2.  Introduction
 Diagnosis
 Brief Pathology
 Treatment and Prognosis
 Other symptoms/complications
 Phases
 Other Neurodegenerative diseases
 Quiz

3.  PD is a movement disorder
› Prevalence: 100 – 180/100,000 in UK
› Incidence: 4 – 20/100,000 in UK
› M > F
 Parkinsonism – syndrome of:
› Bradykinesia (poverty of movement)
› Resting tremor
› Rigidity
› Varying degrees of postural instability

4.  Asymmetrical onset
 Slow progression
 Good response to L-dopa therapy
 N.B. only 60% develop tremor!

5.  Clinical – structural imaging normal
 Helpful signs:
› Micrographia
› Loss of arm swing
› Facial hypomimia (mask like)
› Cogwheel stiffness
› 4 – 7 Hz resting tremor

6.  Symmetrical onset
 Early falling
 Early cognitive impairment
 Prominent autonomic disturbance (sphincter
involvement)
 Pyramidal tract or cerebellar signs
Classic MCQ trick innit!

7.  Loss of dopamine producing cells in the
substantia nigra
 Also involves Serotonin, Acetylcholine and
Noradrenaline neurotransmitters
 Lewy bodies (intraneuronal protein inclusions)
 Most not genetic unless present < 30
› Parkin gene

8.  PD is progressive
 Pharmacological intervention changes as the
condition advances
 No universal first line treatment
› Patient choice and all that jazz!

9. Drug Group Examples Side Effects
Dopamine
Agonists
Bromocriptine
Pergolide
Cabergoline
Apomorphine
Pramipexole
Ropinorole
• Neuropsychiatric
• Ergots fibrosis
• Give Domperidone with
Apomorphine
• Hypotensive reactions
• SOOS and day sleepiness
Levodopa
Give with dopa-
decarboxylase
inhibitors
Co-careldopa (Sinemet)
(Ldopa + Carbidopa)
Co-benyldopa (Madopar)
(Ldopa + Benserazide)
• Response fluctuations ‘on-
off’
• Dyskinesias
• Anticholinergic
• Post. Hypotension
• Psychiatric
• N,V
MAOIs Selegiline
• Postural Hypotension
• Anticholinergic type
• Sleep disorders
• Confusion
• Nausea

10. Drug Group Example Side Effects
COMT Inhibitors
- Prevent peripheral
breakdown of Ldopa
- Can be used 1st line
according to NICE
Entacapone
Tolcapone
N,V
Diarrhoea, Constipation
Abdo pain
Urine goes red-brown
Dry mouth
Confusion
Insomnia etc
Amantidine
- Weak dopamine
agonist
- Antiviral
Amantadine
Hydrochloride
Anorexia
Nervousness
Insomnia
Reduced concentration

11.  Depression: 40%
› Note overlap with motor Sx of PD
 Autonomic disturbance and pain
› Constipation
› Postural Hypotension
 Significant disability
 Sleep disturbance
 Impotence
 Salivary problems
 Excessive sweating
 Urinary problems
 Cognitive problems – late!

12. Diagnosis  Refer to Specialists
› Medication may not be necessary
Maintenance  Medication prescribed
› Medications increase over time, monitor
› Essentially stable
Complex  Motor fluctuations: on-off/dyskinesia
› Other meds added: Amantadine, ?  agonist, ? add anti-psychotics
› Provide information support and advice, monitor regularly, prevent
psychotic symptoms! Avoid hospital admission
Palliative
› Medications less effective, may be no observable benefit. ?PEG – early.
› Symptom control, specialist services, end of life choices

13.  Parkinson Plus Syndromes:
› Multiple System Atrophy
› Progressive Supranuclear Palsy
› Dementia with Lewy Bodies
› Corticobasal degeneration
 Drug induced Parkinsonism:
› Neuroleptics
› Antiemetics – which one?
› Lithium
 Vascular Parkinsonism :
› Marked sparing of upper limbs
› Check vascular RF

14. Parksinson’s Disease:
 Is usually inherited
 Presents with early falling
 Should show a good response to L-dopa
 Can be treated with Deep Brain Stimulation
 Usually presents with symmetrical onset
 Constipation is a symptom

15.  NICE guidelines
 COMP2 presentations from blackboard…
grr!
 Medicine At a Glance.
 www.wikipedia.org
 www.meducation.net