserazide.)
• Side effects are common.
Levo dopa preparations.
Yes.Required by law.
Drivers medical unit at DVLA
Criminal offence under RTA 1988
Take home messages
• Diagnosis of PD is clinical and can be difficult.
• Every patient should be referred to secondary care
to confirm the diagnosis and initiate treatment
• Treatment should only be started if there is
functional impairment
• Levodopa is the gold standard but DA cause much
less diskinesia
• Follow up should be life long
Thank you.
• .
ANY QUESTIONS ?
Outline
1. History
2. Diagnosis
3.Differential diagnosis
4.Cost factors
5. Local scene
6. Take home messages
Historical aspects
• James parkinson [ 1755- 1824] 1817
• Charcot - ‘la maladie de parkinson’
• Lewy [1921]
• Carlson [1958]
• Birkmayer, Hornykiewicz [1961]
• Cotzias [1967]
• Hoehn and yahr [1967]
Why is diagnosis of PD and
parkinsonian syndromes challenging?
• Diagnosis is clinical
• Presence and progression of clinical features
Supportive for PD
Atypical for PD “ Red ”flags
• Most difficult in early stages
• Large number of imitators of PD
• Co morbidity and confounders increase with age
• Tremors, shaking
• Gait disorders
• Slowness and true bradykinesia
Diagnostic Challenges
• Prevalence of Signs of Parkinsonism in the “Normal”
Elderly Population
• Co-existent Pathology
– Cerebrovascular Disease
– Depression
– Arthritis
• Differential Diagnosis
– Essential Tremor
– Parkinson’s Plus Syndromes
– Alzheimer’s
– Lewy Body Disease
Challenge tests
• Oral levodopa/ subcutaneous apomorphine
• False positives [e. g. M.S.A.] and false
negatives
• Lowest sensitivity / specificity in early
disease
• Not recommended routinely
• ‘Priming’
Cost Overview
• Direct Costs NHS
Social services
Private Expenditure
(Financial Benefits)
• Indirect Costs
Lost earnings
OR
• TOTAL = Direct + Indirect
Lost leisure time
OR
Carer replacement cost
Total Cost of PD Care 1994
£382,705
£, 000 %
•Out-patient 19,147 5
•Drugs 26,900 7
•Hospital In-patients 49,386 13
•Home Care 107,915 28
•Residential Home 179,358 47
Conclusions: PD Economic Impact
(1)
• Parkinson’s Disease is an expensive condition
• The greatest single costs relate to lost earnings in younger
patients; long term institutional care in older patients
• Mean direct costs per patient is inversely proportional to
age:
• c£4,000 per annum below 65 years
• c£9,400 per annum over 85 years
• Mean direct annual costs is inversely proportional to
disease severity
• Hoenhn & Yahr stage (0-1) c£3000
• Stage 5 c£18,400
• Greater than five fold increase
Previous Cost Estimates (2)
• “Moving and Shaping” PDS, 1999
Estimated costs of PD
£ 3,500-10,000 per patient
£7-20,000 per GP
£560,000-£1.6m per PCG
• Dodel 2000 MoDis (Barcelona)
• Nuijten Oct. 2000 EFNS
– 50,000 Euro in 5 yrs (£6k pp/pa)
– model used in justification of additional drug cost
What can we except in the near
future?
• Neuroprotective agents. – Problems in trial
designs.
• Continuous dopaminergic stimulation.
Rotigotine patch,once daily formulations of
pramipexol and Ropinirole.
• Neurorestoration- Stem cell implants, Nerve
growth factors
Conclusions: the Economic Impact
(3)
• Within NHS costs, the split between
primary care (incl drugs) and secondary
care is roughly equal across age groups.
I am not sure what is wrong with him and would value your
advice.
Case 1 – GP’s letter
• What is the most likely diagnosis and why?
• What is the relevance of the duration of the
history?
• What is the relevance of the physical type
of tremor and the trouble it is causing?
• Is the lack of response to Levodopa
relevant?
Case 1 – Your history & examination
His gait has deteriorated over the last few years and now he is rather
confused.
The home situation is getting very precarious and the family desperately
need him to be treated effectively.
Case 2 – GP’s Letter
• Has he got Parkinson’s Disease?
Motor complications
Disease progression
develop
Add small amounts of Levodopa
Add Entacapone