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An 82-year-old gentleman has been referred with a tremor and some slowness of movement (bradykinesia) by his GP who would like advice on starting medications. His wife has been encouaging him to see the GP for several years. He has been very reluctant and only now is seekign help. You see the patient and he complains of slowing up over the past 2 years and people have commented on his "shake". He is now embarrassed going out and the shake worsens when he is anxious. He is frustrated at not being able to walk to the corner shop now as it takes him so much time and he almost fell.
You see him and there is a more flexed gait and posture and tremor over a year. When you get him to walk there is an absence of arm swing. You ask him to do up his shirt buttons which he finds very difficult. He seems to find it very difficult to turn over in bed at night. There is a dry scaly rash on his face. He is not on any medications other than PRN paracetamol. Other than that he has no sleep disturbance. he has noticed that he needs to take laxatives more often now. His wife feels that he is depressed.
What do you suspect is the diagnosis
What are the usual clinical findings?
Where is the cause in the brain
What is the spectrum of movement disorder?
Is imaging useful
Responsiveness to medical therapy cannot be predicted from a scan. A Normal DATscan is comma-shaped: What we are seeing is the highlighted putamen and caudate and B PD is a full stop or period: reduced activity in caudate
What is the current treatment?
What are the side effects of treatment with L-Dopa
How do you manage Nausea related to L-Dopa
He is having on / off phenomenon - what is this and how may it be treated
In PD are there any surgical options
References
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Case # 5 Shakes
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This looks and sounds very much like Idiopathic Parkinson's disease which is a progressive movement disorder with both motor and non-motor effects. It sounds like it is fairly advanced now which makes the diagnosis easier.
There is a loss of the pigmented dopamine-secreting neurones of the substantia nigra in the midbrain. There is no clear understanding of why this occurs. This forms part of the extrapyramidal system which affects the smoothness and control of motor systems.
One can simplistically think of Parkinson's disease as one end of a spectrum of too little movement (too little dopamine) and Chorea “dance” (Excess Dopamine) as the other end of the spectrum. Drugs that treat PD may cause dyskinesias and extra movements, drugs for chorea induce parkinsonism.
Generally, no. The diagnosis is largely based on a clinical presentation in an older patient with a steady progression of the clinical signs and no obvious secondary cause. In a younger patient or one with the atypical disease, one might consider a DaTscan which is useful in the following questions which is usually is a tremor due to Parkinson's disease or essential or dystonic tremor or functional.
Hypotension, Nausea, Confusion, Dyskinesias are troubling and are extra non-voluntary uncontrolled movements that may even be painful
Domperidone is usually recommended
He is seen by a specialist who considers a COMT (catechol-O-methyl transferase) inhibitor. This again prevents Dopamine breakdown and helps to regulate levels and so may be added on to therapies.
Surgery: this is an option for some patients where medications are not controlling symptoms adequately. It involves Deep brain stimulation (DBS) surgery in which electrodes are inserted into a targeted area of the brain, using MRI (magnetic resonance imaging) and recordings of brain cell activity during the procedure. A second procedure is performed to implant an IPG, impulse generator battery (like a pacemaker) under the collarbone or in the abdomen. The IPG provides an electrical impulse to a part of the brain involved in motor function. Those who undergo DBS surgery are given a controller to turn the device on or off. There is a small risk of infection, stroke, bleeding or seizures. DBS surgery may be associated with reduced clarity of speech. A small number of people with PD have experienced a cognitive decline after DBS surgery.