This was a lecture in the course "Significant Medical Conditions in Seniors" presented at Peer Learning in Chapel Hill, NC, USA in 2016 by Michael C. Joseph, MD, MPH.

1. Parkinson Disease
Michael C. Joseph, MD, MPH
(Peer Learning)
October 26, 2016

2. Outline
 Historical Perspective
 Epidemiology
 Symptoms
 Progression
 Treatment
 RESOURCES
 CREDITS

3. Historical Perspective
 First described by British doctor James Parkinson in An
Essay on the Shaking Palsy (1817).
 Research progressed slowly until the 1960’s.
 In the 1960’s the disease was linked to the loss of
dopamine-producing cells in the brain.
 Public Awareness campaigns include Parkinson Disease
Day (on the birthday of Dr. James Parkinson, April 11), and
the use of a red tulip as a symbol of the disease.

4. Epidemiology
 Affects 1 in 100 persons over age 60 in the U.S.
 Average age of onset is 60 years
 5-10 % of patients experience symptoms before age 40
 60,000 new cases diagnosed each year in the U.S.
 Numbers are higher because of dismissal of symptoms or misdiagnosis
 More than 1 Million cases currently in the U.S.
 More than 5 Million cases currently in the World
 NOT Gender-Specific

5. Famous Patients
 American:
−Michael J. Fox
−Muhammad Ali
−Janet Reno
−Johnny Cash
−Billy Graham
−Howard Clement
−Foreign:
 Mao Zedong (?)
 Deborah Kerr
 Bob Hoskins

6. Classic Diagnostic Criteria
 Tremor;
 Rigidity;
 Slowness of movement;
 Postural instability.

7. PD Subtypes
 Primary or Idiopathic (unknown cause);
 Secondary or Acquired (e.g. pesticides);
 Hereditary Parkinsonism (1 in 5 PD
patients has a 1st-degree relative with the
disease);
 “Parkinson Plus” syndromes or “Multiple
System Degeneration” (MSD).

8. Brain Pathology
 The neurotransmitter dopamine is
responsible for smooth coordination of
muscle movements, motivation, and
mood
 60% of these cells die before the first
symptoms appear
 The typical PD patient has lost 85 % of
these cells

9. Movement Disorders
(External Signs)
 Hand tremors:
−Typically involves a rhythmic back-and-forth motion
of the thumb at 3 bpm;
−Most evident when the limb is at rest or the patient
is under stress.
 Rigidity or resistance to movement:
−“en bloc” turns;
−“masked facies”.

10. Movement Disorders
(Muscle Asynchronicity)
 Muscles associated with movement all have
opposing muscles
−when one is activated, the other is relaxed.
 The brain’s signals in PD patients become
confused
−both sets of muscles remain engaged and
contracted.

11. Movement Disorders
(Motion)
 “Bradykinesia”
−spontaneous movements can become progressively
slower, and may actually cease.
 Postural Instability
−impaired balance and coordination;
−Positive “Pull Test”;
−Patients lean unnaturally backward or forward
(stooping).

12. Movement Disorders
(Gait)
 Reduced arm swing.
 Decreased stride length
 Those who tend to lean backward have to step backward first before they
begin walking (retropulsion).
 Some develop a mid-stride halting (“FOG” - freezing of gait), which creates a
risk for falls.
 Short, quick steps (festinating gait). It can appear as if they are scrambling
forward to keep their balance.
 VIDEO: Gait Disorders (3:45)
 https://www.youtube.com/watch?v=Be2Enu65ZE8
 Terminology:
Truncal Dystonia – rigid twisting of the trunk to one side.

13. Non-movement Symptoms
 VIDEO
 Top 10 Non-movement Symptoms (9:00)
 https://www.youtube.com/watch?v=h78x80xAMEk
 Terminology:
Vagus nerve – controls autonomic (self-
regulating) functions such as digestion,
heartbeat, and breathing.

14. Mild Parkinson’s
 Movement symptoms may be inconvenient,
but do not affect daily activities.
 Movement symptoms, often tremor, occur on
one side of the body.
 Friends may notice changes in a person’s
posture, walking ability or facial expression.
 Parkinson's medications suppress movement
symptoms effectively.
 Regular exercise improves and maintains
mobility, flexibility, range of motion and
balance, and also reduces depression and
constipation.

15. Moderate Parkinson’s
 Movement symptoms occur on both sides of the
body, and the body moves more slowly.
 Trouble with balance and coordination may
develop.
 “Freezing” episodes — when the feet feel stuck
to the ground — may occur.
 Parkinson's medications may “wear off” between
doses or cause side effects (“dyskinesias”).
 Regular exercise, with physical and occupational
therapy, are important for good mobility,
balance, and independence.

16. Advanced Parkinson’s
 Great difficulty walking.
 In wheelchair or bed most of the day.
 Assistance needed with all daily activities.
 Cognitive problems may be prominent,
including hallucinations and delusions.
 Balancing the benefits of medications with
their side effects becomes more
challenging.

17. The Neurologic Exam
 VIDEO:
 Examining the PD patient (9:00)
https://www.youtube.com/watch?v=sJqKvajUC3k&fea
ture=em-share_video_user
 Terminology:
 “Glabellar reflex” – blinking when the glabella region
(between the eyes) is tapped.
 “Doll’s Head” or “Doll’s Eyes” Sign – rotating of the eyes in
the opposite direction of the head movement.

18. Treatment
Medications:
 L-dopa (replaces dopamine);
 Dopamine agonists (act like
dopamine);
 Other Central Nervous System (CNS)
agents.
Surgery:
 Deep Brain Stimulation (DBS).

19. RESOURCES
(Living with Parkinson’s Disease)
 VIDEO:
 Parkinson’s: A Guide for
Patients and Families (25:00)
 https://www.youtube.com/watch?v
=fGlmOaC5Jko&feature=youtu.be

20. CREDITS
 Parkinson’s Disease.html
 https://www.michaeljfox.org
 http://www.pdf.org/en/progression_parkinsons
 https://en.wikipedia.org/wiki/Parkinson's_disease
 Examining the patient
 https://www.youtube.com/watch?v=sJqKvajUC3k&feature=em-share_video_user
 Parkinson’s Disease: A Guide for Patients and Families (25 min)
 https://www.youtube.com/watch?v=fGlmOaC5Jko&feature=youtu.be
 Gait Disorders
 https://www.youtube.com/watch?v=Be2Enu65ZE8