Parkinsonism

- A clinical syndrome characterized by (cardinal signs)

o Tremors (rest tremors)

o Rigidity (cogwheel)

o Bradykinesia (slowness in execution of motion / slow movement)

- Types of parkinsonism

o Primary parkinsonism = Parkinson’s disease (PD)

o Secondary parkinsonism – neuroleptics/antipsychotics (especially typical antipsychotics e.g. haloperidol), Wilson’s disease, stroke.

o Parkinsonism plus syndrome (PPS) – Progressive Supranuclear Palsy (PSP), Multiple System Atrophy (MSA).

[NB: since secondary parkinsonism is treatable thus it is important to recognized and accurately diagnose this.]

- Clinical diagnosis of PD:

o Asymmetrical signs of parkinsonism

o No clinical evidence of PPS & secondary parkinsonism

o Marked response to dopaminergic drugs

o Postural instability is the 4th cardinal sign, but it emerges late in the disease, usually after 8 years or more.

Proposed stages of Parkinson's disease (PD) based on extrapolations from pathologic, clinical and brain imaging studies. Broken black lines indicate that, by itself, Lewy (-synuclein) protofibril or fiber pathology is not sufficient to make the pathologic diagnosis of PD. Broken blue lines represent non-motor signs that usually precede clinical recognition of PD, including impaired olfaction, sleep and mood disturbances, and constipation. Broken yellow lines indicate that fluctuations may be less apparent in the late stages of PD. (Taken from Harrison's online)

- Treatment of PD:

o Early stage : dopaminergic drugs (i.e. dopamine agonist e.g. Mirapex / pramipexol & Requip / ropinirole)

o Late stage : brain surgery (Deep Brain Stimulation / DBS, pallidotomy & thalamotomy)

- Differences between PD & PPS

	Parkinson’s disease (PD)	Parkinsonism plus syndrome (PPS)
1	Response to dopaminergic drugs & brain surgery are good.	Poor response
2	Better long term prognosis (less aggressive course)	Poorer long term prognosis (more aggressive course)