PARKINSON’S DISEASE :
DIAGNOSTIC CRITERIA AND
EARLY MANAGEMENT
Andradi S.
Department of Neurology, University of Indonesia,
Jakarta, Indonesia
CURRICULUM VITAE
Nama : Dr ANDRADI SURYAMIHARJA SpS (K)
Tempat/tanggal lahir : Tangerang, 13-11-1938
Pendidikan :
• 1964 Dokter , FKUI
• 1972 Dokter Spesialis Saraf, FKUI, Jakarta
• 1985 University of New South Wales,Sydney, Australia.
• Workshops/courses: Parkinson’s disease and Movement Disorders
• Botox injections, Stroke, Pain, Vertigo
• EEG, Epilepsy
Pekerjaan :
• 1963 - 2003 Staf Pengajar Bagian Saraf FKUI
• 2002 - 2003 Koordinator Penelitian Bagian Saraf FKUI
• 1986 - 2003 Ketua Sub-Bagian Neuro-otologi Bagian Saraf FKUI
• 1975 - 2003 Staf Sub-Bagian Neuro-oftalmologi Bagian Sara FKUI
• 2001 - 2003 Staf Pengajar International Class FKUI
Organisasi :
• Anggota IDI
• Anggota/Pengurus PERDOSSI (Perhimpunan Dokter Spesialis Saraf Indonesia)
• Ketua Komisi Ujian Nasional, Kolegium Neurologi Indonesia
(sampai dengan tahun 2011)
• Anggota WFN ( World Federation of Neurology)
• Anggota ASNOS ( Asian Neuro-ophthalmology Society)
• Anggota / Anggota Pengurus Pokdi Nyeri, Pokdi Vertigo, Pokdi Stroke,
Pokdi Parkinson dan Movement Disorders
• Anggota/Pengurus Ikatan Keseminatan Kardioserebrovaskular Indonesia
(IKKI)
• Anggota AAN (American Academy of Neurology)
PARKINSON’S DISEASE:
CLINICAL DIAGNOSTIC CRITERIA
1. Historical Diagnostic Criteria
Symptoms: Tremor, Rigidity, Akinesia, Postural Instability (TRAP)
• Two of three cardinal symptoms (2/3 TRA)
- Tremor, Rigidity, A kinesia / bradykinesia
OR
• Three of four symptoms (3/4 TRAP)
Tremor, Rigidity, Akinesia, Postural instability
OR
• Responsive to L-DOPA.
PARKINSON’S DISEASE:
NEW CLINICAL DIAGNOSTIC CRITERIA
(UK Parkinson’s Disease Society Brain Bank / UKPDSBB)
Step 1. Diagnosis of Parkinsonism
Step 2. Exclusion criteria for Parkinson’s disease
Step 3. Supportive prospective positive criteria for
Parkinson’s disease
UKPDSBB CLINICAL DIAGNOSTIC CRITERIA
Step 1. Diagnosis of PARKINSONISM
√ BRADYKINESIA
+
At least ONE of the following:
√ RIGIDITY
√ REST TREMOR (4-6 Hz)
√ POSTURAL INSTABILITY not caused by primary
visual, vestibular, cerebellar, or proprioceptive
dysfunction
UKPDSBB Clinical Diagnostic Criteria
Step 2 Exclusion criteria for Parkinson’s disease
• History of repeated strokes with stepwise progression of
parkinsonian features
• History of repeated head injury
• History of definite encephalitis
• Oculogyric crises
• Neuroleptic treatment at onset of symptoms
• More than one affected relative
• Sustained remission
Step 2 Exclusion criteria for Parkinson’s disease (cont’d)
• Strictly unilateral features after 3 years
• Supranuclear gaze palsy
• Cerebellar signs
• Early severe autonomic involvement
• Early severe dementia with disturbances of memory, language,
and praxis
• Babinski sign
• Presence of cerebral tumor or communication hydrocephalus
on imaging study
• Negative response to large doses of levodopa in absence of
malabsorption
• MPTP exposure
CBD
(Corticobasal Degeneration)
Asymmetric Parkinsonism with Poor Response to
Levodopa
Apraxia and Alien Limb
Spasticity, Rigidity, Dystonia
Gait and Balance Problem
Dementia always occurs, but may be a late feature
MSA
(Multiple System Atrophy)
Cardinal Findings
Parkinsonism that is poorly responsive to Levodopa
Autonomic Failure (Low Blood Pressure)
Cerebellar Signs
Long Tract Signs (Spasticity)
Striato-Nigral Type (Parkinsonism First)
Shy-Drager Syndrome (Autonomic Failure First)
Olivo-ponto-cerebellar Type (OPCA-Ataxia First)
Ataxia
Symptomatic Interruption of the Cerebellar Pathways
Dysmetria (Poor targeting of planned movements)
Dysdiadochokinesia (Poor sequencing of planned
movements)
Intention Tremor (Past Pointing)
Gait Abnormalities
Wide based gait
Poor balance
*Drunken Sailor’s Walk*
LBD
(Diffuse Lewy Body Disease)
Unlike PD, Lewy Bodies rapidly spread throughout
the brain, including the cerebral cortex
Levodopa Responsive Parkinsonism
Rapidly Progressive Dementia
Hallucinations
PSP
(Progressive Supranuclear Palsy)
Early Postural Instability and Falls
Parkinsonism (Unresponsive to Levodopa)
“Stone Face”
Dementia
Ocular Signs
Drug Related Parkinsonism
Haldol and other antipsychotic medication cause
symmetric findings that are indistinguishable at
times from Idiopathic Parkinson’s Disease
Reglan is a dopamine blocker and is an important
cause of Parkinsonism in elderly patients (currently
used as an anti-nausea medication)
UK PDSBB CLINICAL DIAGNOSTIC CRITERIA
Step 3. Supportive prospective positive criteria for
Parkinson’s disease
Three or more required for diagnosis of definite Parkinson’s disease in
combination with step one
• Unilateral onset
• Rest tremor present
• Progressive disorder
• Persistent asymmetry affecting side of onset most
• Excellent response (70-100%) to levodopa
• Severe levodopa-induced chorea
• Levodopa response for 5 years or more
• Clinical course of ten years or more
CONCLUSIONS
Diagnostic Criteria
1. Parkinson’s disease is one of the types of
Parkinsonism which is characterized by Tremor,
Rigidity, Akinesia, and Postural Instability (TRAP)
2. Diagnosis of PD is based on clinical findings,
comprising of 3 steps: diagnosis of Parkinsonism,
differentiating Parkinsonism types, and positive
symptoms supporting PD
TREATMENT STRATEGIES IN PD
Parkinson’s Disease
Idiopathic Progressive Degenerative
Underlying cause ? Neuroprotection ? Neurorestoration ?
Symptomatic
SYMPTOMATIC TREATMENT
I. MEDICAL
1. Pharmacologic
a. Dopaminergic agents
b. Cholinergic agents
c. Non-motor symptoms therapy
2. Non-pharmacologic
Education, self-help group, exercise, speech therapy
II. SURGICAL
1. Ablative / Lesioning
Thalamotomy, pallidectomy.
2. Deep Brain Stimulation
Pallidum, nucleus subthalamicum
SYMPTOMATIC TREATMENT
I. MEDICAL
1. Dopaminergic:
- L-Dopa/benserazide
- Dopamine agonist: oral bromocryptine, ropinirole,pramipexole, apomorphin,
patch rotigotine
- MAOB inhibitor: selegilline, rasagiline
- COMT inhibitor: entacapone, tolcapone.
- NMDA receptor antagonist: amantadine.
2. Cholinergic:
trihexyphenidyl.
BRAIN
Ganglia basalis
Dopamin Acetylcholin Normal
MAO MAO I ( selegiline )
Anticholinergic
Perokside Radical H (Trihexylphenidyl)
Dopamin Tissue
Receptor D2 Dopamin damage
Decarboxylase
Levodopa Acetylcholin PD
BLOOD BRAIN BARIER
Levodopa 3 OMD
COMT Inhibitor
COMT
Dopamin Agonist (entacapone)
Decarboxylase
Ergot
Decarboxylase Inhibitor
Non Ergot Dopamin
(bromocryptin) (pramipexole, (Benzeraside)
rotigotine) PERIFER (carbidopa)
PHARMACOLOGIC TREATMENT
When to initiate therapy ? Which agent for which patient?
● When to initiate therapy ?
Pharmacologic therapy is initiated when functional impairment appears.
● Which agent to choose ?
Benserazide/L-Dopa, DA agonist (oral, patch), MAOB-I, COMT-I, or Anticholinergic ?
● For which patient ?
- Age : < 60 yo, > 60 yo
- Stage: early, advanced
- Drug adverse effect
- Cost
Algoritma Penatalaksanaan Penyakit Parkinson
Gangguan Fungsional
Ya Tidak
Terapi Neuroprotektif
Terapi simptomatik
Antioksidan
Tremor dominan ?
Ya Tidak
Antikolinergik Usia < 60 tahun Usia > 60 tahun
Dopamin Agonis (oral: Pramipexole
patch: Rotigotine) Dopamin agonis (oral: Pramipexole Levodopa
patch: Rotigotine)
Dopamine agonis+levodopa dosis rendah
Dosis levodopa optimal
Respon terhadap pengobatan
Baik Tidak respon Wearing off Diskinesia
COMT-Inhibitor Turunkan dosis levodopa
Maintenance dosis Tingkatkan dosis
Kombinasi Dopamin Tingkatkan dosis dopamine
rendah Diagnosa lain
agonis+ levodopa agonis
tambah levodopa Beralih ke dopamine agonis
antikolinergik Pembedahan
TREATMENT OF EARLY PD
INITIAL THERAPY FOR EARLY PD
IN YOUNG PATIENTS ( < 60 yrs )
● Agents
Anticholinergic, DA agonist (oral, patch), amantadine, or MAOB-I.
● Benefit
- mild symptomatic control for 6-8 months
- less than L-Dopa
● Motor complications: < L-Dopa
Non-motor complications : > L-Dopa
(Hallucination, somnolence, orthostatic hypotension)
INITIAL THERAPY FOR EARLY PD
IN OLD PATIENT ( > 60 yrs )
● Agents: - L-Dopa , or
- DA agonist (oral, patch) / other dopaminergics
• Options (both are acceptable):
1. L-Dopa
- The most effective
- Motor and non-motor complications after few years
add DA agonist (oral, patch) / other DA-ergics
2. DA agonist or other dopaminergics
- Less effective later needs L-Dopa
- Adverse effects: hallucination, somnolent, orthostatic hypotension.
CONCLUSION
Early Treatment
- Current treatment of Parkinson’s disease is mainly
symptomatic, since therapeutic modalities to slow the
progression of this disease are not yet proven efficacious.
- To initiate symptomatic treatment consider:
- Functional impairment
- Patient age
- Disease stage
- Severity of clinical symptom
- Drug profile
THANK YOU..
