Parkinson disease

Clinic

• PD or simply Parkinson's, is a long-term degenerative disorder of CNS that mainly affects the motor system.
• Symptoms usually emerge slowly, and as the disease worsens, Non-motor symptoms become more common.

Sign / Symptoms

Parkinsonism

It is the most obvious and early symptoms of PD including

• Tremor: Which disappears during voluntary movement of the affected arm and in the deeper stages of sleep
• Rigidity:
  • Caused by increased muscle tone, an excessive and continuous contraction of muscles / Lead-pipe rigidity / Cogwheel rigidity.
  • It is often asymmetrical and affect Neck / Shoulder muscles
  • With the progression of the disease, rigidity typically affects the whole body and reduces the ability to move.
• Bradykinesia: Slowness of movement
• Difficulty with walking / Postural instability / Impaired handwriting
• Slurred / Monotonous / Quiet voice
• Mask-like facial expression

Cognitive problems / Dementia

• Executive dysfunction: Planning, Cognitive flexibility, Abstract thinking, Rule acquisition, Inhibiting inappropriate actions, Initiating appropriate actions, Working memory, and Control of attention.
• Slowed cognitive processing speed, impaired recall, and impaired perception and estimation of time
• Visuospatial difficulties: Facial recognition , Perception, Orientation

Behavioral problems

• Psychosis /Hallucinations / Delusions 50%/: Psychosis is now believed to be an integral part of the disease.

• Minor hallucinations:
  • Sense of passage : Something quickly passing beside the person)
  • Sense of presence (Something /someone standing just to the side or behind the person)
• Full blown vivid, formed visual hallucinations and paranoid ideation.
• Auditory hallucinations are uncommon in PD, and are rarely described as voices.

Emotional problems

• Behavior / Mood alterations are more common in PD without cognitive impairment than in the general population and are usually present in PD with dementia.
• The most frequent mood difficulties are depression, apathy, and anxiety.
• Anxiety 30–40%
• Panic attacks
• Apathy 16.5–40%
• Anhedonia 5-75%
• Impulse-control disorders, including pathological gambling, compulsive sexual behavior, binge eating, compulsive shopping, and reckless generosity
• Dopamine dysregulation syndrome – with wanting of medication leading to overuse – is a rare complication of levodopa use.
• Punding: Repetitive, aimless, stereotyped behaviors occur for many hours, is another disturbance caused by anti-Parkinson medication

Autonomic dysregulation

• Orthostatic hypotension
• Oily skin
• Excessive sweating
• Urinary incontinence
• Impotency

Sleep problems

• Daytime drowsiness (Narcolepsy)
• RBD: REM behavior disorder (PD or dementia with Lewy bodies)

Sensory systems problems

• Anosmia: Impaired sense of smell
• Disturbed vision
• Hyperstasia / Tingling
• Paresthesia (Numbness)

Gastrointestinal problems

• Constipation
• Gastroparesis
• Salivation
• Oropharyngeal dysphagia
• Small intestinal bacterial overgrowth

Patophysiology

• Motor symptoms result from the death of cells in the substantia nigra, leading to a dopamine deficit. The cause of this cell death is poorly understood, but involves the build-up of misfolded proteins into Lewy bodies in the neurons.

• Causation is unknown
• Diagnosis of typical cases is mainly based on symptoms
• No cure for PD is known

Classification

• Parkinson's disease is the most common form of parkinsonism and is sometimes called idiopathic parkinsonism.
• There are other Parkinson-plus syndromes that can have similar movement symptoms including
  • Lewy body dementia: Motor symptoms + Early onset of cognitive dysfunction + Hallucinations
  • Multiple systems atrophy which has three forms
    • Autonomic predominance
    • Cerebellar predominance
    • Parkinsonian predominance
  • Progressive supranuclear palsy (PSP): Rigidity + Early falls + Bulbar symptoms + Vertical gaze restriction. It can also be associated with frontotemporal dementia.
  • Corticobasal syndrome (CBS). Asymmetric parkinsonism + Dystonia + Alien limb + Myoclonic jerking

5 Entities

Parkinson Disease is a clinical syndrome characterized by

• Tremor
• Bradykinesia
• Rigidity
• Postural instability: Ataxia

Parkinsonism

	JE	WNE	CJD	RBS
Rigidity	+++	+++	+++	+++
Tremor	+++	+++	+	+++
Bradikinesia		+++	+++
Ataxia	+++	+++	+++
Parkinsonism	+		+

	WNE	JE	CJD	RBS	WEE	FFI	HSV-1
Parkinsonism	+++	+++	+++	++	+	+	+
Dementia		+++	+++			++
Psychosis		+++	+++	+++			+++
Depression		+++			+++	+++	+++
Anxiety				+++		+++
Apathy		+++
Orthostatic Hypotention							+++
Incontinence
Impotency							+++
Paresthesia			+++	+++			+++
Hyper Stasia							+++
Anosmia							+++
Constipation						+++	+++
Dysphagia			+++			+++
Salivation				+++
Gastric palsy

Remedies

Plb