Chapter 21: the Parkinson's disease spectrum

Question 1

Parkinson’s disease

Answer 1

Is a chronic disease and has a progressive nature where symptoms worsen over time and new symptoms may arise. It cannot be prevented, cured or its progression delayed, only symptomatic treatment is available. More men than women have the disease and it’s onset is between 50 and 70. Industrialization and pollution of the environment are also associated with the development of Parkinson’s disease. Non-smoking, non-caffeine consumption and adequate exercise are protective factors against the disease.

Question 2

Motor symptoms of Parkinsons

Answer 2

• Bradykinesia: slowing of movement.
• Akinesia: difficulty starting movements.
• Hypokinesia: lack of automatic movements (can lead to drooling or reduced facial expressions.)
• Rigity: stiffness of the muscles.
• Micrographia: small writing
• Resting tremor: the shaking or trembling of a limb at rest.
• Postural instability: inability to balance due to loss of postural reflexes.

Question 3

Types of Parkinson’s:

Answer 3

1. Tremor-dominant type
2. Postural instability and gait difficulty (PIGD) type: associated with a more progressive course, faster cognitive decline and more frequent occurrence of depressive symptoms.

Question 4

Movement Disorder Society-Unified Parkinsons Disease rating scale

Answer 4

Consists of 4 parts:
1. non-motor experiences of daily living
2. motor experiences of daily living
3. motor examination
4. motor complaints

The Hoehn and Yahr scale can be used in addition:
1. Unilateral involvement only
1.5 Unilateral and axial movement
2. Bilateral movement without impaired balance
2.5 Mild bilateral disease
3. Mild to moderate bilateral disease, but physically independent
4. severe disability, but still able to walk or stand
5. wheelchar-bound or bed-ridden unless assisted

Question 5

Non-motor symptoms

Answer 5

• Sensory symptoms: pain, olfactory (reuk) impairment, visual impairment.
• Sleep disturbances: insomnia, daytime sleepiness, REM-sleep behavioural disorder (dream-enactment behaviour).
• Autonomic symptoms: constipation, bladder problems, weight loss etc.
• Neuropsychiatric disorders: depression, anxiety, impulse control, apathy etc.
• Cognitive impairment: will result in dementia.
• Fatigue: 50% of the patient experience this.

Question 6

Parkinson’s in the brain

Answer 6

Caused by a degeneration of dopamin-producing neurons in the substantia nigra. This is part of the ganglia-thalamo-cortical circuit, which regulates motor, cognitive and behavioural processes.

Question 7

Diagnosis of Parkinsons

Answer 7

A diagnosis can be made when not only the non-motor symptoms are apparent, but also the motor symptoms like bradykinesia with either tremor or rigity. An MRI can rule out other causes, while the PET or SPECT investigates the presence of dopaminergic deficiency.

Question 8

Parkinsonism

Answer 8

A diagnosis of Parkinsonism will be considered when the motor symptoms do not improve slightly after the use of Parkinson’s medication.

Question 9

MSA (multiple system atrophy)

Answer 9

An early autonomic disorder, combined with severe speech and swallowing, cold and blue discolored hands and feet, impaired trunk balance and severely stooped posture, which makes people quickly wheelchair bound.

Question 10

PSP (progressive supranuclear paralysis)

Answer 10

More upright or even slightly stretched backwards posture. Shows disturbances in eye movements, disinhibition and emotional instability.

Question 11

CBD (corticobasal degeneration)

Answer 11

Heterogenous and hard to diagnose, but some symptoms can be persistent muscle contraction and difficulty controlling a limb (alien limb syndrome).

Question 12

Lewy body dementia (LBD)

Answer 12

Prominent cognitive impairment and neuropsychiatric symptoms that even arise before motor symptoms.

Question 13

Treatment of Parkinson’s

Answer 13

• Medication: can be used to target the dopaminergic system in the brain, like levodopa. However, the medication can cause nausea, daytime sleepiness, hallucinations and impulse control disorders. In the long-term the medication can last for a shorter period or take longer before it becomes effective.
• LCIG: A gel that causes more continuous dopaminergic stimulation, which leads to more constant levodopa levels.
• Deep brain stimulation: Implanting a thin wire with electrodes within the subthalamic nucleus. The electrode is connected to a stimulator that is placed under the skin and can alter the abnormal signals in the brain, which leads to improvement in motor and non-motor symptoms
• Antidipressants and antipsychotics: Can be administered to treat the depressive symptoms and hallucinations in Parkinson’s disease. In the more advanced stages.
• A multidinisciplinary team: can help with physcial therapy, exercise therapy, occupational therapy, speed therapy and dietetics.

Question 14

Cognitive impairment in Parkinsons’s disease

Answer 14

People can develop impairments in executive functioning and attention, problem with flexibility, working memory, planning and keeping track. This makes it even harder for patients to perform the controlled actions purposefully. They can also develop memory, language and visuospatial impairments: learning new skills, retrieving information, understanding complex sentences, word-finding and problems with orienting in time and space.

Question 15

Two-level diagnostic criteria (of cognitive symptoms)

Answer 15

1. Level 1: global cognitive screening
2. Level 2: Extensive neuropsychological examination with a minimum of 2 tests per cognitive domain that requires the expertise from a neuropsychologist.