Parkinson disease.pdf

Amr Hassan MD,FEBN
Professor of Neurology
Cairo University
Parkinson’s disease

The ‘shaking palsy’
• First described in detail by Dr. James
Parkinson in 18171,2
• The essay described six cases of the disease
that would later become known as Parkinson’s
disease (PD):1,3
– “Involuntary tremulous motion with
lessened muscular power, in parts not in
action and even when supported, with a
propensity to bend the trunk forward and to
pass from a walking to a running pace”
– “In this stage the sleep becomes much
disturbed. The bowels, which had been all
along torpid, now in most cases, demand
stimulating medicines of considerable
power: the expulsion of faeces from the
rectum sometimes requiring mechanical
aid”
2
1. Parkinson. An Essay On The Shaking Palsy. 1817;
2. Pfeiffer et al (eds). Parkinson’s Disease. 2013; 3. Lees et al. Lancet 2009;373(9680):2055–2066

• In the 1870s Jean-Martin
Charcot refined the clinical
descriptions of ‘paralysis agitans’
(literally ‘shaking palsy’):1
– “Long before rigidity actually
develops, patients have significant
difficulty performing ordinary
activities: this problem relates to
another cause… their problem
relates more to slowness in
execution of movement rather
than to real weakness”
3
• Charcot rejected the terms
‘paralysis agitans’ and ‘shaking
palsy’ and, instead, coined the
term ‘Parkinson’s disease’1,2
• There was wide debate about
whether PD was a ‘neurosis’ or
had a distinct physiological cause2
• In 1895, an autopsy on a patient
with PD led Édouard Brissaud to
suggest that an area of the brain –
called the substantia nigra – was
affected as the source of PD2
1. Goetz. Cold Spring Harb Perspect Med 2011;1(1):a008862;
2. Pfeiffer et al (eds). Parkinson’s Disease. 2013

The dopamine deficiency hypothesis
• Loss of neurons in the substantia
nigra is the hallmark of PD1
• These cells normally produce the
neurotransmitter dopamine1,2
• The projections follow a pathway
to the striatum, known as the
‘nigrostriatal’ pathway2
• Motor symptoms appear after
approximately 50% loss of the
neurons in this region3
4
The substantia nigra, and surrounding brain structures
(adapted from Tortora & Derrickson, 20094)
1. Lees et al. Lancet 2009;373(9680):2055–2066; 2. Pfeiffer et al (eds). Parkinson’s Disease. 2013;
3. Cheng et al. Ann Neurol 2010;67(6):715–725; 4. Tortora & Derrickson. Principles of Anatomy and Physiology. 2009
Dopamine is known to be the neurotransmitter most critically involved in
PD2
Thalamus
Subthalamic
nucleus
Substantia
nigra
Globus
pallidus
Putamen
Caudate
nucleus
Corpus
callosum

Lewy bodies
• The neuronal degeneration of PD is
accompanied by Lewy pathology1
• Lewy pathology consists of
abnormal aggregates of protein1
• Lewy pathology is not specific to
PD, but its distribution within the
brain seen in patients with PD is1
• Lewy bodies are found in the brains
of about 10% of people older than
60 years of age who have died
without evidence of neurological
disease (so called ‘incidental Lewy
body disease’)1
5
1. Lees et al. Lancet 2009;373(9680):2055–2066
Lewy pathology

α-synuclein
• Lewy bodies are made up of the
protein α-synuclein1
• α-synuclein is a component of the
synapse – the inter-neuron space1
• α-synuclein normally exists in a
soluble, non-folded form1
• But, in the pathological state seen
in PD, α-synuclein aggregates into
filaments and forms Lewy bodies1
• These filaments appear to be toxic
to neurons – although the exact
mechanisms are still unclear1
6
1. Lee & Trojanowski. Neuron 2006;52(1):33–38
Monomeric
α-synuclein
Aggregated
α-synuclein
α-synuclein
fibrils Lewy bodies

CLINICAL PICTURE OF
PARKINSON’S DISEASE
7

Parkinsonism
• Parkinsonism is a clinical syndrome and, typically, when the condition
appears to be idiopathic and responsive to levodopa therapy, is referred
to as Parkinson’s disease1
• The four cardinal features of the parkinsonian syndrome are:2
– Bradykinesia
– Muscular rigidity
– Resting tremor
– Postural instability (and gait impairment)
• These features are not always observed in every patient, at any given
time2
8
1. Chaudhuri & Ondo. Handbook of Movement Disorders. 2009;
2. Massano & Bhatia. Cold Spring Harb Perspect Med 2012;2(6):a008870

Motor symptoms – bradykinesia
• Bradykinesia – slowness
of movement1
– Akinesia – lack of
movement1
– Hypokinesia –
poverty of movement1
• Arguably the defining
feature of PD1
• Bradykinesia is a major
cause of disability in
patients with PD2
9
• Bradykinesia manifests as:3
– Progressive loss of speed and/or amplitude
during rapid repetitive movements
– Hypomimia (decreased facial expression and
blinking)
– Hypophonia (softer voice)
– Difficulty swallowing
– Micrographia (progressively smaller
handwriting)
1. Pfeiffer et al (eds). Parkinson’s Disease. 2013; 2. Ellis et al. Parkinsonism Relat Disord 2011;17(9):693–697
Micrographia
responding to
therapy

Motor symptoms – muscular rigidity
• Rigidity – resistance to movement1
• ‘Cogwheel’ rigidity – rhythmic brief increases in resistance during
passive movement (caused by rigidity combined with tremor)1,2
• ‘Lead pipe’ rigidity – smooth rigidity through the whole range of
motion1
• Affects neck, arms, legs2
• Rigidity in the back can lead to stooped appearance1
• Patients complain of difficulties turning in bed, or rising from a chair1
10
1. Pfeiffer et al (eds). Parkinson’s Disease. 2013;

Motor symptoms – resting tremor
• Resting tremor – “a rhythmic oscillatory involuntary movement that
comes about when the affected body part is relaxed and supported by a
surface”1
• ‘Pill rolling’ tremor – simultaneous rubbing movements of thumb and
index finger against each other1
• The tremors are typically relieved by purposeful, active movement1
• Often asymmetric1
• The most common presenting feature of PD (the ‘shaking palsy’)2
• Presenting symptom in 70% of patients; however, tremors never
develop in up to 20% of patients with PD2
• Usually at first affecting the hand, but can also affect the jaw or lower
limbs1
11
1. Massano & Bhatia. Cold Spring Harb Perspect Med 2012;2(6):a008870;
2. Pfeiffer et al (eds). Parkinson’s Disease. 2013

Motor symptoms – postural instability
• Postural instability is the fourth
cardinal feature of PD1,2
• Patients lose postural reflexes and
develop a stooped posture1
• Postural instability can lead to falls1
• Typically occurs late in PD2
• Postural instability is useful in
differentiating from other forms of
parkinsonism where it may be an
early feature2
12
1. Massano & Bhatia. Cold Spring Harb Perspect Med 2012;2(6):a008870;
2. Williams & Litvan. Continuum (Minneap Minn) 2013;19(5 Movement Disorders):1189–1212

Motor symptoms – gait impairment
• In patients with PD, walking may be affected1
• Parkinson gait is characterised by slow, small steps1
• Turning around is slow and performed with multiple small steps1
• ‘Freezing’ of steps mid-stride, or more commonly when starting to walk
(‘start hesitation’), turning, upon reaching the target (‘destination
freezing’) or when walking through a narrow passageway1
• Festination – fast succession of steps, with the patient at times only able
to stop at an obstacle1
13

The non-motor symptom complex of

• Neuropsychiatric:1
– Depression
– Anhedonia (inability to feel pleasure)
– Apathy
– Anxiety
– Cognitive dysfunction
– Confusion
– Dementia
– Psychosis (hallucinations/delusions)
– Impulsive–compulsive behaviours
• Hyposmia (loss of sense of smell)1
• Pain1
15
• Sleep disorders:1,2
– Insomnia
– Daytime sleepiness and sleep
attacks
– RBD (REM sleep behaviour disorder)
• Autonomic dysfunction:1
– Constipation
– Urogenital dysfunction
– Orthostatic hypotension (sudden
drop
in blood pressure on standing)
– Dysphagia (difficulties in swallowing)
– Hypersexuality/sexual dysfunction
REM=rapid eye movement
1. Chaudhuri & Ondo. Handbook of Movement Disorders. 2009;
2. Goldman & Postuma. Curr Opin Neurol 2014;27(4):434–441
Non-motor features accompany all stages of PD and
substantially impact patients’ quality of life1,2
The non-motor symptom complex of

DIAGNOSIS OF PARKINSON’S
DISEASE
16

Differential diagnosis
• There are no laboratory tests that can definitively diagnose PD during
life
• To make a diagnosis of PD, the physician must distinguish between
different forms of parkinsonism:1
– Parkinson’s disease
– Secondary parkinsonism
– Parkinsonism as part of another neurodegenerative disorder (e.g., multiple
system atrophy, progressive supranuclear palsy, corticobasal degeneration, or
Lewy body dementia)
• …and from other diseases (e.g., essential tremor, dystonic tremor)1
• Differentiating from other causes and forms of parkinsonism is
challenging, especially in the early stages – and a substantial proportion
of patients are incorrectly diagnosed1
1. Tolosa et al. Lancet Neurol 2006;5(1):75–86
17

Causes of secondary parkinsonism
Infectious1,2
• Encephalitis lethargica and other viral infections
(e.g., AIDS, PML); prion disease; neurosyphilis;
toxoplasmosis; Japanese B encephalitis
Toxic1
• Carbon monoxide; cyanide; carbon disulphide;
MPTP; manganese; solvents
Drug induced1
• Dopamine receptor blockers; classic neuroleptics;
atypical antipsychotics; dopamine-depleting
drugs; other drugs
Brain tumours1
• Supratentorial and brainstem tumours;
arteriovenous malformations
Cranial trauma1
• Striatal variant of dementia pugilistica; chronic
subdural haematoma; midbrain trauma
Metabolic1
• Hypoxia; hypoparathyroidism; familial basal
ganglia calcification; extrapontine myelinolysis;
chronic liver disease; Wilson’s disease
Vascular1
• Vascular parkinsonism
Miscellaneous1
• Huntington’s disease; SCA mutations; FTDP-17;
neuroacanthocytosis; dentatorubropallidal-luysian
atrophy; normal pressure hydrocephalus;
haemiatrophy–hemiparkinson syndrome;
psychogenic parkinsonism; autoimmune
encephalitis3
AIDS=acquired immune deficiency syndrome; FTDP-17=frontotemporal dementia with parkinsonism linked to chromosome 17;
MPTP=1-methyl-4-phenyl-4-propionoxypiperidine; PML=progressive multifocal leukoencephalopathy; SCA=spinocerebellar ataxia
1. Tolosa et al. Lancet Neurol 2006;5(1):75–86; 2. Jang et al. Biochim Biophys Acta 2009;1792(7):714–721; 3. Çoban et al. Behav Neurol
2014;2014:935379
There are many causes of parkinsonism, other than Parkinson’s disease
18

Differential diagnosis – Wilson’s disease (1)
Left panel: Abnormal T2
hyperintensities in the lentiform
nucleus (left arrow) and
thalamus (right arrow),
bilaterally
Right panel: ‘Face of the giant
panda sign’ of the midbrain
(arrow)
The patient also had
Kayser–Fleischer rings, and a
very low level of serum
caeruloplasmin, 0.02 g/l
(reference range 0.17–0.35 g/l)
Images courtesy of Shen-Yang Lim
Young man with Wilson’s disease

Differential diagnosis – Wilson’s disease (2)
Axial CT scan of the brain showing hypodensities in the
lentiform nuclei (initially misdiagnosed as ‘infarcts’)
Axial T1 sequence showing cerebral atrophy
(moderately severe) and cavitation of the lentiform
nuclei
Patient is able to ambulate, but is almost anarthric

Differential diagnosis – Wilson’s disease Kayser–
Fleischer rings
Images courtesy of Shen-Yan Lim
Kayser-Fleischer ring
in Wilson’s disease

Differential diagnosis – multiple system atrophy (MSA)
•
Case of patient with multiple system atrophy, mixed parkinsonism and cerebellar
(MSA-PC) subtype, in clinically advanced stage
Top panel: Axial T2 image shows
‘hot cross bun sign’ (left arrow),
with pontine and cerebellar
atrophy; and hyperintensity in the
middle cerebellar peduncle (right
arrow) Middle panel: Mid-sagittal T1
image shows severe atrophy of
the pons (left arrow) and
cerebellum (right arrow), but
relative preservation of midbrain
volume
Bottom panel: Coronal gradient
echo (GRE) sequence showing
bilateral putaminal hypointensity,
more marked than in the globus
pallidus

Differential diagnosis – progressive supranuclear palsy (PSP)
•
T1 mid-sagittal image shows the
‘hummingbird sign’ (i.e.,
concavity of the upper border of
the midbrain) (arrow)
Image courtesy of Shen-Yang Lim
Case of progressive supranuclear palsy (PSP)

Differential diagnosis – corticobasal degeneration (CBD)
•
Coronal FLAIR images demonstrate cerebral atrophy, most pronounced
in the left parietal region (arrows indicate sulcal enlargement)
FLAIR=fast fluid-attenuated inversion recovery
Case of corticobasal syndrome presenting with a ‘useless right hand’

DIAGNOSTIC CRITERIA
25

UK Parkinson Society Brain Bank clinical
diagnostic criteria (1992)

– clinically established Parkinson’s disease
• Parkinsonism – bradykinesia plus either rigidity or rest tremor1
• Clinically established PD:1
– Absence of absolute exclusion criteria; at least 2 supportive criteria; no ‘red flags’
29
BVFTD=behavioural variant frontotemporal dementia; MDS=movement disorder society
1. Postuma et al. Mov Disord 2015;30(12):1591–1601
Absolute exclusion criteria1
• Cerebellar signs
• Supranuclear gaze palsy
• Established diagnosis of BVFTD
• Parkinsonism restricted to the lower
limbs only for >3 years
• Treatment with an antidopaminergic,
or with dopamine-depletion agents
• Absence of response to levodopa
• Sensory–cortical loss
• No evidence for dopaminergic
deficiency on functional imaging
• Other parkinsonism-inducing condition
Red flags1
• Rapid deterioration of gait
• Absence of motor symptom
progression over 5 years
• Early bulbar dysfunction
• Respiratory dysfunction
• Early severe autonomic failure
• Early recurrent falls due to misbalance
• Disproportionate anterocollis
• Absence of common non-motor
features of disease during >5 years
• Pyramidal tract signs
• Bilateral symmetric presentation
Supportive criteria1
• A clear and dramatic positive
response to dopaminergic
therapy
• Levodopa-induced dyskinesia
• Documentation of resting tremor
of a limb
• A positive diagnostic test of
either olfactory loss or cardiac
sympathetic denervation on
scintigraphy
MDS clinical diagnostic criteria (2015)

– clinically established Parkinson’s disease
• Parkinsonism – bradykinesia plus either rigidity or rest tremor1
• Clinically probable PD:1
– Absence of absolute exclusion criteria; presence of 1 or 2 ‘red flags’ counterbalanced by equal
number of supportive criteria
30
Red flags1
• A clear and dramatic positive
therapy
• Levodopa-induced dyskinesia
• Documentation of resting tremor
of a limb
• A positive diagnostic test of
either olfactory loss or cardiac
sympathetic denervation on
scintigraphy

31
•Cerebellar signs
•Supranuclear gaze palsy
•Established diagnosis of BVFTD
•Parkinsonism restricted to the lower
•Treatment with an antidopaminergic,
•Absence of response to levodopa
•Sensory–cortical loss
•No evidence for dopaminergic
•Other parkinsonism-inducing condition
Red flags1
• Early severe autonomic
failure
• Early recurrent falls due to
misbalance
• Absence of common non-
motor features of disease
during >5 years
• Bilateral symmetric
presentation

32
Absolute exclusion
criteria1
• Established diagnosis of
BVFTD
• Parkinsonism restricted to
the lower limbs only for >3
years
• Treatment with an
antidopaminergic,
or with dopamine-depletion
agents
• Absence of response to
levodopa
• No evidence for
dopaminergic deficiency on
functional imaging
• Other parkinsonism-
inducing condition
Red flags1
•Rapid deterioration of gait
•Absence of motor symptom
•Early bulbar dysfunction
•Respiratory dysfunction
•Early severe autonomic failure
•Early recurrent falls due to misbalance
•Disproportionate anterocollis
•Absence of common non-motor
•Pyramidal tract signs
•Bilateral symmetric presentation

33
Red flags1
•A clear and dramatic positive
therapy
•Levodopa-induced
dyskinesia
•Documentation of resting
tremor of a limb
•A positive diagnostic test of
either olfactory loss or
cardiac sympathetic
denervation on scintigraphy

STAGES
35

Clinical pearls in management of EARLY

37
1. DeMaagd & Philip. Pharmacol Therapeut 2015;40(8):504–510
Years
1 3–5 4–6 5–7
Onset
Diagnosis
Honeymoon
Dopaminergic
therapy-related
motor complications Non-dopaminergic
symptoms
Death
Prescription
Pre-motor/
Prodromal phase
-15 to -10
Cardinal symptom
presentation
Treatment
PD may begin insidiously, with early symptoms presenting in up to 90%
of patients in a subtle fashion, such as difficulty getting out of a chair1
Stages of Parkinson’s disease

38
EDS=excessive daytime sleepiness; MCI=mild cognitive impairment;
RBD=REM (rapid eye movement) sleep behaviour disorder
Adapted from: Kalia & Lang. Lancet 2015;386(9996):896–912
Pre-motor/prodromal period
PD diagnosis
-10
-20 10 20
Time (years)
Early Advanced/late
Dysphagia
Postural instability
Freezing of gait
Falls
Complications
Motor
Non-motor
Bradykinesia
Rigidity
Tremor
Fluctuations
Dyskinesia
Psychosis
Constipation RBD
EDS
Hyposmia
Depression
Pain
Fatigue
MCI
Urinary symptoms
Orthostatic hypotension
Dementia
0
Clinical symptoms and time course of
Parkinson’s disease progression

Stages of Parkinson’s disease

MDS research criteria for prodromal
Parkinson’s disease (2015)
1. The probability of having prodromal PD is
estimated based on age (i.e., the prior
probability)1
2. Diagnostic information is obtained on as many
variables as possible. These can include:1
– Environmental risk variables
(e.g., sex, smoking, caffeine use)
– Genetic risk variables
(from family history or results of genetic
testing)
– Prodromal symptoms and signs
(e.g., constipation, hyposmia, motor
testing)
– Biomarker testing
(e.g., dopaminergic imaging)
42
The diagnostic strength of each variable is
expressed as a likelihood ratio; positive test
results increase the disease probability (ratio
>1), and negative test results decrease the
disease probability (ratio <1)1
3. Once all information is collected, all likelihood
ratios are multiplied by each other. The total
likelihood ratio for an individual patient is then
compared with the threshold required to give
more than an 80% probability of having
prodromal PD (this ranges from likelihood ratio
95–1,000, depending on age)1
If this threshold is met, probable
prodromal PD is diagnosed1
1. Berg et al. Mov Disord 2015;30(12):1600–1611
Prodromal PD refers to the stage wherein early signs or symptoms of neurodegeneration are present,
but classic clinical diagnosis based on fully evolved motor parkinsonism is not yet possible1

SCALES COMMONLY USED IN
RESEARCH
43

MDS Unified Parkinson’s Disease Rating Scale
(MDS-UPDRS)
• Measures disease progression1,2
• Combination of 4 sections:1,2
– I: Non-motor aspects of experiences of
daily living
– II: Motor aspects of experiences of
daily living
– III: Motor examination
– IV: Motor complications
• Items are rated on a 5-point scale:1,2
– 0 = normal (no impairment/disability)
– 1 = slight
– 2 = mild
– 3 = moderate
– 4 = severe (maximum impairment/
disability)
44
MDS=Movement Disorder Society
1. Goetz et al. Mov Disord 2008;23(15):2129–2170; 2. Goetz et al. Mov Disord 2007;22(1):41–47
Items include:
• Cognitive
impairment
• Hallucinations and
psychosis
• Depressed mood
• Anxious mood
• Apathy
13 questions
Items include:
• Eating tasks
• Dressing
• Hygiene
• Turning in bed
• Walking and
balance
• Handwriting
13 questions
Items include:
• Time spent with
dyskinesia
• Functional impact
of fluctuations
• Complexity of
motor fluctuations
6 questions
Items include:
• Speech
• Facial expression
• Finger taps
• Toe tapping
• Arising from chair
• Posture
• Gait
18 questions
Non-motor
ADL
Motor
ADL
Motor
examination
Motor
complications
IV
III
II
I

Hoehn & Yahr scale
• The Hoehn & Yahr scale is a physician-
administered rating to establish the
severity of PD1
• Useful to roughly classify the disease,
but it lacks sensitivity to a patient’s
clinical condition1,2
• The scale ranges from 0 to 5 – with
extra stages at 1.5 and 2.5 in the
modified version1-3
45
Stage 0: No signs of disease
Stage 1: Mild, unilateral
Stage 1.5: Unilateral with axial involvement
Stage 2: Bilateral, no impairment of balance
Stage 2.5: Bilateral, mild, recovery on pull test
Stage 3: Mild to moderate, some postural
instability, physically independent
Stage 4: Severe, major debilitation, requires
some assistance but can walk or
stand unaided
Stage 5: Very severe, wheelchair/bed-bound
if unaided
1. Hoehn & Yahr. Neurology 1967;17(5):427–442; 2. Jankovic. In: Pahwa et al (eds). Handbook of Parkinson’s Disease. 2003;
3. Goetz et al. Mov Disord 2004;19(9):1020–1028

Schwab & England ADL (SEADL)
• The SEADL scale estimates the
abilities of patients with PD relative to
their state before the disease was
diagnosed1
• A score of 100% indicates complete
independence, whilst 0% indicates an
individual in whom vegetative functions
are no longer functioning1,2
• The scale is graduated in 10% steps,
and is intended to allow physicians and
patients to agree on the performance
achieved in activities of daily living1,2
46
100% Completely independent; able to do all chores
without slowness, difficulty, or impairment;
essentially normal; unaware of any difficulty
80% Completely independent in most chores; some
activities take twice as long; conscious of
difficulty and slowness
60% Some dependency; can do most chores, but
exceedingly slowly and with much effort; some
tasks cannot be done; common errors
40% Very dependent, but still able to assist with all
chores; however, few can be done independently
20% No tasks done independently; can provide slight
help with some chores; but requires substantial
assistance for all activities
0% Vegetative functions with loss of control of
swallowing, bladder, and bowel functions;
bedridden
1. Schwab & England. In: Gillingham et al (eds). Third Symposium on Surgery on Parkinson’s Disease. 1969;
2. Jankovic. In: Pahwa et al (eds). Handbook of Parkinson’s Disease. 2003

Cognitive scales used in PD research
Mini-Mental Parkinson test
(MMP)1
• Derived from the non-PD specific
mini-mental state examination (MMSE)
• The MMP tests the following items:
orientation, visual registration,
attention/mental control, two-set verbal
fluency, visual recall, shifting, and concept
processing
• The MMP is a valid and reliable measure of
cognition in patients with PD
47
Parkinson’s Disease – Cognitive
Functional Rating Scale (PD-CFRS)2
• A PD-validated instrument for measuring
cognitive dysfunction useful in clinical and
research settings
• It is a questionnaire given to a
knowledgeable informant covering 12 items
of cognition
Montreal Cognitive Assessment (MoCA)3
• A brief, 10-minute cognitive screening tool
covering 8 domains of cognitive functioning
• The MoCA has high sensitivity and
specificity for detecting mild cognitive
impairment
1. Mahieux et al. Behav Neurol 1995;8(1):15–22;
2. Kulisevsky et al. Parkinsonism Relat Disord 2013;19(9):812–817;
3. Nasreddine et al. J Am Geriatr Soc 2005;53(4):695–699

MANAGEMENT OF
48

Initiation of Levodopa in early Parkinson’s
disease

We conclude that motor fluctuations and dyskinesias are not associated with the
duration of levodopa therapy, but rather with longer disease duration and higher
levodopa daily dose. Hence, the practice to withhold levodopa therapy with the
objective of delaying the occurrence of motor complications is not justified.
Initiation of Levodopa in early Parkinson’s
disease

Anticholinergics
Monotherapy
Three Class II trials found anticholinergic monotherapy more effective than
placebo in improving motor function (bornaprine and benzhexol).
Biperiden was as effective as apomorphine for parkinsonian tremor (Class III).
Two systematic reviews concluded that anticholinergics have a small motor
effect, but that evidence for a specific effect on tremor is inconclusive.
Adjunctive therapy
Class II studies of trihexyphenidyl , benzotropine and bornaprine in levodopa-
treated patients and two systematic reviews conclude that there is a minor effect
on PD symptoms and that tremor-specific data are inconclusive.
Prevention of motor complications
No studies available.
Safety
The clinical use of anticholinergics is limited by cognitive and neuropsychiatric
side effects (Class IV ).

MAO-B inhibitors
Monotherapy
Five of six studies (Class I and II ) and a meta-analysis concluded that there is
a small symptomatic effect of selegiline.
Two large placebo-controlled trials with rasagiline in early PD (Class I ) showed
a modest benefit.
Adjunctive therapy
No consistent beneficial effect was demonstrated in studies (Class I) for the
addition of selegiline to other antiparkinsonian therapies in non-fluctuating
patients.
Selegiline has shown no effect in preventing motor complications (Class I;
Class II). No studies are available with rasagiline.
Safety
Dopaminergic adverse reactions may occur. The risk of tyramine-induced
hypertension (‘cheese effect’) is low. MAO-B inhibitors carry a small risk of
serotonine syndrome, particularly when combined with other serotonergic
agents.

Amantadine blocks NMDA glutamate receptors and may have an
anticholinergic effect and release presynaptic dopamine stores.
Monotherapy
3 Class II studies and 2 systematic reviews concluded that there is an improvement of
parkinsonism.
Adjunctive therapy
Addition of amantadine to anticholinergics was superior to placebo (Class II ).
Amantadine was beneficial as an adjunct to levodopa (Class II ).
Two systematic reviews also suggest that amantadine is probably effective.
No studies available.
Safety
Side effects include dizziness, anxiety, insomnia, vomiting, oedema, headache,
nightmares, ataxia, confusion/agitation, constipation/diarrhoea, anorexia, xerostomia
and livedo reticularis [<5%].
Amantadine

Amantadine: ER formula new indications

New COMT inhibitors: Opicapone

FIRST STEP (Class I ) assessed as secondary endpoints the occurrence of motor
complications, and no difference was found between two arms.
STRIDE-PD (Class I )
compared levodopa/carbidopa/entacapone and levodopa/carbidopa, using the
same levodopa target dose (100 mg four times daily) in both arms.
Time to onset of dyskinesia was significantly shorter in
the levodopa/carbidopa/entacapone group.
There was no difference in wearing-off .
Safety
COMT inhibitors induce dopaminergic reactions. Diarrhoea occurs in 3–5% of
patients 2–3 months after initiation and may require discontinuation.
Tolcapone can rarely increase liver enzymes, and postmarketing surveillance
reported a few cases of fatal hepatotoxicity. The European Medicines Agency lifted
the suspension of tolcapone for patients who fail to respond to other COMT
inhibitors, but imposed strict liver function tests.
COMT inhibitors

Istradefylline
Istradefylline is a selective antagonist at the adenosine A2A receptor (A2AR),
but the precise mechanism by which it exerts its therapeutic effect in
Parkinson's disease is unknown
Istradefylline reduces "off" periods resulting from long-term treatment with
the antiparkinson drug levodopa.

Recommendations of the EFNS/MDS-ES on
management of EARLY Parkinson's disease
MAO-B inhibitor (selegiline, rasagiline) (Level A)
Oral or transdermal dopamine agonist. Pramipexole, piribedil,
ropinirole and rotigotine are effective (Level A).
Initial treatment with an agonist can be recommended in younger
patients (GPP).
Ergot derivatives are not recommended as first-line medication
because of the risk of fibrotic reactions
Levodopa is the most effective symptomatic drug (Level A).
Controlled-release formulations or adding entacapone is not effective
in the delay of motor complications (Level A)
Amantadine or an anticholinergic (Level B)
Rehabilitation: because of the lack of evidence in early-stage disease,
a recommendation cannot be made

Practical recommendations for the adjustment of initial therapy
in patients without motor complications
1. Patients not on dopaminergic therapy
2. Patients on dopaminergic therapy
3. Patients with disabling tremor

1- Patients not on dopaminergic therapy
If a patient has started on an MAO-B inhibitor, anticholinergic,
amantadine or a combination of these, a stage will come when there
is a requirement for adding levodopa or a dopamine agonist (GPP)

2- Patients on dopaminergic therapy
If on dopamine agonist therapy:
Increase the dose (GPP)
Switch between agonists (Level C)
Add levodopa (GPP)
If on levodopa:
Increase the dose (GPP)
Add an agonist (GPP)
Add a COMT inhibitor (GPP)

3- Patients with disabling tremor
If significant tremor persists:
Anticholinergics (GPP)
Clozapine (Level B)
Beta-blockers (propanolol)
Deep brain stimulation

management of Parkinson's disease
Therapeutic interventions Level of recommendation
Symptomatic control of
parkinsonism
Levodopa Effective (level A) Not applicable
Levodopa CRe Effective (level A) Ineffective (level A)
Apomorphine Not useda Not useda
Bromocriptineb Effective (level B) Effective (level B)
Cabergolineb Effective (level B) Effective (level A)
Dihydroergocryptineb Effective (level A) No recommendationc
Lisurideb Effective (level B) Effective (level C)
Pergolideb Effective (level A) Effective (level B)
Piribedil Effective (level C) No recommendationc
Pramipexole Effective (level A) Effective (level A)
Pramipexole CRe Effective (level A) Not available
Ropinirole Effective (level A) Effective (level A)
Ropinirole CRe Effective (level A) No recommendationc
Rotigotinef Effective (level A) No recommendationc
Selegiline Effective (level A) Ineffective (level A)
Rasagiline Effective (level A) No recommendationc
Entacaponed No recommendationc Ineffective (level A)
Tolcaponed No recommendationc No recommendationc
Amantadine Effective (level B) No recommendationc
Anticholinergics Effective (level B) No recommendationc
Rehabilitation No recommendationc No recommendationc
Surgery Not used Not used
•a Subcutaneous apomorphine is
not used in early PD.
•b Ergot derivates cannot be
recommended as a first-line
treatment because of the risk of
valvular heart disorder.
•c No recommendation can be
made because of insufficient data.
•d Transdermal patch.
•e Controlled release.
•f Entacapone and tolcapone should
always be given with levodopa.
Because of hepatic
toxicity, tolcapone is not
recommended in early PD.

Dyskinesias and motor fluctuations

Dyskinesias and motor fluctuations across
disease stages

Management of Dyskinesias and motor
fluctuations

Algorithms for the treatment of motor
problems in Parkinson's disease
Acta Neurologica Scandinavica, Volume: 136, Issue: 5, Pages: 378-385, First published: 30 January 2017, DOI: (10.1111/ane.12733)

Acta Neurologica Scandinavica, Volume: 136,
Issue: 5, Pages: 378-385, First published: 30
January 2017, DOI: (10.1111/ane.12733)

THANK YOU
amrhasanneuro@kasralainy.edu.eg

Parkinson disease.pdf

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Parkinson disease.pdf

Similar to Parkinson disease.pdf (20)

More from Amr Hassan

More from Amr Hassan (20)

Recently uploaded

Recently uploaded (20)

Parkinson disease.pdf