Parkinsonism

PA R K I N S O N ’ S D I S E A S E
 Definition

 First described by James Parkinson “ as disease with insidious

onset characterized by slowly progressive

Akinesia,

Rigidity,
Postural abnormality, and
Tremor.
The disease predominantly presents late in life i.e

second half of life.

It is a chronic and disabling disease however, variety of

drug treatments can reduce mortality and disability.

 Epidemiology

Commonest neurodegenerative disease after

Alzheimer’s with estimated incidence of 20/100,000
and prevalence of 150/100,000.

Cumulative life time risk of an individual

developing the disease is 1in 40.
Slightly more common in men than women

Prevalence rate is higher in United states than in Africa

and china
 Etiology / Predisposing factors

Idiopathic parkinson’s disease the cause is unknown

Parkinsonism

 Post infective viral infection “ encephalitis lethargica

 Drug induced ( neuroleptic eg reserpine, phenothiazines and

butyrophenones.
 Features of other neurodegenerative diseases eg progressive supra

nuclear palsy, multiple system atrophy, corti-cobasal degeneration etc

 Toxin ( MPTP) 1 methyl 4 phenyl 1,2,3,6 tetra hydropyridine.

 Genetic synuclein gene (chr 4)AD and parkin gene (chr 6)AR
 Pathology

The hall mark is loss of pigmented neurones in the pars

compacta of the substantia nigra this cell contain

neuromelanin and employ dopamine as neurotransmitter.

In all cases of parkinson’s disease the degenerative cells

contain eosinophilic inclusion bodies, LEWY BODIES

Profound loss of DOPAMINE in the stratum (putamen

and caudate) and substantia nigra.

Biochemical studies show a decrease of dopamine in

the caudate nucleus and putamen.

 Clinical features

Tremor
 Initially unilateral and occurs at rest, increase by emotion and stress.
 Arms are mostly affected
 Frequency of 4 to 6 Hz (pill- rolling)

 Rigidity
 Affect all muscles, but most marked in the neck and trunk and proximal
muscle of the shoulder or hip
Akinesia

 poverty (hypokinesia) and slowness (bradykinesia)

Postural changes

 Generalized flexion of limbs, neck, and trunk and postural instability

causing falls
Other features

 Face is bland and mask- like

 Voice loses volume and normal modulation “ soft and monotone”

 Patients walk slow, small steps without swinging the arms; initial

difficulty starting to move ( freezing).

 Micrographia

 Drooling of saliva, dysphagia, constipation, urinary frequency and

urgency

 Excessive sweating and greasy skin seborrhoea

 Postural hypotension

 Depression occur in 30% of patients

 The mean age of onset is about 55years.

 Onset under 40yrs is rare.

 Onset is usually on one side, but progression to both side associated with
disability.

 Patients develop difficulty with speaking, eating, dressing, walking.

Staging
• Hoehn Yahr Staging of Parkinson’s disease

• 1 : Unilateral involvement
• 2: Bilateral involvement but no postural abnormality
• 3: Bilateral involvement with postural imbalance; patients lead an
independent life.
• 4: Bilateral involvement with postural instability; patient requires
substantial help.
• 5: Severe, fully developed disease; the patient is restricted to bed and
chair.
Differential diagnosis

 Cerebral hypoxia ( CO)

 Cerebrovascular disease

 Metallic poisoning

 Early onset dementia

 Hypothyroidism

 Depression
 Management

 Exercise and rest

 Emotional support
 Drug treatment should be adapted to the patients needs which vary with

the stage of the disease

Drug treatment for tremors

Treatment for Akinesia and postural imbalance

 Treatment

Levo dopa + AAAD inhibitor

• Sinemet

• Madopar

Anti cholinergic

 Trihexyphenidyl ( benzhexol)
Dopamine receptor agonists
• Bromocriptine
• Lisuride
• Pergolide
• Cabergolide
• Pramipexole
• Ropinirole

Catechol –O- methyl transferase inhibitor

• Entacopane
Mono amine oxidase B inhibitor

Selegeline

Other agent

 Anti oxidant

Vitamin C and E

 Anitiviral

Amantadine
Stereotactic neurosurgery

• Small lesion in the ventrolateral nucleus of the thalamus (thalamotomy)

Tissue transplant

• Fetal or autologous dopamine- contaning adrenal medulla and glia cell –

line neurotrophil releasing factor

THANKS FOR LISTENING