Belinda Kessel
Geriatrician and General Physician with a Specialist Interest in
Movement Disorders
8 th July 2010

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67 year old left handed gentleman with a right sided tremor
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Tremor present for 10 months and occurs at rest and posture (driving, holding golf club)
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Wife noticed decreased arm movements when walking but gait not shufffly
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No changes in speech, swallow or memory but long standing constipation

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Reduction in facial expression
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Resting tremor on right
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Mild increase in tone with cogwheeling on right
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Mild bradykinesia with decrease arm swing on right.

 Idiopathic right sided tremulous Parkinson’s disease
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Started on a dopamine agonist and titrated
Information given on PD and drug side-effects
Told to inform DVLA
Follow up 2/12 with PD nurse specialist
Further referrals to physiotherapy, OT and SALT as required including invite to new PD patient information course


Shakes/tremors

Abnormal movements such as tics, chorea, dystonias

Bradykinesia (slow movement)
Not falls alone- refer Falls Clinic
Paradoxically if known movement disorder no need to send to falls clinic as well

 Parkinson’s Disease


Bradykinesia

Rigidity
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Tremor
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Postural Instability

 Parkinson’s Disease
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Essential Tremor

Features of
Tremor
Essential tremor
Parkinson’s disease
Symmetry
When occurs
Other symptoms
Family History
Helps tremor
Length of time
Symmetrical Asymmetrical
On action At rest none Rigidity bradykinesia
Not usually yes
Alcohol
Over 5 years
Not usually
6-24 months

 Parkinson’s Disease

Essential Tremor

Cerebrovascular Parkinsonism
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Drug Induced Parkinsonism
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Parkinson Plus Syndromes
– Multi System Atrophy (MSA)
– Progressive Supranuclear Palsy (PSP)
– Lewy Body Dementia (LBD)
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Others

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Salbutamol
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Lithium
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Sodium Valproate

Anti-dopaminergics
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Anti-emetics
– Stemetil (Prochlorperazine)
– Maxalon (Metoclopramide)
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Anti-psychotics
– Typicals eg Haloperidol and Chlorpromazine
– Atypicals eg Risperidone and Olanzepine
– Don’t forget depot injections
Anti Dementia drugs (anti cholinesterase inhibitors)
– Rivastigmine, Donepezil

It can take up to 6 months for Parkinsonian drugs to wash out the system
Dilemmas
 Do they have underlying Parkinson’s
Disease worsened by the drug
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Can the offending drug be stopped
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Do they need urgent treatment for their movement disorder

 Rarely ‘urgent’
 Send drug treatment naïve
– May be wrong diagnosis
– May not be on best drug
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Full drug history

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Determined by age
•
< 65years to the neurologists
• >/= 65 years to me (Belinda Kessel)
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Consider alternative diagnosis to PD
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Consider what drugs they are on

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Seen by consultant -/+ registrar on first visit
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Tests may be arranged eg MRI brain scan
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Often diagnosis on first visit
– Given lots of information eg leaflets
– Website/telephone number of PD society if appropriate
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Letter to GP and patient gets copy

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Referred as appropriate to
– Speech and language therapists
• For assessment and therapy
• For PD awareness course
– Physiotherapist
– Occupational therapist
– PD community support worker
– Parkinson’s Disease nurse specialist for first follow up (Lynne Waller PDNS)

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Information for patient
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Titration of drugs/monitoring of side effects
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Monitoring symptoms both motor and non-motor
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Referral to appropriate therapist
 Advice for patient, carers and GP’s in clinic or by phone
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Liaison between hospital staff and patient
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Unable to do home visits

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Still a clinical diagnosis
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Levo-dopa or apomorphine challenge tests not recommended
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Trial of medication still good indicator
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Brain scans;CT or MRI are to check for other causes eg stroke disease

TM
123
Shows dopamine uptake in basal ganglia
Differentiate PD from;

Essential Tremor
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Dystonic Tremor
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Drug induced Tremor and Parkinsonism
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Cerebrovascular Parkinsonism
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Lewy Body Dementia or Alzheimers
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Poor response to Parkinson treatment

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Multi System Atrophy
(Shy Drager Syndrome)
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Progressive Supranuclar Palsy
(Steele Richardson Olszewski disease)
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Lewy Body Dementia

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Presence of early instability and falls
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Pyramidal or cerebellar signs
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Downgaze palsy
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Early autonomic failure
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Early confusion/hallucinations
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Poor response to L-dopa

These may often predate the onset and therefore the diagnosis of motor symptoms by 4-6 years

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Anosmia
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Restless Legs
Syndrome
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Sleep disturbance
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Urinary problems
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Bowel problems
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Weight loss
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Speech/swallow problems
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Dizzyness on standing
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Memory Problems
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Apathy
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Hallucination/ nightmares
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Depression
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Excessive sweating
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Double Vision

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Preferably not before seeing the specialist
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If possible we start a Dopamine Agonist
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Other options are;
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L-Dopa +/- COMT
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MAO inhibitor
NB no evidence yet of any drug being neuroprotective

1.
Anticholinergics - Benhexhol
- Orphenadrine
S.E.; anticholinergic increase dystonias neuropsychiatric
2.
Amantidine - mild anti-Parkinson effect
Useful in dyskinetic patients
Rarely can cause confusion

3.
Leva-Dopa
Madopar=l-dopa and benserazide
Sinemet=l-dopa and carbidopa
Different preparations
- capsules
- dispersible tablets
- controlled release

4.
Dopamine agonists
Old ; Pergolide, Lisuride, Bromocriptine
Cabergoline
New ; Pramipexole (Mirapexin),
Ropinerole (Requip)
Rotigotine patch (Neupro)
Apomorphine - s/c by injection or infusion

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Peripheral oedema
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Postural hypotension
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Confusion and hallucinations
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Nausea (use Domperidone)
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Lung and cardiac valve fibrosis (ergot)
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Somnalence and SOOS
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Dopamine Dysregulation Syndrome and
Impulse Control Disorders

Information sheet of Dopamine Agonists
The following drugs are commonly used in patients with Parkinson’s disease and are classed as Dopamine Agonists. They are
Ropinirole (Requip ®), Cabergoline (Cabaser ®), Pramipexole (Mirapexin ®). There is also a transdermal patch called Rotigotine
(Neupro
®). These drugs can be useful to help the tremor and the slowness seen in Parkinson’s patients. Occasionally side effects occur, the most common one being nausea on first starting the drug, so often you will be given an anti-nausea drug called
Domperidone (Motilium
®) to prevent this.
Other side-effects sometimes seen are swelling of the ankles , dizziness on standing due to blood pressure dropping and also occasionally some confusion or hallucinations .
Sleepiness can occur and it is advisable when first starting this drug and during the period of increasing the dose (titration period) that if you drive a car you should always be with another person, in case the sleepiness comes on whilst driving.
A very rare side-effect with Cabergoline is fibrosis of the lungs and narrowing or leaking of the heart valves. This would give increasing shortness of breath over a period of time. If you get shortness of breath whilst taking the drug let your GP or Specialist know but don’t stop the drug immediately as it is much more likely that the breathing problem is due to other causes not related to the
Parkinson treatment. We now monitor by yearly chest X-rays and heart scans (echocardiograms).
The Rotigotine patch can occasionally cause a local skin reaction (1 in 20).
Very rarely with Parkinson drugs people taking them do normal things more excessively than usual , for example; eating, gambling, shopping, hoarding objects or having sex. Do let the doctor/nurse know if you or your partner thinks this is happening to you.
Most of the side-effects are mild and it is not necessary to stop the drug. However, if you feel the side-effects are outweighing the benefit of the drug, then we would consider stopping the drug. It is best to try and contact either Anne Martin or the doctor who prescribed the drug to discuss this, as it is usually not advisable to stop the drug suddenly, unless you have just started it. Often the symptoms go away if the dose of the drug is decreased, rather than completely stopping the drug. You may not notice any difference in your movements/tremor on starting the new drug but this may be because the dose to start with is small and is gradually built up.
Therefore please continue taking it. If you need further information, please do not hesitate to get in touch with Lynne Waller, the
Parkinson Nurse , or your Consultant through their secretary, whose numbers are available via the hospital switchboard ( 01689
863000 ).
If you do not understand the above information or have concerns then do not start the new drug until you have further discussed them with either Lynne Waller or your Specialist.

5.
COMT inhibitors - Entacapone (Comtess)
Use in conjunction with L-dopa
Smoothes out fluctuations
S.E. - neuropsychiatric
- increases dyskinesias
Commonly used in conjunction with Sinemet
Plus in the form of Stalevo
6.
Selegiline, Rasagiline - MAO-B Inhibitors
NB care with tricyclics as risk of Seratonin
Syndrome

1.
2.
3.
Fluctuations
Dyskinesias
Confusion or hallucinations


Fluctuation and dyskinesias
– Manipulation of the drugs
– New routes of administration
– Surgery

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Lesioning
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Deep Brain Stimulation (DBS)

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Confusion and hallucinations

Psychiatric Side-effects
-’last in, first out principle’
- Order of stopping;
- anticholinergics
- selegiline
- amantidine
- dopamine agonists
- MAO-I
- L-dopa


Anticholinesterase Inhibitors – LBD, apathy
– Rivastigmine
– Donepezil
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Atypical antipsychotics – hallucinations, agitation, dementia
– Quetiapine
– Clozapine (Psychiatrists only)