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  1. 1. Parkinson’s disease is a progressive neurodegenerative disorder that results in deterioration of neurons in basal ganglia.
  2. 2. EPIDEMIOLOGY  Incidence = 0.2 / 1000  Prevalence = 1.5 / 1000  The incidence and prevalence both increase with age.  Sex incidence is almost equal.  It is less common in smokers.
  3. 3. Typical Age of Onset  Average age of onset is 60 yrs.  5-10% of cases occur under the age of 40. Referred to as Young-Onset Parkinson Disease.  Rarely seen under age 30.
  4. 4. Famous Faces of Parkinson Michael J. Fox Katharine Hepburn Muhammad Ali Mao Tse Tung Pope John Paul II Johnny Cash
  5. 5. Etiology  Parkinson’s disease is referred to as idiopathic (unknown cause).  Genetic link is seen in a small number of Parkinsons cases.  Larger genetic link is found in youngonset Parkinsons disease.  MPTP cause severe parkinsonism in young drug users
  6. 6. Risk factors  Positive family history  Male gender  Head injury  Exposure to pesticide  Consumption of well water  Rural living
  7. 7. Factors which decrease incidence of PD  Smoking  Coffee drinking  Use of NSAIDS  Estrogen replacement in postmenopausal women
  8. 8.  Repeated head trauma  Infectious & post infectious disease  Drugs (neuroleptics, antipsychotics , alpha methyldopa, lithium carbonate , fluoxetine )  Toxins MPTP Cyanides Methanol
  9. 9. Unilateral Parkinsonism  Vascular  Traumatic  Neoplasm Lower body Parkinsonism It may represent a form of vascular parkinsonism
  10. 10. Parkinsonism plus syndrome  Features of parkinsonism associated with complex clinical presentation  Failure to respond to treatment  Worse prognosis Examples include : 1. Shy Dragger syndrome 2. Steel Richardson syndrome 3. Parkinsonism-dementia plus
  11. 11. PATHOLOGY There is depletion of pigmented dopaminergic neurons in the substantia nigra, atrophic changes in substantia nigra and depletion of neurons in locus coeruleus.
  12. 12. PATHOLOGY Reduced dopaminergic output from the substantia nigra to globus pallidus leads to reduced inhibitory effect on subthalamic nucleus, neurons of which become more active in inhibiting activation of cortex resulting in bradykinesia.
  13. 13. CLINICAL FEATURES  Tremors  Rigidity  Akinesia / Bradykinesia  Postural instability T R A P
  14. 14. Head bent forward Tremors of head Maslike facial expression Drooling Rigidity Stooped posture Weight loss Akinesia tremors Loss of postural reflexes Propulsive gait CLINICAL FEATURES
  15. 15. General Features  Expressionless face (mask like)  Greasy skin  Soft rapid indistinct speech, monotonous  Glabellar tap sign / Myersons sign  Flexed posture  Impaired postural reflexes
  16. 16. Gait  Slow to start walking  Shortened stride  Rapid small steps tendency to turn en bloc  Reduced arm swing  Impaired balance on turning
  17. 17. Tremors  Resting (4 - 6 Hz)  Postural (8-10 Hz)
  18. 18. Rigidity  Cogwheel : mostly in upper limbs  Plastic / lead-pipe: mostly in lower limbs
  19. 19. Bradykinesia  Slowness in initiation or repeating movements  Impaired fine movements
  20. 20. Hoehn & Yahr Scale  Stage I: Unilateral involvement only, usually with minimal or no function impairment.  Stage II: Bilateral or midline involvement w/o impairment of balance.  Stage III: 1st signs of righting reflex impairment; functionally restricted in his/her activities but can lead independent life. Disability mild/moderate.  Stage IV: Severely disabled. Able to walk & stand unaided but is markedly handicapped.  Stage V: Confined to bed.
  21. 21. Investigations  There is no specific medical test used to diagnose Parkinson disease.  However, MRIs and blood tests are used to rule out other possible conditions that have similar symptoms to Parkinson disease.
  22. 22. TREATMENT  Drug therapy  Surgerical Treatment  Physiotherapy  Speech therapy
  23. 23. LEVODOPA  It is the oldest and most effective treatment of PD.  Brain enzymes modify the drug to create dopamine.  It reduces slowness and stiffness of muscles.  Given in combination with peripheral decarboxylase inhibitors, carbidopa & benserazide.  Combinations are called Sinemet & Madopar respectively.
  24. 24. Adverse effects: Nausea, vomiting, hypotension,orofacial dyskinesias, dystonias, hallucinations.  Two important phenomenon associated with levodopa use are: 1) end- of- dose deterioration 2) on-off phenomenon
  25. 25. Anticholinergic agents  Useful effects on tremors & rigidity but do not help bradykinesia.  Adverse effects : Dry mouth , blurred vision , difficult urination , constipation, confusion, hallucinations
  26. 26. Amantadine  Useful in controlling dyskinesia produced by dopaminergic treatment later in the disease.  Adverse effects: livedo reticularis , peripheral edema, confusion , seizures
  27. 27. Dopamine receptor agonists Bromocriptine , lisuride , pergolide ,cabergoline , ropinirole & pramipexole
  28. 28. OTHER DRUGS  COMT inhibitors: Catechol-O-methyl transferase inhibitors  Selegeline
  29. 29. Surgical procedures are now available for specific patients who no longer respond to drug treatments.
  30. 30. PALLIDOTOMY It is a neurosurgical procedure that can reduce many of the symptoms of Parkinson Disease Performed by a neurosurgeon, who inserts a hallow probe into the globus pallidus and then liquid nitrogen is circulated in the probe.  The probe destroys part of the globus pallidus by creating a scar .
  31. 31. The patient is awake during the procedure which takes about 6 hours. It can permanently eliminate dyskinesias Reduces tremor, rigidity, bradykinesia and shuffling gait. It is not a cure.
  32. 32. Stereotatic thalamotomy Used to treat tremors
  33. 33. Deep Brain Stimulation An electrode is placed in one of several parts of the brain (thalamus, globus palladus, or subthalamic nucleus). The electrode is attached to a computerized pulse-generator which is put under this skin in the chest. Symptoms are relieved through the regulation of electrical impulses from those three areas of the brain.
  34. 34. Deep Brain Stimulation
  35. 35. Current Research  Neural grafting, or transplantation of nerve cells, is an experimental technique proposed for treating the disease. Investigators have shown in animal models that implanting fetal brain tissue from the substantia nigra into a parkinsonian brain causes damaged nerve cells to regenerate.  Gene Therapy
  36. 36. General Treatment Strategies  Develop routine for self care  Help family/care partner, along with patient, create ideas for adapting home environment to meet the patient’s needs. Modified kitchen Modified bathroom Full bathroom and bedroom on first floor Lift chair Remove rugs/carpet/furniture that could be easily tripped over
  37. 37. Social Participation  Support groups  Important to encourage continued involvement in activities important to their life.  Participation in activities which are not physically taxing.  Introduce techniques for enhancing voice volume.
  38. 38. job Educate & inform co-workers Explore work-at-home options Adapt job requirements as disease progresses
  39. 39. Prognosis  Depends upon the age of onset  If symptom starting in middle life ,the disease is usually progressive & likely to shorten lifespan.  After 70 is unlikely to shorten life or become severe.