Parkinsonism and other movement disorders

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Parkinsonism and other movement disorders

• PRM de Bittencourt
• www.unineuro.com.br

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The concept of Parkinsons disease

• 1977 started classical neurology training
• 1982 first started with a large amount of
  clinical work
• 1985 depression definitely associated with
  Parkinsons, imipramine replaced other
  anticholinergics

• It was thought Parkinsons evolved without
  dementia, with depression, perhaps dementia at
  the end
• Initial surprise at the great number of cases
  cured of Parkinsons disease

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The most frequent cause of parkinsonism in
Curitiba in the 80s labirintitis

• 1988 Chouza e Melo-Souza, parkinsonism due to
  cinarizine and flunarizine
• 100. Cunha CA, Bittencourt PRM, Kohlscheen KL,
  Mercer LM. Reversible parkinsonism induced by
  cinarizine and flunarizine. Revista Médica do
  Paraná 5013-16, 1993

• Letter to CD Marsden in 1986
• 1988 Dr Marsden diagnosis is really difficult
• Recommended a number of criteria

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Present vision (Litvan 2003)

• Pathologically, patients with parkinsonism and
  dementia may be classified as tauopathies or
  sinucleinopathies, based on their aggregates of
  abnormal proteins

• There are no biologic markers at the moment that
  allow the diagnosis of the various disease that
  start with parkinsonism or dementia, and their
  clinical diagnosis may be a challenge

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Parkinsonism with dementia

• tauopathies (PSP, Pick disease)
• synucleinopathies (Parkinson, dementia with Lewy
  bodies
• Drug-induced (combination of drugs,
  anti-cholinergics, or dopaminergics)
• Infeccious (Creutzfeldt-Jakob, HIV)
• Vascular

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Parkinsonism with dementia

• Toxic (Wilson, manganese)
• Tumoral (primary, secondary, chronic subdural
  hematomas)
• Normal pressure hydrocephalus
• Post-traumatic (dementia pugilistica)
• Sleep apnoea

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synucleinopathies

• Parkinsons
• akynesia postural disturbance with axial
  involvemente, rigidity, response to L-PODA
• Lewy body disease
• Demential more proeminent
• More rapidly progressive
• N response to l-DOPA

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tauopatias

• Familial
• Frontotemporal lobe dementia with parkinsonism
  associated with chromosome- 17

• Frontal behaviour (disinhibition, isolation,
  disfunction executive aphasia) parkinsonism

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Typical Parkinsons patient

• 60 year-old, male, non-smoker, brought by family
  or refered by clinician due to
• Slowness
• Lack of volition, apparent sadness
• Motor difficulty with every day activities
• Sleep disturbances

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Typical Parkinsons

• Consults other physicians because
• Labyrinth (dizzines, postural instability, gait
  difficulty, apparent lack of balance)
• Vertebral column lumbar pain, difficulty moving
  legs

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Physical Examination

• Posture parkinsonian
• Gait parkinsonian
• Slowness of movemento rigidity
• Lack of movement akinesia
• Tremor
• Asymetric signs

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On physical exam

• Cardiovascular, respiratory, abdominal, head,
  neck, limbs normal
• Movement thought slow

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Diagnosis therapeutic test

• Response to l-DOPA
• Immediate
• Dose-dependent
• 3/3h
• ¼ de 250mg

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Medical diagnosis

• Systemic investigation normal
• Neuroimaging normal
• CT
• MRI

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Diagnosis functional

• Neuroimaging functional normal
• SPECT
• PET
• EEG with mapping of alpha at low normal

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Functional diagnosis

• IQ Memory normal
• WAIS
• Weschler Memory Scale
• Minimental

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Natural history until 80s

• 1-2 years before diagnosis
• 5 years good response to L-DOPA
• 5 years partial incapacity with multiple drugs
• 2-3 years with terminal incapacity
• Dysphagia aspiration

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Natural history after the 80s

• 1-2 years before diagnosis
• 5 years good response to post-DA stimualtors
  pramipexole
• 5 years good response to small doses of L-DOPA
  given at short intervals or SR multiple drugs
• 5 years partial incapacity with multiple drugs
• 2-3 years with terminal incapacity
• Dysphagia aspiration

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História natural após ano 2000

• 12 anos de diagnóstico, resposta a estimuladores
  pós sinápticos pramipexole, pequenas doses de
  L-DOPA ou SR múltiplos medicamentos
• 5 anos de incapacidade parcial com múltiplos
  medicamentos ou estimulador de gânglios da base
  com retorno quase ao estado inicial, em pacientes
  com menos de 70 anos
• 2-3 anos de incapacidade terminal
• Disfagia broncoaspiração

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Multiple drugs

• Tricyclics, venlafaxine, bupropione
• entacapone
• quetiapine
• Avoid anticholinergic effect
• Avoid depressive effect

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Environmental treatment

• Collection of cars versus mechanic
• Ballroom dancing, snooker, tricot
• Wedding invitations, model ships and airpplanes
• Physical exercise
• Extremely healthy life
• Repetitive routine with novel fine and physical
  motor and mental acitvities

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Essential tremor

• Familial ou episodic
• Rapid, action, symetric, diffuse
• Propranolol, alcohol, phenobarbitone
• Caffeine, dopaminergic substances
• Benign
• Cigarrete

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Dystonias

• Tardive dyskinesia
• Psychogenic dyskinesia
• Focal dystonia
• Facial hemispasm
• Generalized dystonia
• Dystonic cerebral palsy

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Choreas

• Sydenham
• pregnancy
• Huntington
• Drug induced
• Antipsychotic
• Metochlopramide
• Fluoxetine
• L-DOPA

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Chorea, dyskinesia, dystonia

• Botox
• Anticholinergics
• Mood stabilizers
• DA blockers
• Benzodiazepines